Ultimate Merge Flashcards
Conjunctivitis:
Viral vs Bacterial vs Allergic
a) UL vs BL
b) “stuck shut”
c) dcg
d) dcg reappear after wiping
e) other complaints
f) conj. appearance
tx and MoA for each
a) UL->BL vs UL——> vs BILATERAL
b) all
c) serous, thick/purulent, serous
d) no, YES, no
e) burning/gritty vs unremitting dcg vs itchy
f) bumpy vs non-bumpy vs bumpy/chemosis [bumpy=follicular] [edema=chemosis]
Viral: tx compresses +/- anti-hist/decongestant
Bacterial: tx topical abx (erythromycin, polymyxin-TMP, azithromycin); CONTACT lens (FLUOROQUINOLONE drops)
ALLERGIC: tx mast cell stabilizer (olopatadine, azelastine), antihistamine/decongestant drops
What dz’s do you see tau protein in but what types of aggregates?
Alzheimers-NFTs of tau
Pick’s-round aggregates of tau
Common complication in those with treated Hodgkin’s Lymphoma?
secondary malignancy (often in Lung but many others)
PROLACTINOMA (3) popluations and px and detection
Management of Prolactinoma?
1) premenopausal - detected early
- galactorrhea, infertility, oligo/amenorrhea, hot flash, bone loss
2) postmenopausal - detected late
- visual deficits/headache (2/2 mass effect)
3) men - detected late
- vLibido, gynecomastia, impotence, infertility (h/a, visual)
DOPAMINE AGONIST
surgery if refractory
1) dx. benign vs malig? potential? no mass, mass, or other?
a1) intermittent, UL bloody discharge in PREmenopausal woman? hist?
a2) bloody dcg in POSTmenopausal woman? hist?
b) BL cyclical (menstrual) breast pain
c1) painless, firm, mobile lump in young woman
c2) overgrowth of c1 (>5cm) and older pt than c1
d1) asymp/bloody discharge+lump
d2) eczematous changes of the nipple
e) smoker/vitA def. nipple retraction
1)
a1) benign intraductal papilloma; epithelial+MYOepithelial; no mass
a2) malig intraductal papillary carcinoma; ONLY epithelial
b) benign fibrocystic change; lumpiness; NO MALIG POTENTIAL unless sclerosing calc. adenosis (2x), ductal hyperplasia (2x), or atypical hyperplasia (5x) is present
c1) benign fibroadenoma [MC in premenopausal females]; mobile, well-circumscribed mass; NO MALIG POTENTIAL
{um, estrogen sensitive, but is it non-cyclical?}
c2) Cystosarcoma Phyllodes
d1) DCIS
d2) malig Paget’s Dz of Breast (underlying DCIS has spread to nipple)
e) PERIDUCTAL mastitis
Which type of breast cancer does Tamoxifen treat?
What is the most important prognostic factor in breast CA?
LOBULAR carcinoma in situ (which is a RF for invasive lobular carcinoma)
TNM staging (tumor burden)
Explain the benefits;risks of the following SERMs and think through each:a) Tamoxifen b) Raloxifene !
tx?
(2) risk modifications
(3,2) MoA
a)
- tx breast CA
- reduces osteoporosis risk; predisposes endometrial CA-
- estrogen receptor ANTagonist in breast (tx and ppx)
- estrogen receptor AGONIST at osteoclasts; inhibits bone turnover
- estrogen receptor (partial) AGONIST on endometrium
b)
- tx osteoporosis
- reduces breast CA risk; predisposes VTE
- estrogen receptor AGONIST on bone
- estrogen receptor ANTagonist in breast and vagina
nipple discharge* and breast mass in multiparous postmenopausal woman 2 ddx
- BENIGN plasma cell MAMMARY DUCT ECTASIA (*GREEN/BROWN dcg)
- malig Ductal CA in Situ (*bloody dcg)
Fat embolus vs Pulmonary Contusion
FE= AMS+petechiae following a 12-72 hour latency
PC= blunt chest trauma: dyspnea, tachypnea, chest pain, hypoxemia worsened with IVF
Natural infection immunity vs Vaccine immunity?
-- Levels during the following? a) early b) window c) recovery
sAg+anti-c
(elevated both during initial infx and window)
–
Vaccine - anti-S (IgM)
Nat. Imm- anti-S (IgM) + anti-C (IgG!)
a) E, S, anti-C (IgM)
b) anti-C (IgM) only!
c) anti-C (IgG), anti-E, anti-S
[DNA in all 3]
NBS in suspected gout or pseudogout?
What condition do you typically see pseudogout in and why?
What is a weird cause of CPPD/chondrocalcinosis/pseudogout? What else can this cause and is it reversible? What is chondrocalcinosis?
How treat gout? (2)
Arthrocentesis (joint aspirate, fluid analysis)
Hyperthyroidism predisposes pseudogout development.
Hemochromatosis;
lol restrictive cardiomyopathy that’s reversible (vs amyloidosis, sarcoidosis, scleroderma)
Chondrocalcinosis is calcified articular cartilage.
1) ACUTE:
a) NSAID
b) Colchicine
c) Corticosteroids
2) PREVENTION:
a) allopurinol, febuxostat (XOi; decreases uric acid production)
b) Probenecid (inhibits uric acid reabsorption)
c) Rasburicase (metabolizes uric acid) [tx TLS]
Ocular, Vascular, and Cardiac manifestations of opioid use? What are these mediated by?
MiOsis, hypOtension, BRADYcardia
histamine release
Compare/contrast the nodes:
a) Osteoarthritis
b) Gouty Arthritis
c) RA
a) H/B Nodes: bony nodules
b) TOPHI: can ulcerate and drain a chalky material (dist. calcinosis cutis)
c) Flesh-colored, nontender
c) “volcano” with central keratotic plug
d) another name for skin tag
c) keratoacanthoma
d) acrochordon
Initial treatment strats for RA.
What do you give if unresponsive for 6 months?
Classify this category of drugs. What do you need to test for prior to starting?
non-biologic DMARD (methotrexate!) + NSAID/celecoxib/glucocorticoids (relief while awaiting DMARD response)
Add biologic (anti-tnf alpha) or a second non-bio if refractory.
DMARD = non-biologic (methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, azathioprine) + biologic (etanercept, infliximab, adalimumab, toclizumab, rituximab)
[TEST FOR HEP B/C and TB!]
EM vs SJS vs TEN
targetoid s/p HSV infx vs
bullae/desquamation 2/2 “triggers”
v10% = SJS ^30% = TEN
triggers = sulfonamides, carbamazepine, lamotrigine, phenytoin, sulfasalazine, NSAIDs, allopurinol, mycoplasma
What is senile purpura? mech
Suppurative hidradenitis
““acute” SH-looking things
Explain why purulent vesicles can form in allergic contact dermatitis?
BENIGN ecchymoses in elderly patients (nasty hands) due to loss of perivascular CT
Chronic follicular occlusive disease; painful inflammatory nodules and draining sinus tracts. ODORUS (“rotten stretchmarks”)
Intertrigo. More erythematous.
Scratching can lead to 2ndary infxn
Tx frostbite?
Warm water rewarming. Only debride later
What are the two types of scaphoid fractures and how to tx each?
a) NON-displaced (fine radiolucent line or nL xray; v2mm displacement and no angulation) : wrist immobilization for 6-10 wks
b) DISPLACED: open reduction, internal fixation
What is osteonecrosis and what causes almost all of these cases? What are 4 synonyms?
gold standard dx?
Osteochondritis dessicans, aseptic necrosis, avascular necrosis, ischemic necrosis
Corticosteroid, alcohol
also SLE and sickle cell
MRI! (commonly hip. ttp + predinosone/SLE etc. )
What is scleroderma crisis? What does it present with (3)?
What GI issue are scleroderma ppl (as well as DM) at risk for?
Pulmonary manifestation of scleroderma?
Sudden RF (urinalysis can be nL)
MAHA (schistocytes!)
Malig HTN
Sm. Intestinal Bacterial Overgrowth (2/2 lack of proper motility); also angiodysplasia
INTERSTITIAL LUNG DZ! (FIBROSIS)
pulmonary arterial HTN
Burr Cells (echinocytes)
HJ bodies
Spur Cells (acanthocytes)
Target Cells
Spiculated/serrated; Liver dz / ESRD
Basophilic remnants; functional asplenia/splenectomy
Irregular projections; Liver dz
Bull’s eye; hemoglobinopathy (thallasemia); obstructive liver dz
ACLS
How are the (2) different forms of persistent tachyarrythmias treated based on the (2) broad category of symptoms?
What to avoid in WPW?
1) Wide or narrow (qrs) complex
2) STABLE - MEDICINE (amiodarone); UNSTABLE-CARDIOVERT
a) narrow-complex (ex. paroxysmal SVT) tx vagal
b) wide-complex (ex. sust. monomorphic VT) tx (2)
in WPW avoid drugs that increase conduction thru the accessory pthwy (BB, CCB, digoxin, adenosine [av block]); instead tx with procainamide or ibutilide
PALPABLE KIDNEYS, hepatomegaly, nephrotic syndrome, LVH, recurrent pulmonary infection.
tx?
Secondary amyloidosis
tx colchicine
Unexplained elevation in CK and signs of myopathy?
Consider hypothyroidism
Most serious ADR of anti-thyroid drugs?
FIRST AND SECOND MC for Radioablation? [ppx/tx?]
Most serious ADR of hydroxychloroquine? What is this used for?
Agranulocytosis (methimazole)
1) !!!!HYPOTHYROIDISM (MC, unpreventable, but tx with T4) [destruction of folliciles]
2) Exace. of ophthalmopathy [ppx w/ corticosteriods before and after]
SLE w/ isolated skin and joint involvement. ADR: RETINOPATHY (eye exam q6months)
What is the “herald patch” and what does it signify?
1) erythematous papules w/ Sandpaper texture
2) rosy telangiectasia over cheeks, nose, chin
3) allergies + umbilicated vesicles on top of healing atopic dermatitis
4) Lichenification vs Lichen Planus, vs Lichen Simplex Chronicus vs Lichen Sclerosis
5) non-comedogenic erythematous pap/pustules in central face
6) another name for suppurative hydradenitis
7) STABLE SIZED pale/yellow papules on the central face
8) more common on LE, **centrally dimples when pinched; nontender and hyperpigmented [path?] tx?
9) more common on upper, **UNCHANGED when pinched; small central keratin plug (dot?) spontaneously resolves and recurs[path?] tx?
10) dry scaly patch, rough skin, horny plates, extensor surfaces, “lizard skin”
Brown/pink/scaly plaque with central clearing; first symptom of ‘pityriasis rosea’
1) actinic keratosis
2) rosacea [PRECIP. BY HEAT, HOT DRINKS, TEMP CHANGE]
3) Exczema Herpeticum tx acyclovir! esp in infants
4) thickening bc of scratching vs hyperkeratosis/HepC (pruritic, purple, polygonal, planar, papules & plaques) vs hyperplasia of vulvar squamous epi (itchy!) vs increased risk SSC vulva “parchment”
5) acne (papulopustular) rosacea
6) acne inversa (hydradenitis suppurativa)
7) sebaceous hyperplasia
8) dermatofibroma [path: fibroblast proliferation]; if symptomatic, bleeding, or evolving, tx cryosurg or shave exision
9) MC cutaneous cyst: epidermal inclusion cyst/epidermoid cyst/epidermal cyst wrong (benign nodule with normal epidermis that produces keratin [path: when epidermis is lodged into dermis due to trauma or comedones] may become inflammed; tx for cosmetic or infxn
10) icthyosis vulgaris
Rheumatology Pharm
moa and ADR
1) Methotrexate
2) Hydroxychloroquine
3) Sulfasalazine
4) Azathioprine
5) cyclosporine
6) Leflunomide
7) anti-TNF (adalimumab, certolizumab, etanercept, golimumab, infliximab)
1) DHFr-ase inhibitor (purine antimetabolite); macrocytic anemia MCV^100 Hg v12; stomatitis, hepatotoxicity
2) TNF and IL-1 suppressor; G6PD def. hemolysis, GI/visual disturbance!!! (retinitis)
3) TNF and IL-1 suppressor; stomatitis, hepatotoxicity, hemolytic anemia
4) bone marrow suppression; pancreatitis
5) predisposes viral infx and lymphoma; nephrotoxic
6) pyrimidine synthesis inhibitor; hepatotoxicity, cytopenia
7) infection, demyelination, CHF, malignancy
Preload: Hypovol vs cardiogenic (myoC cont.)
SVR: The above vs septic
MvO2: The above vs septic
decreased vs increased PRELOAD
increased (hypovol) vs decreased (septic) SVR
decreased (hypovol) vs increased (septic) MvO2
define RTA
RTA 4
RTA 2
RTA 1
Fanconi
a) hypophosphatemia sx
how to tx ATN 2/2 rhabdo
RTA = decreased urinary excretion of H+ leading to ACIDIFICATION of the TUBULES leading to
hypERchloremic NAGMAcidosis w/ ALKALINE URINE!
4) “aldosterone resistance” or deficiency
often seen in DM2!!!*****
2) “proximal” = lack of HCO3 reabsorption = hypERchloremic hypOkalemic NAGMA
(hypokalemia bc more Na delivered to DCT)
[contrast emesis: hypOchloremic hypOkalemic ma]
1) “distal” = hypOkalemia and **inability to generate HCO3 2/2 DCT’s inability to secrete H+
Fanconi: PCT defect. increased secretion of all AA’s phophate, bicarb etc.
a) weakness, rhabdo, paresthesia, resp failure
NS!
EKG changes and MoA :
Class IA, 1B, 1C
2
3
4
Class 1: Na blocker
a) quinidine, procainamide, disopyramide
b) Lidocaine, Mexilitine
c) Flecainide and Propafenone - prolonged QRS (ONLY DURING TOLERANCE)
Class 2: Beta block - increased PR
Class 3: Amiodarone, Ibutilide, Dofetilide, Sotalol - increased QT
Class 4: Calcium blocker - increased PR
Painful, red eye, opacification/ulceration of the cornea assoc. w/ contact use? Organism?
Painful, peripheral and central retinal necrosis on fundoscopy (2)
vs
Painless with fluffy granular lesions around the retinal vessels; not assoc w/ keratitis/conjunctivitis
Contact-lens-assoc. keratitis (medical emergency!)
Pseudomonas
HSV or VZV
CMV
Myocardial contusion vs aortic injury
Aortic inury WIDENED MEDIASTINUM
2 things that can cause a centripetal rash
RMSF, Secondary syphilis
Opportunistic Infections in HIV
(Ppx, Tx?) [risk factors]
CD4 count:
a) -200
b) -150
c) -100 (2) 1alg
d) -50
FC ppx summary
Overall general summary
a) Pneumocystis jirovecii ppx TMP-SMX (+steroids for pulm function IF PAO2 v70 or A-a>35) alternative to TMP: dapsone; [oropharyngeal candidiasis], IV pentamadine if refractory, PO atovaquone, [PO primaquine+clinda]
b) Histoplasma (ppx Itraconazole) [ohio/mississippi river valley]
c) Toxoplasma (ppx TMP-SMX) [pos. Toxo IgG Ab]
TREAT: sulfadiazine, pyrimethamine
candida esophagitis MC (alt HSV, CMV, apthous)
NBS: tx empiric fluconazole
a) if no improvement, do upper endoscopy +biopsy
b) Large ulcer, deep/distal/LINERAR, tx ganciclovir/foscarnet (for CMV)
c) if small, round/OVOID, tx acyclovir (for HSV)
d) MAC (ppx azithromycin, clarithromycin)
FC summary ppx:
At CD4 count
Progression of Alcholic Liver Disease and prognosis with cessation of EtOH
1) Fatty (completely reversible)
2) hepatitis (completely reversible)
3) cirrhosis/fibrosis (completely IRreversible)
Painless blisters, increased dorsal-hand skin fragility, facial hypertrichosis/hyperpigmentation.
What is this seen in (rmm hehe)
vague abdominal pain, neuropsychiatric issues
how do you dx this?
what drug commonly precipitates this? what type of drug is it?
Porphyria cutanea tarda
extrahepatic manif. of Hep C
acute intermittent porphyria
urine porphobilinogen
primidone (MoA: anticonvulsant that converts into phenobarbital and phenylethylmalonamide)
What two things can topical 5FU treat?
Superficial BCC, actinic keratoses
Hiv ppx
a) PPD>5mm
a) Isoniazid + B6 (Pyridoxine) 9 months
***(vs RIPE-2mo+RI-4mo for ACTIVE tb)
Lidocaine benefits/risks
a) asystole
b) Vfib
c) overall prog
d) VPBs
Increases the risk of asystole
Decreases the risk of VPBs, Vfib
Overall prognosis unaffected
a) Intense surgical wound pain, “dishwasher” dcg, paresthesia
b) fever, chest pain, leukocytosis, mediastinal widening, purulent dcg
c) fever, leuk, tachycardia, CP, few weeks s/p surg for congenital heart dz
Dx, NBS
a) Necrotizing surgical site infx; emergent surgical exploration
b) acute mediastinitis s/p cardiac surg; tx debridement + abx
c) autoimmune postpericardiotomy syndrome: tx NSAIDs or steroids
Ddx for pulmonary ID in HIV
a) cavitary lesions (4+1)
b) pneumonia
a)
TB!!!!
Nocardia (gram+, acid fast, filamentous/branching rod)
Gram neg. rods
Anearobes
Coccidiodomycosis (SW US)
invasive Aspergillosis (halo sign on CT!)
b) pneumocystis (PCP)
What is the pathogenic mech. for osteomyelitis in DM foot ulcer
CONTIGUOUS SPREAD
vs direct inoculation in trauma
vs hematogenous in adults
a) Pt 3+ months s/p TKA px with joint infx.
b) px 3- months, acutely?
c) asymmetric polyarthralgias, tenosynovitis, rash
d) asymmetric oligoarthritis, oral ulcers, urethritis, enthesitis (achilles pain), conjunctivitis tx?
MC org in each?
a) 3+ months s/p arthroplasty:
- coag negative staph (epidermidis)
b) v3 months s/p arthroplasty
- staph aureus
c) gonococcal arthritis
d) Reactive Arthritis (2/2 chlamydia, campylobacter, etc.);
NSAIDs
What are the two ways disseminated gonococcal septic arthritis could present?
Tx?
vs RF, px and dx tx for septic arthritis (non-gonoccocal)
a) migratory asymmetric polyarthralgias
tenosynovitis (wrist, ankle fingers, knees)
skin rash/dermatitis/pustules
OR
b) isolated purulent mono/oligoarthritis without derm
[purulent arthritis in sex active = gonococcal UPO]
Tx IV ceftriaxone 1-2wk; switch to PO cefixime when improved
underlying joint dz (RA, OA, prostetic, gout), DM, IA gluc injections, IVDA, +80y
px - acute monoarthritis, hot/edema/vROM, ^ESR/CRP
tx - based on gram stain/blood cultures
a) gram + = vanc
b) gram - = 3rd gen cephalo
c) negative gram stain =
i) immunocompetent = vanc
ii) immonoCOMPROMISD = VANC + 3RD CEPH
THEN: arthroscopic washout (closed drainage) or
arthrotomy (open drainage)
CSF findings and tx in the following:
a) HSV encephalitis
b) Bacterial meningitis
c) Cryptococcal meningitis
d) RMSF
a) LYMPHOCYTIC predominance, elevated protein, nL glucose; tx IV acyclovir
b) NEUTROPHILIC predominance, elevated protein, LOW glucose; tx IV dexamethasone + ceftriaxone + vancomycin (ampicillin in >50y)
c) ELEVATED OPENING PRESSURE, low glucose, elevated protein; tx IV amphotericin (+flucytosine), maintenance w/ fluconazole
d) mimics VIRAL
OSA vs Pickwickian Syndrome (Obesity hypoventilation syndrome)
What are 3 systemic weird px of Pvera
OHS has daytime ABNORMAL BLOOD GASES (aka hypercapnea and hypoxemia during the day)
(persistent underventilation of the lungs… chronically high PaCO2, low PaO2……)
(LATER, BOTH can have polycythemia, pHTN, RVfail)
[therefore OHS often have concomitant OSA]
1) gouty arthritis (^cell turnover) 2) PUD (^histamine from basophils) 3) HTN (hypervolemia)
Fungus
- risk/location
- path
- px
- imaging
- dx
- tx
a) Histoplasmosis
- SE/mid-atlantic/central US
- acute pneumonia
- cough fever malaise
- hilar LAD
- histoplasma serum or urine Ab
- ITRACONAZOLE
b) Aspergillosis
- IC, chemo, glucocorticoids
- invasive pulmonary dz
- fever, cough, dyspnea,
- CXR - cavitary
- CT- halo/moon sign (air crescent)
c) Coccidiomycosis
- SW US/ valley (california/AZ)
- primary pulm + secondary cutaneous/arthralgia
- norm. pleuritic CP
- …
d) Sporotrichosis
- dimorphic mold (hyphae)
- SQ infx, reddish nodule/papule, ulceration. lymphatic
e) BLAgStomycoses (“bone, lung, and genitals/skin”)
- south, MIss/OH riv. valleys, midwest/great lakes
- pneumonia
- wartlike violaceous nodules
- osteomyelitis
- prostatitis, ortchitis
- dx culture/microscopy, antigen
- tx oral itraconazole; IV ompho if severe/i/c
Two etiologies of Primary Hyperaldosteronism (MC cause of secondary HTN)
tx?
a) UL adenoma - surgery
b) BL hyperplasia - aldosterone antagonists (spironolactone)
What medication to avoid in Restrictive Lung Disease? What other side effects does this drug have
Obstructive?
Amiodarone (sinus brady, heart block, HEPATITIS, corneal deposits, blue gray skin discoloration, peripheral neuropathy)
Beta-blockers
Elderly patient with bone ANEMIA, bone pain, RF, and hypercalcemia.
NBS in mgus to exclude MM?
Multiple Myeloma UPO
Metastatic skeletal bone survey
Coverage:
1) Amoxicillin
1) gram neg. “HELPS” H. Flu, E. Coli, Listeria, Proteus, Salmonella
Widended pulse pressure, strong peripheral arterial pulsation (brisk carotid upstroke), systolic flow murmur, tachycardia, flushed extremities (one warmer than the other).
Phys?
AV-fistula (high output CF)
Increased preload, increased CO, decreased SVR
Symmetric small inflammatory arthritis resolving within 2 months (+/- ANA, RF)
Viral ARthritis, (parvoB19, hepB/C, HIV, rubella)
tx nsaids
anorexia, weakness, Diarrhea, nausea, fatigue + (arrhythmia MC to digitalis)
Hypoglycemia, wheezing, hypotension, bradycardia, shock/seizures/delirium
txs to lower serum potassium (besides kayaxelate and “CaGluconate”. What weird abx
Status asthmaticus, receives inhaled beta-agonists, what side effects to worry about?
Think Digoxin tox. [color alterations lol]; tx Dig Fab
ATRIAL TACHYCARDIA W/ AV BLOCK
mech: increased ectopy and vagal tone
Beta blocker overdose; tx 1) IVF + atropine 2) GLUCAGON
Beta agonist (albuterol), insulin+glucose, Moderate w/out EKG changes- loop+IVF Symptomatic or K^ 6.5 - hemodialysis
hyPOkalemia (muscle weakness, cramps, arrhythmia, tremor, palp/headache) vs hypER (muscle weakness, flacid paralysis, asystole)
3 Ddx for immediate postop fever
What is postoperative cholestasis? 3pathophys?
Prior infx, FEBRILE HEMOLYTIC TXFUSION RXN, malig hyperthermia
Benign condition ~2-3 days s/p a PROCEDURE W/ HYPOTENSION AND MASSIVE TRANSFUSION in which cholestasis occurs by
a) hypotension leading to decreased hepatic fxn
b) increased bilirubin load from transfusion
c) decreased bilirubin clearance by kidneys 2/2 tubular necrosis
Prolonged tachyarrythmia/RVR + LVSD . Tx?
dist?
Tachycardia-mediated cardiomyopathy (reversible)
tx agressive rate control (restoration of NSR?)
vs CHF which is more irreversible
What vaccines do you give to splenectomy patient and when (4)?
Pathophys of why?
How long does the sepsis risk last s/p splenectomy?
***EITHER 2 WEEKS BEFORE OR 2 WEEKS AFTER
1) PCV13 + meningococcal + Hib
2) PPSV23 [8 WEEKS LATER]
impaired PHAGOCYTOSIS against encapsulated organisms. Ab won’t really work till 2 weeks later
30+ y to life
Leukemia/Lymphoma
a) Lymphocytes with fine, irregular cytoplasmic projections that yield a strong acid phosphatase rxn upon stain with tartaric acid (TRAP+). another name for this? TREATMENT?!
b) MC leukemia in west dx? What indicates the worst prognosis?
c) splenomegaly, neutrophilic leukocytosis (left shift), BASOPHILIA, and low leukocyte alk-phos, no LAD
d) Non-Hodgkin’s Lymphoma tx
e) increased blasts, young patient
f) Which is treated by ATRA
g) Which is tx by imatinib
a) Leukemic Reticuloendotheliosis [Hairy Cell Leukemia] (CD11c)
tx - purine analogs {aka adenosine deaminase} inhibiors [cladribine (2-chlorodeoxyadenosine), pentostatin}
b) Chronic Lymphocytic Leukemia (CLL); smudge cells, mature small lymphocytes predominant; thrombocytopenia=poorest prog; “leukemia of old age”
c) Chromic Myeloid Leukemia (CML); [9,22] [bcr, abl] [philly]
abnL tyrosine kinase activity
d) CHOP
e) ALL
f) APromyelocyticL (a subtype of AMyeloidL)
g) CML (tyrosine kinase inhibitor)
Path of MM and consequence.
Classic tetrad of of MM
What are the symptoms of hypOOOOOOOcalcemia. Causes?
Mg and reflex relative to calcemia?
Malignant monoclonal prolif of plasma cells
Increased risk for infxn 2/2 decrease in fnxnL Ab’s
CRAB (hyperCalcemia, renal impairment, anemia, bone lysis)
bone lysis = back pain!?
HypERRRreflexia, CRAMPS, convulsions rarely, periooral tingling?
Caused by increased albumin-binding and BLOOD TRANSFUSION (citrate)
vs “immobilization hypercalcemia”
Follows Ca++
Acute occipital headache, gait ataxia/vertigo, repeated vomiting in hypertensive patient. Dx? Tx?
Cerebellar hemorrhage, evacuative craniotomy
[can present with blepharospasm, 6th nerve palsy, conjugate deviation, and coma in severe cases]
(FEVER IS COMMON IN ANY BRAIN HEMORRHAGE!)
What structures are commonly affected in the following injuries?
a) Anterior shoulder dislocation nerve injury?
b) Radial head fracture/dislocation?
c) Surgical Neck of the humerus?
d) Midshaft humeral fracture?
e) Medial epicondyle of humerus fracture?
f) Saturday Night Palsy? Crutch injury?
g) Dorsal wrist laceration/compression?
h) Supracondylar humeral fracture?
a) Axillary
b) Radial (preserved triceps, but) only weakened extension of digits
c) Axillary
d) Radial (but triceps preservation! wrist drop tho)
e) Ulnar
f) Radial
g) Radial (but no motor deficits since radial n. doesn’t innervate any muscles in the hand. Only sensory loss here)
h) BRACHIAL ARTERY and Median n.
explain the following [a,c,e are the dopamine antagonistic effects of antipyschotics]:
a) decreased dopamine activity in MESOLIMBIC pathway
b) increased dopamine activity in MESOLIMBIC pathway
c) decreased dopamine activity in NIGROSTRIATAL pathway
d) increased dopamine activity in NIGROSTRIATAL pathway
e) decreased dopamine activity in TUBEROINFUNDIBULAR pathway
f) increased dopamine activity in TUBEROINFUNDIBULAR pathway
What regulatory mechanism can happen when taking fluphenazine, for instance.
a) this is what makes antipsychotics efficacious
b) delusions/hallucinations in schizophrenia; euphoria from drug use
c) extrapyramidal side effects from antipsychotics: acute dystonia, akathisia, parkinsonism
d) chorea, tics
e) hyperprolactinemia: amenorrhea, galactorrhea, sexual dysfunction, gynecomastia
f) hypOprolactinemia
Shivering 2/2 hypothermia (thermoregulatory dysruption)
Meningeal signs, Sudden vasomotor crash, flank petechiae, death. Dx?
Waterhouse-Frederichson in the setting of meningococcemia, leading to adrenal hemorrhage which leads to death
HSP px, 2 most common complications, tx
Typically abdominal pain, palpable purpura (with normal coag panels), hematuria, arthralgia, scrotal pain/edema
Intussusseption (due to bowel wall edema and localized hemorrhage, typically small bowel ileo-ileal vs usually ileo-colic, therefore may not be seen on enema) and GI bleed
Tx pain control, corticosteroids if severe
Contraindications to rotavirus vaccine? What is a known small complication of rotavirus vaccine?
What are the live vaccines and when are they contraindicated?
Risk of intussusseption, therefore if patient has hx of intussuseption then don’t administer vaccine. Other regular contra. are allergies to ingredients, SCID, etc.
MMR, varicella, zoster, live-attenuated influenza, c/i when
CD4v200
Manifestations of lyme disease
1) early localized: erythema migrans (targetoid rash), malaise
2) early disseminated:
a) carditis: AV block, cardiomyopathy
b) neuro: facial nerve palsy, meningitis, encephalopathy, conjunctivitis
c) MSK: migratory polyarthralgia
d) skin: multiple erythema migrans, generalized LAD
3) Late/chronic: arthritis, encephalomyelitis, peripheral neuropathy
Reactive arthritis vs Lyme Arthritis
Reactive: acute, asymmetric oligoarthritis, 1-4 weeks following urethritis or diarrhea
Lyme: happens in the setting of untreated localized disease; history of recent travel to the northeastern/upper midwestern states; monoarticular/oligoarticular arthritis (knee) following several months of migratory polyarthralgia;
NBS: ELISA and Western Blot, tx. Amoxicillin if there’s no other Lyme stuff going on. Otherwise Ceftriaxone?
Painless antepartum hemorrhage with fetal decline (sinusoidal tracing or bradycardia) shortly after rupture of membranes; materal vitals preserved.
Dx?
Ddx of antepartum bleeding
Vasa previa (maternal vitals preserved bc it’s fetal bleeding)
a) Normal labor - bloody show, small amount of bleeding
b) Placental abruption - abdominal pain, HYPERTONIC/tender uterus; YOU DON’T NEED BLEEDING TO MAKE THIS DIAGNOSIS!
c) Uterine rupture - abdominal pain, palpable fetal parts, CESSATION OF UTERINE CONTRACTIONS
d) Placenta previa - painless, low lying placenta
e) Vasa previa - PAINLESS; if ruptured, baby dies
previas=painless
ption/pture=painful
Gestational HTN vs Chronic HTN
Severe Preeclampsia. Tx?
Gestational: new onset >20 weeks 140+/90+
Cr of 1.1 or doubling of Cr, bp 160/110 or more, transaminitis, thrombocytopenia, cerebral/visual signs, pulmonary edema
STABILIZE, then DELIVER!
With labs; treatment, distinguish:
HELLP
Intrahepatic Cholestasis of Pregnancy
Acute Fatty Liver of Pregnancy
HELLP - hemolysis, proteinuria, increased LDH; delivery w/mag to prevent convulsions
ICoP - NORMAL PT/PTT; ursodeoxycholic acid
AFLP - increased PT/PTT, increased creatinine/uric acid, hypoglycemia; delivery
Patient with Grave’s Disease has a baby and the baby is low birth weight, tachycardic, irritable.
Dx?
Path?
Tx?
- Neonatal thyrotoxicosis
- anti-TSH receptor antibodies cross placenta and trigger hyperthyroid symptoms
- methimazole and beta-blockade (atenolol?)
Px of RUPTURED ectopic pregnancy?
Px of of Molar preg
Distinguish ectopic pregnancy from molar pregnancy
Cervical/adnexal tenderness, orthostasis/hemodynamic instability, diffuse abdominal pain
vs
high hcg, hyperemesis gravidarum, theca leutein cysts, MASS/ENLARGED UTERUS
ECTOPIC DOESN’T HAVE A MASS
Postpartum woman, pulmonary symptoms, multiple nodules on CXR.
Dx?
Best confirmatory test?
Choriocarcinoma
b-HCG
What is the triad of gestational trophoblastic disease in general. Examples of GTD?
vaginal bleeding, enlarged uterus, pelvic pain
choriocarcinoma
Ddx of vaginitis (3)
a) causative agent
b) discharge
c) inflammation?
d) labs, pH, etc.
e) treatment
1) Trichomoniasis
2) Bacterial Vaginosis
3) Candida Vulvovaginitis
1) [can also cause strawberry cervix]
a) trichomonas vaginalis
b) THIN, yellow-green, frothy, malodorous
c) motile trichomonads, pH>4.5
d) inflammation
e) metronidazole, treat partner
2)
a) gardnerella vaginalis
b) THIN, whitish, fishy, malodorous
c) clue cells, + whiff test (amine odor on KOH), pH>4.5
d) NO inflammation
e) metronidazole
3)
a) candida albicans
b) THICK “cottage cheese”
c) pseudohyphae, normal pH (3.8-4.2)
d) inflammation
e) fluconazole
a) 3 Emergency contraception and MOA
b) Medical abortifacient regimen
c) preferred contraception for lactating mothers. why?
PO Ulipristal (anti progestin, delay ovulation) PO Levonorgestrel (progestin, delay ovulation) copper IUD (inflammatory rxn hostile to ova and sperm)
Mifepristone + misoprostol
progestin-only pills. no VTE risk and no estrogen to pass into milk or affect milk quality.
What is the only absolute contraindication to breastfeeding?
What are other contraindications to breastfeeding?
GALASCTOSEMIA
active substance/alcohol abuse, active TB, HIV
Hep B and C NOT considered contraindications, neither is mastitis
Causes of elevated maternal AFP?
Decreased?
a) elevated:
- multiple gestation (look for improper fundal height for age)
- congenital nephrosis/obstructive uropathy
- ventral wall defects (gastroschisis, omphalocele)
- open NTDs (open spina bifida, anencephaly)
b) decreased:
- aneuploides (trisomy 18, 21)
MENORRHAGIA
Heavy feeling in the abdomen, chronic constipation, urinary frequency, pelvic mass
dx?
ddx? and define and tx?
Fibroid (uterine leiomyoma)
[mass can compress colon and bladder leading to those symptoms]
- enlarged uterus
- clots
adenomyosis - dysmenorrhea/menorrhagia, but wouldn’t have bowel and urinary symptoms, wouldn’t have a mass. boggy on exam
- typically >40 years, MULTIPAROUS
- enlarged, globular, boggy uterus (glandular hyperplasia)
vs
endometriosis - dysmenorrhea/menorrhagia, but wouldn’t have bowel and urinary symptoms, wouldn’t have a mass. laparoscopy for dx
- typically younger, NULLIPAROUS
- normal sized uterus (no glands, it’s outside the uterus)
- dyschezia, dyspareiunia, infertility! (inflamm/adhesion, etc.)
-RF: early menarchy, outflow obstruction
Tx -
1) nsaids +/- combined OCP
2) laparoscopy to confirm (dx and tx)
endometritis
-foul smelling s/p instrumetnation/abortion, FEVER
TX - clinda + gent [POLYMICROBIAL]
vs
endometrial CA/hyperplasia
- hx of obesity, nulliparity
- small uterus, NON-tender
- irregular bleeding
1) Complications of cryptorchidism and how to avoid this?
2) Indications for surgery in hydrocoele?
Hydrocele (dx + NBS)
Varicocele (dx + NBS)
1)
(prevented by bilateral orchiopexy)
Testicular torsion (affixed to wall in orchiopexy), subfertility (better w/pexy), and malignancy (lower risk w/ pexy)
2) persitent beyond 1 yr
3)
Cryptorchid testes, [absent uterus], absent upper vagina, breasts (androgens converted to estrogens),
vs
normal ovaries, [absent uterus], absent upper vagina, external genitalia normal
transillumination? yes; resolves spontaneously by 1 year, surgery if unresolved by that time
transillumination? no; resolves spontaneously, surgery if a) bilateral, decreased sperm count, or painful
NBS in isolated thrombocytopenia!
PREDNISONE FIRST!
Unable to relax grip, balding
Myotonic Dystrophy
CSF analysis
Neutrophil HAS to be bacterial
Viral usually NO ^protein
Lymphocytes could be viral, TB, cryptococcal, lyme, or ricketts
Cryptococcal in IVDA/AIDS
Antibodies:
1) anti-mitochondrial
2) anti-smooth muscle, anti LKM
3) anti-Jo 1 (antisynthetase), andti-Mi-2 (antihelicase)
4) ANA, dsDNA
5) ASO
6) Ro/SSA; La/SSB
7) topoisomerase-I
1) PBC
2) AUTOIMMUNE hepatitis
3) dermatomyositis
4) SLE (sens; specific)
5) acute rheumatic fever/recent strep infxn (migratory polyarthritis, pancarditis, syndenham, erythema marginatum, SQ nodules); usually LE, migratory arthritis
- affects Mitral Valve (can be stenosis or regurg, ^CRP and prolonged PR. ppx PCN for GAS)
6) Sjogren
7) Scleroderma
Endocarditis causative agents:
a) nosocomial UTI
b) Prosthetic/pacemakers/vasc. cath; IVDA
c) IBD/colon CA
d) Immunocompromised, prolonged abx, indwelling cath
e) dental, respiratory biopsy/I and D…
sentence
tx
a) Enterococcus faecalis
b) Staph (MC) epidermidis (coag neg); aureus
c) Strep bovis (gallolyticus)
d) fungi
e)
i) viridans (STREP sanguinis, mitis, oralis, MUTANS, sobrinus, milleri) [ tx IV penicillin G -or- ceftriaxone ]
Staph - MC HAIE
Strep - MC CAIE
a)
b) empiric IV vanc; can switch to oxacillin if clx show MSSA
c)
d)
e) Penicillin G (aqueous)
- (amp-sulbactam for Hacek?)
Two possible causes for macrocytic anemia in Sickle Cell?
Others?
1) Folate def. (increased RBC turnover)
2) Hydroxyurea use
hypothyroidism, liver dz, myelodysplastic, AML, zidovudine, chemotherapy
alcohol, B12
Shoulder Pain ddx:
Adhesive Capsulitis (“frozen shoulder”) vs Biceps Tendinopathy vs Rotator Cuff Tendinopathy (tests?) vs Glenohumeral OA vs subacromial bursitis
a) ROM
b) pain
c) weakness
decreased PASSIVE AND active ROM; stiffness>pain
vs
ANTERIOR shoulder pain (lifting, carrying, overhead reach); weakness uncommon
vs
NORMAL ROM; pain w/ abduction, ext rotation, subacromial tenderness; Neer/Hawkins test
vs
Decreased passive AND act. ROM and ext. rotation; trauma
vs
PAIN with active ROM and passive I-rot and forward-flex; caused by repetitive overhead motions
What do the following EKG changes signify
a) prolonged PR interval
b) F waves
c) electrical alternans
d) delta waves
e) new onset RBBB
f) 2 P’s before each QRS
g) increasing PR, decreasing RR, constant PP; dropped QRS
a) FIRST degree heart block, benign
b) a-flutter
c) QRS varies from beat to beat - pericardial effusion (+JVP, muffled heart sounds, and hypotension)
d) WPW
e) acute right heart strain (PE)
f) SECOND degree AV block 2:1 Mobitz 2
g) SECOND degree mobitz 1
Anemia of Chronic KIDNEY!!!!!! DISEASE
2) regular anemia of chronic dz
a) morphology
b) Tx
c) important complication and strat to avoid
a) microcytic hypochromic
b) EPO
c) iron def. bc of rapidly depleted stores
2) tx underlying (ex. methotrexate if RA)
Kid has low CD19 cell count but normal CD3. Dx? Tx for maintenance therapy?
Bruton’s X linked (bc low B cells and normal T cells).
Tx. IVIg
Prodrome of measles
Measles vs Roseola px
Measles vs Rubella
vs RMSF
Cough, Coryza, Conjunctivitis, Koplik spots
Tx - Vit A!!!
In measles the rash appears when the fever peaks, in roseola (HHV-6) the rash appears as the fever resolves
Similar but Rubella is milder and sorter, no oral koplik spots in Rubella. . Both cephalocaudal. Measles “darkens” but rubella doesn’t.
RMSF = centripetal spread (hands to in)
Vitamin Def.:
Zinc A B1 B2 B3 B5 B6 B9 B12 C D E K
Zinc - RF: TPN; alopecia, skin lesions, abN taste, impaired wound healing
Selenium - RF: TPN; CARDIOMYOPATHY
A - poor night vision, hypoparathyroidism, dry skin, impaired immunity
B1 (thiamine) - beriberi, wernicke’s
B2 (riboflavin) - angular chelosis, stomatitis, glossitis
B3 (niacin) - diarrhea, dermatitis, dementia, death
B5 (pantothenoate) - burning feet
B6 (pyridoxine) - peripheral neuropathy
B9 (FOLATE) - megaloblastic anemia/HSMneutrophils
B12 (cyanocobalamin) - “folate” + dorsal column signs
C - SCURVY (ecchymoses, bleeding gums, petechiae)
D - rickets, osteomalacia
E - peripheral neuropathy, hemolytic anemia (without MMA)
K - INCREASED PT/INR; “giving warfarin”
Carpal Tunnel Findings
Proximal vs Distal lesions of the median nerve?
THENAR ATROPHY
PARESTHESIA IN FIRST 3.5 DIGITS
THENAR and MIDPALM SENSATION INTACT
distal lesions (carpal tunnel, lunate dislocation)
vs proximal lesions (aka supracondylar humeral fracture) where thenar and midpalm sensation compromised (branch given off beforehand)
ACLS (no pulse aka cardiac arrest)
Vfib or pulseless Vtach tx? (3)
a) PEA/Asystole
- definition
1) DEFIB (shock) first
2) 1mg Epi q3min + CPR q2min
3) repeat defib + amiodarone
a) NO SHOCK but same-ish algorithm as above. def of PEA: organized rhythm on monitor but no pulse
Approach to Acute Lower Back Pain.
What are the Red Flags (~12)?
Red Flags: > 1 month, night, >50y, constant/dull/unremitting/unrelieved by rest/NOT exacerbated by movement, constitutional signs, hx of malig, IVDA, infx risk, trauma
1) If no red flags, conservative 4-6 wk
2) If RED flags, ESR+plain films
a) if abN, MRI (vertebral osteomyelitis will px w/ nL xray and ^ESR)
3) If cord compression signs, MRI
HIV (immunocompromised) neurology:
a) papilledema, fever, headache
b) CD4
c)
d) NON-RING-ENHANCING
e) RING-enhancing
a) cryptococcal meningoencephalitis
b) CMV
c) HSV-1 encephalitis
d) PML (JC polyoma virus)
e)
1) toxoplasma gondii (Toxo serology not necessarily specific in the US)
2) Primary CNS Lymphoma (esp. with + EBV DNA in CSF)
a) egg shell calcifications of hepatic cyst on CT
-cause!?
tx!?
b) cysts in the brain or liver
-cause!?
c) bloody diarrhea + liver signs (fever + RUQ pain)
-cause, tx?
a) HYDATID cyst 2/2 echinococcus granulosus
- SHEEP/dogs
- albendazole+aspiration
b) cysticercosis 2/2 taenia solium
- PIGS
c) amoebic liver abscess
- entamoeba histolytica; tx METRONIDAZOLE! (+paromycin for intraluminal coverage)
Leprosy
px
epid
dx
insensate, hypopigmented patch of skin
asian
acid-fast bacilli (mycobacterium leprae) on skin BIOPSY
Mixed Essential Cryoglobulinemia vs HSP
both have palpable purpura!
Cryo - assoc/ hep C and LOW complement
HSP - normal complement
Immunologic Blood Transfusion rxns
a) timing
b) path
c) sx
1) Febrile Nonhemolytic (MC)
2) acute hemolytic
3) delayed hemolytic
4) anaphylactic
5) urticarial/allergic
6) acute lung injury
1)
a) 1-6 hrs
b) cytokine accumulation during blood storage
c) fever, chills
2)
a) within 1 hr
b) ABO incompatibility ; + direct coomb’s
c) fever, flank pain, RF/DIC
3) 2-10 days; anamnestic Ab response/+D-coomb’s; fever
4) seconds; anti-IgA; shock, angioedema, resp distress
5) 2-3 hrs; angi-IgE + mast; flushing, pruitis
6) 6 hours; donor anti-leukocyte Ab; resp distress
Polymyalgia Rheumatica vs Fibromyalgia
sx
lab
tx
STIFFNESS, vROM in shoulders/neck/hips
VS
point tenderness and NORMAL physical exam
+/- decreased hematocrit; ESR!^ VS NORMAL
glucocorticoid taper
VS
exercise, sleep hygiene, stress reduction + TCAs, levomilnacipran/duloxetine [SNRI], pregabalin
EKG
a) inferior wall infarct, (vessels?)
b) STEMI affecting right-heart
c) pathophys of above phenomenon
d) POSTERIOR wall MI (B)
e) anterior
a) inferior leads (2, 3, avF) ST-elevation (RCA, LCX)
b) left-most leads (1, avL) ST-depression RCA (or elevation if LCX)
- right sided EKG to confirm RV infarct
c) RV involvement is common in inferior infarcts, leading to RVF (JVD, kussmauls increase of JVD with inspiration, and clear lung fields) leading to marked hypotension
d) V1-V3 ST- DEPRESSION
1 & avL ST-ELEVATION if (LCX)
1 & avL ST-DEPRESSION if (RCA)
e) V1-V6 (LAD)
What 4 other things do you need to screen for if you’re tx gonorrhea/chlamydia PID
1) syphilis (RPR)
2) cervical cancer (PAP)
3) Hepatitis B (HBsAg)
4) HIV
+HepC if IVDU
management of PNH?
1) Folate + Iron supp
2) ECULIZUMAB + N. MENINGITIDIS (bc eculizumab inhibits MAC formation)
Orthopedic Injuries
a) cause?
b) complications
1) Supracondylar Humeral Fracture
- “3” complications
1)
a) FOOSH
b)
i) brachial artery + median nerve (MC!)
ii) cubitus varus deformity (NOT limb length discrepancy!)
ii) compartment syndrome + volkmann contracture
Limb length discrepancy more common in more proximal humeral fractures
What is bacillary angiomatosis?
RF?
Dx
Cat Scratch nbs?
Immunosuppresed; caused by bartonella henselae/quintana
angioma-like blood vessel growths; large pedunculated exophytic papules with collarette of scale; resembles pyogenic GRANULOMA (benign vascular red papular tumor, pedunculated, bleeds) or cherry angioma. [resembles Kaposi!]
dx biopsy; tx abx
cat scratch tx azithromycin (Ab test or +warthin starry-stain to confirm)
High alk phos, constitutional, splenomegaly?
dx tx, mAT
Disseminated MAC w/ hepatosplenic involvement
CD4
azithromycin ppx
azithromycin or clarithromycin tx
most accurate test = NAA (nucleic acid amplification)
Microcytic/Hypochromic anemia simulating iron-def but iron studies show ^serum iron and -TIBC
dx
tx
Sideroblastic Anemia
pyridoxine
What are the recommended vaccines for adults (age 19+)? (3)
HIV?
Chronic Liver Disease
1) Influenza yearly
2) one Tdap then Td (booster) q10y
3) Pneumococcus
a) +65y: PCV13 + PPSV23 6-12 months after
b) -65y w/ high-risk: PCV13 +PPSV23 8 wks after, then q5y
c) -65y w/ med-risk: PPSV23 only
“medium risk” = smoker, EtOH, DM, chronic heart/lung/liver disease, nursing home
“high risk” = Sickle cell, asplenic, immunocompromised, cochlear implant, CSF leak
If HIV+:
1, 2, 3b
+ HepA Vaccine (gay sex, HepB+, HepC+, IVDU)
+ HepB Vaccine
+ HPV (9-26y)
+ meningococcus (11-18y, closed quarters, asplenic/complement deficiency)
LIVE (attenuated?) VACCINES CONTRAINDICATED IF CD4 v200
MMR, rotavirus, varicella, zoster, nasal flu, yellow fever,
If Chronic Liver Dz:
1, 2, 3b
+ HepA Vaccine
+ HepB Vaccine
What are the STD screening recommendations.
Confirmatory tests?
1) HIV
a) Age 15-65 (v65): one time *HIV p24 + antibody testing* if +, HIV-1/2 Ab immunoassay the "d-dimer" (if - but ^ios) HIV RNA (additionally pregnancy, MSM, unprotected sex, co-STD)
b) IVDU, MSM, homeless shelter, jail, partner of HIV+:
annual
2) Syphilis
a) No routine screening for syphilis. Only pregnant 1st prenatal visit, co-STD, MSM, whore, jail.
3) Gonorrhea
a) No routine screening gonorrhea in men (it’ll be symptomatic and obvious).
b) Screen sexually active women who are v25y, no condoms, multiple partners, co-STD, pregnancy
c) MSM at extra-genital sites
4) HepB! if high risk (unprotected or MSM)
5) HepC! (if transfusions before 1992 or baby boom?)
Cor Pulmonale vs Constrictive pericarditis
a) causes
b) clinical signs
c) imaging
a) COPD, PE [hypoxic vacoconstriction in lung-> PULMNONARY ARTERY HTN> 25 -> right ventricular hyperrophy]
vs TB (asia/africa), viral, RADIATION!, cardiac surg
AKA Hodgkin’s!
b) Loud, split P2; pulmonary HTN
vs (kussmaul [paradox INCLINE in CVP w/ insp], ascites/pedal edema), pericardial knock (early diastolic heart sound after S2), sharp x and y descents
constrictive = CALCIF RING AROUND HEART (pericardium)!
c) you see calcifications! confirm dx
Febrile/chills, w/ sudden onset of SHARPLY demarcated, erythematous, edematous, tender skin lesions with RAISED borders. FIREY RED
(What if it’s POORLY demarcated)
Dx?
Cause?
MC location?
purulent cellulitis subtypes (3) and def. and mc causative agent
Erysipelas [type of cellulitis that involves the superficial dermis]
vs (cellulitis, not raised)
Group A beta-hemolytic strep pyogenes
vs (beta-hemolytic strep, Staph Aureus)
Legs. (…)
Purulent Cellulitis (staph aureus!):
a) folliculitis
b) furuncles (boils) - folliculitis into dermis leading to abscess
c) carbuncles - multiple furunlces aggregated
Survival/prognosis/mortality
a) STEMI long-term prognosis
- strongest influence?
- ideal
b) COPD mortality reduction
c) CHF mortality reduction
d) Sudden Cardiac Arrest
a) “time to restoration of coronary perfusion” via
i) PTCA (-90 min ideal)
ii) fibrinolysis (-30 min ideal)
b) smoking cessation, oxygen
c) spironolactone, ACEi …
d) time to effective resuscitation
- bystander CPR
- rhythm analysis
- defibrillation
What is a complication that may arise in dehydrated post op patients? Path? Px? Tx?
Acute Bacterial Parotitis
staph aureus MC
painful chewing, erythematous parotid gland expulsing purulent saliva
adequate hydration and oral hygiene both pre and post op
EPIDEMIOLOGY
a) adrenal insufficiency?
a) DEVELOPING COUNTRIES: TB (look for CALCIFICATION)
DEVELOPED: autoimmune
Approach to Meningitis (bacterial for now)
- Algorithm
- Empiric Regimen
1) ^ICP? (immunosuppressed, FND, papilledema, AMS)
a) YES
b) NO
2)
a) BLOOD CULTURES, empiric, CT-head, LP
b) BLOOD CLX+LP, empiric
3) alter therapy based on LP if appropriate
dexamethasone + (3rd ceph + vanc) 1 month - 50y
dexamethasone + (3rd ceph + vanc + Amp) 50+y
–
(4th ceph + vanc) skull penetration/NS/shunt
(4th ceph + vanc+ Amp) im/comp
(amp+cefotaxime/AMG) v1 month
Notes:
amp covers listeria (alt: TMP-SMX)
steroids for when there’s pneumo, d/c if no pneumo
meropenem or ceftazidime can replace cefepime
Indications for Carotid Endarterectomy (2)
Statins?
Aspirin 81
1) ALL symptomatic 70+% stenosis
2) MEN asymptomatic 60+% stenosis
1) Clinically significant atherosclerotic dz (CAD, CVD, PAD)
2) LDL>190 (high intensity)
3) ANYONE age 40-75 w/ DM
- note, you don’t always give ACEi; pressure has to be 140/90 or higher
4) ASCVD>9%
1) >50y
Foot Injuries
a) Stress Fracture tx?
b) Plantar Fasciitis
c) Achilles Tendinopathy
d) Morton Neuroma
e) Tarsal Tunnel Syndrome
a) Insidious; focal pain in navicular or metatarsals; RF: abrupt increase in training, poor running mechanics, female with eating dz;
- tx rest and analgesia
b) Worse when initiating running or first steps of the day
c) Burning pain/stiffness
d) Common digital nervitis: Numbness/pain between 3rd/4th toes; **clicking sensation when palpating space between 3rd/4th toe while squeezing metatarsal joints. (wearing heels?)
e) Compression of tibial n. at ankle; burning/numbness/aching of distal plantar surface of foot/toes
Diarrhea
a) MC febrile, bloody; what caution!?
b) ddx for LONG TERM (+2wk) traveller’s diarrhea
c) ddx for SHORT term (-2wk) traveller’s diarrhea
d) asia, africa, centra/south america, ab pain bloody diarrhea
a) E Coli; avoid empiric abx bc precip HUS
b) (nonbloody, watery)
1) cryptosporidium parvum
2) cystisospora
3) microsporidia
4) cyclospora
5) GIARDIA
c)
1) rotavirus/norovirus (brief, vomiting)
2) ETEC, EPEC (contaminated food/water)
3) Campylobacter (abdominal pain PSEUDOAPPY, bloody)
4) Salmonella (fever)
5) Shigella (bloody, ab pain)
d) entamoeba histolytica
Diuretics
[prostaglandins normally vasodilate]
1) loop diuretics potentiate PGs! Therefore NSAIDs can cancel this therapeutic effect!
2)
a) ATP-dep K+ channel opening, which leads to vasodilation
b) thiazides are ATP-dependent K+ channel OPENING (like diazoxide/minoxidil), which decreases insulin release from the pancreas [contrast sulfonylureas which BLOCK K+ channels] (c/i in diabetes?)
c) LOOPs and thiazides decrease urate excretion by increasing net urate reabsorption (by either increased reabsorption directly, or decreased secretion back into the lumen)
1) Natriuresis! (except with osmotic diuretics)
2) Look for Kaliuresis (if you don’t see this, it’s an Aldosterone antagonist)
3) Look for Bicarbonaturesis (if you see this, it’s CAi/acetazolamide)
4) Look for Calciuresis (if you see this, it’s Loop)
1) Acetazolamide (but paradoxical hypOkalemia) and Aldosterone Blockers cause ACIDOSIS
LOOPs and Thiazides cause ALKALOSIS
dx, TREATMENT!?!?!?
Slowly growing, nontender mandibular indurated mass with yellow granular pus s/p dental, poor oral hygeine, malnutrition, DM, or i/s
Purulent crusting lesions/ulcers s/p traumatic inoculation (“puncture wound while gardening”)
Cervicofacial Actinomycosis (yellow “sulfur granules)
actiNo aNaerobe, gram + an
tx Penicillin
Nocardiosis
noCAERdiosis, AERobic, gram+ (*partially acid fast)
tx TMP-SMX
px - TB-like, pulm nodules, pneumonia-like; CNS!
1 ) PERIorbital edema, myositis, eosinophilia/CPK; w/ fever, subungual splinter hemorrhages, and conjunctival/retinal hemorrhages?
2) Nonproductive cough then intestinal signs
3) RETRO-orbital pain, fever/h-a, rash, myalgia/arthralgia
4) POLYARTHRALGIA, LYMPHO/THROMBOCYTOPENIA fever/h-a, myalgia, conjunctivitis
5) tropical, Skin, Pulm, GI (NO DIARRHEA)
what do 3 and 4 share in common
1) Trichinellosis - roundworm/pork
a) intestinal stage (sp 1 week of ingestion)
b) muscle stage (sp 4 weeks of ingestion) - eosinophilia, CK
2) Ascaris Lumbricoides
a) pulm phase
b) intestinal phase
3) dengue fever
4) chikungunya
5) strongyloides stercoralis
both caused by AEDES mosquito
Shift work vs Delayed sleep-phase
!!!
?
“not your fault”
vs “YOUR fault”
desire/work schedule incongruent w/ internal clock
vs
internal clock incongruent w/ desire/work schedule
sleep problems after beginning night shift
vs
night-shift worker rollin’ along just fine (which isn’t normal, societally) until all of a sudden required to work day shift and gets fucked, BUT CAN SLEEP IN ON THE WEEKENDS
*** delayed sleep-phase = “night owl” common in teenagers
TOXICITY and POISONING
NBS in the following overdoses? MoA?
1) TCA.
- Overall tox?
- What EKG changes do you see and what electrolyte abN does this resemble; what NOT to give
2) Aspirin - what acid base disturbance
3) Acetaminophen
- what else is this antidote used for
4) Organophosphates
5) Hyperkalemia
6) Torsadde’s w/ prolonged QT
7) Caustic (oven cleaner, draino, KOH, lye)
8) isopropyl vs ethanol vs methanol vs elthylene glycol
1) general: NaHCO3, IVF, charcoal, supp 02/intubation
- CNS (coma, convulsion, sedation), anticholinergic (hot, mydriasis/cycloplegia?, ileus, urinary retention, dry mouth), cardiac (MC cause of death)
“cgACh” [anti-cardiac fast Na, anti-GABA-a, anti-Alpha1, anti-Cholinergic, anti-H1]
TCAs inhibit fast Na channels in the his purkinje system and myocardium, decreasing conduction velocity and increases repolarization, prolongs absolute refractory periods, leading to hypotension, ^QRS, and vtach/vfib
do NOT give physostigmine (even thought there’s anti-cholinergia). it worsens heart conditions.
NaHCO3 - tx cardiotox (>100 msec QRS, v-arrythmia)
moa: sod-bicarb ALKALINIZES everything and increases extracellular SODIUM. The alkalinity keeps the TCA neutral (nonionized) and away from the sodium channels. The extracellular sodium increases the electrochemical gradient across cardiomyocytes, which helps keep the heart going (negates cardiodepression)
Resembles hyperkalemia (except hyperkalemia has peaked T and depressed ST and no ^QT) in its prolonged PR/QRS/QT
2) MIXED resp alk (stim resp center) and AGMA (acid buildup from uncoupling of oxPhos
tx- NaHCO3 -
3) NAC
- nephroprotection for radiocontrast induced nephropathy
- mesna is used to prevent hemorrhagic cystitis in the setting of cyclophosphamide use
4) (organophosphate = anticholinesterase = procholinergic = bradycardia, miosis, salivation)
tx - atropine + pralidoxime
5) calcium gluconate; kayaxelate; SABA; insulin+glucose; loop+IV fluids
6) Mg++ SO42-
7)
a) ABCs
b) decontaminate
c) barium esophogram w/in 24h
d) strictures at 2-3 wks can form
8) iso isn’t AGMA (mudpiles) and has absent ciliary reflex and dysconjugate gaze
vs methanol has blindness, APD, central scotoma
vs ethylene glycol has flank pain and Ca oxalate
Ddx for hair loss in all ages
What is Pediculosis Capitis
a) Tinea Capitis
- Trichophyton tonsurans (black dot tinea capitis) [MC in blacks]
- Microsporum Canis, Microsporum audouinii
- transferred thru fomites (ie combs)
- scaly erythematous patch, may progress to alopecia leaving a black dot
- dx KOH, tx ORAL GRISEOFULVIN (contacts tx selenium sulfide or ketoconazole shampoo)
b) Autoimmune
- Alopecia areata (smooth areas of hair loss w/out scaling)
- Discoid Lupus Erythematosus (plaques, cutaneous lesions, inflammation of hair follicle, photosensitivity, pruitits
c) pressure-induced (postoperative) alopecia
- prolonged pressure on the scalp after surgery under general anesthesia
d) trichotillomania
- irregular pattern and length
- Pediculus humanus capitis (head louse)
- pruritis but NO ALOPECIA
MC CAUSE of steatorrhea?
Steatorrhea + villous atrophy on biopsy + NEGATIVE IgA anti-tissue transglutaminase . Explain
1) What is the utility of the D-Xylose test?
2) Explain “abnormal” vs “normal” result
3) Etiologies for each result
Chronic Pancreatitis 2/2 EtOH
Still CELIAC! it was confirmed on biopsy. they probs have IgA deficiency
1)
Xylose is already fully digested; all it needs is intact sm. intestinal mucosa for absorption
Pancreatic Enzymes are NOT required for carbohydrate digestion!
Therefore, the utility of the D-xylose test is to determine the etiology of suspected malabsorption (steatorrhea, etc.)
2)
Abnormal = DECREASED D-xylose absorption, DECREASED D-xylose in urine, INCREASED D-xylose in feces
Normal = INCRESED D-xylose absorption, INCREASED D-xylose in urine, DECREASED D-xylose in feces
3)
Abnormal suggests proximal small intestinal disease (celiac, etc.)
Normal suggests pancreatic etiology (because the brush border is intact, the steatorrhea must be due to fat malabsorption)
Performance enhancement ADRs
a) Androgen abuse (4)
b) autologous transfusion (1)
c) EPO (MC to LC ADR) 1 (3)
a) GYNECOMASTIA!!!!!!!!!!!!!!!, POLYCYTHEMIA, LVH, (decrease HDL ^LDL)
b) only increased hematocrit
c) increased hematocrit, (HTN!, headaches, flu-like)
What is erythema nodosum and how should you work it up?
Painfus erythematous/violaceous SQ nodules on anterior LL
Can be benign, but also can signify serious dz such as
a) recent strep MC (ASO aka anti-streptolysin O)
b) sarcoidosis (CXR) [uveitis too]
c) TB (PPD)
d) Histoplasmosis, Coccidiomycosis
e) IBD exacerbation (stool, colon studies)
HIV and co. PHarm
What are the ADR of the following: (reverse)
a) pancreatitis
b) HSR
c) Lactic Acidosis
d) SJS
e) Hepato failure
f) Crystal-induced AKI
g) AIN
a) didanosine
b) abacavir
c) any NRTIs
d) any NNRTIs
e) nevirapine
f) ACYCLOVIR, sulfonamides, methotrexate, ethylene glycol, protease inhibitors
g) penicillins, PPIs…e tc?
Thyroid
a) increased thyroid, suppressed TSH + RAIU uptake only in 1 lobe (suppression in the rest of the gland)
b) RAIU patchy
c) RAIU markedly reduced
c) Hashimoto
a) thyrotoxicosis 2/2 toxic adenoma
b) toxic multinodular goiter
c) painless thyroiditis
d) hypO or euthyroid
Extrahepatic Hepatitis Manifestations
b)
c)
B) PAN (immune complex deposition in BV walls)
C)
- porphyria Cutanea tarda (photosensitivity; vessicles/erosion on hands)
- membranoproliferative GN
- mixed essential CRYOglobulinemia (immune complex deposition in BV walls, low complement)
4/5: leukocytoclastic vasculitis (HSP?), lichen planus
Patient receiving abx and TPN develops bleeding at the IV site. Explain both causes
Vit K def (abx destroy gut flora, no enteral nutrition)
RVMI (RVentr. MI)
a) EKG
b) px (3)
c) goal and justification of tx. and what to avoid.
1) initial (expound)
2,3) “unique”
4) avoid
a) ST-elevations in (2, 3, avF), since RVMI is usually caused by inferior wall infarcts
b) MI signs, HYPOTENSION (decreased left heart filling), JUGULAR VENOUS DISTENTION (due to RV dysfunction)
c) RH is failing so they need HIGH preload to maintain CO;
1) initially tx like normal MI*
2) in patients with hypotension and low/normal JVP, give HIGH-FLOW IVF to increase preload
3) if JVP is elevated, IVF less helpful
4) AVOID NITRATES, OPIATES, DIURETICS (since these can precipitate hypotension)
Reperfusion therapy + *MONABScH (! caution in RVMI)
PCI/tPA Morphine (!) Oxygen Nitrates (!) [give for CHF, CP, HTN; C/i!!! in RVMI, sildenafil] [Aspirin + P2Y12* r-block] = "dual antiplatelet" Beta-block (~) Statin Heparin/Enoxaparin/Fondaparinux
P2Y12 is the Gc ADP receptor (clopidogrel, prasugrel, ticlopidine, ticagrelor) aka THIENOPYRIDINES aka ADP antagonist
Bone Tumors
1) What is Giant Cell Tumor of Bone? Alternate name? Benign/malignant? trick Location?!
2) Osteoid Osteoma vs Osteoblastoma: (both benign tumors of osteoblasts) (4)
3) Chondroma vs Chondrosarcoma locations
1)
Giant Cell Tumor (OsteoCLASToma) is a benign, aggressive, bone tumor.
-epiphysis of the distal femur and proximal tibia.
-Unlike most bone tumors which occur most commonly in males, giant cell tumors of bone most commonly occur in females in early to mid-adulthood (20-40 years of age).
-Radiologic imaging of giant cell tumors of bone show destructive lytic lesions near joints, with a characteristic “double bubble” or “soap bubble” appearance.
less
-Giant Cell/Osteoclastoma is the ONLY bone tumor in the EPIphysis!
2)
An osteoblastoma is a benign, bone-producing tumor similar to osteoid osteoma, but unlike an osteoid osteoma, is not self-limited (with a nidus usually greater than 2 cm in diameter).
- Osteoblastoma pain not relieved by aspirin (vs osteoid osteoma, nocturnal and relived by aspirin)
- Osteoblastomas most commonly occur in the (metaphysis?) of vertebrae vs osteoid osteoma usually the cortex of the diaphysis of the long bones.
- Osteoblastomas are most commonly seen in young patients (10-30 years of age).
- Histology of osteoblastomas, similarly to osteoid osteomas, show a NIDUS of vascular osteoblastic tissue (interlacing trabeculae of immature woven bone lined by regularly arranged osteoblasts) surrounded by normal reactive bone. but blastoma nidus >2 cm in diameter.
3) medulla/fingers vs medulla/pelvis
always medulla for chondros!
Biostat Definitions
1) Hazard Ratio
1) Ratio of event occurring in tx arm vs non-tx arm
a) less than 1 = tx arm had lower event rate
2)
Study Design
1) Factorial Design
2) Parallel-group
3) Crossover
4) Cluster
1) randomization to different interventions w/ additional study of 2 or more variables
ex. BB, CCB, ACEi and each has two different bp endpoint groups
2) Randomizes one tx to one group and a different tx to another group. No other variables
ex. Drug vs placebo
3) group of participants is randomized to one tx for some time, and the other group is given an alternate tx for the same period of time. Then switch.
4) Grouping of different data point into similar categories; randomization at the level of groups
Indications for Lymph Node Biopsy
Indications for sputum culture
Often normal in children, young adults. s/p infx, rubbery
Bad signs:
Painless, firm, immobile
Biopsy if >2 cm. Observe otherwise
- MRSA
- bioterrorism
- Legionella (+urine Ag/ab?)
- TB
- fungal
Malaria hallmark.
ddx
What is Hereditary Hemorrhagic Telangiectasia (Osler.Weber.Rendu)?
Cyclical fever + random shit.
BABESIOSIS is “malaria” in america (NE/MW)
px endemic area w/ tick bite, esp. if hemolysis or splenectomized. HEMOLYSIS/JAUNDICE!
AVMs (pulm, R-L) px recurrent nose bleeds and oral lesions
“ruby papules on the lips that blanch”
Rash:
1) Fever, starts at wrists ankles, involves palms and soles, spreads centrally
2) Fever, maculopapular rash entire trunk, palms and soles
3) High fever, cranial-caudal spread
4) Fever + occipital/post LAD, THEN maculopapular rash in a crainal caudal pattern sparing palms and soles
1) RMSF
2) 2ndary syphilis
3) Measles tx vita A!
4) Rubella
Statistical analysis
1) Compare PROPORTIONS; 2x2 table
2) Compare 2 MEANS (2)
3) 3 or more MEANS
1) Chi square
2) two sample z/t test
3) ANOVA
The three “trisomies”
mnemonic: PED
Quad screen results for
a) trisomy 21
b) trisomy 18
c) ventral wall defects (omphalocele, gastroschisis)
1) Patau (13), cleft lip, microphthalmia, cardiac malformations
2) Edward (18), microcephaly, prominent occiput, micrognathia, closed fists with index finger overlapping middle finger and pinky overlapping ring finger, rocker bottom feet
3) Down (21), upward slanting palpebral fissues, epicanthal folds, brushfield spots, flat face
a) decreased AFP, decreased estriol, increased beta-hcG, increased inhibin A
b) decreased AFP, decreased estriol, DECREASED b-hcG, NORMAL inhibin A
c) INCREASED AFP, normal everything else
Post- bone marrow transplant px w/ pneumonitis and bloody colitis
Stool showing oocytes on modified acid fast stain of stool in HIV patient
(dry cough + bloody diarrhea)
PPX for any transplant
MC cause of death in renal transplant, dialysis
CMV pneumonitis
1) cryptosporidium parvum 2) could also be isospora belli (LC)
TMP-SMX!
HepB vaccine, influenza, pneumococcus
Ganciclovir for CMV!!!! TMPSMX for PCP UTI and others
CVASCULAR DZ! (50%)
MYELOPROLIFERATIVE
- def?
- 4 classic ddx?
What is Leukemoid rxn? ddx?
P vera vs Reactive 2/2 hypoxemia vs Reactive 2/2 ectopic EPO
examples
def: proliferation of myeloid lineage (RBC, neutro/basoph/eosino, monocyte, megakaryo); can transform to acute leukemia
a) P. Vera (JAK2 kinase mutation) [BUDD CHIARI!]
b) Essential Thrombocythemia (JAK2) [unique: no gout risk, marrow fibrosis, or AL]; hemorrhagic and thrombotic sx
c) Primary Myelofibrosis (JAK2) [you see extramed hematopo]
d) CML (granulocytes) [aka BASOPHIL, eosino, neutro]; 9,22; bcr-abl. left shift
LEUKEMOID (granulocytosis 2/2 infection)
vs
CML (bad)!
Leukocyte AlkPhos (inflammation) POSITIVE NO basophilia or (9,22) -vs- LAP NEGATIVE BASOPHILIA and (9,22) present
Sa02 nL in p. vera, EPO LOW (negative feedback)
Sa02 LOW in reactive, EPO HIGH [COPD]
Sa02 nL in ectopic, EPO HIGH [RCC]
Signs of bacterial meningitis + petechiae/purpura
MENINGOCOCCAL MENINGITIS
Plasma Cell Dyscrasias
4 DDX for Elevated Serum Protein w/ normal albumin (gamma gap)
How to distinguish
1) MM
2) MGUS
3) Waldenstrom (HYPERVISCOSITY!) of blood due to IgM spike)
4) Amyloidosis
MGUS vs MM:
NO anemia, renal, hyperCa, lytic bone vs YES v3 g/dL M protein vs ^3 v10% plasma cells in BM vs ^10% MM HAS ELEVATED B2-MICROGLOB! NO end-organ damage vs YES
MC paroxysmal tachycardia in ppl w/out HD?
mech?
tx? (expound)
PSVT (aka AV nodal reentry tachy)
RE-ENTRY AV accessory conduction pathways
tx VAGAL MANEUVERS (decrease AV conduction)
a) cold water immersion
b) carotid massage
c) valsalva
Order of COPD exac. MANAGEMENT
(don’t forget CXR, EKG, ABG to r/o CHF, pneumonia etc)
1) inhaled SABA +/- ipratropium
2) PO Glucocorticoids
3) PO Abx
* if these fail
1) Noninvasive positive-pressure ventilation (mask)
* if 2 hours of this fails
2) Invasive mechanical ventilation (endotracheal tube)
Ddx for mediastinal mass based on location
1) Middle (5)
2) Anterior (4)
3) Posterior (3)
1) MIDDLE
a) bronchogenic cyst
b) tracheal tumors
c) pericardial cysts
d) lymphoma/LAD
e) aortic aneurism (arch!)
2) ANTERIOR (4 T’s)
a) Thymoma
b) retrosternal thyroid
c) teratoma, mixed germ cell tumor
d) “terrible” lymphoma
3) POSTERIOR (all neurogenic tumors are here!)
a) Esophageal Leiomyoma (symptomatic when >5cm)
b) meningocele
c) enteric cysts
Pathogen of the following arrhythmias:
1) A-fib
2) A-flutter
3) PSVT (aka AVNRT)
4) Sinus Tachycardia
5) WPW
1) Ectopic focus within pulmonary veins
2) Re-entrant circuit around tricuspid annulus
3) Re-entrant circuit from accessory (total 2, 1 fast 1 slow)
4) SA node discharge 100-180/min
5) AV bypass tract (aberrent)
DoC in cancer-related cachexia
1) Progesterone analogs (megestrol, medroxyprogesterone)
2) Corticosteroids (less preferred than ^)
3) Mirtazapine
Patient px with symptoms resembling RA, but
NO JOINT SWELLING
ACUTE ONSET v6wks
dx? tx? prog?
Parvovirus B19 viral arthritis
dx anti-B19 IgM Ab (w/in 10-15 days of ifxn)
tx- reassurance; will resolve within 1 month
Which syndrome would one see the following cardiac abnormalities in:
a) CAVSD (complete A/V septal defect, failure of the endocardial cushions to fuse), VSD, ASD
b) VSD
c) supravalvular aortic stenosis
d) conotruncal abnormalities (define this)
e) congenital heart block
f) coronary artery aneurysm
a) Trisomy 21 (Down)
b) Trisomy 18 (Edward)
c) William’s Syndrome
d) Truncus arteriosus, Tetralogy of Fallot, interrupted aortic arch; DiGeorge, Velocardiofacial syndromes
e) Neonatal Lupus
f) Kawasaki disease
Tx for Lyme Disease and Rocky Mountain Spotted Fever in kids and pregnant women
Lyme meningitis with heart block?
Lyme: Amoxicillin and preg!
RMSF: Doxycycline (not sure about preg)
Lyme meningitis w/ heart block? IV ceftriaxone
Ecthyma gangrenosum vs pyoderma gangrenosum
a) cause
b) description
c) common occurence
VS PYOGENIC GRANULOMA!
a) pseudomonas vs NEUTROPHILIC ULCERATION
b) hemorrhagic pustules w/ surrounding erythema -> necrotic ulcers
vs
inflammatory pustule/papule/vesicle/nodule -> expanding ulcer w/ purulent base and ragged violaceous borders
c) commonly occurs as a pseudomonas skin infxn in the setting of neutropenia
vs
occurs w/ underlying systemic dz (IBD, RA, AML)
PG - dx biopsy tx steroids
pyogenic granuloma - benign vascular tumor (resembling Kaposi) that grows into a pedunculated or sessile shiny mass and bleeds easily; upper lip and oral mucosa MC. px first as red papule
Fever and sore, erythematous tonsils/throat in a person with thyroid dz.
NBS
AGRANULOCYTOSIS
D/C METHIMAZOLE/PROPYLTHYOURACIL
Physical Exam/Monitors
What do the following test for/signify
1) Hepatojugular reflux
2) Pulmonary Capillary Wedge Pressure
3) Pulmonary Artery SP
1) distinguish cardiogenic vs hepatogenic lower extremity edema
a) edema 2/2 HF: ^JVP, +HJR
b) edema 2/2 Liver: nL or vJVP, -HJR
2) LEFT!!!!! atrial pressure (LVEDP)
3)
“inflammatory muscle picture” + (tremor + tachycardia)
(symmetric proximal muscle weakness and tenderness [delts, hip flexors])
+(thyroidism)
= thyroid myopathy!
What is Erlichiosis?
cause
Tx?
Sentence?
“RMSF without the spots”
Erlichia chaffeensis, ewingii within the amblyomma americanum tick
se/south central US
MORULATED RBC!
tx Doxy (just like RMSF!)
NBS in “hypertension and; hypokalemia”
What about JUST hypertension but with BL masses? NBS?
aldosterone:renin ratio
a) both elevated and ratio ~10, 2ndary hyperaldo
- diuretic, cirrhosis/CHF, RVHtn, renin-oma, maligHTN, coarctation
b) both decreased, “other”
- CAH, glucocorticoid resistance, exogenous, cushings
c) increased aldo, decreased renin and ratio +20,
PRIMARY hyperaldo:
ADRENAL CT
POLYCYSTIC KIDNEY DISEASE
not sure… u/s? NBS is to watch out for BERRY ANEURYSMS and hepatic cysts! lol (diverticula, hernia, and valvular dz too)
Pathophys of Carpal Tunnel Syndrome in the following variations
a) Pregnancy
b) Hypothyroidism
c) Primary Systemic Amyloidosis
d) Acromegaly
e) RA
Which one is BL and the most severe?
a) accumulation of fluid in carpal tunnel (3rd trimester)
b) MUCOPOLYSACCHARIDE-PROTEIN COMPLEX DEPOSITION that presses on peri/endoneurium of median nerve [BL AND MOST SEVERE]
c) Amyoid fibril deposition w/in carpal tunnel
d) BL medial n. compression 2/2 soft tissue enlargement caused by synovial edema and tendon hyperplasia
e) tenosynovitis -> increased compartment pressure
Postexposure HIV ppx?
Recommendations for HIV prenatal, intrapartum, postpartum (treatment, etc.)
contrast with HSV??? idk
BLOOD, mucous memb, broken skin, bodily fluids other than feces/urine/nasal/saliva/sweat/tears
- IMMEDIATE 3-drug antiretroviral for 4 weeks*
1) TWO NRTI’s (tenofovir, emtricitabine)
2) integrase inhibitor (raltegravir), protease inhibitor, or NNRTI
prenatal: Triple HAART therapy during pregnancy (dual NRTI + NNRTI or protease inhibitor)
intrapartum: zidovudine if dx late
postpartum: continue triple therapy, zidovudine for neonate for 6 weeks with serial PCR testing
summary: triple therapy for mom, zidovudine for baby
Ankylosing Spondylitis clinical manifestations
ANTERIOR UVEITIS (not bechet) Sacroiliitis Apophyseal (facet) joint arthritis, Enthesitis (inflammation of insertion of tendons)
etc.
What is pathognomonic for Chrons
non-caseating grandulomas 60%
can also be seen in yersinia, sarcoidosis, and GI-TB
CP relieved by leaning forward, renal failure
NBS?
Hemodialysis
[uremic pericarditis!]
AEIOU
Acidosis: refractory, pH 7.1
Electrolyte AbN: EKG changes, K>6.5
Ingestion: toxic alcohol, salicylate, lithium, valproate, carbamazepine
Overload: of vol, refractory to diuretic
Uremia: symptomatic (encephalopathy, pericarditis, bleeding)
Thyroid unique presentations by lab
a) increased ESR
b) increased alpha subunits
c) decreased thyroglobulin + LOW RAIU
a) dequervain’s
b) TSH-secreting pituitary adenoma
c) exogenous!
Malaria PPX agents.
a) mefloquine
b) atovaqone-proguanil
c) (hydroxy)chloroquine
d) primaquine
e) doxycycline
a) PREGNANCY, chloroquine-resistant (SE asia, sub-saharan)
b) same but not good for preg
c) not good for resistant areas
d) p. ovale and p. vivax ONLY (korea, mexico, s. amer)
e) inexpensive
Most common complication in burns? What would the physio be?
What about if adequate initial fluid resuscitation?
Hypovolemic Shock
vBP3…, vCO2…vPCWP1…^SVR 4(compensation)
Bacterial infection (bronchopneumonia/burn wound infxn) leading to septic shock.
What can cause refractory hypOkalemia? Who does this typically happen to and what else is fucked with them?
What can cause refractory renal failure
hypOmagnesemia can lead to refractory hypokalemia (and torsaddes!?)
(chronic alcoholics have low Mag, low phosphorus, and low potassium)
Hepatorenal syndrome doesn’t respond to fluids and labs mimic prerenal! (high creatinine, low urine Na)
a) central ulceration, pearly
i) trunk
ii) face
b) Chronic scar that develops into a painless, non-healing, bleeding ulcer. NBS?’
c) melanoma tx
d) actinic keratoses and other low-risk SSC (in situ) tx
a) MC skin cancer: BCC
i) excision ON TRUNK (electrodessication, curretage)
ii) mohs ON FACE
- –
b) SSC, PUNCH BIOPSY
- –
c)
1) nbs: confirm dx w/ histopath:
- EXCISIONAL BX! remove the entire lesion w/ narrow margins and depth thru SQ fat.
2)
a) if depth v1mm, excise tumor w/ 1cm tumor-free margin
b) if depth ^1mm, SENTINEL LN BX
- —
d) 5-FU
Trousseau’s syndrome and example
Migratory superficial thrombophlebitis that signifies occult visceral malignancy (aka pancreatic tumor), stomach, lung, prostate, etc.
NBS ct ab to look for malig
Unexplained superficial venous thrombosis at usual cites (chest, arm). Itchy red streaks. Dx, nbs
Trousseau’s sign (migratory thrombophlebitis)
CT ab for malig
Pathophys and 3 causes of Baker’s popliteal cyst
pphx- excessive fluid production by inflamed synovium
1) RA
2) OA
3) cartilage tears
Can rupture into the calf, resembling DVT!
How would bronchiectasis show up on imaging? (2 modes)
How could renal cysts show up on CT? (two types)
TAA on cxr? cause?
Picture that CT w/ bronchial dilation
XRAY nonspecific findings: linear atelectasis, dilated/thickened airways, irregular peripheral opacities
Other: cough, SPUTUM, dyspnea, hemoptysis, fatigue, weight lossf
Think of that picture.
a) simple cyst - thin walls, very round (unilocular), no solid component, no enhancement, no septae, ASYMPTOMATIC, no followup needed (reassurance)
vs
b) malignant cystic mass - thick irregular wall (multilocular), heterogenous components (solid and cystic); contrast enhancement present!!!; hematuria/hypertension/pain; requires followup imaging and uro eval for malig
“vacuum tube” looking thing in wide mediastinum; atherosclerosis
High retic count, acute hemolysis (where?) exac by sulfur drugs/primaquine/dapsone as well as fava beans, but NORMAL enzyme levels
vs?
(in spleen!)
G6PD def! acute hemolysis, the old cells get lysed early and the reticulocytes (w/ normal g6pd fnx) predominate, which is why you may see nL enzyme activity
vs
Pyruvate Kinase def.
chronic hemolysis
NOT assoc w/ sulfa, NO BITE CELLS
vs
Sickle crisis
painful
assoc w/ howell jolly bodies
BUN:Cr ratios
Urine excretion
1) Pre renal >20:1
Low urine Na (v10 mEq/L)
(hypovolemia, orthostatic hypotension)
2) Intra v20:1??? (crystal)
3) Post renal
a) >20:1 early
b) v20:1 late
“BUN follows Na” BUN reabsorp req intact tubule
“Aldosterone reabsorbs Na (and BUN!)”
[aldosterone increased in prerenal bc hypovolemia]
**BUN:Cr most sensitive indicator of pre-renal azotemia/hypovolemia/orthostasis because often patients may be on diuretics and therefore urine sodium may not be that reliable
Auer Rods
APL M3 subtype
a) Normal Renal function w/ hematuria, hemarthrosis, MALE
b) Menorrhagia
a) HEMOPHILIA (hemarthrosis, skeletal muscle hemorrhage)
b) vwD (abnormal platelet plug formation)
Woman has a rash that worsens on sun exposure + CP.
!!!PROLONGED PTT (dz is procoagulant but is ANTI in vitro)
Lupus anticoagulant 2/2 SLE
a) PCOS (stein-levinthal syndrome) MANAGEMENT (2/3)
b) talk about hormone levels and what this would put the person at increased risk for
c) Rapidly developing virilization. Suspect? NBS?
- how to ditinguish ovarian vs adrenal source of virilization
a)
- WEIGHT LOSS + COMBINATION OCP (for hyperadrogenism and menstrual dysfxn)
- clomiphene for FERTILITY/ovulation induction
- (metformin if co-morbid DM2)
b) estrogen is adequate, progesterone is lacking. this is unopposed estrogen so there is increased endometrial cancer risk
c) androgen-secreting neoplasm of ovary or adrenal; serum test and DHEAS
- test + DHEAS = ovarian source (could still be CAH?)
- NO test + DHEAS = androgen-secreting adrenal
PCOS = NO! ^17-OH
Mnemonic for fetal heart rate monitoring, intrapartum
VEAL-CHOP
Variable decels - Cord compression/prolapse, oligohydramnios
Early decels - Head compression
Accels - Ok (normal fetal oxygenation)
Late decels - (utero)placental insufficiency
UL hip pain on the outer surface of thigh making it difficult to sleep
Deep hip pain worsened on internal rotation
Distinguish these two dx?
Trochanteric bursitis
Osteoarthritis
TENDER TO PALPATION vs not
alcoholic w/ dysphagia/odynophagia, fever, drooling, crepitus in submandibular space
dx
cause
tx
MC cause of death
Ludwig’s Angina (rapidly progressive bacterial cellulitis of the submandibular and sublingual spaces)
staph / anaerobes s/p dental?
ampicillin-sulbactam (unasyn) + tooth extraction (intubation if needed)
asphyxiation
DM w/ foot pain; deformed right foot, degenerative joint disease, difficulty walking.
Dx?
Causes/path?
Tx?
Neurogenic Arthropathy! (Charcot joint!)
[“Diabetic joint ulcer”]
Conditions that cause neuropathy/ DECREASED PROPRIOCEPTION/PAIN/TEMP (2/2 DM vasculopathy, trauma, syringomyelia, spinal cord injury, vit B12, TABES DORSALIS), causes patients to unknowingly traumatize their weight bearing joints
Xrays will show DJD, osteophyte, loose bodies
tx underlying + mechanical devices (special shoes)
Approach to endocarditis
1) obtain serial BLOOD CULTURES (3 from separate venipuncture sites)
2)
a) if stable/subacute (general malaise w/ no fever)
- culture-directed therapy
b) if unstable, begin empiric while cultures are cookin’
- vanc+gent
vanc = staph, strep, enterococci
A:
What are the “3” things a water deprivation test do
Pt has Nephrogenic DI. Fluid choice?
B:
SIADH tx? (2)
vvvv
C:
which 3 pathologies have polyuria and low urine osm
A:
1) Exclude polydipsia (urine osmolality corrects)
2) distinguish between central and nephrogenic DI (when it doesn’t correct after H20 dep., administer desmopressin to see if there’s response)
- central DI if response; tx - desmopressin?
- nephrogenic DI if no response; tx - gentle diuresis?
1) free water - if euvolemic
2) .9 NS - symptomatic hypovolemia (HD instabl., dry MM, vTurgor etc.)
3) D5 (hypotonic) - Asymptomatic hypovolemia
B:
1) if asymptomatic: fluid restriction +/- salt tablets
2) if symptomatic: HYPERtonic saline (3%) +/ -vaptans
NOT normal saline!
C:
Primary polydipsia, central DI, nephrogenic Di
1) What are 3 specialized Packed RBC (blood transfusion) options and their indications? a,b,c
d) Indications for regular pRBC and why?
2) What is whole blood and when should that be given?
3) Indications for
a) platelet transfusion
b) cryoprecipitate (def)
c) FFP (def)
1)
a) irradiated
- BM transplant recipients
- Cellular immunodeficiency
b) LEUKOREDUCED
- chronically transfused patients
- transplant
- previous FEBRILE NON-HEMOLYTIC TRANSFUSION REACTION
c) Washed
- IgA deficiency
- complement-dependent autoimmune hemolytic anemia
- continued allergic rxns
D) pRBC can increase oxygen carrying capacity in severe anemia:
pRBC:
trauma patient who doesn’t respond to 2L IVF
“stable” GIB with Hgb v7
“unstable” GIB with Hgb v9
*** 1 unit pRBC should increase Hgb 1 for every ^3 in Hct
2)
TAUMA where MASSIVE transfusions are needed
(Donor’s blood is colleced as WHOLE blood and THEN separated into components like FFP, pRCB, platelets, cryoprecipitate).
3)
a) Platelet Transfusion
i) spontaneous hemorrhage risk:platelet count v10,000/microL
ii) active bleeding + v50,000/microL
iii) CNS risk + v100,000
b) cryo (factor 8, fibrinogen, vWF, factor 13 [fibrin stabilizing factor])
i) given in deficiencies of any of those
c) FFP (contains all clotting factors and plasma proteins)
i) INR > 1.5 ; given during severe coagulopathy (liver dz, DIC, supraTx warfarin)
RHF (CLEAR lung, ^JVP, hepatomegaly, HJR, ascites, edema, pericardial knock (define), calcifications on CXR)
dx
answer questions above
2 ddx
PK = middiastolic sound
constrictive pericarditis
vs amyloidosis (you’d see LV thickness)
vs valvular (could be, but you’d have to see evidence on echo)
Ddx for “pulmonary-renal” syndromes and tx
What else needs this treatment?
a) GOODPASTURE - anti-GBM
tx EMERGENCY PLASMAPHERESIS, +/- (cyclophosphamide, steroids)
b) Granulomatosis w/ polyangiitis (wegeners)
tx cyclophosphamide + steroids
c) PAN, idiopathic RPGN
TTP and Myasthenic Crisis ALSO NEED EMERGENT PLASMAPHERESIS (“plasma exchange”)
Approach to flu
*** do not vaccinate if px w/ symtoms
1) Oseltamivir:
a) if presenting WITHIN 48 hours of sx onset
b) if >48 hours BUT high risk (old, preg, immunosuppresed, native american, morbid obese, etc.)
c) if >48 hours BUT haven’t shown any improvement
2) all others: supportive
Which microcytic anemia has high iron?
High TIBC?
Thall
iron def
Fever, leukocytosis, LUQ pain?
3 more sx of this condition?
RF?
Splenic Abscess
+ left pleuritic CP, left pleural effusion, splenomegaly
infection w/ hematogenous spread (ENDOCARDITIS)
immunospurres
Patient dx with sarcoidosis
TB negative, no acid fast seen
LN bx show non-case-granulomas
Given steroids, deteriorates rapidly
What could cause this? 3
What is hypersensitivity pneumonitis; give 3 examples w/etiologies.
Which 2 pneumoconioses resemble other pulmonary diseases? Pathopys of each? Which ones do they resemble and how?
Not TB, since negative; so TB mimicking dz (histoplasma, blastomyces, coccidiooides)
*remember to exclude these before using immunosuppresives!
Histoplasma - hilar LAD, erythema nodosum, Mississippi
Blastomyces - less likely if hilar LAD, mississippi
Coccidio - need southwest.
Non-caseating Granulomatous and eosinophilic rxn to an antigen leading to interstitial fibrosis and restrictive LD
Farmer’s lung is caused by exposure to Actinomycetes spores in moldy hay.
Pigeon breeders lung is caused by environmental exposure to birds/poo (pets, pet shop worker).
Humidifier (or “air conditioner”) lung is caused by thermophilic bacteria in heated water.
—–
Silicosis
- path: impaired PHAGOLYSOSOME formation by alveolar macrophages (increased risk for TB)
- resembles TB due to calcifications in upper lobe
Berylliosis
- path: leads to NON-caseating granulomas + BL HLA
- resembles Sarcoidosis
Treatment options for the two types of impetigo
1) Bullous impetigo: S Aureus, yellow enlarging flaccid bullae, tx cephalexin, dicloxacillin, clindamycin
2) NON-bullous impetigo: S Aureus/S Pyogenes, painful, non-itchy pustules/honey crusted lesions, topical muciprocin
What is Methemoglobinemia? mnemonic?
Findings? Classic
Cause?
Tx?
Methemoglobinemia results from oxidation of ferrous iron (Fe2+) to ferric iron (Fe3+) leading to a reduced affinity for oxygen. (Fe2 binds O2)
Classic findings for patients with methemoglobinemia include cyanosis and chocolate colored blood.
Caused in general by oxidant stress
Methemoglobinemia is treated with:
Methylene blue, acting as a cofactor to propagate the methemoglobin to hemoglobin transition
Vitamin C, which may be beneficial by acting as an electron donor to limit reactive oxygen species formation or by altering iron levels
How and when do you tx Follicular B-Cell Lymphoma (NH)?
MoA?
What are B-symptoms?
Pathophys?
MC subtype of HL?
Tx Rituximab when symptomatic; chemotherapy low dose is an option
MoA: anti-CD20
B-symptoms are fevers, chills, night sweats
Reed Sternberg cells secrete cytokines and attrack lymphocytes (which make up the bulk of the tumor)
MC HL is nodular sclerosing (70%) [lacunar, fibrosis]
1) What is Menetrier’s Disease?
2) path?
3) tx and mechanism?
BBB) Recurrent painLESS lower GIB assoc w/ ESRD and Aortic Stenosis?
1) Gastric hyperplasia of mucosa…hypertrophied rugae…excess mucus production with resultant protein loss and parietal cell atrophy with achlorhydria. Precancerous. Rugae resemble brain gyri
2) TGF-alpha/EGFR overexpression (epidermal growth factor receptor)
3)
Treatment of any associated cytomegalovirus or Helicobacter pylori infection
Antisecretory agents (H2-receptor antagonists, proton pump inhibitors)
Octreotide (somatostatin analogue that may regulated EGFR signaling downstream)
Cetuximab (monoclonal antibody to EGFR)
Angiodysplasia
What is a duodenal hematoma, how does it arise, how do you treat?
Duodenal hematoma (blunt abdominal trauma); tx with NG suction
DeQuervain’s Tenosynovitis
- px? classic?
- physical exam?
Jersey vs Mallet vs Trigger vs Dupuytren’s Contracture vs Felon
Thumb pain
“Fist thumb twist” (closed fist, ulnar deviation elicits pain, radial no pain)
[new mother holding newborn with open thumb]
Jersey finger – torn flexor tendon; can’t flex finger; tx splint
Mallet finger – torn extendor tendon; affected finger can’t extend; tx splint
Trigger finger - fascia of middle finger; difficulty with flexion; tx steroids [trigger thumb: pain over palmar aspect of 1st MCP
]Dupuytren’s contracture - fascia pulls on all the fingers; scandinavian alcoholic; tx surg to release fasia
Felon – abscess of nail pulp; TENDER, fever, leuk; tx I&D + abx
a) pathophys of “ape hand”
b) Pathophys of “hand of benediction”, “benediction claw” and “a-ok claw” (3)
c) “ulnar deviation” vs “radial deviation” upon attempted wrist flexion?
d) “full claw hand”
a) Median nerve injury (at wrist) - loss of THUMB OPPOSITION
b) Median nerve injury (at elbow) - when you ask patient to make a fist, digits 4 and 5 CAN be flexed bc of .5 FDP innervation from intact ulnar nerve but 2 and 3 CAN’T bc affected .5 FDP from median nerve injury. Thumb CAN’T be flexed either
- or- AT REST, ulnar nerve injury which reverses z-position in lumbricals 3+4 (digits 4+5), BUT THUMB CAN BE FLEXED
- vs- AT REST, median nerve injury can lead “ok” sign from reversed z-position in lumbricals 1+2 (digits 2+3)
c) median nerve injury (at elbow) - FCU acts unopposed but FCR is paralyzed
- vs- ulnar nerve injury (at elbow) - opposite
d) INFERIOR TRUNK C8-T1 injury (essentially median and ulnar both) - AT REST! all lumbricals paralyzed, so over time, z-position get reversed, leading to full claw
What are two “atypical” lab finding in hyperPTH? Pathophys?
1) increased URINARY cAMP!
PTH hits the tubules, and the PTH receptor is Gs coupled, activating adenylate cyclase, which affords cAMP, leading to cAMP in the urine.
2) increased SERUM alkaline phosphatase
alk phos generates an alkaline environment in the bone which allows MINERALIZATION (lay down bone) “so why is this elevated in hyperPTH?” read on:
PTH receptors are on osteoBLASTS, therefore PTH activates osteoBLASTS (osteoblasts mineralize bone and also activate osteoCLASTS)
osteoBLASTS produces alk phos when it lays down bone
Compare the exotoxins/MoA of C. tetani and C. botulinum:
Botulinum toxin (botox) and tetanus toxin (tetanospasmin)—both cleave the releasing protein synaptobrevin, thereby inhibiting neurotransmitter release. However, although they share a similar mechanism, these toxins affect the release of different neurotransmitters:
Tetanus toxin cleaves synaptobrevin → inhibits release of GABA and glycine → rigidparalysis.
Botulinum toxin cleaves synaptobrevin → inhibits release of ACh → flaccid paralysis.
What are the 3 groups of serovars for Chlamydia Trachomatis and what do they cause? How do you treat each?
Approach to Neonatal conjunctivitis (3)
Serovars:
A-C: trachoma (follicular conjunctivitis and corneal neovascularization [pannus]) scarring, blindness)
tx. topical tetracycline or oral azithromycin
D-K: NEONATAL conjunctivitis and neonatal atypical pneumonia; STI
tx. oral erythromycin
L1-L3: lymphogranuloma venereum
tx PO doxycycline or azithromycin
ddx:
1) Chemical; v24 hours; caused by silver nitrate/no exudates or purulence
tx supportive, lubrication
2) Gonnococcal; 2-5 days; eyelid swelling + purulence;
tx IM/IV ceftriaxone/cefotaxime single dose; [ppx erythromycin ointment]
3) Chlamydial (D-K); 5-14 days; eyelid swelling + bloody/mucoid
tx oral erythromycin
Note: Chlamydial (A-C) results in follicular conjunctivits, as well as pannus (corneal neovascularization), is more common in immigrants on young children (not neonates)
What sort of drugs can end up relaxing the uterus? What does this put the mother at risk for?
[tocolytics:]
MgSO4
beta-agonists (ritodrine, terbutaline)
halothane
Risk of Uterine Atony, and in turn, Postpartum hemorrhage
Recite the categories of DM2 drugs with the mnemonic. Examples and MoAs? Hierarchy of management?
STaB M(ellitus) A(nd) G(lucose) S(ucks) D(ick)
Sulfonylureas (tolbutamide, chlorpropamide, acetohexamide; glipizide, glyburide) [K+ channel blockade->depolarization beta cells-> opens Ca++ channels-> release of insulin]
Thiazolidinediones (-glitazone) [increased target insulin sensitivity, decreased hepatic gluconeogenesis]
alpha-glucosidase inhibitors (acarbose, miglitol) [induces malabsorption of disacharrides -> osmotic diarrhea/flatulence]
Biguanides (metformin) [decreased hepatic gluconeogenesis, decreased glucose-6-phosphatase activity]
Meglitinides (repaglinide, nateglinide) [“sulfonylurea analog”]
Amylin Analog (pramlintide) [decreased gastric emptying, decreased glucagon]
GLP-1 Analogs (exenatide, liraglutide) [increase insulin, decrease glucagon]
SGLT-2 inhibitor (canagliFLOzin) [decresased glucose reabsorption in the PCT]
DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin) [increased insulin, decreased glucagon, by preventing degradation of GLP-1 by DPP-4]
Hierarchy (alternatives in parenthesis)
Start with Metformin (TZD). Next try more Met (TZD) and add sulfonylurea. Now try Insulin (GLP-1 analog, DPP-4 inhib)
General approach to dosing: [qHS=bedtime, qAC=preprandial]
1) Basal (qHS)
2) Meal Coverage (qAC)
a) .5 units/kg body weight
b) half of this to qHS, half of this to qAC
c) use all of the qHS allotment as long-acting (glargine, detemir, protamine-zinc)
d) spread the qAC allotment over the meals as rapid-acting (lispro, aspart, glulisine)
[note: the remaining insulins not addressed in this regimen are short-acting (regular, semilente) and intermediate-acting (isophane/NPH, lente)]
Offer 4 ddx for Bilious Emesis and for each:
1) first of all, Which two of the above present exactly the same, only with differing pathogenesis?
2) Which xray sign is common to all 4 and how do you distinguish them?
3) How are they all treated?
a) Duodenal Atresia, Annular Pancreas
b) Intestinal Atresia
c) Malrotation
1) Duodenal Atresia and Annular Pancreas present exactly the same
2) Double bubble on all;
DA/AP have paucity of gas distal to obstruction (there was no chance for gas to even get there bc failure of recannalization happened in utero)
IA does have multiple air fluid levels distal to obstruction (bc multiple levels of obstruction)
M has normal gas pattern (bc this happens after birth)
3) tx Surgery (for IA resection+ counsel mom)
Genital Herpes vs Chancroid vs Primary Syphilis vs Lymphogranuloma Venereum vs Granuloma Inguinale (Donovanosis)
a) pain?
b) number/appearance?
c) organism?
d) lymphadenopathy?
e) prognosis? (just the ulcer!)
a) yes, yes, NO!, no, no
b) multiple/erythematous base, multiple/deep, single/indurated, small/shallow, extensive/beefy
c) HSV, H. Ducreyi, T. Pallidum, C. Trachomatis, Klebsiella Granulomatis
d) Yes, Yes, YES!, No, No!
e) Acyclovir, Ceftriaxone/Macrolide, IM Penicillin Benzathine x1, Doxycycline/Erythromycin, Doxycycline/TMP-SMX 3wk
Distinguish ischemic colitis from IBD
What is acute mesenteric ischemia? px? risk? lab? (4) dx? tx?
IC - spares rectum, acute (s/p AAA repair), ULCERATIONS ON COLONOSCOPY and cyanotic mucosa. CT shows thickening of bowel wall can be seen
IBD - doesn’t spare rectum chronic
Periumbilical pain, out of proportion to PE
essentially same as MI
^lactate, ^amylase, metabolic acidosis, leukocytosis
1) CT (preferred) or MRA
2) mesenteric angiography is stills suspicious
tx abx, NG decompression, surg if needed,
Why should you be careful giving O2 in COPD? Give 3 pulm pathophys and 2 CNS pathophys explanations.
When you give O2, CO2 retention happens via:
1) Decreased RR 2/2 loss of “hypoxic drive”
2) Hyperoxic vasodilation (aka loss of compensatory vasoconstriction) leading to V/Q mismatch
3) The increase oxyhemoglobin has a reduced affinity for CO2 (for pickup) in the periphery [haldane effect]
In the CNS, CO2 retention leads to:
1) Hypoxic vasodilation (seizures)
2) Acidosis (upregulation of GABA and glutaMINE; downregulation of aspartate and glutaMATE, leading to AMS)
Preferred method of intubation in cervical trauma?
Non-comedone monomorphic acne. What is the cause?
Orotracheal
Corticosteroid-use
Indications for Parathyroidectomy? (Ca, age, DEXA, GFR)
Ca >1 above normal
age v50y
DEXA T-2.5
GFR v60
What is a hemangioblastoma? Angiofibroma? Angiomyolipoma?
What PnP syndrome assoc with HBoma? What genetic syndrome is HBoma assoc w/?
Lymphatically, where does RCC typically like to spread?
Hematogenously?
A hemangioblastoma is a tumor of vascular origin that is most often located in the cerebellum.
Hemangioblastomas can produce erythropoietin, leading to a secondary polycythemia
Hemangioblastoma can be associated with the von Hippel-Lindau syndrome when found with a concurrent retinal angioma.
Angiofibroma: benign vascular tumor usually px with adolescent male with UL nasal obstruction and hx of recurrent epistaxis; assoc. w/ tuberous sclerosis
Angiomyolipoma: hamartoma of the kidney; assoc. w/ Tuberous Sclerosis
Retroperitoneal Lymph Nodes
IVC invasion; Bone, Brain, Lung, Liver
Laryngeal Papilloma. Etiology? Characteristics in kids vs adults?
etiology: HPV 6 and 11 (remaining etiologies below for contrast)
Laryngeal Papilloma is single in adults and multiple in children!
HPV-1 through HPV-4 cause verruca vulgaris (common skin and plantar warts)
HPV-6 and HPV-11 cause condyloma acuminata (genital warts) and laryngeal papillomasin children
HPV-16 and HPV-18 are associated with intraepithelial neoplasia and anogenital carcinoma of the uterine cervix, penis, and anus (HPV-16 and 18 together account for 70% of cervical cancers).
Gardasil, the HPV vaccine, contains capsid proteins of types 6, 11, 16, and 18.
The Gardasil (quadrivalent) HPV vaccine is given in three doses to boys and girls age 11-12. (It may be given up to age 26 if the patient did not receive the vaccine at the recommended age.)
Explain how B12 def., MTHFR/Folate def., and cystathionine beta-synthase def. lead to thrombotic risk: (see topic notes for clarity)
Lab Values of hyperhomocyseinemia/hyperhomocystinuria for the following etiologies/deficiencies:
a) B6
b) Folate
c) B12
1) Normally N5,10-methyleneTHF is “methylated” by MTHFR to N5-methylTHF, which along with B12 is a COFACTOR for homocysteine methyltransferase (aka methionine synthase) to convert homocysteine to methionine
2) Normally, cystathionine beta-synthase uses B6 to convert homocysteine to cystathionine (and then to cysteine)
[homocysteine damages endothelium and is pro-thombotic.] this is the key to all the mentioned pathogeneses
1) B12/Folate def. (TAI, these deficiences will prevent homocyteine from being used/disposed of)
2) Cystathionine beta synthase def. (similar: can’t get rid of homocysteine to cystathionine)
a) increased homocysteine (need B6 for CBS); increased methionine (excess homocysteine spilling into methionine synthesis bc nowhere else to go)
b) increased homocysteine (HMT/MS not working, homocysteine backs up); decreased methionine (need “folate” for HMT/MS)
c) increased homocysteine (HMT/MS not working, homocysteine backs up); decreased methionine (need B12 for HMT/MS); increased methylmalonic acidemia/uria (need B12 for MMCM)
CBS= cystathionine beta-synthase HMT/MS = homocysteine methyltransferase/methionine synthase MMCM = methylmalonate CoA mutase
Central vs Peripheral Vertigo
1) Central: vertigo cerebellar or brainstem lesions, usually assoc w/ with CN signs (e.g. diplopia, dysarthria, dysphagia), weakness, ataxia, and other changes that may indicate a central process.
Post. Fossa Tumor, Acoustic Neuroma
Stroke
MS
-hearing loss, -tinnitus, +CN signs, +Brainstem Signs
NBS: MRI
2) Peripheral: vertigo assoc w/ with inner ear etiology
BPPV
Meinier’s (Endolymphatic Hydrops)
Labyrinthitis/Vestibular Neuronitis
+Hearing Loss, +Tinnitus, -CN Signs, -Brainstem Signs
Labyrinthitis
- acute inflammation of the middle ear
- couple weeks after URI, classically
- HEARING LOSS, TINNITUS, VERTIGO, DYSEQUILIBRIUM, NAUSEA/VOMITING (versus central which has NO HL/T)
- tx supportive
Vestibular Neuronitis = Labyrinthitis WITHOUT the hearing loss
What causes nystagmus in alcoholic?
Black eschar. Dx? Tx ? epid?
B1 def (thiamine)
IVDU/prison; tx doxy, cipro, raxibacumab (spores(
DRUG SIDE EFFECTS
1) Tacrolimus
2) Cyclosporine
3) !Mycophenolate
4) Azathioprine
5) succinylcholine
1) nephrotox, htn, neurotox, glucose intolerace, infection, malignancy (SSC skin), diarrhea/gi
2) tacrolimus + GINGIVAL HYPERTROPHY, HIRSUITISM
3) MMMMMarrow suppression
4) dose-related diarrhea, leukopenia, hepatotox
5) hyPERkalemia; give vecuronium or rocuronium instead
Pt w/ bp 70/30 and AMS, and crackles, EKG shows absent P waves, narrow complex, and irregularly irregularR-R. Tx?
Perstent tachyarrhytmia
DC CARDIOVERSION (bc he’s not stable)
pharm cardioversion (amiodarone, quinidine) if STABLE.
DC cardio (unstable); vagal maneuvers +/- ADENOSINE
Indication for impromptu Tetanus Vaccination (4)
Postexposure rabies prophylaxis (3)
Based on whether the wound is CLEAN/MINOR or DIRTY/SEVERE as well as IMMUNIZED (+3 toxoid doses) or UNIMMUNIZED (-3 toxoid doses)
**Tetanus IMMUNOGLOBULIN is only given for
DIRTY/SEVERE + UNIMMUNIZED
[toxoid=(Td, Tdap, TT, or DT)
Give toxoid:
clean + immunized + last dose >10 years ago
clean + unimmunized
dirty + immunized + last dose >5 years ago
Give toxoid PLUS TIG:
dirty + unimmunized
High risk animal (bat/racoon/skunk/fox/coyote):
try to test animal, if +, give Rabies PEP
Low risk animal (squirrel, chipmunk, mouse/rat, rabbit)
NONE
Dog, cat, or ferret
try to quarantine and observe for 10 days. if neg., no PEP. if pos., PEP
Contact health dept if livestock or other unkown animal
Tick bite, endemic, nO rash, but hemolytic anemia, jaundice. tx?
Flulike, hepatitis, or pneumonia in a meat processor/vet
Babesiosis (via ixodes tick); azithro-atovaquote or quinine-clindamycin
Q fever (coxiella burnettii)
Central hypogonadism (def.) + central hypothyroidism (def.)
dx
ddx
(low LH and test) + (low TSH and T4)
nonfunctioning pituitary adenoma
not risperidone bc that doesn’t affect the pituitary-thyroid axis
Ddx casuses for nasal septal perf
1) WHISTLING NOISE S/P RHINOPLASTY
2) Trauma/ manual
3) syphilis/TB/sarcoid
4) cocaine
5) wegeners
Hypocalcemia px, workup and ddx
vs
Hypercalcemia PX!? workup and ddx
note, CKD hypocalcemia has 2 mech: 1) phosphate retention 2) binds calcium and vCa++ or 1) less calcitriol (VitD) is produced bc shot kidneys 2) less Ca++ absorbed
3) HYPOCALCEMIA
4) ^PTH
5) TADA! 2ndary hyperPTH
px - vague (fatigue, anxiety, depression), spec. (tetany, perioral tingling, carpopedal spasms? treausseau/chovstek?)
1) repeat and consider alternative causes
- ^Mg++
- recent blood transfusion (^citrate, hemodilution)
- 2/2 to drug
2) MEASURE PTH
a) normal, low
- (para)thyroidectomy
- polyglandular autoimmune syndrome
- Cancer mets, hemochromaosis, Wilson’s
b) high
- Vit D def. (rickets/osteomalacia)
- CKD
- pancreatitis/sepsis/tumor lysis syndrome
px: Stones, bones, groans/moans, psychiatric overtones
NBS: repeat or check PTH
a) High (meaning this shit is PTH dependent)
- primary/tertiary hyperPTH (tertiary=longstanding, gets numb)
- familial hypercalcemic hypocalciuria
- lithium or teriparatide induced
b) Low,
NBS: measure
PTHrP, 25D and 1,25D, and ELECTROPHORESE urine and serum
- calc of malig (low 1,25 w/ super high calcium >13)
- VitD tox
- hctz, theophylline (usually v11)
- milk alkali (acute hypercalcemia, alkalosis, and RF from overdosing calcium containing antacids)
- thyrotox
- vit A tox
- immobilization
- misc (adrenal insuff, acromeg, pheo)
Hordeolum tx
chalazion. NBS
Dacryocystitis
Episcleritis?
(stye) Abscess located over the upper or lower eye lid. Staph aureus. Frequent hot compresses + abx
px as lid discomfort. chronic granulomatous inflammation of the MEIBOBIAN gland; NBS bx/histopath to r/o BCC
Inflamm changes in the medial canthus. Staph aureus, strep beta hem
Mild pain, super red, discharge, patchy
Joint pain in SLE vs RA
non-deforming in SLE (even though it’s severe pain)
Normocytic anemia, splenomegaly, retic, jaundice, ^indirect bili, ^LDH, DECREASED haptoglobin
dx? (2) etiologies px's tx the unique complication
DX: AUTIMMUNO HEMOLYTIC ANEMIA
Warm vs Cold
IgG vs IgM (both have direct coomb and anti-C3)
penicillins/immuno/viral infx
vs MYCOPLASMA, MONO
(both lymphoprolif)
tx steroids/spenectomy vs rituximab/fludarabine and avoid cold
complications: VTE vs Ischemia/gangrene 2/2 cold, levido reticularis
Thyrotox vs Pheo vs Malig Hyperthermia
a) fever
b) thyroid signs
c) potassium
a) fever vs NO FEVER vs fever
b) LID LAG vs none vs none
c) normal vs normal? vs HYPERkalemia (and CK, rigidity, hypercarbia)
another name for HSP IgA dep
another name for hairy cell leukemia
Leukocytoclastic vasculitis (HSP is a subtype but yea) Leukemic Reticuloendotheliosis
Best INITIAL test for MG?
Most ACCURATE for:
MG?
Polymyosistis?
Guillain-Barre?
ACh receptor antibody
single fiber EMG
Muscle biopsy
Nerve conduction velocity
What is the only indication for intrathecal abx?
Ommaya reservoir (intraventricular catheter) infection
(this thing is used to dump chemo right into the brain for CNS lymphoma; this could get infected so put vanc right in there)
MC vessel affected in stroke?
Explain. How does this present in terms of
a) “periph?”
b) eyes? !!!
c) Speech? !!!
What other vessels are less common?
MCA (90%)
a) CONTRA weakness or sensory loss
b) CONTRA homonymous hemianopsia; eyes “look at lesion”
- ex. left MCA results in right-deficits, eyes can’t see right side so they compensate by looking left (aka towards lesion)
c) aphasia if stroke is on dominant hemisphere
- speech and handedness are on same hemisphere (aka if right handed, then you have left-dominant brain and left-sided speech centers)
Patient only shaves the right side of his face.
Dx?
Where is the lesion?
Hemi-neglect syndrome
RIGHT (non-dominant) parietal lobe
What 2 things should you suspect when you see weight loss and hx of IVDU?
What workup sequence for an unprovoked first time seizure? Second+ time seizure?
Workup for status epilepticus?
HIV
HepC
1) Noncontrast head CT (emergency); MRI (non-emergency)
2) EEG to dx
1) then you can use a) benzos etc.
a) benzo
b) phosphenytoin
c) phenobarbital
d) neuromuscular blockade (succinylcholine)
e) midazolam; propofol + intubation
Intracranial hemorrhage
Neurologic findings for:
a) Basal Ganglia
b) Thalamus
c) Cerebral Lobe
d) Cerebellum
e) Pons
a) (rupture of Charcot Buchard aneurysm 2/2 hyaline art 2/2 HTN)
- contra. hemiparesis and hemisensory loss
- gaze palsy
b)
- contra. hemiparesis and hemisensory loss
- upgaze palsy
- conjugate AWAY from lesion, towards hemiparesis (vs MCA infarct which is TOWARDS lesion, away from hemiparesis)
- nonreactive miotic pupils
c)
- contra. hemiparesis (frontal) or hemisensory (parietal)
- homonymous hemianopsia (occipital)
- conjugate TOWARDS lesion, away from hemiparesis
- seizures
d)
-facial weakness
-ataxia/nystagmus
-occipital h/a and neck stiffness
NO: hemiparesis
d)
- pINpoint reactive pupils
- deep coma & total paralysis w/in minutes
What is the definition of brain death? (3)
What can you still find in a brain dead patient?
1) absence of brainstem reflexes (corneal, oculovestibular, pupillary, caloric, pharyngeal)
2) “not dead until warm and dead” aka exclude hypothermia
3) prove irreversibility (imaging showing herniation, etc.)
DTRs (spinal cord still working)
Gait Disorders
def; phys. exam; cause
a) Cerebellar
b) Gait apraxia (frontal gait)
c) Parkinsonian
d) Steppage (foot drop)
e) Vestibular
f) Myotonic Dystrophy, Muscular Dystrophy
a)
- ataxia, wide based;
- ROMBERG, dysdiadochokinesia, dysmetria, nystagmus
- EtOH/drug, vitB12 def.,
b)
- magnetic (freezing)
- NPH, frontal lobe degeneration
c)
- festinating (shuffling), hypokinetic, narrow-based
- bradykinesia, resting tremor, postural instability, decreased arm swing [cogwheel rigidity]
d)
- foot drop, high step + slap
- assoc/distal sensory loss and weakness
- caused by motor neuropathy (MC L5 or common peroneal)
- also caused by dorsal roots or post. columns
e)
- disequilibrium
- normal sensation, reflexes, motor
- nausea, vertigo
- [acute labyrinthitis/vestibular neuritis, meniere’s dz]
f)
-waddling (2/2 gluteal weakness)
Compare and contrast px for the following:
a) Lacunar (posterior limb of internal capsule) infarct
b) MCA infarct
c) ACA infarct
d) vertebrobasilar infarct
a) [does not present with cortical signs or AMS]
- pure motor (face, arm, and leg equally)
- unilateral hemiparesis
- (mild dysarthria)
- NO: sensory, agnosia, apraxia, aphasia, neglect, hemianopsia, (stupor, coma, LOC)
b)
- contralateral SensoriMotor in 1) face 2) arm 3) legs
- aphasia (if dominant hemisphere)
- hemineglect (if non-dominant hemisphere)
- conjugate eye deviation TOWARDS infarct
- homonymous hemianopsia
c)
- contralateral sensorimotor in lower limbs
- urinary incontinence
- emotional, dyspraxia
- abulia (lack of will/initiative)
d) [“alternate syndromes”]
- ipsilateral cranial nerve involvement
- contralateral hemiplegia
- (ataxia)
Name 5 of the MC lacunar syndromes and their locations
MC cause of lacunar strokes?
1) Pure sensory syndrome (VPL thalamus)
2) Pure motor hemiparesis (post. limb of int. capsule)
3) Ataxic Hemiparesis (anterior limb of int. capsule?)
4) Sensorimotor syndrome
5) Dysarthria-clumsy hand syndrome (basal pons)
HYPERTENSION is MC cause
1) Pathophys of heat STROKE vs heat EXHAUSTION
ice water immersion
2) What are the two types of heat STROKE and the NBS for each?
1)
a) stroke - ^40 temp, +AMS!!!; inadequate thermoregulation
b) exhaustion - v40 temp, -ams; inadequate fluid/electrolyte replacement
2)
a) exertional, young - ice water immersion
b) non-exertional elderly - gastric cold lavage, evaporative cooling
4 ddx for Heat-Related Illness and pathophys (further subdiv. as needed).
1) Heat Stroke (+AMS!!!!!!, +40 temp) [vs exhausion no AMS and -40 temp]
- path: thermoregulatory dysfunction
- assoc/ rabdo (41+)
a) Exertional
b) non-exertional
2) Heat Exhaustion
- path: inadquate fluid/electrolyte replacement leading to inability to maintain CO
3) Malignant Hyperthermia
- path: uncontrolled Ca++ efflux from Sarc. Retic
- assoc w/ anesthetics and temp can be up to 45
4) Fever
- path: cytokine activation
- assoc w/ upreg of thermoreg setpoint temporarily (hypothalamus); heat dissipation intact, usually v40
Tx of solitary vs multiple brain mets?
Solitary - surgical resection
Multiple - whole brain radiation
What is status epilepticus (2) and what is the risk?
any seizure >5 min
-or-
cluster of seizures without regaining consciousness
PERMANENT INJURY 2/2 EXCITATORY CYTOTOXICITY
Pharmacotherapy options for ISCHEMIC stroke (5)
Pharm for s/p UA/NSTEMI
s/p PCI
intolerant to ASA?
1) stroke within 3-4.5 hours, no c/i:
- tPA (IV alteplase) [nc-CT head to r/o bleed before tPA!]
2) stroke + no prior antiplatelet/not candidate for tPA
- aspirin
3) stroke + already on aspirin
- aspirin + dipyridamole
- aspirin + clopidogrel (esp. if athero)
4) stroke + afib
- long term anticoag (warfarin, dabigatran, rivaroxaban)
Note: aspirin is the only one shown to reduce recurrence
aspirin + clopidogrel (12 months of 2ndary prevention)
aspirin + clopidogrel (30 days post op)
clopidogrel alone can substitute ASA if intolerant
First distinguish via CN
a) Lateral Medullary (wallenburg, PICA/vertebral)
b) Lateral Pontine Syndrome (AICA)
c) Medial Medullary Syndrome (ASA)
d) Medial Pontine Syndrome (pontine arteries)
e) Medial Midbrain Syndrome (weber, PCA)
These syndromes typically all have long tract signs with unique cranial nerve involvement. Violation of this rule is pontocerebellar angle syndrome in which you have (d) but without long tract signs. Usually caused by a tumor (shwannoma)
rule: CN deficits are ipsi, body are contra
a) CN 9, 10!
- [contralateral body pain & temp loss (STT)]
- [ipsilateral face pain & temp loss (spinal nucleus of CN 5); ex. loss of direct CORNEAL reflex but not consensual]
- [ipsilateral horner’s (hypothalamic/sympathetic)]
- ipsilateral dysphagia, dysarthria, dysphonia, hoarseness, diminished gag (bulbar CN 9, 10)
- ipsilateral ataxia (inferior cerebellar peduncle)
- ipsilateral vertigo, nystagmus (vestibular nucleus)
ie. falling towards side of lesion, difficulty sitting upright
b) CN 7, 8!
- [contralateral body pain & temp (STT)]
- [ipsilateral face pain & temp loss (spinal nucleus of 5); ex. loss of direct CORNEAL reflex]
- [ipsilateral horner’s (hypothalamic/sympathetic)]
- ipsilateral facial weakness (CN 7)
- ipsilateral sensorineural hearing loss/tinnitus (CN 8)
c) CN 12!
- [contralateral spastic paresis (CST/pyramid)]
- [contralateral loss of vibration/proprioception (dorsal column/medial lemniscus)]
- ipsilateral flaccid paralysis of tongue; deviation TOWARDS lesion (CN 12)
d) CN 6!
- [contralateral spastic paresis (CST)]
- [contralateral loss of vibration/proprioception (medial lemniscus)]
- ipsilateral? medial strabismus (CN 6)
e) CN 3!
- [contralateral spastic paresis (CST)]
- contralateral LOWER face weakness
- ipsilateral oculomotor palsy: dilated pupil, strabismus, ptosis (CN3)
On CT scan how to brain hemorrhages look? Infarcts?
bleed: hyperdense
infarct: hypodense
1) What is central cord syndrome and what are 3 causes?
2) Central cord syndrome vs anterior cord syndrome
cause?
sequelae?
3) What is the “unique” finding in central cord syndrome and explain this
Central cord syndrome:
1) HYPEREXTENSION injury 2/2 pre-existing spondylosis (MC)
2) Syringomyelia
3) Intramedullary Tumor
hyperextension of neck
-vs-
burst fracture of the vertebrae (or ASA issue)
burning sensation? and paralysis in UPPER limbs only
-vs-
BL loss of motor and pain/temp below the lesion (STT)
Weakness/hyporeflexia (CST/ventral horn)
Urinary Incontinence (descending autonomics)
3) more pronounced in UL bc those fibers are situated more central in the CST
Guillain-barre vs spinal cord compression
Recite approach to weakness rules (4ish)
Both have weakness and stuff, but GBS has hypOreflex
BUT IF YOU SEE BABINSKI or incontinence, IT’S SPINAL CORD. PERIOD. also look for hx of CA/mets
prEsynaptic NMJ (LEMS), impaired reflexes pOstsynaptic NMJ (MG), reflexes intact
If there are sensory issues, it’s not NMJ in origin
Severe hyporeflexia indicative of PN?
Yea obv you know what parkinson’s is, but are the 3 cardinal signs and dx criteria? for #3, expand to 5 and define. a fourth sign is postural instability. give 3 examples
1) Resting Tremor (asymmetric MC px!!!!!)
2) Rigidity (uniform leadpipe or oscillating cogwheel)
3) Bradykinesia
- hypophonia (soft speech)
- hypomimia (decreased facial expression)
- micrographia (small writing)
- festinating gait (narrow, shuffling, short strides, NO ARM SWING)
- difficulty initiating movements
Need 2/3 for a clinical diagnosis. Can be further confirmed w/ physical examination (MAT)
4) Postural instability
- frequent falls
- flexed axial posture
- loss of balance when turning or stopping suddenly! or when pushed lightly
Characteristic findings of acute angle-closure glaucoma
What can precipitate it?
**injection, pupillary dilation/unresponsiveness*
“halos”
eye pain, headache, lacrimation
anticholinergics and other things that cause pupillary dilation (like darkness). (ex. tolterodine for urinary incontinence, sympathomimetics, nasal decongestants)
[can lose eyesight just like in temporal arteritis]!!!!!!
What is the one way to distinguish temporal arteritis and migraines from Acute angle-closure glaucoma?
What is a long term complication of temporal arteritis besides blindness? (think about this one!)
DILATED, NON-REACTIVE PUPIL
Glucocorticoid-induced myopathy; pt should have gotten steroids in the EC.
Pt with LE more than UE weakness, painLESS
Which headache can have Horner’s with it?
Tx? Ppx?
In addition to abortive therapy for migraine, what else can be given along with that, if appropriate?
tx? Ppx?
Cluster can have horner
tx 100% O2, intranasal zolmitriptan, subQ sumitriptan
ppx VERAPAMIL, lithium, ergotamine, steroids, topiramate
Migraine:
-triptan
IV anti-emetics (prochlorperazine, metoclopramide, chlorpromazine) if there is vomiting
b-blockade
Amitryptiline
anti-convulsant (valproate, topiramate)
verapamil
contralateral hemianesthesia and SEVERE DYSESTHESIA (pain), transient hemiparesis/athetosis/hemiballism
THALAMIC-VPL STROKE (Dejerine-Roussy sndrome)
the dysesthesia is characteristic (thalamic pain phenomenon)
Nerve responsible for corneal sensation
Workup for Corneal Abrasion (3)
TRIGEMINAL V1 (ophthalmic)
ABSENCE OF EYE PAIN SUGGESTS CORNEAL ABRASION WITH DYSFUNCTION OF V1
1) PUPILLARY LIGHT REFLEXES, inspect for foreign body w/ penlight
2) visual acuity w/ ophtho referral if decreased
3) if 1 and 2 show corneal staining defect, THEN FLUORESCEIN exam
Dx criteria for MM? (“2”) EOD?
Tx? (2)
What 2 roles do radiation play in MM
DoC for bisphosphonate therapy
Dx:
1) +10% plasma (clonal) cells
-OR-
2) Plamsacytoma on BM bx
- AND- 1 of the following:
a) end organ damage (RF, ^Ca++, anemia, lytic bone)
Tx:
1) autologous hematopoietic stem cell transplantation [IF ELIGIBLE]
[if INELIGIBLE]
1) lenalidomide + dexamethasone
2) bortezomib
RADIATION:
- palliative for lytic lesions/ cord compression
- plasmacytoma tx
ZOLEDRONIC ACID (anti-MM)
Pro-coagulant dz vs anti-coag dz
Pro-coagulant:
- Factor V Leiden (MC!?!)
- Anti-PLA
- AT3 def.
- Protein C/S def.
Anti-coagulant:
-TTP (ADAMTS)
-
SECONDARY HYPERTENSION
1) Fibromuscular Dysplasia
a) what are 3 categories of px?
b) dx (2)
c) tx?
2) ?
3) coarctation of the aorta
1) a)
i. renal artery: refractory HTN, flank bruit, flank pain
ii. cerebrovascular: amarousis fugax, TIA, carotid bruits
iii. other: horner’s, neck pain, headache
b) CT-angiography; duplex U/S
c) angioplasty + stent
2)
- HTN
- hypeRcalcemia
- nephrolithiasis
- neuropsychiatric sx (could be MEN2a or b [pheo])
3) brachial-femoral delay
CARPAL TUNNEL SYNDROME
A: px? (w/ anatomic justification)
B: TREATMENT
give 5 ddx etiologies and pathophys of CTS, which one is the worst?
A:
- THENAR CUTANEOUS SENSORY SPARING
- THENAR ATROPHY (motor fibers of median n.)
- PARESTHESIA IN FIRST 3.5 DIGITS (palmar DIGITAL sensory branch of median n.)
palmar CUTANEOUS sensory branch of median n. given off proximally, therefore this is spared in CTS (bc CTS affects right at the wrist)
B:
1) Splint (nocturnal) if refractory: 2) Steroid injection (oral is an option) if refractory: 3) Surgery (Carpal Tunnel Release/Transv. Carpal Ligament)
1) Hypothyroid - matrix deposition - BL AND WORST
2) Amyoidosis - Fibril deposition (ESRD… beta 2 microglob
3) Pregnancy - fluid accumulation (3rd trimester)
4) RA - tenosynovitis
5) Acromegaly - hypertrophy BL!
What are fasciculations indicative of?
!!!LOWER!!! MOTOR NEURON DZ
(LMN)
as well as flacidity!
MYOPATHY
5 ddx based on px
5 ddx based on ESR CK
(organizer is first, money is at the bottom of card)
Normal ESR:
1) Glucocorticoid (nL CK)
2) Statin (+CK)
3) Hypothyroid
Normal CK:
1) Glucocorticoid
2) PMRheumatica
Elevated ESR:
1) POLYMYALGIA RHEUMATICA
2) inflammatory (dermatomyositis, polymyositis)
1) GIM - painLESS, LE first; nL labs
2) PMR - painful, resp. to steroids; ^ESR
3) Inflammatory myositis - proximal, TtPalp, may have rash assoc.; ^BOTH
4) Statin & hypothyroid; muscle pain, weakness, +/- rhabdo; nL ESR, ^CK
Patient with parkinsonism, impotence, orthostatic hypotension, incontinence, and other autonomic dysfunction
some ddx considerations
Multiple System Atrophy (Shy Drager Syndrome)
triad:
1) parkinsonism/cerebellar ataxia
2) dysautonomia/urogenital dysfxn
3) pyramidal signs
tx. fludrocortisone, alpha-agonists, salt supplements, constrictive garments in LL
Riley-Day syndrome - AR, ashkenazi children, dysautonomia/orthostasis
DM if longstanding can cause autonomic neuropathy but not just with 6 months
What is the pathophysiologic triad of Multiple System Atrophy (aka what are the “systems?”)
1) striatonigral degeneration
2) dysautonomia (shy-drager)
3) olivopontocerebellar atrophy
Myasthenic Crisis vs MG-cholinergic crisis
How to differentiate this similarly-presenting things?
a) you know
vs
b) pt w/ MG on AChEi with
Edrophonium (short-acting AChEi) test: a) will improve, b) will worsen
Approach to:
A) MYASTHENIC CRISIS (5 and justification)
B) MYASTHENIA GRAVIS
A)
1) ABC/intubate if necessary
2) d/c AChEi (decrease airway secretions)
3) PLASMAPHERESIS preferred over IVIG bc of its faster onset
+4) initiate immunomodulators (prednisone, azathioprine, mycofenolate mofetil, cyclosporine, tacrolimus)
B)
1) Pyridostigmine
2) Prednisone
- other immunomodulators if refractory
3) Thymectomy if less than 60y
Presentation and Explanation for central (intracranial lesion) vs peripheral (Bell’s palsy) facial nerve palsy?
[don’t forget Ramsay Hunt (herpes zoster oticus) can also cause Bell’s Palsy]
Central (stroke, tumor, ischemia, etc.): forehead sparing (because there is BL UMN innervation of forehead by CN7; therefore if it's affected, the contralateral side will compensate)
Peripheral (Bell’s):
- forehead affected (bc UniL LMN innervation; therefore if it’s affected, there’s no CL innerv. to compensate)
- hyperacusis (denervation of stapedius)
unique in Bell’s = saggy brow/forehead + ptosis + inability to close eye + loss of taste
ADRs
a) Amantadine
b) dopamine agonists
c) selegiline
a) ankle edema, levido reticularis
b) somnolence, confusion, hypOtension
c) insomnia, confusion
COLD-RELATED ILLNESS
3 categories and tx for each
mild, moderate, severe
tx all with warmed IV fluids -AND-
a) mild:
INCREASED shivering, tachycardia, tachypnea
90-95F [32-35C]
-Passive EXTERNAL warming (remove wet clothes)
b) moderate:
DECREASED shivering, bradycardia, hypoventilation
82-90F [28-32C]
-Active EXTERNAL warming (warm blankets, heating pads, warm baths)
c) severe:
coma, shock, arrhythmias
v82F [28C]
-Active INTERNAL warming (warmed peritoneal/pleural irrigation, warmed humidified oxygen)
Approach/heirarchy to Hyperemesis Gravidarum (severe naus/vom in preg)
1) Doxylamine-Pyridoxine
(D-P=diclegis, D=unisom, P=vit B6)
+ginger
+hydration
2) add anti-H or anti-5-HT3 (diphenhydramine, meclizine, dimenhydrinate, ondansetron)
3) add anti-Dop (prochlorperazine, metoclopramide); methylpred taper and chlorpromazine if extreme w/ dehydration
[remember to replete fluid, elec, + thiamine (B1)]
AMS in HIV patient w/ Ring-Enhancing lesion(s)
Ddx (2)
compare/contrast
1) Cerebral Toxoplasmosis
- usually multiple spherical lesions in basal ganglia
- pos. Toxo serology is common in USA and therefore non-specific
- shouldn’t be Toxo if pt is on TMP-SMX
2) Primary CNS Lymphoma
- usually SOLITARY, PERIVENTRICULAR
- !!! pos. EBV DNA in CSF is specific!
Peds: cmV periventricular, toXo scattered thru corteX
1) Torus Palatinus
Px?
Tx?
2) Nasopharyngeal SSC
- Path?
- Epid.?
- px
- Dx?
- Tx?
1)
Fleshy exostosis of the hard palate in a young person; painless
No tx necessary, surg if interfering
2)
- EBV infection!
- China, Mediterranian
- Biopsy + MRI
- classic: neck mass, epistaxis, recurrent otitis media 2/2 eustacian tube dysfnx; common: headache, neck mass, CN involvement
- radiation
Pt on warfarin:
1) What things would potentiate bleeding/supra-therapeuticity
2) Clotting/sub-therapeuticity?
1) CYP inhibitors: (anti-coagulant)
- ACETAMINOPHEN
- nsaids
- amiodarone
- cimetidine/omeprazole
- cranberry juice/vitE
- thyroid hormone
- SSRIs
- abx/antifungals (metronidazole)
2) CYP inducers: (pro-coagulant)
- vit K (ginseng, spinach, brussel sprouts)
- carbamazepine
- OCP
- phenobarb
- rifampin
- St. John’s wort
Neurocardiogenic Syncope (vasovagal)
3 causes?
NBS (2)
Emotion distress, painful stimuli, prolonged standing
NBS: clinical dx, but in uncertain cases
TILT-TABLE TESTING
THORACIC TRAUMA
General approach? (ABC+3) [theres a separate card]
a) aortic injury (3) vs myocardial contusion
b) bronchial rupture (3)
c) pericardial tamponade (3)
d) pulmonary contusion (MC after blunt)
e) diaphragmnatic rupture
1) ABCs
2) Trauma Resuscitation (FAST, AP supine CXR, EKG)
3) Specific tx:
i) pneumothorax [v breath sounds unilat.] - needle (2nd ICS) THEN tube thoracostomy (5th ICS)
ii) hemothorax [CXR signs] - tube thoracostomy
iii) pericardial tamponade [U/S showing pericardial effusion] -pericardiocentesis
4)
i) Chest CT (preferred)
ii) angiography/aortography (if CT is equivocal)
iii) TEE (if unstable)
iv) ED thoracotomy (if pulseless or Chest Tube output +20 mL/kg)
a) LEFT-hemothorax, RIGHT-deviation of mediastinum, DEPRESSION of left main bronchus; widened mediastinum [otherwise hypotension, AMS, trauma signs]
-vs-
NO MEDIASTINAL WIDENING!
b) SubQ Emphysema, pneumomediastinum, pneumothorax refractory to chest tube placement
c) ^JVP, hypotension, tachycardia; REFRACTORY to fluid resuscitation
d) hypoxemia WORSENED by IVF + resp. distress s/p blunt trauma
e) herniation of abdominal contents into thoracic cavity; NG tube in the thorax is diagnostic
General Approach to THORACIC TRAUMA
ABC+3
1) ABCs
2) Trauma Resuscitation (FAST, AP supine CXR, EKG)
3) Specific tx:
i) pneumothorax [v breath sounds unilat.] - needle (2nd ICS) THEN tube thoracostomy (5th ICS)
ii) hemothorax [CXR signs] - tube thoracostomy
iii) pericardial tamponade [U/S showing pericardial effusion] -pericardiocentesis
4) Remaining algorithm:
i) Chest CT (preferred)
ii) angiography/aortography (if CT is equivocal)
iii) TEE (if unstable)
iv) ED thoracotomy (if pulseless or Chest Tube output +20 mL/kg)
NBS in clavicular fracture with bruit?
General management of clavicular frxr
a) middle 1/3 (MC)
b) distal 1/3
-angiography to r/o subclavian and plexopathic injury
a) bracing, rest, ice (closed reduction with figure eight brace)
b) ORIF (open reduction, internal fixation)
Alternative names for each.
Anatomical divide?
Tx?
Compare and contrast preseptal and orbital cellulitis presentation
MC predisposition for pOstseptal Orbital cellulitis?
APPROACH
Headache +/- proptosis +/- CN3,4,5,6 palsy
= cavernous sinus thrombosis!***
PrEseptal pEriorbital cellulitis vs pOstseptal Orbital cellulitis
anterior to orbital septum vs posterior to orbital septum
outpatient oral Abx vs inpatient IV Abx
Seen in both:
- eyelid tenderness, erythema, and edema
- fever, leukocytosis
Unique to pOstseptal Orbital cellulitis:
- diplopia
- ophthalmoplegia
- pain with extraocular eye movements
- proptosis
- vision impairments
Bacterial Sinusitis
--- Orbital: 1) CT head to confirm 2) Empiric Abx (staph, strep pneumo) IV Vanc + one of the following -pip/tazo -amp/sulbactam -ceftriaxone -cefotaxime
Periorbital: 1) if SUSPICIOUS OF orbital, CT head to r/o 2) Empiric Abx (staph, strep pneumo) PO Clinda +/- TMP-SMX + one of the following -amox -amox/clav -cefdinir -cefpodoxime
Iron (tx?) vs Lead poisoning
1) characteristics (3 each)
2) tx for Fe poisoning
Approach to LEAD poisoning (1,2abc)
Iron poisoning: hematemesis, acidosis, hypovolemic shock, tx deferoxamine
Lead poisoning: anemia, poor appetite, headaches, ab pain, irritability
suspect LP/risk factors? then:
1) VENOUS lead level
2) stratify and NBS:
a) v44 mcg/dL: no tx; repeat levels in 1 mo.
b) 45-69 mcg/dL: tx DMSA (dimercaptosuccinic acid) or succimer
c) 70+ mcg/dL: tx EDTA (british anti-Lewisite) + dimercaprol (Ca di-Na edetate)
IMMUNODEFICIENCIES
[lymphocytically nL unless otherwise specified]
Humoral Immunodef.:
2) IgA def.
a) labs
b) assoc.
c) presentation/manifestation (labs, asoc., px) (3)
3) hyper-IgM vs transient hypogammaglobulimenia of infancy
4) CVID
5) DiGeorge px
i) Bruton’s X-linked agammaglobulinemia vs CVID
ii) Kid has low CD19 cell count but normal CD3. Dx? Tx for maintenance therapy?
*SCID=ADaDef?
CGD… burkholderia and the weird combos.
NTZB test… does NOT turn blue= CGD
1) TEA-TIME
T-cell dysfunction Hyper IgE, A Thrombocytopenia (impaired platelet production) Infection (otitis media) LOW IgM Eczema
2)
a) ABSENT v50 IgA, NORMAL IgM!
b) assoc. w/ anaphylactic rxn; need washed transfusion!
c) recurrent sinopulmonary, Gi, uro infxns
3)
a) ^IgM, LOW IgG, IgA
4) NORMAL B CELLS BUT DECREASED !OUTPUT of B cells
5) Neonate w/ hypocalcemic seizures and “cardiofacial” defects
i) Bruton’s (BOYS, XLINKED) has reduced B-cells (tyrosine kinase issue) while CVID does not. They both can have low [Ig] however. Bruton’s earlier in life and boys.
ii) Bruton’s X linked (bc low B cells and normal T cells).
Tx. IVIg
What is the def./level of acet. poisoning
Approach to acetaminophen poisoning. (“3”)
7.5+g dose or 150+mg/kg peds
pre) CHARCOAL (gastric decontamination) [if v4 hrs]
1) check Acetaminophen level
2) NAC [if 10+mcg/mL or ^nomogram]
Effects of HCTZ?
Define the triad of metabolic syndrome
HYPERGLYCEMIA, hypertrigliceridemia, hyper-LDL
HYPERCALCEMIA, hyponatremia, hypokalemia
[via K+ channel potentiation in the pancreas, INHIBITING insulin release]
1) HTN 2) dyslipidemia (^TGL, ^HDL, [^fast Glu]) 3) abdominal obesity
HEART BLOCKS
a) 1st. tx (2)?
b) 2nd (2)
c) 3rd
d) complete. tx?
a) first degree [delayed conduction thru AV node]
- ^PR interval
- (a?) P always follows QRS!!! (unlike other blocks)
tx - normal QRS: reassure; prolonged QRS: electrophys testing
b) second degree
- mobitz 1 [Wienkiebach]- dropped QRS!, increasing PR, decreasing RR, constant PP
- mobitz 2 - 2:1 P:QRS (2p’s before each QRS) [seen in RCA occlusion bc AV nodal artery] {inferior MI}
c) complete 3rd degree AV block
- no P w/ QRS!
- needs a reentry circuit, otherwise death (escape rhythm)
- tx temporary pacemaker
Ascending Thoracic Aortic Aneurysm vs
Descending pathophys?
how to reduce risk of CCB-induced peripheral edema? Pathophys?
a)
- cystic medical necrosis (aging)
- 2/2 Ehlers-Danlos, Marfans
b) atherosclerosis
a) PRECAPILLARY (arterial) preferential dilation by CCB leads to edema
b) POSTCAPILLARY (venous) preferenial dilation by ACE/ARB to mitigate
Indications for URGENT hemodialysis?
AEIOU
Acidosis (metabolic) - pH v7.1
Electrolytes - K+ ^ 6.5 or symptomatic [remember, insulin+glucose is the fastest way though]
Ingestion
- alcohols
- lithium/valproate/carbamazepine
- ASA
Overload (fluid overload refractory to diuretics)
Uremia
- uremic pericarditis
- uremic encephalopathy
- bleeding
HYPERTHYROIDISM (ACUTE)
Initial Approach To Thyroid STORM (def a, b, c)
overall strategies (6)
agents (what are the 3 settings you’d ever use PTU?)
a) In a pt with longstanding hyperthyroid (Graves, Toxic Adenoma, Toxic Multinodular Goiter),
b) sometimes after a precipitating event (surgery, trauma, infection, acute iodine load)
c) showing evidence of:
1) Biochemical hyperthyroidism +
2) signs of life threat (high output CF, hyperpyrexia, AMS, etc.)
[also can have n/v/ab pain, ophthalmopathy, lid lag, tremor, moist/warm skin]
1) reduce adrenergic tone
2) block new synthesis
3) block release
4) block peripheral conversion from T4 to T3
5) promote vasomotor stability and tx concomitant adrenal insufficiency
6) decrease enterohepatic recycling of thyroid hormone
First!: (1-2 are for IMPENDING storm aka severe thyrotox; 3-4 are added if storm)
1) beta-blockade (propranolol!, atenolol if reactive airway?)
2) thionamide (PTU blocks periph conversion, methimazole does not)
a) PTU (if ICU, first trimester, or refract to radioablation and methimazole)
b) otherwise METHIMAZOLE bc longer half life and less tox
3) hydrocortisone
4) cholestyramine
ONE HOUR LATER:
- iodine**
Long term:
- radioablation
What type of shock gives you a LOW mixed V02?
High? Why?
nL PCWP, high RAP and high PAP. D?
Low = hypovolemic (2/2 vperfusion and increased 02 extraction)
High = septic shock
both have low PCWP and low right atrial pressures
acute massive PE!
PULMONARY HYPERTENSION
Approach?
1) Echo
2) Right Cath
3) Graded Exercise improves mortality; Lung Transplant is curative!
4) Pharm based on etiology:
a) sympomatic idiopathic:
- epoprostanol, sildenafil, bosentan
b) 2/2 left ventricular failure:
- ACE/ARB, diuretic
c) 2/2 hypoxemia from chronic lung dz:
- oxygen, bronchodilator
d) 2/2 chronic thromboembolic occlusion of pulmonary vasculature
- long term anticoagulation
SYNCOPE CLASSIFICATION
1) Neurocardiogenic (vasovagal, reflex mediated, situational)
2) Orthostatic Hypotension
3) CARDIAC (brady/tachyarrhythmia, structural HD)
Expound upon Cardiac Arrhythmia EKG findings in syncope (6)
sinus bradycardia sinus pauses SA block AV block Nonsustained v-arrythmia short or long QTc
ACUTE CORONARY SYNDROME!
- (3) conditions
- initial approach (~9)
- post-EC approach (a, b)
- possible preferred regimens (3-5)
a) STEMI
i) +1 mm in 2 contiguous leads
ii) +2 mm in V2 and V3
iii) new LBBB + signs of ACS
b) NSTEMI / Unstable Angina (+biomarkers / -biomarkers)
i) ST-depression, deep T-wave inversion
Initial EC Approach:
1) ABCs, Heart/O2 Monitors, IV access, serial EKGs, supp. O2 goal SaO2 90+
2) Aspirin 325 mg
3) CBC, BMP, Troponin, Coag studies
4) 3 Nitro (IF! chest pain, CHF, HTN) [NOT IF! aortic stenosis, sildenafil user]
5) Tx Left Heart Failure with (Nitro, Furosemide, BiPAP)
6) Metoprolol [NOT IF! asthma, bradycardia, CHF, cocaine]
7) Morphine (IF! chest pain, anxiety)
8) IV atropine (IF! unstable sinus bradycardia)
9) Atorvastatin
*STEMI treatment for Licensed Physicians (post-EC):
1) Coronary Reperfusion (within 12 hours of symptom onset)
i) Percutaneous Coronary Intervention (PCI) [preferred]
- within 90 min. of presentation to EC
- within 120 min. of first medical contact (EMS)
ii) Fibrinolysis (tenecteplase) [if PCI not possible]
- within 30 min. of first medical contact
2) anti-PLATELET [aspirin + (clopidogrel, ticagrelor, prasugrel)
3) anti-COAGULANT [Heparin, Bivalirudin] {Enoxaparin, Fondaparinux}
- NSTEMI treatment w/ high TIMI score (post-EC):
1) Diagnostic Angiographic Catheterization
2) Revascularization
i) Angioplasty + Stent (PCI) [1 or 2 vessel disease]
ii) Coronary Artery Bipass Graft (CABG) [3+ vessel disease]
3) anti-PLATELET [as above +/- eptifibatide, tirofiban, abciximab}
4) anti-COAGULANT [as above] {as above}
possible preferred regimens
- aspirin + ticagrelor + heparin
- aspirin + prasugrel + heparin
- aspirin + clopidogrel + bivalirudin
{in NSTEMI, +/- eptifibatide, tirofiban, abciximab to above regimens}
{replace heparin/bivalirudin with enoxaparin or fondaparinux if patient underwent fibrinolysis for STEMI or noninvasive angioplasty for NSTEMI}
Initial tx in Central Retinal Artery Occlusion
ArMD vs Open-Angle Glaucoma
Ocular massage + high flow O2
“pharm D” peripheral vision vs “OPEN ANUS!” TUNNEL vision
OR!!!! central vision loss vs peripheral vision loss
IUFD definition
Best confirmatory test for IUFD?
NBS after induction of labor and delivery of fetal parts?
NBS in IUFD with mother with low finbrinogen?
HELLP syndrome?
NBS in person with fat necrosis of breast?
after 20 weeks gestation but before onset of labor
(otherwise abortion?)
dx - real time ultrasonography (absence of fetal cardiac activity)
Autopsy of fetus to determine cause and help prevent/guide future
Induce labor and deliver, now. (avoid frank DIC)
Same
Observation, self-limiting
Name the 2 differences between threatened abortion vs inevitable abortion
threatened: closed cervix, FETAL CARDIAC ACTIVITY
inevitable: dilated cervix, NO CARDIAC ACTIVITY
threatened ab. is any bleeding
Triad of Uterine Rupture
tx?
- abdominal pain
- fetal HR abnormalities (variable decels)
- recession of the presenting part of the fetus (loss of fetal station)
tx emergency c-section to avoid exsanguination
Ddx for Low DLCO (9 total)
General sequence in managing vent for ARDS (2)
Obstructive (FEV1:FVC v70):
- Emphysema!
- Bronchiectasis? (2/2 CF, post infx, A1ATd, toxic, etc.)
Restrictive (FEV1:FVC ^70):
- Asbestosis
- Sarcoidosis
- Heart Failure
- ILD!!!!!!!!!m
Normal Spirometry:
- Anemia
- PE
- pHTN
1) Decrease FiO2/decrease RR (if alkalotic?)
2) increase peep
Quick review of LUNG CANCER
(4)
- location + hist
- population
- paraneoplastic
MC overall?
RFs?
a) Squamous, central +necrosis, smoker, PTHrP
b) Small cell, central, …., LEMS/ACTH/SIADH
c) AdenoCA, peripheral + a-Sx solit. nodule, nonsmoker/women, clubbing, hypertrophic osteoarthropathy
d) large cell, peripheral, …, gynecomastia/galactorrhea
e) pancoast = superior, C8/T1, horners, (superior sulcus syndrome?)
adeno MC overall aka nonsmall
smoking RF for squamous, small, and large.
OBSTRUCTIVE LUNG DISEASE!
Approach to:
A) asthma (w/categories?)
- What are signs of “impending respiratory failure? (4)”
B) asthma exacerbation
C) COPD
D) COPD exacerbation
Peds?
A) asthma
B) asthma exacerbation
1) PEF (or FEV1)*
a) +40% = mild/moderate
b) -40% = severe
c) (impending) respiratory failure
2) Initial Treatment
a) O2 + SABA + PO steroid (refract or recent steroid use)
b) O2 + SABA + ipratropium + PO steroid
c) intubate/BiPAP? + O2 + SABA + ipratropium + IV steroid (+/- mag, epi, terbutaline)
3) Reassess PEF
a) +70% = good response
b) 40-69% = incomplete response
c) -40% = poor response
4) Dispo
a) home
b) floor
c) ICU
- INCREASE in CO2 (2/2 resp. muscle fatigue, loss of tachypneic drive, decreased breath sounds/absent wheezing, AMS, hypoxia/cyanosis
(adult?) w/ recurent bact infx. in multiple locations. NBS to establish dx?
vs
recurrent infx in SAME location. NBS?
—-
new-onset blood-tinged sputum, afebrile. nbs? dx?
MC cancer in asbestos exposure
serum Ig level (quantitative)
-establish Humoral immunodeficiency as dx
vs
CT chest
-establish BRONCHIAL OBSTRUCTION (2/2 cancer?)
—
Observation, as long as there isn’t sign of PNA or malig or RF
acute bronchitis 2/2 virus
–
BRONCHOGENIC CA (works synergistically w/ smoking)
mesothelioma CAN happen but isn’t MC
Hypertrophic Osteoarthropathy vs Digital Clubbing
What else can you see (single digit?) clubbing in?
aspiration pneumonia vs aspiration pneumonitis
Digital Clubbing - widening of the distal digits that often signifies underlying malignancy; path: VEGF^
(NOT seen in COPD!)
Hypertrophic Osteoarthropathy (pulmonary subtype) = clubbing + arthralgia
AVMs! like osler-weber-rednu, etc. (papules on the lips)
–
days vs hours
abx vs spportive
oral flora/anaerobes vs gastric content
GI BLEED
Approach:
GENERAL RESUSCITATION?
A:
Upper GI Bleed (melena)
B:
Lower GI Bleed (hematochezia/BRBPR)
1) O2, establish IV
2) 1L 0.9 NS /hr +/- pantoprazole to prevent coag protein degradation
3) pRBC
- unresponsive to 2L NS?
- Hgb v7 in stable/healthy
- Hgb v9 in unstable/comorbidity
4) Reverse coagulopathy
a) d/c anticoagulant meds
b) FFP if INR ^ 1.5; IV vit K
c) Platelets if v50,000 (active bleed) or v10,000 (spontaneous bleed risk)
A:
UPPER GIB
B:
LOWER GIB
1) consider upper
2) investigate lower
3) treat
1) ABCs, CBC/CMP/Coag, type/cross
2) First consider UPPER Bleed source
a) NG Aspiration
i) + bile, - blood = pylorus open and NO UPPER BLEED!
ii) + coffee ground/blood = YES upper GIB (assuming pylorus open)
iii) no blood or bile = indeterminate
* ii or iii, do an upper endoscopy. i, continue:*
[basically, you want bile, otherwise the results are useless bc the pylorus could be closed and there still could be upper bleed]
3) COLONOSCOPY
4) no? then arteriography (+/- tagged RBC radionucleide to localize)
5) no? evaluate small bowel will pill endoscopy or duodenoscopy
SCREENING/USPSTF
*sentences:
HIV and cervical stop at 65y
colon, breast, AAA stop at 75y
aspirin and Lung CA ct stops at 80y
odd:
if UC/or Chron’s, 8 yrs later begin colonoscopy q1-2 years
USPSTF:
1) Colonoscopy 50-75y;q10, q5 sig q3FOBT, qY FOBT
- high risk 40 or 10 prior to fam dx; q5
2) Aspirin 81
- Males: 45-79y for MI
- Female: 55-79y for ischemic stroke
3) AAA - 65-75y if ever smoked
4)
a) MALE Cholesterol screen
- 35+y
- 20-35y if high risk for HD
b) FEMALE Cholesterol screen
- 45+y
- 20-45y if high risk for HD
5) Hep C baby boom (1945-1965), IVDA, transfusion v’92
HIV screen OFFER to pts v65y or high risk
Chlamydia v25y sexually active or high risk
6) Lung CA
- low dose CT 55-80y, 30pack-year, quit in last 15 yrs, reasonably willing to get surg
7) Cervical CA
- PAP cytology 21-65 q3
- PAP + HPV DNA 30-65 q5
8) Mammography (50-75) q2
DEXA 65+
Vaccines:
- TdaP 11y, Td q10y thereafter
- HPV 11-26y female, 11-21y male [can be 9]
BILIRUBIN physiology/metabolism
Explain the significance of these findings:
a) + urine bilirubin
b) + urine URObilinogen
c) DARK URINE (2)
d) the only 2 things with ISOLATED conjugated bili
a) CONJUGATED buildup [you’ll have to see unconj too, tai?]
- implies post-hepatic (aka obstructive jaundice)
- ex. pancreatic CA, choledocholithiasis, etc. intrahep cholestasis, hepatitis. [dubin john, rotor]
b) UNconjugated buildup
- implies pre-hepatic
- ex. hemolysis, Gilbert/CNajj, intrahepatic chol of preg
c)
i) increased UROBILINOGEN
ii) increased urine BILIRUBIN
d) Dubin johnson, rotor
Consequence of untreated hyperthyroidism
In creased bone marrow iron seen in what 3 things?
Increased bone loss
Siderblastic anemia, Anemia of chronic dz, Hemachromatosis
Epigastric Tenderness, EGD reveals pyloric mass. Biopsy reveals MALT.
tx approach?
-
Palpable cervical lymph node. Dx? NBS?
1) “triple therapy” to eradicate H. Pylori
- amoxicillin
- clarithromycin
- omeprazole
2) Combo chemo if refractory (CHOP+ bleomycin)
- cyclophosphamide
- adriamycin
- vincristine
- prednisone
- bleomycin
SSC of head/neck. (hx alchohol, tobacco) Panendoscopy (triple endoscopy) - esophagoscopy - laryngoscopy - bronchoscopy
Euthyroid Sick syndrome?
“Low T3 syndrome” with nL TSH
What are 4 “androgens” (3 pro-androgens, they don’t actually interact with the andr. receptor) that are found in females?
Which one is most specific for adrogen-producing adrenal tumors?
1) Testosterone
2) Androstenedione
3) DHEA
4) DHEA-S* [suggests adrogen-producing adrenal tumor]
Hypopituitarism vs Primary Adrenal Insufficiency
1) “triad” of hypopituitarism
2) compare with PAI
1)
a) (secondary) adrenal insufficiency- glucocorticoid deficiency (2/2 low ACTH, low cortisol)
- low appetite, hypoglycemia, hyponatremia, eosinophilia; PALLOR (2/2 low MSH)
b) hypogonadism (2/2 low LH/FSH, low testosterone)
- low T, low libido, ED (women: amenorrhea, infertility)
c) (central) hypothyroidism (low TSH, low T4)
- cold intolerance, constipation, bradycardia
2) ALDOSTERONE is NORMAL IN HYPOPITUITARISM (2ndary adrenal insuff.) because aldosterone is regulated by RAAS, but in primary, it’s just not produced
DM/hyperglycemia with papules on face and limbs, + weight loss, diarrhea, anemia
Dx?
Glucagonoma with (necrolytic migratory erythema)
Glucagon +500 is dx
UTI Patient’s urine stains + for Prussian Blue.
Path?
Dx?
Happens in HEMOLYSIS (+hemosiderin)
likely 2/2 G6PD def.
exac. by recent infection, fava beans, sulfa/antimalarials/nitrofurantoin that creates OXIDATIVE STRESS [nitorfuratoin, TMP-SMX! for uti!]
REVIEW: G6PD creates reduced glutathione which protects the RBC. Otherwse, you precipitate out heinz bodies
Ddx for thyrotoxicosis + low RAIU uptake (5)
1) painless thyroiditis
2) granulomatous thyroiditis (painful, DeQuervain’s)
3) iodine-induced thyrotoxicosis
4) levothryoxine overdose
5) struma ovarii (ovarian tumor that secretes thyroid hormones)
SUSPECT acromegaly. NBS? Subsequent tests?
MC cause of death in acromegaly?
Concurrent GI+ CNS sx (2/2 hypoNa). Suspect…
NEXT BEST STEP IS FIRST GET IGF-1 LEVEL!
- Failure to suppress GH after glucose tolerance test is diagnostic of acromegaly!
- Failure to elevate GH after insulin stimulation test is diagnostic of CHRONIC hypopituitarism
Legionaire
ADRENAL WORKUP
a) Cushing (4 steps)
b) Addison
c) Conn’s
A:
Px - cushingoid (either from ACTH drive or primary cortisol^)
i) r/o exogenous glucocorticoid use
ii) confirm hypercortisolism
- 24 hour urine
- low dose dexamethasone suppression
- PM cortisol
iii) ACTH-INdependent vs ACTH-dependent
iv) localize source
1) 24 hour urine cortisol? L-DDSt, PM cortisol
2) ACTH level
a) low = INdependent = feedback intact
b) high = dependent = feedback not intact
3) Localize
a) Adrenal CT
b) Pituitary MRI (+ high dose dex and CRH, yielding + suppression and ^ ACTH) = Cushing’s DISEASE
4) if b is negative: inferior petrosal sinus sampling, +central step up = Cush Dz
5) if no, or if high dose dexa is NEG, then ECTOPIC ACTH lung
B:
Px - signs of adrenal insufficiency (hypotension, HYPERPIGMENT, hyponatremia, hyperkalemia, eosinophilia, fatigue, NAGMA)
1) AM urine cortisol (pend ACTH, takes forever)
a) low cortisol, HIGH ACTH = primary AI
b) low cortisol, LOW ACTH = secondary/tertiary (central) AI
2) COSYNTROPIN stimulation (cosyntropin = ACTH analog)
- pos. response = rise in cortisol
a) + = NOT primary AI (rules it out)
b) - = primary AI
3) tx
a) MRI + tx cortisol
b) tx cortisol AND fludrocortisone (ald?)
C:
Px - hypertension and hypOkalemia
1) aldo:renin
a) aldo^, ratio +20, aldo +15= primary hyperaldosteronism
b) aldo^ renin^ ~10 = secondary hyperaldosteronism
c) vAldo, vRenin = other (CAH, Glucoc. resistance, exogenous, cushing’s)
2)
a) Adrenal CT; then adrenal vein sample, petrosal sample?
Workup for general HYPERTHYROIDISM
1) TSH, FT4
a) FT4^, TSH^ = secondary, MRI the pituitary. Done.
b) FT4^, TSHv = primary
2) R/o Graves clinically
3) RAIU
a) High = de novo synthesis
- nodular = toxic adenoma, multinod. goiter
- diffuse = Grave’s
b) Low = exogenous (will see low thyroglobulin!)
4) if low (b), measure Thyroglobulin (Tg)
a) high = thyroiditis, iodine-exposure
b) low = exogenous! (factitious)
*low Tg bc not made in the body!
Carcinoid Syndrome nutrition def? pathophys?
Niacin (pellagra: 4d’s dermatitis, dementia, diarrhea, death)
Carcinoid tumor cells use up tryptophan (from niacin) to produce serotonin
[degradement if pre-hepatic or whatever? something from pathoma?]
NEPHROPROTECTION
(what does this cause and how to prevent)
a) acyclovir
b) transplant
c) radiocontrast-induced allergy
d) tumor lysis syndrome
a) cystalline AKI (ppx IVF)
b) tender transplant, autoimmune attack? (ppx corticosteroids)
c) steroids (IVF?) [NAC?] non-ionic contrast!
d) urate crystal nephropathy (ppx allopurinol)
HYPONATREMIA ddx
alternatively:
1) “Is there high serum Osm? +290;
- hyperglycemia or RF
2) “Is there low urine Osm? -100;
- primary polydipsia or beer potomania (malnutrition)
3) “no? Ok then what about Urine Na+ ^ or v25?
- ^ means SIADH, AI, hypothyroid
- v means CHF, Cirrhosis, volume depletion
1) EuOsmolar
a) 2/2 hyperproteinemia, hyperlipidemia
2) Hyperosmolar
a) 2/2 hyperglycemia, mannitols
3) HypoOsmolar
a) Euvolemic
i) urine osm ^than serum osm = SIADH
ii) urine osm and serum osm both decreased = polydipsia/beer potomania
b) Hypervolemic - CHF, nephrotic syndrome, liver fail
c) Hypovolemic
i) renal salt loss = diuretics, ACE, mineralocort. def.
ii) non-renal salt loss = diarrhea, emesis, dehydration
MC Cause of
a) AA Amyloid
b) AL Amyloid
Composition of each?
a) RA
b) MM…. waldenstrom
a) Beta-2 microglobulin, apolipoprotein, transthyretin
b) light chains (lambda) [beta 2 microglob?]
Interstitial cystitis
px?
NBS in new-onset lupus nephritis?
Polymyositis vs Fibroyalgia dist. and tx
Vertebral point tenderness. suspect? (3)
Dyspaeunia; bladder pain improved with voiding exac. by filling
Kidney biopsy
OBJECTIVE weakness vs arthralgia
prendisone vs amitriptyline etc.
1) compression frxr, esp. in older woman w/ osteo. (can be asx, loss of stature, etc.)
2) -OR- spinal cord compression (if picture fits; hx mets) -
3) or vertebral osteoyelitis (if fever)
vs
Lumbosacral strain with paraspinal tenderness
ISOLATED ^alk phos? what other labs?
2 dx?
alternate name?
MC px of this dz?
tx?
Paget's dz bone (osteitis deformans) - urine hydoxyproline - urine C/N-telopeptide - urine pyridinoline [above are markers of bone breakdown]
{also consider MAC esp. if CDv50 and HIV+}
ASYMPTOMATIC!
tx - NEED ADEQUATE VIT D!
w/ NITROGEN-containing bisphosphonates
(IV zoledronate, IV pamidronate)
[bc PO is poorly absorbed]
acetaminophen or NSAID for acute phase of tx
ADR - osteonecrosis of jaw
Calcitonin only if intolerant to above
Rotator Cuff Tendinitis/Impingement (overuse) vs TEAR (foosh)
Lidocaine injection will IMPROVE pain/ROM in rotator cuff tendinitis/impingement, but NOT IMPROVE those pain/weakness in a tear
Pain and guarding during Neer’s Test (passive motion of arm above head) vs Positive drop arm 90 degrees
Foosh/trauma vs overuse
dx tear w/ MRI
RA vs Viral Arthritis
etiology
px
time
path/markers
autoimmune vs Parvovirus b19
morning stiffness +30 min vs v30min
lasting +6 wks vs resolving within 6 weeks
arthroedema and ^inflammatory markers vs none
Sample Items: USMLE
1) Empiric tx for CAP!? (outpatient)
2) Isolated ^GGT ddx? b) Decreased?
3) inclusion bodies on renal transplant biopsy? tx?
4) Bladder mass w/ Acute urinary retention. nbs?
1) First MACROLIDE +/- doxycycline
2) EtOH! phenytoin phenobarb
b) vOCPs, clofibrates
3) CMV tx ganciclovir
4) cath (but scan first? question didn’t have that option)
MC cause of Tinea Versicolor? Tinea Corporis?
What is herpetic whitlow?
Pemphigus Vulgaris vs Bullus Pemphigoid
a) malasezzia GLOBOSA!!!!!!!!
b) Trichophyton Rubrum (confirm hyphae on KOH, tx topical terbinafine, griseofulvin if refractory)
- def. ring shaped scaly patches w/ central clearing and clear borders
Dentist who comes in contact with infected orotracheal secretions (HSV1/2); px throbbing non purulent vessicles on finger; self-limiting
First appears in ORAL MUCOSA; Painful FLACCID blisters, +Nikoslky’s sign, auto-IgG against desmoglein, IF shows IgG deposits intercelllularly in the epidermis; tx steroids +/- azathioprine, methotrexate
vs
Pruritic TENSE blisters; IF shows IgG and C3 deposition in the dermal-epidermal jxn
4 Causes of Priapism. MC drug?
MC DRUG IS PRAZOSIN! (classic assoc. is Trazodone)
1) sickle cell, leukemia (adolescents)
2) trauma (2/2 laceration of the cavernous artery)
3) neurogenic (spinal cord, cauda equina)
4) drugs (PRAZOSIN, trazodone)
1) Flexural surfaces of the wrist and intertriginous areas, intensly pruritic, excoriations with crusted papules/pustules
dx
path
nbs
tx
2) Etiology of painful warts on the bottom of the foot
3) Painles blisters, hypertrichosis, hyperpigmentation assoc w/ Hep C and triggered by EtOH, estrogen, etc.
- best confirmatory test?
- tx for relief and comorbid?
4) Multiple pruritic erythematous papules that progress to severly pruritic serpiginous reddish brown lesions. Path?
Scabies! (can mimic eczema, seborrheic dermatitis, tinea)
path. sarcoptes scabiei,
confirmed w/ mites, ova, feces on microscopy
wash bedding, clothes and put in plastic bag for 3 days (mites can’t live away from skin this long)
tx. topical permethrin or oral ivermectin
–
2) cutaneous verrucae (plantar MC in young and immunodef.)
3) porphyria cutanea tarda!
- urinary porphyrin elevated
- phlebotomy or hydroxychloroquin may provide relief
- IFN-a can provide relief if HepC comorbid
4) sand with dog/cat hookworm larvae of ancylostoma braziliense
Condyloma Acuminata vs Condyloma Lata
EXPOUND upon prognosis/risk/tx
HPV (16/18) [mc STD in US!] vs 2ndary syphilis
verrucous papilliform lesions in anogenital area
vs
flattened pink or gray velvety papules in genitals or MOUTH
HPV increased SSC risk tx 1) trichloroacetic acid or podophylin 2) imiquimod 3) sx (cryosurgery, excision, laser)
PPD guidelines (3)
TB regimens
ADR!
Gram Stain of the following
a) TB
b) Actinomyces
c) Nocardia
PPD is positive when
a) +5 mm and HIV
b) +10 mm and “high risk”
c) +15 mm
a) active TB = RIPE 2mo + RI 4mo
b)
latent TB or ppx = 9 months B6+isoniazid
or = isoniazid + rifampetine qWeekly for 3 months (supervision)
- ethambutol = red/green color blindess and optic neuropathy
- isoniazid hepatotoxicity??? need f/u w/ LFTs. monitor neuropathy (B6 should help)
- -
a) NO GRAM (only acid fast)
b) NO ACID FAST (only gram + )
c) BOTH gram + and partially acid fast (+ filamentous, branching)
What should a transfusion undergo if the pt has had a febrile nonhemolytic transfusion rxn in the past?
Obese female who drinks alcohol. What is her biggest RF for osteoporosis?
Leukoreduction
EtOH!!!! Obesity is actually weight bearing and adipose yields estrogen which is osteoprotective
What are the symptoms of Disruptive Mood Dysregulation Disorder (DMDD)? What is the similar, less intense version of this?
Severe temper outbursts, verbal aggression,
persistent, unremitting baseline irritability
The outbursts occur an average of three or more times per week.
+1 year
Irritability is observed in at least two out of three settings (home, school,
with peers) and is severe in at least one of these locations.
The diagnosis can not be made prior to the age of 6, nor after the age
of 18.
Historical assessment finds that these symptoms were present prior to
the age of 10.
There has been no prior diagnosis of a mania or euphoric mood lasting
longer than 1 day.
The behaviors do not occur as a result of a major depressive or other dis-
order, such as anxiety, persistent depressive disorder, or posttraumatic
stress disorder.
vs Intermittent explosive disorder (3 months with remittance)
Reactive Attachment Disorder (RAD) vs Disinhibited Social Engagement Disorder
Criterion for both:
1) history of absence of adequate caregiving (social neglect) before the age of 5 that leads to inability to appropriately form attachments
2) child must be at least 9 months old
3) persistent if +12 month’s duration
RAD (anaclitic depression):
emotional withdrawal
limited positive affect
rarely seeks or responds to comfort when distressed
lack of basic trust
poor socialization/language skills
poor feeding, immunodeficient, failure to thrive
Disinhibited Social Engagement Disorder:
Reduced hesitancy in approaching and interacting with unfamiliar adults
overly familiar with strangers (that is inconsistent with age-appropriate behavior or culture)
Lack of concern about checking back with an adult caregiver, or wandering away without supervision
Willingness to go off with an unfamiliar adult with little or no hesitation
Hereditary Spherocytosis vs AIHA (2)
path of warfarin induced skin necrosis
+famHx, negative Coomb’s
vs
-famHx, POSITIVE coomb’s
Warfarin inhib. vit-K dep.: 10, 9, 7, 2, C, S
C and S are ANTI-coag
2,7,9,10 are pro-coag
protein C inhibited first; if underlying def., then there will be unopposed PROcoag from 27910, hence necrosis
4 labs in Tumor Lysis Syndrome
Watery to bloody diarrhea?
1) hypOcalcemia
2) hypERkalemia
3) hypERphosphatemia
4) hypERuricemia
hypocalcemia 2/2 phosphate binding and (release of intracellular products to which it also binds to?)
Watery to bloody diarrhea = E Coli (ehec?)
SYPHILIS
1) name the different stages (5, but 3)
2) px for each
3) tx for
a) non-allergic
b) allergic
1) Primary
- painless chancre
2) Secondary
- condyloma lata
- diffuse rash (on hands too)
- LAD
- oral, hepatitis
3) LATENT
- asx
[TX ^^^ IM Benzathine PCN; doxycycline if allergic]
4) Tertiary
- CNS: ARPupil, tabes dorsalis, dementia
- Cardio: Aortic aneurysms/insufficiency
- Skin: Gummas
[TX ^ IV PCN G; IV ceftriaxone if allergic]
5) pregnancy
- risk of transmission/congenital dz
[TX ^ PCN; desensitize + PCN if allergic]
HYPERTENSIVE DISORDERS OF PREGNANCY (4)
How to tx HTN in preg
140/90
1) Primary/preexisting HTN (v20wk or ^2wk postpartum)
2) Gestational HTN (^20wk)
3) Pre-E (^20wk+ proteinuria/end organ)
4) E (pre-E + grand mal)
Tx:
1) labetalol or methyldopa
2) hydralazine or CCB
3) clonidine, thiazides (less acceptable)
pre-E (add IV or IM Mag?)
AMENORRHEA
1) anovulation (2/2 to obesity and leading to co-PCOS?)
-FSH/LH normal
-estrogen normal
-progesterone LOW!
[no withdrawal bleeding bc no P; hence amenorrhea]
Kid with solitary lytic bone lesion (shoulder) with HYPERCALCEMIA
Langerhans Cell histiocytosis X (eosinophilic granuloma)
ddx hyperPTH but usually you’re older.
REPRODUCTIVE ENDOCRINOLOGY
1) Cliteromegaly, NORMAL INTERNAL genitalia, HIGH FSH/LH, LOW estrogen. Dx?
1) Aromatase Def.
2)
GENETIC PEDIATRICS
1) Friedreich ataxia. 3 neuro manifestations and cause? 4 non-neuro.
1) most common type of spinocerebellar ataxia
- ataxia, frequent falling, dysarthria (resulting from degeneration of the spinal tracts [spinocerebellar tracts, posterior columns, pyramidal tracts])
- HYPERTROPHIC CARDIOMYOPATHY [mc death] (90%), skeletal deformities (scoliosis, “hammer toes”), diabetes
Aplastic anemia vs aplastic sickle cell crisis
pancytopenia vs erythrocytopenia
labs (crisis?): severe anemia, low hemoglobin, LOWWWW reticulocyte
crisis: (transient arrest in erythropoiesis, typically due to parvovirus B19,
Patient with Grave’s Disease has a baby and the baby is low birth weight, tachycardic, irritable.
Dx?
Path?
Tx?
- Neonatal thyrotoxicosis
- anti-TSH receptor antibodies cross placenta and trigger hyperthyroid symptoms
- methimazole PLUS beta-blockade
Workup algorithm for amenorrhea
primary vs secondary def.?
Primary = absence of menarche at age 15
Primary: Start with pelvic U/S (uterus present?),
if yes, do FSH.
If that’s high, do karyotyping. If low, do MRI (pituitary/hypothalamic).
If uterus is absent, go straight to karyotyping (female w/ nL T, abN mullerian developmen vs male w/ nL T, androgen insensitivity syndrome.)
Secondary = absence for >3 cycles or >6 months
Always start with SERUM!!!*** (sens.) b-HCG (pregnancy),
then prolactin and TSH (prolactinoma or hypothyroidism)
then FSH and LH (asherman’s, ovarian failure, hypothalamic-pituitary disorders, etc.)
remember, MRI to confirm prolactinoma; hysteroscopy/hyperosalpingogram to confirm asherman’s
MISCELLANEOUS PEDIATRICS
1) “Erythema of the turbinates and nasal septum” suspect?
2) NBS in a baby born to HepB+ mother?
3) BP in Turner’s Syndrome (kid?) is adult different? idk
4) NBS in acquired torticollis?
5) Recurrable, predictable pattern of acute/frequent vomiting that resolves spontaneously, parents have a history of migraines. Dx?
6) RF+hearing loss?
1) Cocaine Abuse
2) give BOTH passive and active immunity (HBIG, HBV)
3) Upper extremities HTN, lower under-perfused.
4) XRAY neck to r/o dislocation/fracture
5) Cyclic vomiting syndrome
6) Alports
What percent fluid loss characterizes mild, moderate, and severe dehydration?
Px of each?
Capillary refill times?
When do you treat and with what?
1) mild: 3-5% (asymptomatic)
2) moderate: 6-9% (decreased skin turgor, irritability, dry mucous membranes, tachycardia, oliguria)
3) severe: 10-15% (cool clammy skin, cracked lips, sunken eyes, sunken fontanel, tachycardia, lethargy, oliguria/anuria)
capillary refill:
Moderate (2-3 seconds)
Severe (>3 seconds)
Mild: oral rehydration
Moderate-Severe: bolus NS
5 ddx for inspiratory stridor.
distinguish them
Laryngotracheobronchitis (croup): barky, age 6 months to 6 years
Laryngomalacia: worse when supine, better when prone
Foreign body aspiration: acute onset
Vascular ring: better with neck extension; px before 1 year
Epiglottitis: tripoding (sitting up and leaning forward), dysphagia, DROOLING, toxic-appearing, ALSO IMPROVES WITH NECK EXTENSION (increases airway diameter), ACUTE, thumb sign. INTUBATE IN OR
HSP px, 2 most common complications, tx
NBS vs MAT
Typically abdominal pain, palpable purpura (with normal coag panels), hematuria, arthralgia, scrotal pain/edema
Intussusseption
a) HSP/ileo-ileal dx TARGET sign on u/s
b) Normal/sp viral infx/peyer patch hptrphy Meckel/***ileo-colic dx air enema
(due to bowel wall edema and localized hemorrhage, typically small bowel ileo-ileal vs usually ileo-colic, therefore may not be seen on enema) and GI bleed
Tx pain control, corticosteroids if severe
If super classic go straight to air enema (dx and tx), but MAT is U/S
ABORTION
a) Spontaneous Abortion (v20wk). NBS?
b) Intrauterine Fetal Demise (^20wk)
a) Spontaneous Abortion (v20wk)
NBS: usually pelvic U/S then see below!
1) Inevitable; OPEN; not dead yet!
2) Incomplete; OPEN; poc usually in cervix
3) Missed; closed; dead, preg sx decrease
* **then: DandC/surg if esp. if HD unstable. (PGs and exp options)
4) Threatened; closed, VIABLE PREGNANCY
* **then: Expectant mgmt until progression to 1, 2, or 3
5) Septic; usually opeN; foul smelling, retained poc
* **then: 1) endometrial and blood clx
2) ABX
3) DandC
[vowels = open; i/o + septic usually open ]
ITP Tx (2):
1) if asx or +30,000 platelets, OBSERVE
2) if bleeding or v30,000 platelets:
STEROIDS OR IVIg
PEDIATRIC Hypertension (HTN) tx heirarchy
a) goals (2) and definitions
c) sentences (2, 3)
A:
Goal: v95th percentile -or- v120/v80
Goal w/ comorbid or end-organ: v90th percentile
[comorbid = obesity, dyslipidemia, CKD, CVD]
[lifestyle = weight reduction, exercise, diet and Na restriction!]
[end-organ= left ventricular hypertrophy]
Normal: v90th
Pre-htn: 90th-95th
HTN: 95th [HTN1 95th-99th; HTN2 99th+]
B:
sentences:
a) only time you’ll ever use pharm (5) :
i) comorbids
ii) end-organ
iii) HTN2
iv) refractory 2ndary
v) refractory HTN1 (refract. 4-6 mo.)
b) LIFESTYLE always a component of tx regardless. You never won’t do lifestyle. (“strep pneumo?”)
1) LIFESTYLE ONLY, FOR:
- pre-htn
2) 4-6 months LIFESTYLE then PHARM, FOR:
- refractory HTN1
3) LIFESTYLE + PHARM, for
- pre-htn w/ comorbid
- HTN1 w/ comorbid
- HTN1 w/ end-organ
- HTN2
- secondary htn REFRACTORY to underlying cause tx
