USMLE questions Flashcards
Describe scombroid poisoning
Scombroid poisoning is a common histamine-induced reaction that occurs within 10-30 minutes of ingesting improperly stored seafood (in temp >15C histidine in fish can undergo decarboxylation and form histamine). Symptoms include flushing, headache, palpitations, abdominal cramps, diarrhea, oral burning (“spicy”). Patients may describe a bitter taste. Exam may be notable for erythema, wheezing, tachycardia, hypotension.
Describe pufferfish poisoning
Form of food poisoning due to toxin (tetrodotoxin) and characterized by PREDOMINANT neuro symptoms: perioral tingling, incoordination weakness, etc.
Describe the management of preeclampsia with severe features
FIRST maternal stabilization: magnesium for seizure prophylaxis, short-acting antihypertensives (labetalol, hydralazine) NEXT delivery planing: preeclampsia WITHOUT severe features = delivery once >37 weeks preeclampsia WITH severe features = delivery >34 weaks
T/F: Phytoestrogens (soy, wild yams) cause nipple discharge
FALSE
Common causes of vision loss in the elderly
Among those >75yo vision loss is caused by… cortical cataracts (40%) & macular degeneration (20%) All patients should be evaluated for macular degeneration as those patients will have less (and possibly no) benefit with cataract surgery
What you should be thinking in a baby with a genital rash….
You must differentiate CONTACT dermatitis (most common) from CANDIDA dermatitis (2nd most common). Contact dermatitis spares creases/skinfolds while candida is a BEEFY red rash with satellite lesions. Contact dermatitis - treat with topical barrier ointments (zinc oxide, petrolatum) Candida dermatitis - treat with topical antifungals (nystatin)
Treatment of tertiary hyperparathyroidism
Parathyroidectomy when electrolyte derangements are persistently elevated (ca, phos, pth), soft tissue calcification or calciphylaxis, intractable bone pain or pruritus. Typically perform parathyroidectomy before renal transplant. Note that bisphosphonates actually make things worse,.
Diagnostic ECG findings of STEMI
1) New ST elevation at the J point in >/= 2 anatomically contiguous leads with the following threshold: > 1mm in all leads EXCEPT V2 and V3 (require MORE) > 1.5mm in women, >2mm in men >40yo and >2.5 in men <40 in leads V2 and V3 2) New LBB with clinical presentation of ACS https://emergencymedicinecases.com/wp-content/uploads/2019/08/Screen-Shot-2019-08-13-at-2.53.25-PM.png https://www.google.com/imgres?imgurl=https%3A%2F%2Flitfl.com%2Fwp-content%2Fuploads%2F2018%2F08%2FECG-LBBB-AF.jpg&imgrefurl=https%3A%2F%2Flitfl.com%2Fleft-bundle-branch-block-lbbb-ecg-library%2F&tbnid=Hh3kvU30NveAoM&vet=12ahUKEwiJqpr__dbpAhWtADQIHcdOCXIQMygAegUIARCOAg..i&docid=74EpJHi54BFfDM&w=1200&h=627&q=lbbb&hl=en-us&client=safari&ved=2ahUKEwiJqpr__dbpAhWtADQIHcdOCXIQMygAegUIARCOAg
EKG finding suggestive of pericarditis
Diffuse 1mm ST elevations with PR depression
Describe RBBB EKG findings
R prime (second R wave) in V1 accompanied by widened S wave in V6
EKG findings suggestive of right heart strain
T wave inversions in leads II, III, and aVF
Describe different etiologies of sinus bradycardia after MI
Sinus bradycardia in INFERIOR wall MI are typically transient and RESPONSIVE to atropine (bc they are due to increase in vagal tone) Sinus bradycardia in ANTERIOR wall MI are due to damage to conduction system BELOW the AV node and AV nodal block is typically NOT responsive to atropine and requires transcutaneous cardiac pacing
Describe the diagnostic algorithm when suspect pheochromocytoma
1 - 24hr urine fractioned metanephrines and catecholamines, plasma fractionated metanephrines > If negative, repeat during spell
2 - CT scan or MRI of abdomen
> Negative - consider further imaging, i.e. MIBG scan, octreotide scan, PET, whole-body MRI
> Positive - surgical eval, genetic testing, MIBG scan if very large (>5cm) tumor (may have extraadrenal disease, mets), alpha and beta blockade prior to surgery
Appropriate use of CENTOR criteria
If a patient has 3 or more of criteria then TEST with rapid strep test (culture takes too long) If <3 criteria then do not need to test Cough (absent) Exudates Nodes (anterior) Temperature OR (younger OR older; <14 +1, >45 -1)
W/u of UTI in babies
All children <24mo with SINGLE febrile UTI should undergo renal and bladder ultrasound to evaluate for hydronephrosis and uretal dilation suggestive of anatomic abnormality If abnormal US or recurrent febrile UTIs THEN undergo voiding cystourethrogram
Diagnosis and treatment of psoriasis
Diagnosis of psoriasis is CLINICAL (bx not necessary) If isolated plaque psoriasis then topical glucocorticoids or vitamin D derivatives (calcipotrient) may be sufficient If joint involvement then SYSTEMIC treatment with methotrexate (not oral steroids - may trigger pustular psoriasis)
Detrimental effects of estorgen/progesterone menopausal hormonal therapy
VTE Breast cancer CAD Stroke Gallbladder disease (mostly in women >60yo)
When to consider stress or pharmacological echo?
Patients with low risk non ST elevation MI or unstable angina based on TIMI score
How do glucocorticoids cause osteoporosis?
They decrease absorption of calcium from the gut, cause renal calcium wasting, and have a direct anti-anabolic effect on the bone. They also suppress the release of GrH from the hypothalamus leading to central hypogonadism
Causes of urinary incontinence in the elderly
A. Genitourinary - > decreased detrusor contractility, detrusor overactivity > Bladder or urethral obstruction (tumor, BPH) > Urethral sphincter or pelvic floor weakness > Urogenital fistula B. Neurological - > MS > Dementia - Parkinson’s, Alzheimer’s, NPH > Spinal cord injury, disk hernia Timon C. Potentially REVERSIBLE - DIAPPERS > Delirium > Infection > Atrophic urethritis/vaginitis > Pharmaceuticals - I.e. alpha blockers, anti holiness is, opiates, CCB (urinary retention/overflow), diuretics > Psychological - I.e. depression > Excessive urine output (I.e. diabetes, CHF) > Restricted mobility (I.e. post surgery) > Stool impaction
When should women be given intrapartum prophylaxis for GBS
GBS bacteriuria or GBS UTI in CURRENT pregnancy (regardless of treatment) GBS-positive rectovaginal culture in current pregnancy Unknown GBS status PLUS any of the following: > LESS than 37 weeks gestation > Intrapartum fever > ROM for > 18hrs Prior infant with early-onset neonatal GBS infection
Describe lab and pathology features of celiac disease
Lab features: > Increased stool osmotic gap > Microcytic anemia, iron deficiency Pathology: villous atrophy!
Treatment of antifreeze (ethylene glyco) ingestion
Fomepizole (better than ethanol) with immediate dialysis
What cause of glomerulonephritis has high association with neuropathy?
Polyarthritis nodosa (PAN) - involvement of every organ EXCEPT the lung Associated with multiple motor and sensory neuropathy with pain
Treatment of IgA nephropathy and Henoch-Schonlein Pupura
These diseases cause glomerular disease via proteinuria and are best treated with ACE inhibitors FIRST and then steroids if needed Henoch-Schonlein purport will resolve spontaneously over time
Drug induced lupus spares…
The kidney and the brain
Best initial tests for suspected lupus
ANA and anti-dsDNA
Treatment of lupus nephritis
Dependent upon extent of disease - BIOPSY demonstrating severity of disease guides therapy > Sclerosis - NO treatment (scar) > Mild disease,early stage, nonproliferation - steroids > Severe disease, advanced, proliferative - MMF and steroids
HUS and TTP
HUS is a TRIAD: 1 - intravascular hemolysis 2 - elevated creatinine 3 - thrombocytopenia TTP is all of the above + 4 - fever 5 - neurological abnormalities
What is the treatment of HUS and TTP?
PLASMAPHERESIS Definitely NOT platelets (make disease worse) or antibiotics (can also make disease worse) - just fueling the fire
Nephrotic syndrome changes
Low albumin (>3.5g lost in urine/day) Hyperlipidemia (lost lipoprotein signals = less removal of lipids) Thrombosis (loss of antithrombin III, protein C, protein S)
Causes of mild transient proteinuria
CHF Fever Exercise Infection Orthostatic proteinuria
What are some dialyzable drugs?
Lithium Ethylene glycol Aspirin
Manifestations of uremia
Hyperphosphatemia Hypermagnesemia Anemia Hypocalcemia
Differential for hypernatremia
Simple dehydration Diabetes insipidus - central (failure to produce ADH) vs nephrite is (insensitivity of the kidney)
Diagnostic algorithm for cause of hypernatremia
Urine osmolality Urine sodium Urine volume If dehydration then osmolality will be increased, sodium will be high, volume will be low In BOTH central and nephrogenic hypernatremia the urine osmolality will be low, urine sodium with be low, volume will be high, & NO change in urine osmolality with water deprivation. DDAVP will result in a decrease in volume and increase in urine osmolality in central but NOT nephrogneic DI
Causes of nephrogenic DI
Lithium toxicity
Hypokalemia
Hypercalcemia
Causes of hypovolemic hyponatremia
Either renal (diuretics) or non-renal (GI, skin losses) Differentiate via urine Na - will be high in renal causes (kidneys are NOT working) and normally low in nonrenal causes (kidneys are working correctly)
By how much does hyperglycemia impact sodium?
Every 100 extra points of glucoses cause an ARTIFICIAL drop in Na of 1.6 points
Impact of adrenal insufficiency on electrolytes…
Causes hyponatremia, hyperkalemia, and metabolic acidosis
Causes of SIADH
Any CNS abnormality Any lung disease Medications - sulfonylureas, SSRIs, carbamazepine Cancer
Derangements caused by SIADH
Hyponatremia (euvolemic)
High urine sodium (>20)
High urine osmolality (>100)
Low serum osmolality
Low serum Uric acid
Normal BUN, Cr, bicarbonate
Rate of correction hyponatremia
Max rate of correction 10-12 mEq/L in the first 24hrs (due to risk of central pontine myelinolysis)
Causes of hyperkalemia
Metabolic acidosis from shift outside of cells
Adrenal aldosterone deficiency such as Addison disease
Beta blockers (inhibit Na/K ATPase activity)
Digoxin toxicity
Insulin deficiency
Diuretics (spironolactone)
ACE inhibitors, ARBs (via aldosterone inhibition)
Prolonged immobility, seizures, rhabdomyolysis, or crush injury
Type IV renal tubular acidosis resulting from decreased aldosterone effect
Renal failure, preventing potassium exertion
Progression of hyperkalemia on EKG
Peaked T waves Loss of p wave widening of QRS
Impact of hypokalemia
Arrhythmia - causes U waves on EKG Muscular weakness - hypokalemia inhibits contraction May lead to rhabdomyolysis
Hypokalemia treatment
Replace the potassium - there is no max dose on oral replacement as the bowel will automatically regulate absorption.
Be cautious in IV replacement though as too quick administration can cause arrhythmia
Avoid glucose-containing fluids - will stimulate insulin and worsen the hypokalemia
Hypermagnesemia causes and impact
Caused by TOO much intake either laxatives or iatrogenic administration (I.e. tocolytic during labor) Impact is muscular weakness and loss of DTRs
Hypomagnesemia impact
Hypocalcemia Cardiac arrhythmia BECAUSE magnesium is necessary for PTH release
Causes of hypomagnesemia
Loop diuretics Alcohol withdrawal, starvation Gentamicin, amphotericin, diuretics Cisplatin Parathyroid surgery Pancreatitis
Causes of metabolic acidosis with increased AG
MUDPILES Methanol intoxication Uremia Diabetic keto acidosis Paraldehyde, paracetamol/acetaminophen Isoniazid toxicity Lactic acidosis (hypoperfusion results in anaerobic metabolism) Ethanol Salicylic acid
Aspirin metabolic derangements
Immediately causes respiratory alkalosis from hyperventilation Over a short period it causes metabolic acidosis from poisoning of the mitochondria and the loss of aerobic metabolism
Most important indicator of DKA severity
Serum bicarbonate
Treatment of ethylene glycol poisoning (antifreeze)
Fomepizole (or ethanol) - like in methanol intoxication (where fomepizole inhibits production of toxic formic acid), fomepizole prevents production of oxalic acid (which binds to calcium and forms crystals, hurting the kidneys) and allows time for dialysis to remove ethylene glycol
Causes of metabolic acidosis with normal anion gap
Diarrhea - loss of bicarbonate and potassium, increased CL- reabsorption causing normal anion gap RTA - > Distal (Type I): inability to excrete H+ ions in distal tubule resulting in accumulation of acid and alkaline urine (stones will form). Serum potassium will also be low because body will excrete + ions in form of K instead of H+. > Proximal RTA (type II): inability to reabsorb bicarbonate in the PRT > Hyporeninemic hypoaldosteronism (type IV): decreased aldosterone production or effect - diabetic patient with normal AG metabolic acidosis (the ONLY RTA with increased K level)
Explain the urine anion gap and how it is used in cases of metabolic acidosis
Urine anion gap (UAG) = Urine Na+ - Urine Cl - UAG can be a helpful way of distinguishing renal vs nonrenal causes of metabolic acidosis because in nonrenal causes of acidosis, the kidneys will excrete more acid and thus more CL- (NH4Cl) leading to a NEGATIVE UAG. If the kidneys are NOT working (renal etiology of acidosis) the UAG will be positive
Describe volume contraction impact on acid/base balance
Volume contraction causes ALKALOSIS because decreased volume stimulates aldosterone which will secrete H+
Most common cause of death in cystic disease
End stage renal failure - - NOT SAH
Routine tests for HTN on CCS
Urinalysis EKG Eye exam for retinopathy Cardiac exam for murmur and S4 gallop
What is the most effective lifestyle modification for hypertension?
Weight loss
First-line antihypertensive
Tricky question guided by a few principles: - Does the patient have diabetes? (If yes, ACEI/ARB) - Does the patient have heart failure? (If yes, beta blocker, acei/arb) (keep in mind chlorthalidone bc studied in ALLHAT and longacting) - CAD? (If yes, beta blocker) - Migraine? (If yes, CCB, beta blocker) - Osteoporosis? (If yes, thiazides) - Depression, asthma? (If yes - NO beta blockers) - Pregnancy - alpha methyldopa - Is the patient black OR old and does not have the above? (If yes, thiazides or CCB) - There is some evidence younger (<50) patients respond best to ACEI/ARBs and beta-blockers but beta blockers are not used unless specific indication because they provide inferior protection against stroke - ACCOMPLISH trial showed that there is some benefit to using different classes in Ab/CD distribution (I.e. more benefit with acei and CCB)
When to investigate for a cause of secondary hypertension?
Red flags - ie young patient, sx of pheochromocytoma If refractory to 3 antihypertensives
BP target
130/80 for general population
Describe when to give pneumococcal vaccine
In ALL patients >65yo give 13PVV then the 23PVV in a year If immunocompromised then 13PVV now, 23 PVV after 8 weeks
3 most likely causes of circulatory disturbances in the setting of trauma
Hypovolemic shock Pericardial tamponade Tension pneumothorax
Describe different etiologies of shock
Hypovolemic - decreased intravascular volume; decreased PCWP Cardiogenic - increased PCWP Neurogenic - decreased cardiac output Anaphylactic Septic
When is craniotomy done on SDH?
When there are lateraling signs and midline displacement is 10mm or more
How does mannitol work?
Mannitol is filtered by the glomeruli but NOT reabsorbed from the renal tubule, the result being decreased water and Na+ reabsorption which leads to decreased extra cellular fluid volume
Presentation of third cranial nerve palsy
Ptosis Unequal pupils Etiologies - PCOMM aneurysm
First choice test when suspect esophageal perforation
Gastrograffin (not barium) esophagram
Describe perioperative risk for different cardiac risk factors: - Low EF - CHF - Recent MI - Severe progressive angina
- EF < 35% is a CONTRAINDICATION to noncardiac surgery - CHF should be optimized medically prior to surgery - Recent MI should defer surgery for 6 months - Severe angina should be worked-up with cath prior to surgery
Describe perioperative risk management of smoking
Order PFTs to evaluate FEV1 (risk high with FEV1 < 1.5, PCo2 high) Cessation of smoking for 8 weeks prior to surgery
Describe perioperative management of hepatic risk
If bili > 2.0, PTT > 16, albumin < 3, encephalopathy > 40% mortality with any one risk factor > 80-85% mortality if 3 or more risk factors are present
Describe perioperative risk of nutritional deficiency
Provide 5-10days of nutritional supplements before surgery > Weight loss > 20% of body weight > Serum albumin < 3.0 > Anergy to skin antigens > Serum transferrin < 200mg/dl > Diabetic coma - absolute contraindication
Describe postoperative fever mnemonic
Wind - Water - Walking - Wound Wind - day 1 - atelectasis - order CXR Water - day 3 - UTI - order UA Walking - day 5 - DVT - order Doppler Wound - day 7 - CT scan for deep infections
VACTERL congenital anomalies
Vertebral anomalies Anal atresia Cardiac anomalies Tracheal Esophageal fistula Renal and/or radial anomalies Limb defects
Treatment of congenital diaphragmatic hernia
Endotracheal intubation, low pressure ventilation, sedation, NG suction Perform surgical repair after 3-4 days to allow for lung maturation
Gastroschisis vs omphalocele
Gastroschisis - defect to the right of the umbilical cord; no protective membrane and bowel looks angry and matted (due to absence of enteric neurons within myenteric plexus and submucosal plexus) Omphalocele - umbilical cord goes to the defect which has a thin membrane under which one can see normal-looking bowel and a little slice of liver (associated with trisomy 18 and 13)
Treatment of exstrophy of the bladder
Surgical repair at a specialized center WITHIN the first 1-2 days of life. Do not delay treatment
Causes of double bubble sign
Duodenal atresia Annular pancreas Malrotation
Appearance of intestinal atresia on X-ray
Multiple air-fluid levels throughout the abdomen
Most common causes of necrotizing enterocolitis in babies
Occurs in premature infants when first fed, most common pathogens are E. Coil and Klebsiella pneumonia
Describe biliary atresia and work up
Incomplete biliary tree that presents usually around 6- to 8- week of life as progressively increasing jaundiced (conjugated bilirubin) Diagnose with serological and sweat test (r/o other causes), HIDA scan for 1 week after phenobarbital (if no bile reaches the duodenum, surgical exploration is needed)
Describe hirschsprung disease
Chronic constipation diagnosed by full-thickness biopsy of rectal mucosa (appears normal on film but no myenteric and submucosal plexus due to failed neural crest cell migration)
Diagnosis/treatment of intussusception
Barium or air enema
How does Meckel diverticula present? How diagnose?
Presents as lower GI bleeding in a child of pediatric age If is a TRUE diverticula of all three layers of bowel wall Diagnose with radioisotope scan looking for gastric mucosa in the lower abdomen Treat with surgical resection
Describe appearance of anterior shoulder and posterior shoulder dislocation
Anterior shoulder dislocation - most common, pt will have arm held close to the body but forearm will be externally rotated; will have associated numbness over the deltoid muscle because the auxiliary nerve is stretched Posterior shoulder dislocation - uncommon but seen in seizures and electrical burns; patient will hold arm close to the body and shoulder will be internally rotated
What nerve may be impacted by humerus fracture? What symptoms would you observe?
Radial nerve - unable to dorsiflex (extend) the wrist; function regained after reduction
What anatomic structure would be impacted in posterior dislocation of the knee? How would this present on exam?
The popliteal artery leading to decreased distal pulses
Treatment of acute epididymitis in men <35yo vs older men
males <35yo - tx for gonorrhea/chlamydia with ceftriaxone and doxycycline older men treat with levofloxacin
Most common cause for newborn baby not to urinate during first day of life… Diagnosis and management…
Posterior urethral valves Catheterize empty bladder and diagnose with voiding cystourethrogram
Management of hydrocele
Watchful waiting in first 12 months (typically resolve) If persists elective surgery in order to decrease future risk of inguinal hernias
Management of cryptorchidism
Should undergo orchiopexy of undescended testes as soon as possible after 4mo of age and should definitely be completed before 2yo
Workup of priapism
Obtain blood gas from the corpus cavernosum to distinguish ischemic (due to decreased venous flow) from nonischemic (due to fistula between cavernosal artery and corporal tissue). Ischemic will show hypoxemia, hypercarbemia, acidemia; nonischemic will show normal levels.
Describe subclavian steal syndrome
Arteriosclerotic stenotic plaque at the origin of the subclavian allows enough blood supply to reach the arm for normal activity but not enough to meet increased demands of exercise (claudication in the arm) resulting in blood being “stolen” from the vertebral artery resulting in syncopal episodes(visual symptoms, equilibrium problems) Diagnose with angiography and treat with bypass surgery
Describe decision to proceed with surgery in abdominal aortic aneurysm
ALL symptomatic aneurysms should get surgery! (urgently, pain etc suggests leaking of the aneurysm and may rupture within a day or 2) Surgery is considered in asymptomatic AAA with diameter >5.5cm or rapid expansion of >1cm/year (or >0.5cm in 6mo)
Causes of conjunctivitis in the newborn (timeline)
Day 0 - Chemical irritation due to silver nitrate (less common now as erythromycin ophthalmic ointment used at delivery instead) Day 2 - Neisseria gonorrhea - tx ceftriaxone Day 7 - Chlamydia trachomatis - oral erythromycin Day 21 - HSV - systemic acyclovir and topical vidarabine
Treatment of the newborn at delivery
Erythromycin ophthalmic ointment (protect against Neisseria) 1mg of vitamin K Im
Association of preauricular tags in the newborn
Hearing loss Genitourinary abnormalities
Describe CHARGE syndrome in neonates
Congenital abnormality usually noticed due to malformation of the iris (“hole” in the iris) C - coloboma of the iris Heart defects Atresia of the nasal choanae growth Retardation Genitourinary abnormalities Ear abnormalities
Significance of absence of the iris in a newborn
Aniridia raises c/f wilms tumor (WAGR syndrome) - screen with abdominal ultrasound every 3 months until age 8 Wilms Aniridia GU anomalies Mental Retardation
Lateral neck mass diagnosis
Brachial cleft cyst - can get infected - give antibiotics, surgery if large
Midline neck mass that moves with swallowing
Thyroglossal duct cyst - can get infected, associated with thyroid ectopia - surgical removal
Signs of infant of a diabetic mother
Macrosomia, hx of birth trauma Hypoglycemia after birth Hypocalcemia Hypomagnesemia Hyperbilirubinemia Polycythemia Cardiac abnormalities - ASD, VSD, truncus arteriosus Small left colon syndrome (abdominal distension)
Saw palmetto is used to…
Treat BPH It is not evidenced based - does NOT appear to improve symptoms, flow measures, or prostate size Help remember this because “saws are manly”
Kava kava is used to…
Treat anxiety and insomnia - while it may help symptoms it is associated with liver toxicity
Saw palmetto side effects
Mild stomach discomfort Increased bleeding risk
Ginkgo biloba use and side effects
Memory enhancement, associated with increased bleeding risk
Ginseng uses and risk
Used for improved mental performance, associated with increased bleeding risk
Black cohosh use and side effects
Used for postmenopausal symptoms (hot flashes, vaginal dryness) SE hepatic injury
Kava kava side effect
Severe liver damage
Echinacea use and side effect
Treatment and prevention of cold and flu SE is anaphylaxis (more common in asthmatics)
Ephedra use and side effects
Used for treatment of cold and flu, weight loss, and improced athletic performance SE: HTN, arrhythmia/MI/sudden death Stroke, seizure
Describe herpangina
Vesicles on the posterior oropharynx associated with fever that occurs in children and is caused by Coxsackie group A virus Self-limiting
T/F: The rates of misuse and overdose are higher with long-acting formulations.
TRUE, surprise!
Describe the potential impacts of amiodarone on thyroid function
- It decreases T4-> T3 conversion (elevated T4, normal T3) but these abnormalities THEN IMPROVE over 3-6 months so NO treatment (or cessation) is necessary 2. Inhibits hormone synthesis (elevated TSH, low T4) 3. Can have either AIT (amiodaraone-induced thyroiditis) type 1 (iodine-induced increased in synthesis) or type 2 (destructive) > AIT type 1: Low TSH, high T3, T4, decreased RAIU, increased vascularit yon US > AIT type 2: decreased TSH, increased T3, T4, undetectable RAIU, decreased vascularity on ultrasound
Impact of aspirin on thyroid hormones
High aspirin >2g displaces thyroid from THBG leading to increased free hormone and decreased TSH
Describe euthyroid sick syndrome
Low T3, may also have low T4 and TSH Mildly elevated TSH in recovery of the illness
VZV vaccine in a patient who lives with someone who is immunocompromised?
Yes, it should be given but patient should be monitored for a rash which would indicate possibility to infect immunocompromised individual
Distinguish major depressive episode from a normal grief reaction
They share many similar features including sadness, anhedonia, sleep and appetite disturbances, impaired concentration, and normal grief can include hallucinations of their loved ones. Importantly however in normal gief the sadness is less persistent and does NOT involve low self-esteem, excessive guild, or active suicidal ideation. Best treatment is education, support, and good sleep hygiene. No meds or psychotherapy.
Hirschsprung disease diagnosis
Presents as neonate with idelayed passage of meconium and expulsion of stool on rectal exam Rectal SUCTION biopsy is the gold standard: demonstrates absence of ganglion cells
Distinguish between hydatid and protozoal liver infection
Hydatid cysts due to Echinococcus granulosus tend to grow slowly over years and remain largely asymptomatic until size >10cm or if cyst ruptures. E. histolytica is an example of a Protozoal liver infection that causes fever, RUQ pain, and hypoechoic liver lesion (amebic liver absess) that has “anchovy paste” and negative gram stain if aspirated. Dx by blood serology.
How to determine if a foreign body swallowed by a child needs to be removed?
First determine what it is - if it is a battery it needs to be removed regardless A coin with an UNKOWN time of ingestion, ingestion >24 hours prior (risk of erosion), or a patient who is symptomatic requires retrieval If swallowed <24hrs and asymptomatic can observe
Osteoporosis T score
-2.5
When is parathyroidectomy indicated for primary hyperparathyroidism?
When patients have symptomatic hypercalcemia, complications (i.e. osteoporosis), or a high risk of complications (moderate to severe hypercalcemia). Also in patients <50yo who are likely to develop complications later in life
Describe osteogenesis imperfecta
Condition of impaired collagen in which patients have blue sclera and multiple fractures
Describe radiographic findings of osteomalacia
Epiphyseal widening Metaphyseal cupping Osteopenia
Primary prevention indications for statin therapy
LDL >190 Age >40 with DM Estimated 10year ASCVD risk 7.5-10%
Secondary prevention indications for statin therapy
ACS Stable angina Arterial revascularization Stroke, TIA, PAD
What are options for HIGH intensity statin therapy?
Atorvastatin 40-80mg Rosuvastatin 20-40mg
Causes of erythema multiforme
HSV Mycoplasma pneumonia Medications (allopurinol, antibiotics) Autoimmune disorders Malignancies
Describe the algorithm for breast masses
If the patient is >30yo > Mammogram +/- ultrasound - If results suspicious, core biopsy If the patient <30yo > Ultrasound +/- mammogram - If simple cyst monitor or electively aspirate - If complex cyst or mass then image-guided biopsy
From which cells does HCC arise?
Hepatocytes themselves!!
What does pulmonary infarct look like on CT?
Like a crescent Do not confuse with metastasis (if present, should be more than one)
When are patients with prostate cancer considered low-risk?
When Gleason score = 6 with <3 cores affected (<50% involvement in each affected core) Normal DRE PSA <10ng/mL
What substance of abuse has a particularly rapid elimination?
Inhalants They may otherwise easily be confused with other substances of abuse (i.e. benzos, alcohol) as they cause mild pupillary dilation
Management of male infant with inguinal hernia?
If asymptomatic elective surgery in 1-2 weeks because increased risk for incarceration with delayed repair
Who can you use short course of combination menopausal hormonal therapy in?
Women <60yo
Who should receive zoster vaccine?
Everyone > age 50
Over the hill is a chicken = zoster vaccine!!
Explain pneumoccocal vaccine schedule
Unique populations: patients with chronic heart, lung, liver disease, diabetes, or those who smoke or use alcohol should receive PPSV23 before age 65 At age 65 all patients should receive 13 PPSV23 and then revaccination with PPSV23 (revaccinate after 3 more years) CHECK
Describe diagnostic criteria of Kawasaki disease
Fever >/= 5 days + >4 of the following: - Conjunctivitis: bilateral, nonexudative - Mucositis: injected/fissured lips or pharyns, “strawberry tongue” - Cervical lymphadenopathy: >1 lymph node >1.5cm in diameter - Rash: erythematous, polymorphous, generalized, perineal erythema and desquamation; morbilliform (trunk, extremities) - Erythema & edema of hands and feet
Treatment of new aflutter (or fib)
Before cardioversion or ablation patients need to be on at least 3 weeks of anticoagulation due to the risk of thromboembolism (which also exists with amiodarone!) In patients with aflutter of known duration <48hrs they can undergo synchonized electral cardioversion due to low thromboembolic risk
What are the autoantibodies in systemic sclerosis?
Anti-centromere antibodies “Systemic sclerosis is sentral” (centromere)
What are the autoantibodies in lupus?
Anti-dsDNA, anti-Smith
What are the autoantibodies in primary biliary cirrhosis?
Anti-mitochondrial
Describe acne treatment
Based on type of acne (although in general topical retinoids > topical antibiotics > oral antibiotics > oral isoretinoin) Comedonal acne - topical retinoids, salicylic, azelaic, glycolic acid Inflammatory acne (papules <5mm and pustules) > mild: topical retinoids and benzoyl peroxide > moderate: topical antibiotics (erythromycin, clinda) > severe: oral antibiotics (tetracycline, macrolides, tmp-smx) Nodular (cystic) acne (large nodules >5mm that appear cystic, high risk of scarring) > Moderate: topical retinoid + benzoyl peroxide + topical antibiotic > Severe: add oral antibiotics > Unresponsive severe: oral isoretinoin
Hypercalcemia symptoms
Stones, Bones, Moans (abdominal), Psychiatric overtones Mild-moderate: nausea, fatigue, constipation, ileus Severe: confusion, weakness, delirium, coma QTc SHORTENING
What electrolyte derangement causes QTc shortening?
Hypercalcemia!
What impact due thiazide diuretics have on calcium?
Increase!
What impact due thiazide diuretics have on calcium? uric acid?
Increase! Increase!
What is the GFR cutoff for quite bad kidney function?
eGFR <30. At this point should have discussion about renal replacement therapies.
What type of scrotal mass is more likely to change with valsalva? What is the best management?
Varicocele - if it is on the left no further w/u required, if on the right may consider further investigation for a mass
Management depends on age:
- in older men w/o concerns re: fertility just symptomatic management with NSAIDs
- if the man is younger it increases risk of infertility and can manage with gonadal vein ligation
Describe management of malignant pleural effusion that reaccumulates
Patients with malignant pleural effusion in general have high mortality and management is palliative In patients with rapid accumulation (in whom serial thoras will not be practical) chemical pleurodesis is the best option (indwelling catheter is associated with higher mortality) Radiation has not proved effective and lobectomy generally not indicated due to poor prognosis
Describe lead toxicity based on levels and appropriate management
Lead toxicity:
- Severe >70
- Moderate 45-69
- Mild <44mcg/dL
Hint: Pb 44 (low threshold) - 77 (severe)
No current data to suggest benefit to treatment of asymptomatic children with DSMA; generally reserved for moderate toxicity
Severe lead intoxication should be treated with parenteral dimercaprol and EDTA
First line method of diagnosis of PCP
Induced sputum (sensitivity is 50-90%)
Management of acute PCP
Depends on ABG to determine if corticosteroids are required - P)2 < 70 or A-a gradient >35 should prompt corticosteroid treatment
Describe risk of secondary malignancies in Hodgkin lymphoma
Hodgkin lymphoma puts patients at risk for secondary malignancies especially lung, breast, thyroid, bone, and GI. Lung cancer risk is especially increased with smoking in combination with prior radiation or chemotherapy.
Describe the phases and management of acetaminophen poisoning
Acetaminophen poisoning has 4 specific stages based on the TIME from ingestion:
- Asymptomatic or nonspecific sx (0-24hrs)
- Hepatotoxicity (24-72hrs)
- Peak of LFT abnormalities (72-96hrs)
- Recovery (4-14 days)
If patient <4hrs from ingestion can give activated charcoal for decontamination.
If >4-24hrs after ingestion, give empiric NAC
Biggest risk factor for pancreatic adenocarcinoma
Cigarette smoking (alcohol consumption actually has little association)
Describe indications for implantable cardioverter-defibrillator vs biventricular pacemaker insertion for cardiac resynchronization
Implantable cardioverter-defibrillator is indicated in patients with:
- Prior MI and LVEF < 30% - NYHA class II or III and LVEF <35%
- Prior VF or unstable VT
- Prior sustained VT without underlying cardiomyopahty
Pacemaker and resynchronization is indicated for:
- LVEF <35% with widened QRS >120ms (different variations on this but think really bad HF + widened QRS)
Factor V Leiden =
Resistance to protein C
Treatment for suspected TCA overdose (prolonged QRS, ventricular arrythmias)
Sodium bicarbonate
What is the threshold for bariatric surgery?
Failure to lose weight with other methods and BMI >40 or >35 plus comorbidity
What are medication options for obesity?
Best is orlistat which works by inhibiting pancreatic lipases resulting in less fat absorption
What is a common infectious cause of blood diarrhea + afebrile? Bloody diarrhea + febrile?
EHEC is usually afebrile and in the history likely to be some exposure to animals
Shigella is usually febrile and contracted through contaminated food or water
Describe screening for neural tube defects in pregnancy
Second-trimester maternal serum alpha-fetoprotein (AFP) - will be elevated Ultrasound - as part of initial screening or to investigate elevated AFP If both are elevated then can perform amniocentesis to obtain amniotic AFP and acetylcholinesterase levels which have high PPV to predict NTD
Describe lichen planus
4Ps: pruritic, planar, polygonal, purple Most commonly involve flexor surfaces
Explain why initiating mechanical ventilation may be associated with an acute drop in BP? Management?
Because the increase in intrathoracic pressure results in a decrease in preload Treat with a NS bolus
Describe parvovirus impacts in pregnancy
It can result in fetal anemia, hydrops fetalis, and fetal demise AT ANY POINT during pregnancy. Risk is greater when infection occurs in the first half of pregnancy but risk persists throughout pregnancy and warrants close monitoring with periodic ultrasound assessments
Treatment of a patient with suspected new bulimia nervosa
Basic laboratory testing would be reasonable but CBT is first-line Patients generally treated as outpatients unless uncontrolled purging present
Diagnosis of PSC
Endoscopic cholangiography or MRCP is usually necessary to appreciate the multifocal areas of stricture and dilation of the intra- and extrahepatic bile ducts CT and ultrasound may show suggestive features but are not sensitive enough
What congenital heart defects are ductal dependent?
Hypoplastic left heart syndrome - dependent upon alternative path of oxygenated blood via PFO and PDA via right heart circulation to supplement impaired left heart circulation
Aortic coarctation may present with respiratory distress and shock after PDA closes but cyanosis would only be present in distal extremities (as distal to aortic narrowing)
Describe Rh alloimmunization in pregnancy and correct use of anti-D immune globulin
Rh alloimmunization occurs in Rh- mothers after exposure to an Rh+ fetus. The main principle of giving immune globulin is to PREVENT the development of maternal antibodies after exposure to fetal blood. Thus if a mother who is Rh- has a first time pregnancy with Rh+ fetus she should receive anti-D immune globulin at 28 weeks and <72hrs after delivery to prevent hemolytic complications in any future pregnancy.
A mom who has ALREADY developed antibodies will not receive any benefit to anti-D immune globulin
Describe the standard initial prenatal lab panel:
Rhesus (Rh) type and antibody screening Hgb or Hct and HCV Rubella and varicella serology Urinalysis and UCx Serologic tests for syphilis, HIV, HBV NAAT for chlamydia Guidelines-based pap test
Lead time bias
When a diagnostic test detects a disease earlier leading to an apparent increase in survival however the difference is merely due to earlier detection and the length of survival is actually unchanged (i.e. PSA in prostate cancer)
Gaucher disease
Had an old mneumonic idk how to recover now
Autosomal recessive lysosomal storage disorder due to glucocerebrosidase deficiency leading to glucocerebroside accumulation within macrophages:
- bone marrow infiltration - anemia, thrombocytopenia
- splenomegaly > hepatomegaly
- skeletal involvement causing bony pain
- low bone density predisposing to pathologic fractures
Describe main features of glycogen storage diseases
Hypoglycemia, hepatomegaly, and muscle pain/weakness (i.e. von Gierke diseasE) NOT bone bone or pathologic fractures like Gaucher’s
Describe PCOS and w/u
Suspect PCOS when 2/3 criteria are present:
- Oligomenorrhea
- Hyperandrogenism
- PCOS Pelvic ultrasound is appropriate for w/u
FSH and LH are typically NORMAL
All patients with PCOS should have oral glucose tolerance test to screen for T2DM
What threshold for knee aspirate should be used for noninflammatory vs inflammatory etiologies?
<2000cells/ml = noninflammatory etiology (i.e. osteoarthritis)
>2000 cells for inflammatory etiologies like rheumatoid arthritis and reactive arthritis
Define infertility
In women <35yo infertility is the inability to conceive with >/=12 months of appropriately timed intercourse w/o contraception
In women >35yo infertility is considered no pregnancy in >/= 6months (due to decreased ovarian reserve and decresed fecundability)
Describe findings of disseminated gonococcal infection
Either purulent monoarthritis or as a triad:
- tenosynovitis - typically involving the distal extremities
- Dermatitis - isolated pustules or papules, primarily on the hands and feet
- Polyarthralgia - asymmetric, migratory joint pain
What is pituitary apoplexy?
Pituitary infarction that usually leads to adrenal crisis, headache, visual symptoms
What sign suggests acute renal failure is specifically due to atheroembolism (compared to CIN, etc)?
Eosinophilia
What type of flank mass typically moves with respiration?
Renal cell carcinoma
Describe best initial regimen for gout prevention
start allopurinol but in the immediate period after initiating patients are at an INCREASED risk for attacks as acute change in uric acid predisposes to flares, thus patient’s should be started on prophylactic short course of colchicine (or NSAIDs) to prevent flare
Describe rabies prophylaxis guidelines
People with anticipated exposure should receive preexposure prophylaxis (day 0,7,21 or 28)
Post-exposure prophylaxis depends on whether someone has been previously vaccinated:
- Unvaccinated: rabies vaccine (day 0,6,7,14) + IVIG
- Vaccinated: Rabies vaccine on days 0 & 3
Describe the likelihood ratio
The probability of finding an event in patients with the disease/probability of the same finding in patients without the disease positive
LR (LR+) = probability of a patient with the disease testing positive/probability of a patient without the disease testing positive
LR= sensitivity/(1-specificity)
Negative LR (LR-) = probability of a patient with the disease testing negative/probability of a patient without the disease testing negative
LR- = 1-sensitivity/specificity
Describe patellofemoral pain syndrome
Condition of anterior knee pain that occurs in young athletes and young women triggered by overuse or malalignment and management is conservative (reduced intensity of exercise, modification, nsaids, stretching and strengthening exercises)
Antibiotic of choice for human bite
Augmentin - covers mix of aerobes and anaerobes
Describe postpartum thyroiditis and treatment
Condition of autoimmune destruction of the thyroid gland that is generally self-resolving but associated with increased risk of hypothyroidism (hashimoto-like) later on
During acute period of thyrotoxicosis sx managed with beta-blockers as antithyroid drugs are not effective (autoimmune destruction and release of preformed hormone)
Explain how sterilization is managed in patients with intellectual disability
Patient’s who lack capacity (i.e. have court-appointed guardian) still have the right to reject sterilization if proposed by their caregiver. Their lack of capacity does NOT come into play. Explore other birth control options
Treatment of akathisia
Decreasing the antipsychotic dose if possible, if not adding propranolol
Where does rotator cuff tendonitis pain typically manifest?
The lateral shoulder
Treatment of organophosphate toxicity
Due to acetylcholinesterase inhibition leading to excess acetylcholine and cholinergic toxicity
Treat with atropine - competitive agonist of acetylcholine muscarinic receptor and decreases cholinergic activity
Also pralidoxime - an acetylcholinesterase reactivator which decreases both muscarinic and nicotinic receptor stimulation
What is the mechanism of myasthenia gravis and its treatment?
Myasthenia gravis is characterized by antibodies to nicotinic AChR leading to its loss from postsynaptic membrane. Pyridostigmine slows the breakdown of acetylcholine by inhibiting acetylcholinesterase (like organophosphates)
Treatment of urethritis based on type
If purulent then think gonococcal urethritis (N. gonorrhoeae)
- Dx by intracellular GN diplococci
- Treat with ceftriaxone plus azithromycin
If nonpurulent then think Chlamydia (other causes but most common)
- Dx aseptic urethral stain with leukocytes
- Treat initially with azithromycin alone
Management of dumping syndrome
High protein diet and smaller food portions
What is THE single most important risk factor for osteoporosis and osteoporotic bone fracture?
AGE (not smoking, alcohol)
Describe surgical management of renal cell carcinoma
If confined within the renal capsule (stage I) partial nephrectomy can be offered If the process extends through the renal capsule but not beyond Gerota’s fascia (stage II) then radial nephrectomy is the best treatment option
Standard PEP
Triple drug therapy (tenofovir, emtricitabine, raltegravir) for 4 weeks
What measure can be used to assess the value of a diagnostic test independently from prevalence?
The likelihood ratio Sensitivity and specificity are also independent of disease prevalence
Describe LR
Positive LR = value of a positive test = probability of a patient with the disease testing positive/probability of a patient w/o the disease testing positive sensitivity/(1-specificity)
Negative LR represents the value of a negative test result. = probability of a patient with the disease testing negative/probability of a patient w/o the disease testing negative. The smaller the LR the less likely it is that the disease is present LR = (1-sensitivity)/specificity
What is external validity?
External validity is the generalizability of a study to other populations and is reflected in the inclusion/exclusion criteria
Treatment of Tourette syndrome
Risperidone (second generation antipsychotics)
alpha-2 adrenergic receptor agonists (clonidine, guanfacine)
Tetrabenazine (dopamine depleter)
Describe organophophate poisoning symptoms
- Muscarinic effects: DUMBELS
Defecation
Urination
Miosis**
Bronchospasm/bradycardia
Emesis
Lacrimation
Salivation
- Nicotinic effets: muscle weakness, paralysis, fasciculations
- CNS: Respiratory failure, seizure, coma
What causes anticholinergic toxicity and how does that differ from organophosphate poisoning?
Anticholinergi toxicity is caused by paroxetine or excess atropine (competitive inhibitor of acetylcholine at muscarinic receptors) and leads to dry mucous membranes, flushing, mydriasis, urinary retention, and decreased bowel motility
Describe alopecia areata
Nonscarring hair loss that is classically well-demarcated, often round, and complete hair loss It is commonly associated with nail pitting Often relapsing or progressive Associated with increased risk of other autoimmune diseases
What is a super important risk factor for cardiovascular disease?
DIABETES (especially in women) - it is considered a coronary heart disease equivalent HTN (>130/80) and smoking are also important risk factors. Smoking is more important when >1ppd
Describe use of steroids in prematurity
Should be given in neonates <34 weeks to help lung maturity and prevent Respiratory Distress Syndrome (RDS); most effective if >24hrs before delivery NO benefit in postnatal corticosteroids
Describe common complications of prematurity (3)
1 - Retinopathy of prematurity - hypoxemia
2 - Bronchopulmonary dysplasia - prolonged high-concentration oxygen; prevent with CPAP
3 - Intraventricular hemorrhage
Treatment for meconium aspiration
Suctioning offers NO benefit after birth and may cause harm!! Treatment: Positive pressure ventilation High-frequency ventilation Nitric oxide therapy Extracorporeal membrane oxygenation
Causes of meconium plugs and ileus in neonates
Plugs:
- Small left colon in infant of diabetic mother (IODM)
- Hirschsprung disease
- Cystic fibrosis
- Maternal drug abuse
Ileus:
- Cystic fibrosis
Newborn has prominent drooling with his first feed, subsequently gags and develops respiratory distress with an infiltrate on CXR. Diagnosis? Method of diagnosis?
Tracheoesophageal fistula (TEF) - diagnose with NG placement - Look for VACTERL syndrome
Double bubble differential on KUB
Duodenal atresia - associated with Down syndrome, polyhydramnios, presents as vomiting with first feed
Annular pancreas
Malrotation/Volvulus - most dangerous
How to identify necrotizing enterocolitis in a newborn?
Will be a neonate with bloody stools, apnea, lethargy after the first feed. May have abdominal wall erythema and distension. Dx with KUB that may demonstrate pneumatosis intestinalis. Tx by stopping feeds, decompression, broad spectrum antibiotics, possible surgical resection
When is hyperbilirubinemia pathological in the newborn?
Bilirubin >12mg/dL in the term infant (bbbbb 12)
Direct bilirubin >2mg/dL at any time
If present on the very first day
Present after the 2nd week of life
What should you be thinking about if jaundice is prolonged (>2 weeks) with NO elevation of conjugated bilirubin (indirect predominant)?
UTI or other infection
Bilirubin conjugation abnormalities - i.e. Gilbert syndrome, Crigler-Najjar syndrome
Hemolysis - Intrinsic red cell membrane or enzyme defects: spherocytosis, elliptocytosis, G6PD, pyruvate kinase deficiency
Treatment of jaundice in the newborn
Phototherapy when bilirubin >10-12mg/dL (normally decreases by 2mg/dL every 4-6hours)
Exchange transfusion in any infant with suspected bilirubin encephalopathy or failure of phototherapy to reduce total bilirubin and risk of kernicterus
Congenital rubella infection signs
Cataracts, deafness, heart defects, blueberry muffin spots (extramedullary hematopoiesis)
Congenital syphilis symptoms
Osteochondritis and periostitis; desquamating skin rash of palms and soles, snuffles (mucopurulent rhinitis), hepatomegaly (mot common finding)
Congenital varicella symptoms
Neonatal - pneumonia
Congenital - limb hypoplasia, cutaneous scars, seizures, mental retardation
What maternal substance of use has higher association of seizures with neonate withdrawal?
Methadone - it also has longer presentation of withdrawal (96hrs)
Lithium congenital abnormality
Ebstein anomaly - tricuspid valve is not formed properly
Warfarin congenital abnormality
Facial dysmorphism (saddle nose) and chondrodysplasia (bone stippling)
Phenytoin teratogenic effect
Hypoplastic nails, typical facies, IUGR
Isotretinoin teratogenesis
Facial and ear anomalies, congenital heart disease
ACE inhibitors teratogenic effect
Craniofacial abnormalities
NSAIDS teratogenic effect
Premature closure of PDA
Sulfonamides side effect on neonate
Displace bilirubin from albumin
Phenobarbital side effect on neonate
Vitamin K deficiency
Beckwith-Wiedemann syndrome
Syndrome of IGF-2 disruption leading to multiple organ enlargement - macrosomia, macroglossia, pancreatic beta cell hyperplasia (hypoglycemia), large kidneys, neonatal polycythemia Increased risk of abdominal tumors - obtain ultrasounds and AFP every y months through age 6 to look for Wilms tumor and hepatoblastoma
Prader-Willi syndrome
Deletion of 15q11 which is paternally derived Decreased life expectancy related to morbid obesity
Robin sequence
Mandibular hypoplasia, cleft palate Monitor airway - obstruction possible until 4 weeks of life
Most common cause of trisomy
NONDISJUNCTION during meiosis
What are the contraindications to breastfeeding?
Galactosemia in baby
HIV
HSV if lesions ON the breast
Acute maternal disease if absent in infant (i.e. tuberculosis, sepsis)
Maternal cancer receiving treatment
Substance abuse
Bedwetting before what age is considered normal
Age 5
Describe encopresis and w/u
Encopresis is unintentional or involuntary passage of feces in inappropriate settings in children >4yo
Best initial test is KUB to help distinguish retentive (constipation and overflow incontenence) with nonretentive (associated with abuse)
Features of ADHD and diagnosis
Triad: Inattention, hyperactivity, impulsivity (at least 6 symptoms of impulsivity and hyperactivity or at least 6 symptoms of inattention)
Must occur in MORE than one setting
Occur often for >6mo
Occur before 12yo
Impair function
Epiglottitis management
Consult ENT and anesthesia
Intubate
Give antibiotics (ceftriazone) and steroids
Give rifampin prophylaxis to household contacts if H. influenzae positive
Management of angioedema
Steroids and epinephrine - if severe intubate for airway protection
Treatment of bronchiolitis
Supportive ONLY unless patient is high-risk (preterm, bronchopulmonary dysplasia) in which case give hyperimmune RSV IVIG or monoclonal antibody to RSV F protein (palivizumab)
In general ribavirin is NOT recommended - it has not been shown to provide clinical benefit
Presentation of chlamydia trachomatis pneumonia in infants
Infants 1-3mo of age with insidious onset
No fever or wheezing (distinguishes from RSV) +/- conjunctivitis at birth
Classic findings: staccato cough, peripheral eosinophilia
For what CF patients can Ivacaftor be given?
Anyone >6yo with at least one copy of the G551D mutation! Helps decrease sweat chloride levels, improve FEV1, and decrease pulmonary symptomst and exacerbations, and improve weight gain
Which treatments have been shown to improve survival in CF?
Ibuprofen - reduces inflammatory lung response
Azithromycin slows rate of decline in FEV1 in patients <13yo
Antibiotics during exacerbations delay progression of lung disease (based on extent of disease or known Pseudomonas or S. aureus - treat appropriately but these patient’s high risk to develop resistance so avoid overuse of antibiotics)
What is the most common cyanotic congenital heart disease in the immediate newborn period?
Transposition of the great arteries presents in the immediate newborn period (Tetrology of Fallot generally presents beyond infancy)
Transposition of the great arteries is the most common in infant of diabetic mother
Surgery AS SOON as possible
(Tetrology of Fallot surgical repair 4-12mo)
When are prophylactic antibiotics indicated in dental procedures?
Prosthetic heart valves
Previous endocarditis
Congenital heart disease (unrepaired or repaired with persistent defects)
Cardiac transplantation patients with valve abnormalities
Most common causes of bloody diarrhea in children and general treatment
Campylobacter
ameoba - E. histolytica
Shigella
E. coli
Salmonella
In general, treatment is supportive. Antibiotics are RARELY used except severe Campylobacter (erythromycin), young patients or severe disease in Salmonella, and C. diff which you always treat, E. histolytica/Giardia (metronidazole), Cryptosporidium (antiparasitics)
Patients with celiac disease have increased risk of…
Osteoporosis and GI malignancies (most commonly enteropathy-associated T-cell lymphoma)
tx E. coli O157:H7?
Presentation and management of HUS?
NEVER give antibiotics in suspected case of E. coli O157:H7 - there is increased risk of HUS
Acute renal insufficiency + thrombocytopenia + anemia
Treatment is supportice care, tx of hypertension, early dialysis
Children with microangiopathic hemolytic anemia, thrombocytopenia, and renal fialure in the absence of blood diarrhea (suggestive of Shiga toxin-mediated HUS) should receive complement therapy with eculizumab
What clinical features helps distinguish between pyloric stenosis and duodenal atresia?
One helpful clinical feature is that patients with pyloric stenosis have NONbilious vomit while those with duodenal atresia have bilious vomit (based on anatomy of obstruction)
Best diagnostic test for malrotation/volvulus
ULTRASOUND - will show inversion of superior mesenteric artery and vein and duodenal obstruction
or Barium enema (cecum is not in the right lower quadrant)
KUB is NOT helpful
Intussusception diagnosis
Generally very suggested by the history
First get a plain film KUB to r/o SBO
Then air enema which is diagnostic and curative
Treatment of vesicoureteral reflux
FIRST antibiotic prophylaxis with Bactrim or nitrofurantoin in the first year to prevent kidney scarring from recurrent infections
If breakthrough UTI, new scars, or failure to resolve then proceed with surgical correction
T/F. Bone scan is never the correct answer in multiple myeloma.
TRUE - bone scan is NOT useful in purely lytic lesions and will not be helpful in multiple myeloma
It IS helpful in metastatic bone lesion, evaluating delayed fractures, Paget disease
Diagnose
Alopecia areata - note clear borders of circular hair loss
Which antipsychotic affects SIX receptors and has least sedating side effect?
Risperidone (for less sedating side effect think “risperidone = raring to go”)
Works on 6 different receptors:
5HT
D1
D2
a1
a2
H1
Management of acute dystonia
Reduce the dose of offending agent
Anticholinergics - benztropine, diphenhydramine, trihexyphenidyl
Treatment of tardive dyskinesia
Stop older antipsychotics
Switch to newer antipsychotics (i.e. clozaril)
Valbenazine (inhibits presynaptic VMAT2 and thereby reduces dopamine release)
What is the advantage of buspirone for anxiety?
There is NO sedative or cognitive impairment thus it is a good option for people with occupations where driving or machinery is involved
Distinguish acute stress disorder from PTSD
Acute stress disorder is diagnosed when symptoms last less than 1 month and occur within 1 month of the stressor
PTSD is diagnosed when symptoms last longer than one month
They otherwise share the same symptoms which fall into three groups: 1) reexperiencing the traumatic event 2) avoidance of stimuli 3) increased arousal
What should you do for a patient with bipolar disorder well-controlled on lithium who is newly pregnant?
D/c lithium to avoid heart abnormalities and choose ECT therapy for first trimester in pts with manic episodes
Then use lamotrigine in the 2nd or third trimester
What is cyclothymia?
A milder form of bipolar
Think dysthmia but for bipolar
Best treated with psychoterapy and divalproex (aka valproic acid, superior even to Lithium)
Describe the cardiotoxicity associated with trastuzumab vs doxorubicin
Trastuzumab cardiotoxicity is generally REVERSIBLE
Doxorubicin is the prototypical example of a type I chemotherapy-related cardiac dysfunction agent and results in irreversible, dose-dependent myocardial damage.
Treatment of grief reaction
Supportive therapy
When is bupropriion a good choice?
In patients with depression who are concerned about weight gain or sexual side effects with other medications.
Cannot have hx of seizures or bulimia.
What antidepressant is associated with prolonged erections?
Trazodone
Side effects of lithium
Acne and weight gain
Dose-related tremors, GI distress, headaches
Hypothyroidism
Polyuria
Nephrotoxicity (long-term)
Teratogenic - Ebstein anomaly
Lithium-induced toxicity presentation
Disorientation, tremors, nausea, vomiting, increased DTRs
Dehydration
Describe treatment of serotonin syndrome
Obviously stop medications contributing
IV fluids
Cyproheptatine to decrease serotonin production
Benzodiazepine to reduce muscle rigidity
Why is it important to ascertain suicidal ideation before initiating an antidepressant?
Welp for many reasons but principally there is an increased risk of suicidal ideation in the first two weeks of starting an antidepressant
Distinguish somatic symptom disorder from illness anxiety disorder
Somatic symptom disorder is when patient has many bodily c/o without evidence of medical illness
Illness anxiety disorder is what was previously described as hypochondriasis - preoccupation over having or developing illness for at least 6 months
Suspect nephrolithiasis in pregnancy… next step?
Renal and pelvic ultrasound
If positive for stone treat supportively
If negative then transvaginal ultrasound
If that’s negative treat empirically or MR urogram or low-dose CT (only in 2nd and 3rd trimester) - try to avoid radiation!!
Orthostatic hypotension definition
>20mmHg change
What oral diabetic medications can cause hypoglycemia?
HIGH HYPOGLYCEMIA RISK:
Sulfonylureas (increase insulin secretion by acting on pancreatic beta cells) - glyburide, glipizide, glimepiride
Meglitinides (work the same as sulfonylureas)- nateglinide, repaglinide
LOW RISK:
GLP-1 agonists - exanatide, liraglutide (increase glucose-dependent insulin secretion)
DDP4 inhibitors (increase endogenous glp-1 and GIP levels) - sitagliptin, saxagliptin
NOT AT RISK:
alpha-glucosidase inhibitors - acarbose, miglitol
SGLT2 inhibitors (inhibit renal glucose reabsorption)- canagliflozin, dapagliflozin
Thiazolidinediones (improve insulin sensitivity) - Pioglitazone
Treatment of DCIS and LCIS
Treat DCIS as precurser to invasive cancer and schedule surgical resection with clear margins, give radiation therapy, and tamoxifen for 5 years
Treat LCIS as a small risk factor and give tamoxifen alone for 5 years (or surveillance)
(classically LCIS is seen in premenopausal women)
Febrile seizures risk
Yes there is a small increased risk of recurrence and epilepsy but not much greater than the general population
Distinguish Legg-Calve Perthes disease from SCFE
Legg-Calve Perthes disease occurs in children age 2-8 and is characterized by painful limp with xray showing joint effusions and widening; due to avescular necrosis of the femoral hip
Treat with NSAIDS, rest, and surgery on BOTH hips
SCFE is a disorder that occurs in adolescence and presents as a painful limp and externally rotated leg in an obese adolescent, xray will show widening of the joint space
Treat with SURGERY - internal fixation with pinning
Treatment of Kawasaki disease
IVIG and high-dose aspirin
(only IVIG has been shown to reduce incidence of cardiovacular complications)
Describe routine care and treatment of sickle cell disease
Routine care:
- Penicillin prophylaxis: 3mo to 5yo
- Immunizations: regular PLUS pneumococcal at 2mo, influenza at 6mo then yearly, meningococcal at 2yo
- Daily folate supplementation
Definitive tx: bone marrow transplant (mortality 10%)
If >3 crises per year or symptomatic anemia: hydroxyurea (decreases frequency of crises and transfusions, does NOT decrease risk of stroke)
If you suspect immune thrombocytopenic purpura what test should you always obtain and why?
Peripheral spear to r/o TTP and HUS
Treatment of immune thrombocytopenic purpura
1st choice: prednisone
2nd choice: IVIG
If chronic ITP then rituximab or splenectomy
*Important: AVIOD platelet transfusion (ab will just destroy) - treatment is NOT based on the platelet count but clinical bleeding
Empiric treatment of neonatal sepsis
Ampicillin and gentamicin until 48-72hr cultures are negative (cover GBS, Listeria, E. coli, Haemophilus)
Add cefotaxime if meningitis is possible
Add acyclovir if child <28 days old
Rubella vs rubeola
Rubella (aka German measles) is characterized by a maculopapular rash that spreads from head to the body and lasts 3 days
“rubella rubies” togavirus
Rubeola aka MEASLES is characterized by a maculopapular rash that spreads from head to the entire body and becomes confluent as it spreads downward; also associated with cough, coryza, conjunctivitis, and Koplik spots
“measles think weasles”
When should you consider preeclampsia?
When patient has sustained BP >140/90
Always get a urinalysis to check for proteinuria (1+ or >300mg on 24hr)
Diabetes screening in pregnancy @24-28wks
50g OGTT to screen
(if positive, confirmatory 3h 100g OGTT with positive result x2 to make diagnosis of gestational diabetes)
Preeclampsia WITH severe features
Preeclampsia + any of the following:
SBP > 160 or DBP >110
New-onset cerebral (headache) or visual disturbance
Hepatic abnormality - RUQ pain or transaminases >2x
Thrombocytopenia <100,000
Renal abnormalities
Pulmonary edema
Placental abruption is associated with…
DIC!!
What should you always do as part of initial evaluation in a pregnant woman with spontaneous third trimester bleeding?
Abdominal ultrasound to r/o placenta previa because you CANNOT do vaginal exam if has placenta previa
Whan are antibiotics for GBS NOT the answer?
Planned c-section WITHOUT rupture of membranes - even if culture is positive
Culture positive in a previous pregnancy but culture negative in the CURRENT pregnancy
Treatment of maternal varicella
Oral acyclovir to mother plus VariZIG to mother AND neonate
treatment of congenital varicella
VariZIG and IV acyclovir to the neonate
Pregnant woman has IgG+/IgM+ CMV, treatment?
This indicates RECENT infection with CMV (as well as past infection)
Treat with ganciclovir or foscarnet to prevent viral shedding and hearing loss; give CMV hyperimmune globulin to reduce the risk of congenital infection
Pregnant woman with active herpes infection and vaginal lesions…
Schedule CESAREAN!!
Neonatal infection with HSV has 50% mortality rate and bad outcomes in those who do survice
Management of HIV in pregnancy
ALL women should be on triple HART therapy that includes Zidovudine
Give intrapartum zidovudine during delivery
ALL women should have C-section (except those with RNA <1,000)
NO breastfeeding
Avoid unnecessary instrumentation
Infant should receive 6 weeks of zidovudine
What lab test portends the highest risk of vertical transmission from mother to fetus of HBV?
Positive HBeAg is associated with VERY HIGH (80-90%) prenatal transmission of HBV
When is HELLP syndrome the answer?
When the description is a patient with: hemolysis (H), elevated liver enzymes (EL), and low platelets (LP)
Treatment of preeclampsia
Treat to goal BP is <160/110 but OK below that because trying to AVOID decrease in uteroplacental blood flow
Seizure management and prophylaxis - protect airway, MgSO4
Induce labor if >37weeks in preeclampsia w/o severe features - attempt vaginal if no contraindications
Choice of medications for Graves disease in pregnancy
PTU during the first trimester
Methimazole in the second and third trimesters
Treatment of asymtpomatic bacteriuria or acute cystitis in pregnancy
cephalexin or amoxacinllin po
Test of cure
MoA of tamoxifen
It is an estrogen receptor ANTAGONIST at breast tissue but an estrogen receptor AGONIST at endometrial tissue
Associated with high risk of thromboembolism
Describe stepwise approach to nonreassuring fetal heart tracing (i.e. variable decels, late decels, decreased variability)
- Discontinue medications such as oxytocin to eliminate possible effect on fetal heart rate
- Change patient’s position (to left lateral)
- Provide high-flow oxygen
- Give IV normal saline bolus
- Vaginal exam to r/o prolapsed cord
- Scalp stimulation to observe for accelerations (reassuring)
Contraindications to breastfeeding
Maternal infections: HIV, active TB, HTLV-1, HSV if lesion on the breast
Drugs of abuse (except tobacco, alcohol)
Cytotoxic medications (methotrexate, cyclosporine)
Galactosemia in the infant
Treatment of invasive breast cancer
When tumor size <5cm -> lumpectomy w/ SLN bx + radiotherapy +/- adjuvant therapy +/- chemotherapy
Always test for ER, PR and HER2/neu receptors
If tumor >5cm or metastatic disease then treatment is SYSTEMIC therapy
Explain the influence of pre- vs post- menopausal status on choice of hormonal therapy treatment in breast cancer?
Both patients who are pre- and post- menopausal can be treated with tamoxifen 5y treatment which reduces recurrence of any hormone receptor + breast cancer (ER+, PR+, etc)
Patient’s who are HR+ and post-menopausal can receive aromatase inhibitors (i.e. anastrozole), patients who are HR+ premenopausal should still receive tamoxifen
When is colposcopy done for an abnormal pap?
When the patient has either:
- LSIL with positive HPV
- HSIL
- Two ASCUS pap smears
When is LEEP the ansewr?
When CIN 2 or 3 is present
Alternatives are: cryotherapy, laser vaporization, electrofulguration, cold-knife conization
(CIN 1 can be monitored with q6 HPV)
Distinguish the following potential causes of amenorrhea:
- Mullerian agenesis
- Androgen insensitivity
- Gonadal Dysgenesis (Turner syndrome)
- Hypothalamic-pituitary failure
- Mullerian agenesis - normal karyotype (XX), normal secondary sex characteristics (breasts = ovaries intact), but shortened vagina because the mullerian duct derivatives failed to form
- Androgen insensitivity - diagnosis when there is NO pubic or axillary hair and karyotype reveals male karyotype (XY), ultrasound reveals testes (normal levels of estrogen and testosterone)
- Gonadal Dysgenesis (Turner syndrome) - absence of secondary sexual characteristics, karyotype is 45 XO and elevated FSH, streak gonads
- Hypothalamic-pituitary failure - NO sexual characteristics but uterus normal on ultraound and FSH low; causes include stress, exercise, anorexia, Kallman syndrome (anosmia)
Standard deviation percentages
68-95-99.7 RULE
Distinguish mineralcorticoid from glucocorticoids
Glucocorticoids are steroids that act primarily like cortisol which is made in zona fasciculata
Mineralcorticoids (i.e. fludricortisone) are steroids that act like aldosterone which is made in the zona glomerulosa
Describe the MEN syndromes
MEN 1: pituitary adenoma, parathyroid hyperplasia, pancreatic tumors
MEN2a: Parathyroid hyperplasia, medullary thyroid carcinoma, pheochromocytoma
MEN2b: Mucosal neuroma, marfanoid body habitus, medullary thyroid carcinoma
Describe HLH
Potentially fatal disease of overactive histiocytes and lymphocytes that commonly presents in infancy (although can be present in all age groups) characterized by fever, hepatosplenomegaly, pancytopenia, lymphadenopathy, and rash
Describe Q-tip test
Mass and leg pain in a young boy with the following
Dx?
Ewing sarcoma - note the onion skinn
Diagnosis?
Sunburst pattern = Osteosarcoma
What are shockable rhythms?
VF/pulseless VT
(PEA/asystole is NOT shockable)
Describe recommended duration of antiplatelet therapy for:
Bare metal stent (BMS) placement
Drug-eluting stent (DES)
BMS: absolute minimum of DAPT for 4 weeks
DES: recommend DAPT for 6-12mo
Ideal DAPT for total of 30 months if possible
Continue aspirin indefinitely
Which cause of vaginosis has normal pH?
normal pH! (3.8-4.5)
Candidiasis
Empiric treatment of CAP
evaluation of precocious puberty
Exudative pleural effusion criteria
Pleural protein/serum protein > 0.5 OR
Pleural LDH/serum LDH >0.6 OR
Pleural LDH >2/3 ULN of serum LDH
HCW exposed to blood of HBV+ patient
What is the treatment?
Depends on the HCW immunization status -
If immune, NOTHING
If NOT immune then give HBV IG and vaccine
Antithrombotic therapy in patients with mechanical valve
Manifestations of hereditary hemochromatosis
Do not get tripped up by elevated ferritin and transferrin saturation
Likelihood of HIT
Breastfeeding vs Breast milk jaundice
Breastfeeding jaundice: exaggerated physiologic jaundice that occurs earlier in an infant with poor latch (inadequate milk intake); Lack of effective breastfeeding causes inadequate milk and calorie intake and results in decreased stooling and increased enterohepatic circulation. Infants may also be dehydrated.
Breast milk jaundice: Indirect hyperbilirubinemia over the first few weeks of life due to increased enterohepatic circulation; thriving infant; moa unclear, hypotheses include factors found in the milk that may inhibit hepatic UGT1A1. BMJ is associated with East Asian infants who are more likely to have a UGT1A1 mutation and weight loss.
What factors impact TBG?
McCune Albright
Differentiate different myopathy etiologies
Describe features of NF type 1
Evaluation of oligoarthritis
Dx and treatment of Pagets
Best diagnostic method is bone scan - most sensitive
Tx bisphosphonates
Pregnancy induced skin changes vs intrahepatic cholestasis of pregnancy
Common causes of shoulder pain differential
Workup of a thyroid nodule
Thyroiditis differential
Tuberous sclerosis
Vaccines for adults
Calculate sensitivity, specificity, NPV, PPV, NNT, LR
NNT:
Odds ratio:
Risk ratio:
Edit!
Highest risk factor for PID
Multiple sexual partners!
Even higher than prior PID
Posterior fat pad on arm xray after falling on outstretched hand (FOOSH)
Significance is that it suggests supracondylar fracture
Lichen sclerosus vs vulvar carcinoma
Lichen sclerosus (first picture) and vulvar carcinoma (second) can appear similar. Lichen sclerosus is a cancer precursor characterized by pruritus that develops into figure-of-eight thinning and lightening of the skin. If there are concerning features such as thickening into plaques or alteration of the normal vulva architecture have a high level of concern for possible vulvar carcinoma and get a biopsy. If simple lichen sclerosus can treat with topical steroids and only biopsy if refractory to treatment.
What type of cranial hematomas in infants is associated with forceps-delivery?
Cephalohematoma (think of someone pulling out with forceps “I see the head…”) - is a hemorrhage that occurs underneath the periosteum (does not cross suture lines) that occurs due to subperiosteal vein shearing
Caput succedaneum is a serosanguinueous fluid collection beneath the scalp that DOES cross suture lines
Subgaleal hemorrhage are hemorrhage under the galea aponeurotica and can occur as complication of vacuum-assisted deliveries but will present as RAPIDLY expanding with hypovolemic shock and blood loss
Distinguish conduct disorder from oppositional defiant disorder
Conduct disorder is about violating major social norms or the rights of others (stealing, fighting, lying, truancy, putting others at risk), with characteristic lack of remorse and indifference to parental feelings
Also associated with torturing animals, destroying property, bullying, forcing someone into sexual activity
If >18yo then antisocial personality disorder
ODD involves defiant d/o towards authority figures and will often break the rules but their behavior does not put others at risk and is more reactionary than deliberate disregard
Treatment of developmental dysplasia of the hip
Referral to orthopedic surgery!
If identified in the first 6 months of life then Pavlik harness for 3 months first
Treatment of acute rhinosinusitis
ALWAYS supportive treatment as clinical features (fever, purulent discharge, etc.) are not reliable distinguishers of viral vs bacterial and the vast majority of cases ARE viral
Pain in a woman with a recent UTI (now resolved) c/o pain that is RELIEVED by urination…
Interstitial cystitis/Idiopathic bladder pain
When do you need to submit changes to a protocol to the IRB?
ALWAYS regardless of whether it actually impacts patients
significance of anti-SSA (Ro) and anti-SSB(La) antibodies in pregnancy?
Confer higher risk of neonatal lupus and small (~2%) but significant risk of congenital heart block
Mothers should continue takign hydroxychloroquien and take aspirin during their pregnancy
Risk of ADHD medications in adults…
HTN - dose-dependent and will not resolve with duration of therapy!
(remember there is a low risk of arrhythmias! I think I got confused because you should get a baseline EKG in both kids and adults!)
Differentiate the following:
Chicken pox
Roseola (HHV6)
Measles
Rubella
5th Disease/erythema infectiosum
Anticipated Cr rise after starting ACE inhibitors?
30% rise in cr from baseline within the first several weeks - stay the course!!
What constitutes elevated urine pH?
5.5
(don’t confuse with vaginal which is 4.5)
Treatment of hypercalcemia
Intravenous fluids
Calcitonin
(do NOT confuse with cinacalcet which is a calcimimetic to reduce PTH)
Long-term with bisphosphonates such as zolendronic acid
Commonly used medications that can raise blood pressure include
NSAIDs
Decongestants
Some antidepressants (venlafaxine)
Oral contraceptives
Systemic glucocorticoids
Stimulants (methylphenidate)
Treatment options for latent TB
Isoniazid and rifapentine weekly for 3 months under direct observation
Isoniazid monotherapy for 6-9 mo
Rifampin for 4 mo
HIT type 2 characteristics
Thrombocytopenia - platelets decline >30-50%
Timing - onset 5-10 days after heparin initiation or <1 day with prior recent heparin exposure
Thrombosis - new thrombosis, progressive thrombosis, skin necrosis
AlTernative causes - no other sauces for thrombocytopenia are present or likely
If it doesn’t meet these characteristics then its regular heparin-induced thyrombocytopenia that will self resolve
Polycythemia in a newborn…
Monitor GLUCOSE levels…
If patient symptomatic (respiratory distress, cyanosis, apnea, irritability, jitterniness) then should administer fluids
Describe pneumococcal vaccine
If never received PCV variations before then: PCV13 @ 65yo then PPSV23 in 1 year
PPSV23 earlier if: smoker, heart disease, lung disease, liver disease, diabetes, alcoholism then: PPSV13 + PPSV23 1 year later
If immunocompromised or CSF leaks or cochlear implants then PSV13 + PPSV23 8 weeks later
