USMLE STEP 3 Flashcards
Pertussis treatment
azithromycin or clarithomycin; start prophylactic treatment in everyone > 6 months
Erythromycin side effect in children
Risk of hypertrophic pyloric stenosis
Definitive treatment of hemochromatosis
deferoxamine
Causes of hemochromatosis
Primary (HFE gene) and secondary (requiring frequent blood transfusions)
Atraumatic hip pain in children
transient synovitis most common cause
Legg Calves Perthes
avascular necrosis of the femoral head
Hemodynamically unstable w/ no known source after EGD?
Angiography. If HDS, consider colonoscopy
If patient is having left lower quadrant pain and low grade fever, is colonoscopy indicated?
No, colonoscopy is contraindicated for risk of colonic perforation in diverticulitis
Risk of injured structures in lateral horizontal eyelid laceration?
orbital septum and levator palpebrae
Risk of injured structures in medial horizontal eyelid laceration?
Canaliculi, punctum and nasolacrimal duct injury
Proper timing of intercourse for conception?
Days 9 - 16
Infertility definition
> 12 months for < 35 yo; > 6 months for > 35 yo
When to get chromosomal analysis for infertility?
Patients with oligospermia or azoospermia on semen analysis or in women w/ > 3 spontaneous abortions
Chronic pain, immobile uterus, and pelvic nodularity are indicative of what?
Endometriosis; consider pelvic laparoscopy for improvement of fertility
Serum ascites albumin gradient
= serum albumin value - ascites albumin value
Portal hypertension is indicated by what?
SAAG > 1.1; but can also be seen with:
CHF
cirrhosis
alcoholic hepatitis
Budd-Chiari
Differential for SAAG < 1.1
malignancy of abdominal organs
tuberculosis
nephrotic syndrome
pancreatitis
serositis
Hypoparathyroidism treatment
Calciferol (25-OH-vitamin D); calcitriol (1,25-vitamin D); CalciFERol is preferred because it has been shown to be effective and is cheaper
Hypoparathyroidism pathology
Low PTH -> lack of conversion of 25-OH-vitamin D to 1,25-vitamin D -> high urinary exceretion of calcium and lack of phosphorous secretion
Organs important for vitamin D synthesis
Liver (25 position) is step 1 of hydroxylation and kidney is step 2 (1 position)
Next step in treatment of hypoPTH patient already receiving calcium and vitamin D
Consider addition of thiazide to
1) decrease urinary calcium
2) increase serum calcium
Risk of oxybutynin
anticholinergic effects -> delirium and falls; risks also present in patients with mysathenia gravis and glaucoma
Valproate pregnancy effects
neural tube defects, craniofacial abnormalities, microcephaly, growth retardation, cleft lip, limb defects, genital abnormalities
Bipolar patients contraindicated drugs
antidepressant monotherapy
Indications for electroconvulsive therapy
unipolar and bipolar depression; catatonia; bipolar mania
Onset of hungry bone syndrome
2-4 days after a parathyroidectomy
Causes of microcytic anemia
TAILS; thalassemia, anemia of chronic disease, iron deficiency anemia, lead poisoning,
sideroblastic anemia
Which sickle thalassemia has no HbA?
Sickle cell beta (0) thalassemia
Differential for high HbA and HbS
sickle cell beta + thalassemia and sickle cell trait
Sickle cell beta + thalassemia subtypes
type I: 3-5% HbA
type II: 8-14% HbA
type III: 18-25% HbA
If 60% HbA -> it is sickle cell trait
Physical exam finding for sideroblastic anemia
hepatosplenomegaly
Target glucose level for stress hyperglycemia
140-180
Diagnostic criteria for DM
1) > 200 serum andom glucose
2) fasting > 126
3) A1c > 6.5
4) OGTT > 200 @ 2h
Medicare Part A covers
hospital, skilled nursing, hospice
Medicare Part B covers
outpatient visits, preventive care, labs, outpatient surgery
Medicare Part C covers
Medicare benefits via private companies
Medicare Part D
Drug coverage
End stage conditions covered by Medicare
disability, ESRD, ALS, and other neurodegenerative diseases
Medigap
optional supplemental plans not covered by part A and B; no meds covered
Definition of a negatively skewed distribution
mean < median < mode
Definition of a positively skewed distribution
mean > median > mode
normal distribution
mean ~ median ~ mode
When is the median a better measure of central tendency than mean?
in positively and negatively skewed distributions
smear findings for thalassemia
target cells
Prophylactic regimens for neisseria meningitidis exposure
1) ciprofloxacin (1 dose)
2) rifampin (BID, 2 days)
3) ceftriaxone (1 dose)
Definition of close exposure to neisseria meningitidis
> 8 hours of exposure w/i < 3 feet of infected
OR
direct exposure to respiratory secretions w/i 7 days
TRUE OR FALSE: Women on OCPs should not take rifampin?
TRUE
Acute hepatitis B infection definition
elevated AST/ALT
+ HBsAg
+ HB IgM core
+ HBeAg
+ HB DNA
Outcome of acute HBV infection
70% asymptomatic; 30% with symptoms (anorexia, nausea, jaundice, RUQ pain)
Definition of chronic HBV
+ HBsAg after 6 months
Postexposure prophylaxis for Hep B
hepatitis B immunoglobulin and hep B vaccine; given within 12-24h
When is interferon therapy beneficial for hepatitis B
when genotype A is present
Risk of developing chronic hep B infection
5%
Difference in disease course for hepatitis B
Older are more likely to be symptomatic
Younger are likelier to have progression to chronic infection
Risk of progression to chronic disease for hepatitis C
75-85%; acutely often asymptomatic
Criteria for thrombolytics in stroke
onset < 3-4.5 hours
Excluded if hemorrhage, trauma, neoplasm, vascular malformation, recent surgery, BP > 185/110, Plt < 100,000, glucose < 50, INR > 1.7
Desmopressin effect on platelet function
agonist activity at V2 -> exocytosis of VWF from WP bodies causing platelet adhesion and protection of FVIII
Vasopressin effects
V1: uterotonic and vasoconstrictor properties
When is DVT risk highest in stroke patients?
Days 2-7; especially with hemiparesis (up to 75%); PE is most common cause of early death in acute stroke
Contraindications to VZV or MMR vaccine
1) anaphylaxis to neomycin
2) anaphylaxis to gelatin
3) pregnancy
4) immunodeficiency
- neoplasm
- suppression
- AIDS
- congenital)
VZV given at:
age 12-15 and age 4-6
VZV for transplant recipients
4-6 weeks prior to transplant
What to do if a VZV immunized patient develops a rash and sibling is immune compromised?
Quarantine immunized patient; give VZIG for seronegative patients
Cyanide toxicity symptoms
Think about this in patients post-MI
Symptoms:
1) skin flushing (early), cyanosis (late)
2) neuro: AMS, HA,
3) cardiac: arrhythmia,
4) pulm: tachypnea followed by bradypnea, pulmonary edema
5) Renal: metabolic acidosis
Nitrodilator physiologic effect
1) Venodilation
2) decreased preload
3) decreased oxygen demand
Treatment for cyanide toxicity from nitroprusside
sodium thiosulfate
palpable purpura, elevated rheumatoid, hypocomplementemia; presenting with fatigue and arthralgias or renal insufficiency (glomerulonephritis)
Mixed cryoglobulinemia syndrome; confirm with serum cryoglobulin
pathophysiology of mixed cryoglobulinemia
vasculitis from deposition of immune complexes (IgG and IgM RF); especially common with hepatitis C or lymphoproliferative, autoimmune disease
GPA distinction from cryoglobulinemia
Findings of respiratory symptoms (sinusitis, rhinorrhea) and normal/elevated complement
Other findings: palpable purpura, glomerulonephritis, fatigue
systemic lupus erythematous distinction from mixed cryoglobulinemia
shares arthralgias and renal disease but no palpable purpura; look for malar rash or discoid lesions
Goodpasture disease distinction from GPA
alveolar hemorrhage and hemoptysis without systemic symptoms; anti-GBM disease
Stages of treatment for mixed cryoglobulinemia
1) immune suppression with prednisone and rituximab
2) treatment of underlying disease
prophylactic treatment for pcp (pneumocystis pneumonia) and toxoplasma
trimethoprim-sulfamethoxazole; dapsone if TMP-SMX untolerated; dapsone + pyrimethamine + leucovorin
When to test for pheochromocytoma
headache, tachycardia, and diaphoresis
orthostatic hypotension, blurry vision, weight loss
early age onset hypertension
familial syndromes (MEN2, NF1, VHL)
Incidental adrenal mass
Dilated cardiomyopathy
diagnostic test for pheochromocytoma
24h urinary metanephrines and catecholamines
Drugs affecting pheochromocytoma testing
tricyclics and decongestants
Workup if urinary metanephrines + but MRI negative
MIBG scan (also obtain if tumor > 5 cm or with familial disorder)
Octreotide scan
Whole body MRI
PET
When to resect a pheochromocytoma
1) alpha blockade for 10-14 days
2) fluid repletion
3) beta blockade after alpha blockade (risk of hypertension)
Surgical complications from pheochromocytoma
1) hypertension -> nitroprusside, phentolamine, or nicardipine
2) hypotension -> NS, pressors
3) hypoglycemia -> IV dextrose
4) arrhythmia -> IV lidocaine or esmolol
Complications from brain death for organ transplantation
1) systemic infection
2) volume depletion (diabetes insipidus)
3) hypotension (ischemia)
PE with … is associated with poor prognosis
elevated cardiac troponin; hypotension; hemodynamic instability
common ABG finding in PE
respiratory alkalosis with elevated A-a gradient
Treatment options for PE
1) anticoagulation - all
2) IVC filter - contraindication to #1
3) thrombolysis - hypotension (SBP < 90) AND low bleeding risk
4) embolectomy - presence of shock or failed #3 w/ persistent hypotension
Antibiotic for mammalian bites
amoxicillin-clavulanic acid to cover pasturella and strep pyogenes
antibiotic for lymphadenitis
clindamycin
cat-scratch disease pathology
non-caseating granuloma
Pathology of otitis externa
infection of the external auditory canal -> pain with manipulation of pinna; contrast with postauricular pain seen in mastoiditis
labyrinthitis pathology
inflammation from mastoid air cells to bony labyrinth of inner ear (cochlea, vestibule, semicircular canals)
presents with vertigo, tinnitus, and nystagmus
Sitagliptin is contraindicated in pts with hx of…?
pancreatitis; dpp-4 inhibitors should not be used in those w/ hx of pancreatitis
Hemophilia inheritance pattern
X-linked recessive; usually occurring in males
Pseudohyphae indicate what on vaginal microscopy…
candidiasis
clue cells indicate what on smear…
bacterial vaginosis (gardnerella)
pear-shaped motile organisms indicate…
trichomoniasis
Name this personality disorder: emotional, attention-seeking, provocative, sexual, shallow, impressionistic and vague, suggestible
Histrionic
Name this personality disorder: avoids abandonment, intense relationships, self-injurious, impulsive, suicidal, intense anger, chronic emptiness, and unstable self-image
Borderline
Name this personality disorder: psychological dependence on others to meet needs
“Dependent; these patients lack ““clingy and emotional”” tendencies seen in histrionic”
marfan syndrome genetic mutation is in…
fibrillin 1
Skeletal findings in marfan syndrome
1) arachnodactyly
2) decreased upper to lower body ratio
3) increased arm to height ratio
4) pectus deformity, scoliosis, or kyphosis
5) joint hypermobility
ocular findings of marfan syndrome
ectopia lentis
cardiovascular findings of marfan syndrome
1) aortic dilatation, regurgitation or dissection (CAUSE OF MORBIDITY AND MORTALITY)
2) mitral valve prolapse
pulmonary findings for marfan syndrome
spontaneous pneumothorax
Standard screening for marfan syndrome
1) counseled on low-intensity exercise
2) TTE or CT chest
Patients with syphilis require a … if they have neurologic symptoms
lumbar puncture
Name the reaction from treatment of syphilis
Jarisch-Herxheimer reaction; no effective prevention is available
Symptoms are fever, malaise, chills, HA, and myalgias
Name the mechanism behind HIV lipodystrophy and ways to treat it
insulin resistance; metformin and TZDs (rosiglitazone and pioglitazone)
Side effects of nicotinic acid for hyperlipidemia
flushing, pruritus, and liver toxicity
Treatment for hypertriglyceridemia in setting of antiretroviral therapy
If triglycerides > 500 -> fibrates first.
If < 500, statins are first-line
Drugs which can cause macrocytosis
trimethoprim, methotrexate, and phenytoin can all cause macrocytic anemia via disruption of folic acid metabolism
MTX inhibits dihydrofolate reductase
Antidote for macrocytic anemia from chronic MTX treatment
Leucovorin aka FOLINIC acid, a more potent folic acid
Common nutritional deficiencies in Celiac disease
iron, calcium, vitamin D, and folic acid
Risk factors for celiac disease patients
osteopenia, osteoporosis
DXA at time of diagnosis and repeat 1 year later
Treatment of dermatitis herpetiformis
dapsone in addition to gluten free diet
Recommended vaccination for celiac disease
pneumococcal vaccination
Symptoms of whipple disease
arthralgia, diarrhea, weight loss
Etiology of infectious mono
EBV
Features of infectious mono
fever
tonsillar pharyngitis +/- exudates
lymphadenopathy
fatigue
Hepatosplenomegaly
What can happen after administering amoxicillin to those with infectious mono?
rash
False-negative rate of testing for infectious mono?
25% false negative rate with Monospot (heterophile antibody) test
transient hepatitis and lymphocytosis can be supportive
Treatment of infectious mono
counsel about avoiding contact sports > 4 weeks; NSAIDs if needed
Possible complications from infectious mono and its treatment
1) airway obstruction
2) aplastic anemia
3) thrombocytopenia
treat with STEROIDS for above
Peritonsillar abscess is usually UNIlateral and presents more often with dysphagia
Recommended treatment for Raynaud
nifedipine or amlodipine or diltiazem
DIHYDROPYRIDINE calcium channel blockers are best
Nitroglycerin is an adjunct agent
Praozosin and other alpha blockers can be used but patients become refractory
Workup for rheumatologic conditions:
ANA RF, CBC, chem panel, UA, complement level
Diagnostic workup for orthostatic proteinuria
split 24h urine collection; normal at night and elevated during daytime
all other workup should be negative
NO further invasive diagnostic workup or treatment needed
Recurrent C diff infection treatment
first recurrence: metronidazole or vancomycin depending on severity
second recurrence: pulsed vancomycin
third recurrence:
fidaxomicin or fecal matter transplant
Definition for severe c diff infection
fever, leukocytosis > 15k, or creatinine > 1.5x baseline
Aprepitant
new anti-emetic that works by blocking substance P and blocking effects of neurokinin
Metoclopramid side effects
extrapyramidal symptoms from blocking D2 centrally and peripherally -> akathisia, dystonia, and parkinson-like symptoms
risk: up to 30% in high-doses
hypomanic symptoms are described by:
decreased sleep, increased energy, pressured speech, increased new ideas
Treatment for severe manic episode
lithium OR valproate
+
antipsychotic
Mania vs severe mania
decreased sleep, hypersexual, pressured speech, hyperactive, grandiose delusions
severe:
psychosis, aggression, high-risk behaviors
Chlamydial conjunctivitis time of symptom onset
5-14 days; transmitted transvaginally by secretions
Manifestations of chlamydial conjunctivitis
eyelid swelling, watery or mucopurulent discharge, thickened and injected conjunctiva (CHEMOSIS)
sequelae of untreated chlamydial conjunctivitis
chlamydial pneumonia at age 4-12 weeks; afebrile with staccato cough and rales
corneal scarring
Treatment for chlamydial conjunctivitis
oral erythromycin
diagnosis of chlamydial conjunctivitis
culture or PCR testing of drainage; requires conjunctival scrapings
chalmydia: intracellular or extracellular organism
INTRAcellular
Risks of living donor kidney transplant
fetal loss, pre-eclampsia
Which has better outcomes, living or deceased kidney transplant?
living
Best donor for living kidney transplant?
sibling with no HLA mismatch
OPTN guidelines on age for living donor transplantation?
if < 18; absolute contraindication to organ transplant
OPTN contraindications for living kidney transplant?
diabetes
hypertension with evidence of end-organ damage
Serotonin syndrome offending medications
SSRI/SNRI, TCA, tramadol, linezolid
MAOI + one of the above
Features of serotonin syndrome
1) mental status (anxiety, agitation, delirium)
2) autonomic dysregulation (diaphoresis, HTN, tachycardia, hyperthermia, vomiting, diarrhea)
3) neuromuscular hyperactivity (tremor, myoclonus, hyperreflexia)
Management of serotonin syndrome
1) discontinue causative meds
2) supportive care
3) prn benzodiazepines
4) CYPROHEPTADINE if above all fail
Common MAOI
phenelzine
tranylcypromine
rasagiline, selegiline
methylene blue
Washout period before starting MAOI
14 days
SSRI least likely to cause discontinuation syndrome
fluoxetine - long half-life
Neuroleptic malignant syndrome pathology
reaction to dopamine antagonism
NMS differences from serotonin syndrome
“lack of neuromuscular hyperactivity -> NO tremor, hyperreflexia, clonus
NMS characterized by ““lead pipe”” rigidity”
Mechanism of glipizide
secreatagogues -> requires pancreatic beta cell reserve
Which drug classes are incretin-based?
DPP-4 inhibitors (sitagliptin) and glucagon-like-peptide 1 agonists (liraglutide, exenatide)
BOTH classes to be avoided in pts with pancreatitis
Metformin contraindication
GFR < 30 ml/min
Pancreatogenic diabetes pathology…
exhaustion of both alpha and beta islet cells from chronic pancreatitis causing a lack of glucagon and insulin; treat with insulin
If a healthcare worker has sustained a fingerstick but the source patient has no HBsAg, what is given?
Hepatitis B vaccination and NO HB immunoglobulin
Name the risk associated with TZD when given to patients with CHF
Pioglitazone and rosiglitazone in the TZD class can cause PULMONARY EDEMA by acting on the PPAR-gamma receptor promoting sodium reabsorption at the collecting tubule; occurs at a rate of 4-6%
consider SPIRONOLACTONE to antagonize the effects of TZD on sodium reabsorption
Risk factors for cerebral palsy
prematurity, low birth weight
Features of cerebral palsy
delayed motor milestones
abnormal tone and hyperreflexia
seizures, intellectual disability
workup for cerebral palsy
MRI +/- EEG +/- genetic/metabolic testing
Most common cerebral palsy subtype
spastic
8 month motor milestones
rolling over
sitting without support
starting to crawl
9 month motor milestones
pull to a stand
cruise
potential MR findings in cerebral palsy
periventricular leukomalacia
ischemic insult
Are gifts permissible to physicians?
Yes, if they are not excessive and not likely to influence care
Treatment of herpes zoster
If presenting within 72h after rash onset, treat with 7 DAYS of oral valacyclovir +/- analgesics
If > 72 hours after rash onset, no antiviral treatment. Treat sympomatically with zinc oxide cream and analgesics
Postexposure prophylaxis for health care workers non-immune to VZV
varicella vaccine within 5 days
no treatment if prior documented immunity
if pregnant or immune compromised, VZIG or valacyclovir
Definition of post-herpetic neuralgia and treatment
> 4 months after rash onset
Treat with TCA, gabapentin, or pregabalin
Treatment of papillary thyroid cancer
1) stage w/ US of neck and cervical lymph nodes first
2) if simple disease w/ nodule < 1 cm -> thyroid lobectomy
3) if complicated or > 1 cm in diameter -> total thyroidectomy
phenytoin toxicity is marked by…
nystagmus on far lateral gaze
may present with blurred vision, diplopia, ataxia, slurred speech, dizziness, drowsiness, lethargy, and decreased cognition –> can proceed to coma
therapeutic range 10-20
Is alcohol abuse an absolute contraindication to cardiac transplant?
yes
poor psychosocial support is a relative contra-indication
When does bone density screening start?
age 65 if no risk factors
risk factors:
1) body weight < 127 lbs
2) steroid use
3) smoker
4) malabsorptive disorder
5) hx of hip fracture
Risks of hormone replacement therapy for menopause
breast cancer, coronary artery disease, stroke, venous thromboembolism
RDA of calcium and vitamin D
1200 Ca2+, no greater than 2000
600-800 Vitamin D, no greater than 4000
Define flexible kyphosis
thoracic kyphosis of 20-40 degrees
should be correctable by voluntary hyper-extension
Define Scheuermann disease
kyphosis that is not easily correctable
Milwaukee brace if angulation is < 70-80 degrees of kyphosis
Severe cases: >70-80 degrees, intractable pain, neurologic abnormalities -> surgical correction
Labs suggestive of a non-functioning pituitary adenoma
suppressed LH and FSH
INCREASED alpha subunits
Usually asymptomatic until mass effect causes neurologic symptoms
Pathological origin of nonfunctioning pituitary adenoma
gonaotrophs
First-line treatment for non-functioning adenoma
trans-sphenoidal surgery
second line is radiation; risk of neurologic injury and hypopituitarism
First line treatment for prolactinomas
dopaminergic medications - eg cabergoline
levels usually associated with prolactinomas
> 200
Hormonal treatment for growth-hormone producing adenomas seen in acromegaly
Octreotide (somatostatin analog)
Symptoms of trichomonas vaginalis
pruritus
green, frothy, malodorous discharge
vaginal inflammation
vaginal pH > 4.5
Treatment for trichomonas vaginalis
metronidazole - single dose 2g
if breastfeeding, patient needs to stop for 24h
If pulmonary contusion is suspected… what is correct management?
hospital observation for 24-48 hours
pain control to prevent hypoventilation
physiotherapy, suctioning, O2 as needed
Signs and symptoms of pulmonary contusion
hemoptysis
dyspnea
irregular but LOCAL opacification
delayed onset of respiratory symptoms
Triad of fat emboli syndrome
rash
altered mental status
respiratory distress
negative CXR
Presentation of hypothalamic amenorrhea
significant exercise
caloric deficit
stress fractures
amenorrhea and infertility
breast atrophy
Hormone findings in hypothalamic amenorrhea
global decrease of
1) GnRH
2) LH/FSH
3) estrogen
Abnormal lab findings in hypothalamic amenorrhea
1) decreased bone mineral density
2) hypercholesterolemia
3) hypertriglyceridemia
Treatment for hypothalamic amenorrhea
increased caloric intake
estrogen
calcium and vitamin D
DXA scan
Diseases associated with primary ovarian insufficiency
age < 40
autoimmune disease
Turner syndrome
prior chemoradiation
Lab findings in primary ovarian insufficiency
elevated FSH
low estradiol
Plaque psoriasis treatment options
< 10% body surface area:
1) topical steroids (eg fluocinonide or betamethasone) for 4 weeks
2) calcipotriene (vitamin D derivative)
> 10% body surface area:
1) narrowband UVB therapy
2) systemic therapy (MTX, biologics)
FACIAL or intertriginous psoriasis
1) tacrolimus
2) low potency steroids (hydrocortisone)
Treatment of psoriatic arthritis
methotrexate or other systemic immune suppression
Joint involvement of RA in the hands
MCP and PIP
Joint involvement of psoriatic arthritis in the hands
DIP
Clinical features of 11-hydroxylase deficiency
Hypertension
Hypernatremia
Hypokalemia
Due to elevated buildup of 11-deoxycortisol and 11-deoxycortisone
True or false, 11-hydroxylase deficiency causes ambiguous genitalia
TRUE
True or false, 17-hydroxylase deficiency causes ambigious genitalia
FALSE
5 alpha reductase deficiency results in what
AR inheritance
Causes 46, XY to appear externally female
Conditions associated with acute severe seborrheic dermatitis (dandruff)
Parkinson disease
HIV
In the pre-contemplation stage, do patients recognize negative consequences?
NO
encourage evaluation of possible consequences
consider explaining risk
Do NOT recommend action
in the stage of contemplation, what do patients think about consequences?
they acknowledge them but are ambivalent
encourage pro and con evaluation of situation
What follows the stage of contemplation?
Preparation; a decision to change has been made
Encourage small steps
What can be done when a patient is in the action stage?
help identify strategies
help identify sources of support
promote self-efficacy
What follows the action stage?
Maintenance
This step should focus on relapse prevention
AND
development of intrinsic rewards
What characterizes sicca syndrome?
Xerostomia (dry mouth)
Keratoconjunctivitis sicca (dry eyes)
Sicca syndrome is associated with what?
Sjogren syndrome
Name possible sequelae from having xerostomia
dental caries
candidiasis
chronic esophagitis
Pseudotumor cerebri is associated with obese women but can be associated with these endocrinopathies…
hypoPTH
hypothyroidism
adrenal insufficiency
Cushing disease
Name medications that can cause pseudotumor cerebri
isotretinoin
all-trans-retinoic acid
minocycline, tetracycline
cimetidine
steroids
danazol
tamoxifen
levothyroxine
lithium
nitrofurantoin
Name the symptoms associated with cluster headaches
localization to the temporal and periorbital region
lacrimation
nasal congestion
nausea
occurring 1-2 periods lasting for 2-3 months
Migraine headaches can present with the following symptoms…
pulsatile/throbbing in nature
nausea/vomiting
photophobia/phonophobia
flashes, loss of vision, dizziness, or tinnitus
What are the hemodynamic characteristics of hypovolemic shock?
Decreased pressures with increased SVR
preload measured by right atrial pressure and PCWP and cardiac index
decreased mixed venous oxygen saturation
What are the hemodynamic characteristics of cardiogenic shock?
Increased preload (RA, PCWP)
Decreased cardiac index
Increased SVR
Decreased mixed venous oxygen
Name the defining characteristic of septic shock
decreased systemic vascular resistance
By what amount does aspirin administration reduce mortality in acute MI?
25% for acute MI
50% for unstable angina
When is prasurgrel given in MI?
ONLY AFTER angioplasty
MOA: blocks ADP induced activation of P2Y12; similar to clopidogrel and ticagrelor
Drugs with mortality benefit for acute MI
Mortality benefit:
Angioplasty/thrombolytics (time dependent)
Aspirin (ASAP)
Metoprolol (no time dependence)
clopidogrel OR ticagrelor (add to aspirin w/ acute MI or if post angioplasty/stenting)
Statins
Dependent mortality benefit:
ACE-I or ARBs (mortality benefit with L ventricular dysfunction or systolic dysfunction)
No mortality benefit:
Oxygen
Calcium channel blockers
Lidocaine
Amiodarone
Nitrates + morphine
Indication for primary angioplasty?
Primary angioplasty; must be done within 90 minutes of ED arrival; no mortality benefit if stable angina is present
indication for thrombolytics
CP < 12 hours
given within 30 minutes of arrival in ED
ST segment elevation in 2 or more contiguous leads
new LBBB
When do you choose PCI over thrombolytics in acute MI?
If access is available to PCI
If the question asks about the single greatest mortality benefit
If there is a contraindication to thrombolysis
Mechanism of thrombolytic therapy
Converts plasminogen to plasmin, thereby breaking down fibrin clots
Mechanism of beta blockers on improving mortality in MI:
Anti-ischemic effect by reduction in HR -> increased ventricular filling time -> increased stroke volume -> increased cardiac output
Anti-arrhythmia due to ischemia
When are verpamil or diltiazem preferred over beta blockers in acute MI?
if intolerant to beta blockers (eg asthma)
if cocaine-induced chest pain
in cases of Prinzmetal angina
Diagnostic criteria for prinzmetal angina?
1) Angina responsive to nitrates w/ one of the following:
- rest angina
- inducible by hyperventilation
- diurnal variation
- CP suppressible with calcium channel blockers
2) transient ischemic EKG changes
3) angiographic evidence of coronary artery spasm in response to ergot, hyperventilation, or acetylcholine
Indications for pacemaker following acute MI
3rd degree AV block
2nd degree, Mobitz II
New LBBB
Symptomatic bradycardia
Indications for lidocaine or amiodarone in acute MI?
Ongoing VTACH or VFIB
Do NOT give prophylactically
When is exertion (eg coitus) acceptable post MI?
2-6 weeks
Name the 3 differences in management with NSTEMI?
1) no thrombolytics
2) Use LMWH
- superior efficacy over UFH. LMWH has mortality benefit
3) Use GPIIb/IIIa inhibitors, which has mortality benefit (EG abciximab, eptifibatide, tirofiban)
4) angioplasty if available as an option
What is the one way to improve mortality benefit when giving GPIIb/IIIa inhibitors?
Combine with angioplasty or stenting
Remember that GPIIb/IIIa is only efficacious in NSTEMI
Name the four indications for CABG
1) Left main coronary artery stenosis >50%
2) 3 vessels w/ >70% stenosis
3) 2 vessels in diabetic patients
4) 2 vessels with low EF
Treatment that improves mortality for stable angina?
Aspirin
Metoprolol
Nitrates do not improve mortality; symptomatic relief only
When are ACE-I or ARBs used in cases of stable angina?
CHF
Is the internal mammary artery or saphenous vein graft better for long-term outcome after CABG?
IMA often patent at 10 years
Saphenous vein becomes occluded at 5 years
Statins are given for coronary artery disease. Which other diseases are considered equivalent to CAD and require statin therapy?
1) Diabetes
2) Peripheral arterial disease
3) Carotid disease
4) aortic disease
5) stroke
Most common statin effect
liver toxicity
Obtain baseline AST/ALT
What is the indication for PCSK9 inhibitors?
familial hypercholesterolemia
hyperlipidemia refractory to statins
MOA: Blocking PCSK9 increases hepatic clearance of LDL
No mortality benefit
In patients with ED and MI, be sure to stop this medication … before giving sildenafil
nitrates
Name high intensity statins:
rosuvastatin 20-40
atorvastatin 40-80
Indicated when risk of 10 year ASCVD risk > 10%
Most complicated statin effect:
rhabdomyolysis
spectrum of myalgia -> rhabdo -> renal failure
Do NOT measure baseline CPK
measure CPK if symptomatic: muscle pain, stiffness, cramping, or fatigue
- also measure Cr and obtain UA
If mild symptoms -> restart statin to establish causality
Name the mechanism for ezetimibe:
decreases cholesterol absorption in the gut
Has been shown to be effective in combination with statins
What is a group of patients that can benefit from bile acid sequestrants?
Diabetes patients
concomitant 0.5% decrease in A1c
Standard of care for CHF exacerbation:
1) oxygen
2) furosemide
3) nitrates
4) morphine
Key clinical features of CHF exacerbation:
S3
Rales
Dyspnea
Orthopnea
Others: edema, ascites, JVD, fatigue
When does screening for HTN start?
Age > 18
Ambulatory BP monitors gold standard
Common causes of secondary HTN from age 0-12?
renal parenchymal disease
coarctation of the aorta
Common causes of secondary HTN from 19-39 years?
1) thyroid dysfunction
2) fibromuscular dysplasia
3) renal parenchymal disease
Key workup for CHF exacerbation…
CXR
EKG
Oximeter/ABG
Echocardiogram
Key feature of hyperaldosteronism?
Hypokalemia
Key features of renal artery stenosis?
increase in serum creatinine > 0.5 to 1 mg/dL AFTER starting an ACE or ARB
Most effective lifestyle interventions for decreasing blood pressure?
Intervention: SBP/DBP
DASH + <1500 mg Na: 11.5/6
<1500 mg Na: 7/3
DASH: 5-6/3
Weight loss (9lbs): 4.5/3.2
Exercise: 4/3
Alcohol: 3/2
THEREFORE: weight loss has the greatest potential impact given added benefit with each pound lost
Smoking: unclear
BP goal for those age > 60 per JNC 8?
150/90
BP goal for age < 60 per JNC 8?
< 140/90
BP goal for those with CKD or diabetes
< 140/90
Firstline treatment for hypertension in non-black population
thiazide
CCB
ACE/ARB
First-line treatment for hypertension in black population?
thiazide
CCB
If hypertensive and with CKD, regardless of race, the antihypertensive regimen should include:
ARB or ACE
In patients with CHF with continued dyspnea after preload reduction, consider these 3 drugs
1) dobutamine (first-choice)
2) inamrinone
3) milrinone
What does wedge pressure measure?
LEFT atrial pressure
Therefore, LV failure = increased LA pressure = increased wedge pressure
Age of colon cancer screening in average risk patients?
Age 50
- -q10 years for colonoscopy
- -FOBT or FIT q1 year
- -FIT-DNA q1-3
- -colonography q5 years
- -flex sig q5 years or 10 if combined with q1 year FIT
What qualifies a patient as a high risk colon cancer patient?
First degree relative < 60 y of age with diagnosed cancer or adenomatous polyps
> 2 first degree relatives with colon cancer at ANY age
Screening for increased risk colon cancer patients?
At age 40 q3-5 years
OR
10 years prior to age of cancer diagnosis in relative
What defines adenomatous polyps?
> 1 cm
villous features
high grade dysplasia
Etiologies of SIADH
1) brain trauma
2) carbamazepine, NSAIDs, or SSRIs
3) pneumonia
4) small cell lung cancer
Diagnosis of hyponatremia in the setting of urine osmolality < 100 mOsm/kg?
psychogenic polydipsia
What is considered inappropriately concentrated urine in the setting of hyponatremia?
> 100 mOsm/kg
What is the key difference in cerebral salt wasting and SIADH?
CSW: Decreased extracellular fluid volume due to renal loss of salt - replete fluid and salt
In SIADH, restrict fluid intake
How do you distinguish between renal or extrarenal loss of sodium in the setting of hyponatremia?
Urinary sodium
< 10 -> think loss from GI or skin
> 20 -> think cerebral salt wasting, diuretics, or addison’s disease
What are the treatments for hyponatremia due to SIADH?
fluid restriction first
salt tablets next
If seizing or in coma, consider 3% saline
What diagnosis is associated with the following symptoms: 1) dysuria 2) postvoid dribbling 3) dyspareunia 4) anterior vaginal mass
Urethral diverticulum
Risk factors: repeated infection, trauma of urethra (vaginal delivery or surgery), stress urinary incontinence
What exam finding is associated with urethral diverticulum?
tender anterior vaginal wall mass
expresses bloody or purulent fluid on manipulation of urethra
Diagnostic testing for urethral diverticulum?
MRI or transvaginal ultrasound
UA/UCx
What are the treatment options for urethral diverticulum?
manual decompression
needle aspiration
surgical repair
Diagnostic method for vesicovaginal fistula?
infusion of methylene blue into bladder
assess vagina with tampon to see if it turns blue
What is the Q-tip test?
used to diagnose urethral hypermobility; a cause of stress urinary incontinence
Positive when > 30 degrees of movement with valsalva
What is the test of choice for diagnosing pneumothorax acutely?
bedside ultrasound
+ when there is no evidence of lung sliding
CT chest is more sensitive but inappropriate if concern for acute decompensation
What syndrome is associated with bicuspid aortic valve?
Turner syndrome
What population is associated with congenital bicuspid aortic valve?
Male
Turner
What is the typical auscultation finding for bicuspid aortic valve?
ejection murmur with a click heard at LLSB
What xray findings can reveal a bicuspid aortic valve?
AV calcification
aortic enlargement (from aneurysmal dilatation)
rib notching
What are the risks from having a bicuspid aortic valve?
infection
valve regurgitation or stenosis
aortic root dilatation
dissection
Indications for balloon valvuloplasty
symptomatic patients
OR
asymptomatic patients anticipating pregnancy or sports
+
aortic stenosis
+
no significant regurgitation or calcification
+
peak gradient > 50 mmHg
Name a common antihypertensive that can result in photosensitivity
hydrochlorothiazide
What are risk factors for neural tube defects?
low folic acid
methotrexate
Antiepileptics
diabetes
prior pregnancy with a neural tube defect
What dosages are given for folic acid?
0.4 mg in normal risk gravid patients
4 mg folic acid IF:
1) On an antiepileptic drug
2) prior pregnancy with a neural tube defect
Most common pathogen for corneal foreign bodies?
Most common: Coagulase negative staphylococcus
Others: streptococcus, haemophilus, pseudomonas
Therefore treat with: erythromycin, sulfacetamide, ciprofloxacin, ofloxacin
What is the indication for AV replacement in bicuspid aortic valve?
severe stenosis or regurgitation + symptoms of left ventricular dysfunction
Define publication bias
where trials with positive results are published but
negative results are not
Name the risk factors for pulmonary aspergillosis:
stem cell or organ transplantation
prolonged neutropenia
chronic steroids
AIDS
What is the classic triad for aspergillosis?
cough
pleuritic pain
hemoptysis
Nodules with ground glass opacity OR cavitations with air-fluid levels indicate what infection?
aspergillus
Which drug increases the risk of euglycemic diabetic ketoacidosis?
SGLT2 inhibitors
Mechanism:
decreased insulin:glucagon ratio -> stimulating ketogenesis
Respirations associated with DKA?
Kussmaul respirations
Name the metabolic abnormalities that can occur with SGLT2 inhibitors
Hyperkalemia
Hyperlipidemia
Euglycemic diabetic ketoacidosis
Where can ectopic thyroxine production take place?
ovaries
Name a single etiology to explain the following clinical features in a newborn: 1) macrosomia 2) hypocalcemia 3) hypoglycemia 4) hyperviscosity 5) cardiomyopathy 6) cardiac heart failure
Gestational diabetes
What is the expected blood sugar in a neonate born to a mother with gestational diabetes?
HYPOGLYCEMIA - because the baby is generating insulin but has no intrinsic hyperglycemia
What is the mechanism for hyperviscosity in neonates when a mother has gestational diabetes?
polycythemia vera
What is the expected echocardiographic finding in a neonate born to a mother with gestational diabetes?
hypertrophic myocardium
What is the mechanism of hypertrophic myocardium in babies born to mothers with gestational diabetes?
glycogen deposition in myocardium
ESPECIALLY in the interventricular septum
leading to VENTRICULAR OUTFLOW obstruction
Name the malformation syndrome that results in four chamber cardiac dilatation in neonates
cri du chat syndrome
If a baby is hemodynamically stable at birth but decompensates with acute heart failure and shock several days after birth, what has pathologically occurred?
Closure of the ductus arteriosus
Treat with prostaglandin E1
Causes of delayed (several days) cardiac failure in the newborn from closure of ductus arteriosus?
Aortic stenosis
Hypoplastic LV
Coarctation of the aorta
What is seen on echocardiogram in Ebstein’s anomaly?
atrialized RIGHT ventricle
tricuspid regurgitation
What is the treatment for hypertrophic cardiomyopathy in babies due to glycogen deposition due to hyperglycemia?
Conservative therapy
Glycogen will be depleted during fasting
To answer the question: if patient has a condition X, how likely is the patient to have a + test result compared to patients with a - test result?
positive likelihood ratio
How can you individualize sensitivity and specificity data?
Calculate likelihood ratios -> obtain the pre-test odds
LR * pre-test odds = post-test odds
What is verification bias?
When researchers conduct the gold standard ONLY to confirm a positive or negative result in SELECT group of patients
What is contamination bias?
control group unintentionally receives the intervention
What is selection bias?
When study participants are selected in a non-random fashion or if they are LOST to follow up
What are the four criteria for capacity?
1) communicates a choice
2) has understanding of situation
3) understands the risks of not proceeding
4) able to offer rationale
What are the contraindications for bupropion?
seizure hx or TBI
Eating disorders
What is the contraindication for varenicline?
risk of cardiovascular events
renal insufficiency - cleared by KIDNEYS
note the former black box warning for risk of NEUROPSYCHIATRIC problems (especially if unstable or hx of suicidal attempt)
Which is more effective: varenicline or bupropion?
varenicline
What is the simplest distinction between palliative care and hospice care?
palliative care can be offered concurrently with disease-modifying therapies
hospice care is provided when there is no continuation of life-prolonging therapy
What is the cause and treatment of plantar warts?
HPV
salicyclic acid with tape to keep acid in place (for 2 - 3 WEEKS)
alternative: liquid nitrogen
Which occupations are associated with increased risk of warts?
meat, poultry and fish handlers
What is the risk of liquid nitrogen therapy in dark-skinned individuals?
hypopigmentation
What are the JONES criteria for rheumatic fever?
Joints (migratory)
Carditis
Nodules
Erythema marginatum (target rash)
Syndenham chorea
requires 2 of the above
OR
requires 1 + minor criteria
(fever, arthralgia, esr, crp, prolonged PR)
Which sex is more at risk for rheumatic fever?
GIRLS
ages 5-15
What is the sequelae from untreated rheumatic fever?
mitral regurgitation/stenosis
What EKG finding is a minor criteria in the diagnosis of rheumatic fever?
prolonged PR interval
Describe the findings of syndenham chorea
emotional lability
distal hand movements
decreased strength
pronator drift
When does syndenham chorea develop?
1-8 months after initial infection
What is the treatment of syndenham chorea?
penicillin until ADULTHOOD for secondary prevention
to prevent recurrent rheumatic fever
Which patients require further evaluation for resumption of sexual activity after a MI?
NYHA class IV heart failure
severe valvular disease
significant arrhythmias
refractory angina after PCI
Name the rapidly progressive, ulcerative skin disorder that is seen in neutropenic patients and the etiology
ecthyma gangrenosum
pseudomonas bacteremia
treat with antibiotics; no indication for surgery
Mechanism of ecthyma gangrenosum?
invasion of vascular structures -> inducing secondary necrosis
What is the dermatological progression of ecthyma gangrenosum?
macules -> bullae -> gangrenous ulcers
violaceous margins
especially in anogenital, axilla, and extremities
Fever, muscle pain, and purple-colored bullae are suggestive of…
clostridial myonecrosis
What is mycosis fungoides?
Cutaneous T-cell lymphoma
Invasive candida can affect which organ system?
Eyes -> endophthalmitis
especially in setting of neutropenia
Agents used against pseudomonas
gentamicin/tobramycin
imipenem/meropenem
ceftazidime/cefepime
ciproflox/levofloxacin
piperacillin-tazobactam
aztreonam
If diagnosis of perforated peptic ulcer is suspected, what are the next steps in management?
IV antibiotics
PPI
surgery
Define failure to thrive
when children are < 5th percentile in weight
or
down-trending weight across 2 or more major percentiles (50th, 25th, 10th)
What is the most common cause of failure to thrive?
Inadequate intake
What does a positive serum anti-citrullinated peptide antibody indicate?
polyarticular juvenile idiopathic arthritis
What are features suggestive of lyme arthritis?
able to bear weight
afebrile
well-appearing
What is the alternative to doxycycline for treatment of borrelia?
amoxicillin
especially in children < 8 OR
for pregnant or lactating women
What adverse effects can doxycycline cause?
tooth discoloration
skeletal problems
What is osteochondritis dissecans?
avascular necrosis of the femoral head
What are associated diseases with avascular necrosis of the femoral head?
1) SLE
2) sickle cell
3) antiphospholipid syndrome
4) hemodialysis
5) HIV
6) s/p renal transplant
7) Caisson’s disease
What is Caisson’s disease?
decompression sickness
What are the most common causes of avascular necrosis?
1) steroid use
2) excessive alcohol intake
Treatment options for avascular necrosis of the femoral head?
1) Core decompression (stage 1 or 2 - radiographs without head collapse)
2) osteotomy
3) total replacement
Risk factors for ovarian cancer
1) early menarche
2) later menopause
3) genetic mutation
Protective factors for ovarian cancer
1) OCP
2) breastfeeding
What is the most common allergen associated with asthma?
house dust mites
What is ABO hemolytic disease?
Baby is A+ or B+
Mom is O+
What is the treatment of ABO hemolytic disease?
Depends on the degree of unconjugated hyperbilirubinemia
mild: breastfeed
moderate: phototherapy
severe (> 25): exchange transfusion
Make this diagnosis: 1) pelvic pain 2) dysmenorrhea 3) deep dyspareunia 4) dyschezia
endometriosis
Physical exam findings for endometriosis
1) immobile uterus
2) cervical motion tenderness
3) adnexal mass
Medical management of endometriosis
NSAIDS
OCPs
GnRH agonists
Treatment of infertility due to endometriosis
surgical resection
IVF
What are classical physical exam findings for subacute combined degeneration?
Specific: hyperreflexia, spastic paresis
Loss of vibratory sense
Romberg
Age of presentation for Wilson disease?
Age 5-35
Most common neurologic symptom of Wilson disease?
dysarthria
Mechanism of anemia in B12 deficiency
intramedullary hemolysis
Labs to check for hemolysis
LDH
haptoglobin
Indirect bilirubin
What is the mechanism of serum sickness?
immune complex formation (TYPE III HYPERSENSITIVITY) - ie antigen and antibody (IgG) combination
Features of serum sickness like reaction?
1-2 weeks after antigen exposure
fever, rash, polyarthralgia
Offending agents associated with serum sickness like reaction?
antibiotics, especially beta lactams or sulfa drugs
acute hepatitis B
Treatment for serum sickness reaction?
Stop offending agent
Supportive care
Steroids/plasmapheresis if severe
Extrahepatic manifestations of hepatitis B infection?
polyarteritis nodosa
more likely membrane nephropathy
less likely membranoproliferative glomerulonephritis
What defines anaphylaxis?
IgE mediated immediate hypersensitivity
TYPE 1 - reaction against a soluble antigen
What is the mechanism of a type II hypersensitivity reaction?
cytotoxic autoantibodies (IgG) directed against patient’s own blood cells
What mediates a type IV hypersensitivity reaction?
Macrophages
What time of hypersensitivity reaction is the allergy to penicillin?
type II
What type of hypersensitivity reaction are the following diseases? transfusion reaction autoimmune hemolytic anemia erythroblastosis fetalis Goodpasture’s syndrome
type II, complement dependent
Cell type which mediates type IV delayed hypersensitivity reactions
CD4+ T lymphocytes
What cell line is chronic lymphocytic leukemia?
B cell
What are the possible treatments for seborrheic dermatitis?
antifungals (selenium sulfide, ketoconazole)
topical steroids
calcineurin inhibitors (pimecrolimus)
Treatment for tinea capitis?
oral Griseofulvin or terbinafine
Treatment for tinea corporis?
Griseofulvin
Treatment for scabies?
permethrin
alternatively, ivermectin is a possibility
When does screening for group B streptococcus in pregnant women occur?
35-37 weeks
What is the treatment for group B streptococcus in pregnant women?
Penicillin
If a pregnant woman has a history of prior pregnancy complicated by Group B strep, are antibiotics indicated?
YES
How long must membranes be ruptured for prophylactic administration of antibiotics?
> 18 hours
&
unknown GBS status
Should penicillin be given for GBS if the mom has a fever?
YES, if GBS status is unknown
Should penicillin be given for GBS if the mom is less than 37 weeks gestation?
YES, if GBS status is unknown
What common condition can these organisms cause? Chlamydia Salmonella Shigella Yersinia Campylobacter
Reactive arthritis
Which category of rheumatic disease does reactive arthritis fall under?
spondyloarthropathy
Does B27 positivity increase risk of reactive arthritis?
YES, especially in the setting of acute infection.
Doubles the risk
What side effects are associated with anabolic steroids in females?
changes in mood
acne
hirsutism
+/- eating disorders
clitormegaly
hair loss
Is voice deepening reversible in women who use anabolic steroids?
NO
Name the etiology for the following symptoms in men: decreased sperm count decreased testicle size gynecomastia
endogenous steroids
True or false, acute infection with HCV requires vaccination against Hep A or B?
TRUE
Diagnosis of spontaneous bacterial peritonitis requires what white cell count?
250
In splanchnic vasodilation, what happens to peripheral vascular resistance?
DECREASE in PVR ->
decreased renal perfusion
If there is bilateral nipple discharge, the first test should be…
pregnancy test
galactorrhea workup
What are the criteria for pathologic breast discharge?
spontaneous
unilateral
persistent
What is the most common cause of nipple discharge?
papilloma
Do women under 30 receive mammograms if there is abnormal breast discharge?
NO, breast is too dense
Can hypothyroidism cause hyperprolactinemia?
yes
What are the three P’s of MEN 1?
pituitary
pancreatic
parathyroid
What are the indications for parathyroidectomy?
symptomatic hyperCa++
End-organ damage (osteoporosis, CKD, nephrolithiasis)
Complications (urinary excretion of Ca++ > 400)
serum calcium > 1 mg/dL above ULN
Risk factors that indicate need for higher INR goal in aortic valve replacement…
1) a fib
2) EF < 30%
3) prior VTE
4) hypercoagulable state
Does mitral valve replacement require a higher INR than uncomplicated aortic valve replacement?
YES, 2.5 - 3.5
What TSH level warrants treatment for hyperthyroidism?
TSH < 0.1
If TSH is 0.1 - 0.5, what risk factors are needed to warrant treatment?
1- age > 65
2- heart disease
3- osteoporosis
4- nodular thyroid disease
Best medication to raise HDL?
Niacin
Mechanism of orlistat?
intestinal lipase inhibitor
Normal carbamazepine levels?
4-12
What is preferred? Greater QALY or DALY?
QALY should be higher
Time trade off better if higher
DALY better if lower
Treatment for paget disease of bone?
Bisphosphonates
Alendronate (6 months)
risedronate (2 months)
When is treatment of paget disease of bone indicated?
intolerable pain
involvement of weight-bearing bones
neuological disease
hypercalcemia, hypercalciuria
CHF
Mechanism of bisphosphonates?
inhibits osteoclastic resorption
Diagnostic criteria for STEMI
> 2 contiguous leads
> 1mm in all leads except V2 and V3
> 1.5 mm in women, > 2 mm in men in leads V2 and V3 if < 40
> 2.5 mm for men < 40 in V2 and V3
What do anti-centromere antibodies indicate?
CREST
Anti-mitochondrial antibodies indicate what?
Primary biliary cirrhosis
Anti-smith antibodies indicate…?
SLE, low sensitivity of 25%
Anti-Ro/SSA suggest…?
Sjogren’s
What antibody can be followed to correlate with disease activity?
Anti ds-DNA
May anticipate occurrence of lupus nephritis
SLE symptoms treated by hydroxychloroquine
arthralgia
serositis
cutaneous symptoms
When is methotrexate indicated for SLE?
After lack of response to prednisone
Organ involvement
Risk of what neurologic disease is associated with rituximab?
progressive multifocal leukoencephalopathy
Indications for treating immune thrombocytopenia with IVIG/steroids?
Only if the patient is:
BLEEDING (indication in both pediatrics and adults)
In adults: patients should be treated if they have platelets < 30k OR are experiencing bleeding
Where does bleeding associated with ITP occur?
mucocutaneous -
1) epistaxis
2) hematuria
3) GI bleed
Laboratory findings of ITP
megakaryocytes on smear
< 100k platelets
What is the treatment for TTP-HUS?
plasma exchange
If a patient is Rh + and has a spleen, what is the treatment for ITP?
Anti-Rh(D)
Under which category of neurologic disease is blepharospasm?
dystonia
What are possible triggers of blepharospasm?
light
irritants
First line treatment for blepharospasm?
botulinum toxin
What defines unhealthy alcohol use?
F: > 3 drinks/day
>7 drinks/week
M: > 4 drinks/day
>14 drinks/week
Drugs indicated for agitation in acute delirium in elderly?
antipsychotics
NO BENZODIAZEPINES - unless due to alcohol withdrawal
Symptoms of hypertrophic cardiomyopathy?
fatigue
dyspnea
The following echo findings suggest: 1) asymmetric septal hypertrophy 2) systolic anterior motion 3) left ventricular outflow obstruction
hypertrophic cardiomyopathy
Inheritance pattern for hypertrophic cardiomyopathy?
autosomal dominant
Initial monotherapy for hypertrophic cardiomyopathy?
beta blockers
can add verapamil OR disopyramide for persistent symptoms
What is the indication for alcohol septal ablation?
Cases of hypertrophic cardiomyopathy unresponsive to medical therapy
OR
LVOT gradient > 50 mmHg
What drugs should not be used in hypertrophic cardiomyopathy?
vasodilators
ACE-I/ARBs
nitrates
Why should vasodilators NOT be used in hypertrophic cardiomyopathy?
Because decreased peripheral resistance can cause increase in the left ventricular outflow tract obstruction
When is a ICD indicated for hypertrophic cardiomyopathy?
NYHA Class II/III HF
LVEF < 30-35%
Prior MI
Ventricular fibrillation or tachycardia
What is an early finding of compartment syndrome?
paresthesia
Atypical features of ITP such as bone pain, fevers, weight loss, lymphadenopathy, splenomegaly, neutropenia, or anemia warrants what treatment?
bone marrow biopsy
Recurrent bleeding, no response to IVIG or steroids, and chronic immune thrombocytopenia warrants what treatment?
splenectomy
warranted in cases of CHRONIC ITP
Name SIG E CAPS
sleep changes
loss of interest
guilt
decreased energy
cognitive changes
appetite changes
psychomotor retardation
suicidal ideation
Schizoaffective is distinguished from schizophrenia in what way?
Mood symptoms are present throughout illness w/ and w/o psychosis
Major depression/bipolar with psychotic features differs from schizoaffective and schizophrenia in what way?
psychosis occurs exclusively during periods of mood symptoms
Hallmark of schizophrenia?
Mood symptoms are brief and generally not a defining feature
What worsens visual hallucinations in cases of lewy body dementia?
dopamine agonists
When does erythema migrans from borrelia develop?
3-7 days after infection
What is the length of tick attachment that is required to transmit lyme disease?
> 36 hours
borrelia needs to travel from the tick’s gut to the tick’s salivary glands
tick ENGORGEMENT is a surrogate marker
Tenderness of the medial knee along joint line indicates what?
medial collateral ligament injury
NO significant hemarthrosis
Clinical features of locking, catching of the knee indicate what injury
meniscal tear
effusions can develop SLOWLY
A patient has chronic overuse and has pain over the ANTERIOR KNEE reproduced by knee extension w/ compression of the patella
likely patellofemoral pain syndrome
What is the preferred treatment of hyperthyroidism during the first trimester?
propylthiouracil
What is the preferred treatment of hyperthyroidism during the second and third trimester?
methimazole
What are the mechanisms by which pregnancy affects thyroid hormone?
1) stimulation of thyroid binding globulin leading to increased bound thyroid -> stimulates production of additional thyroid hormone
2) inhibition of TSH from pituitary but stimulation of thyroid hormone production
What are the findings of typical T4 and TSH in pregnancy?
decreased TSH
elevated total T4 and free T4
What is tilt table testing used for?
to differentiate between neurocardiogenic syncope (vasovagal) and orthostatic hypotension syncope
ultimately a poor test - low SN and SP
What are the 3 features of vasovagal syncope?
1) inciting event (standing, stress, pain)
2) prodrome (nausea, pallor, sweating, warmth)
3) recovers quickly
Treatment for actinic keratosis?
topical 5-fluorouracil cream (3-6 weeks)
imiquimod
diclofenac
photodynamic therapy
liquid nitrogen
surgical excision
curettage
What is a important examination feature of actinic keratosis?
felt better than seen
What is the risk of progression from actinic keratosis to squamous cell carcinoma?
20%
Candida vaginitis has what type of discharge?
cottage cheese, white
Treat with fluconazole
True or false, partner needs to be treated if there is a positive diagnosis of trichomoniasis.
True
What is the risk of flagyl in babies?
loose stools
candidiasis
Treatment of chlamydia trachomatis cervicitis is…
azithromycin single dose
doxycycline bid for 7 days
Treatment for gonorrhea is…
ceftriaxone, single IM 250 mg
but DUAL therapy with azithromycin is recommended for treatment of concurrent chlamydia irrespective of chlamydia results
If a woman is diagnosed with chlamydia vaginitis and is breastfeeding, what should she do?
continue to breast feed, no known effects despite excretion in milk
Screening regimen for HIV?
HIV antigen (p24)
HIV1/2 antibodies
What is the window period for HIV screening?
1-4 weeks of infection
When does post-exposure prophylaxis of HIV need to start?
< 72 hours after exposure
preferably starting within 1-2 hours
True or false, hepatitis B testing should occur before starting HAARTs?
true
Diseases to screen for prior to starting HAARTs?
TB
hepatitis C
Treponema
Gonorrhea
CV disease screening before HAART initiation
hypertension
hyperlipidemia
DM
tobacco abuse
What first changes after addressing iron deficiency anemia in children?
increase in reticulocyte count
What are the best diagnostic tests for paget disease of bone?
radiographs
alkaline phosphatase
serum calcium
bone scan
Wallenberg syndrome localizes where?
lateral medulla
What are the typical symptoms associated with infarct of the lateral medulla
vestibulocerebellar symptoms
sensory loss (ipsilateral face and contralateral trunk/limbs)
ipsilateral bulbar muscle weakness
autonomic dysfunction
If a patient presents with Horner’s syndrome, hiccups, and lack of automatic respiration, you should consider which diagnosis…
Lateral medullary syndrome
A type 2 error refers to:
FALSE NEGATIVE: not detecting an effect when there is one
BETA LEVEL
A type 1 error refers to:
FALSE POSITIVE: detecting an effect when there is not one
ALPHA LEVEL
Fever, unilateral eye pain, and fungating retinal lesions w/ vitreal extension (MOUND-LIKE lesions) suggest what?
Candida endophthalmitis in the setting of immune suppression
especially if central venous access is present
What is the treatment for candida endopthalmitis?
vitrectomy and systemic amphotericin B (for 4-6 weeks)
Can consider fluconazole or voriconazole but NOT ketoconazole
Treatment for mycobacterium avium?
clarithomycin and rifabutin
What is the empiric treatment for community acquired pneumonia in the outpatient setting?
macrolide or doxycycline if healthy
What is the empiric treatment for CAP in the outpatient setting if patients have comorbidities?
fluoroquinolone or beta lactam + macrolide
What are the regimens for CAP in a non-ICU setting?
fluoroquinolone
or
beta-lactam + macrolide
What are the regimens for CAP in an ICU setting?
beta-lactam + macrolide
OR
beta-lactam + fluoroquinolone
CURB 65 stands for?
CONFUSION
UREMIA (> 19)
RESPIRATORY RATE (>30)
BP (<90 SBP OR < 60 DBP)
AGE > 65
grading scale for assessment of pnemonia treatment - outpatient vs inpatient
What are risk factors for MRSA in pnemonia?
recent flu or antibiotic use
cavitary infiltrates
septic shock
respiratory failure
Why are systemic corticosteroids contraindicated in psoriasis?
risk of induced pustular psoriasis
What are risk factors for intussusception?
MOST COMMON: recent viral illness -> lymphoid hyperplasia of Peyer patches
OTHER:
- malformation (Meckels)
- HSP
- Celiac disease
- tumor
- polyps
What is the classic triad of intussusception?
vomiting, abdominal pain, passage of blood
other findings
- sausage shaped mass
- currant jelly stools
Social circumstances in which a minor can provide their own consent… (EMANCIPATED MINOR)
1) homeless
2) is now a parent
3) married
4) military service
5) financially independent
6) high school graduate
What is the pathophysiology of currant jelly stools in intussusception?
telescoped bowel -> vessel compression -> bowel ischemia -> rectal bleeding
What is the primary risk of air enema?
intestinal perforation < 1% of cases
increased risk with
1) small bowel obstruction
2) age < 6 months
What is scombroid poisoning?
ingestion of improperly stored seafood ( ie > 15 degrees C)
What is the pathophysiology of scombroid poisoning?
histidine undergoes decarboxylation -> forms histamine
What are the symptoms of scombroid poisoning?
flushing, throbbing headache, palpitations, abdominal cramps, diarrhea, and oral burning
begins within 10-30 minutes after ingestion
+/- erythema, wheezing, tachycardia, and hypotension
What are the symptoms of pufferfish poisoning?
perioral tingling, incoordination, weakness
Symptoms of vertebrobasilar insufficiency?
vertigo, dizziness, dysarthria, diplopia, and numbness
Risk factors for vertebrobasilar insufficiency?
DM, hypertension, hypercholesterolemia, arrhythmia, CAD, and smoking
Vertigo, tinnitus, nausea, and imbalance suggest….
labyrinthitis
Kawasaki disease CRASH stands for…
conjunctival injection
rash
adenopathy
strawberry tongue
hands and soles
+ 5 days of fever
Difference between rubella and measles…
measles: typically ill-appearing with higher fevers
measles rash is darker
