UW mix 2 Flashcards
Acute headache, nausea, blurry vision, sluggish and dilated pupil, and conjunctival injection
Acute angle closure glaucoma! Emergency, can cause permanent optic nerve damage in hours
Triggers for acute angle closure glaucoma?
Decongestants, antiemetics, anticholinergics (including trihexyphenyl used for the tremor in parkinson’s)
Parkinson’s treatments
Levodopa (DA precursor), pramipexole (DA agonist), and entacapone (increases DA stimulation), and selegiline (MAOI b)
7 year old girl, precocious puberty, ovarian mass -
Granulosa cell tumor - malignant, estrogen - secreting tumor.
Rule of 2’s
For Meckel’s diverticulum - 2% prevalence, 2% symptomatic at age 2, 2:1 male to female ratio, within 2 feet of the ileocecal valve
How to diagnose Meckel’s
Technicium 99 scan - with patient with painless hematochezia
Fancy names for disturbances in cerebellar lesions
Dysdiadochokinesia - difficulty w/ rapid alternating movements
Dysmetria - past-pointing on finger-to-nose testing
Limb ataxia
Intention tremor
Dextromethorphan - uses, mechanism, SEs
Cough suppressant, NMDA antagonist, can cause dissociation
Ptosis, down and out gaze, diplopia, and normal pupillary response? Cause? Common etiology? What if had no pupillary dilation to light?
Ischemic oculomotor (CNIII) nerve palsy, usually from diabetes causing ischemic neuropathy - If also pupillary response gone - involves inner and outer (parasympathetic) fibers of CNIII nerve - would be lacunar infarct
Poison Ivy - what type of hypersensitivity reaction?
Type IV (IVy!) - delayed, T-cell mediated response. Requires previous exposure. Like contact dermatitis.
Name 4 types of hypersensitivities?
Type I: immediate, IgE mediated
Type II: cytotoxic, IgG and IgM
Type III: immune complex deposition (PSGN, SLE)
Type IV: delayed, T cell mediated
DeQuervain tenosynovitis - classic population and findings
New mothers that hold babies with thumbs up. Pain at radial/dorsal base of thumb
Pure motor hemiparesis, sudden onset - most likely?
Lacunar stroke - no cortical signs (aphasia, agnosia, ataxia, etc). Maybe in BG or internal capsule
internal carotid artery problem like dissection - sx
maybe neck pain, thunderclap headache, sx of ischemic stroke (hemiparesis, facial droop, aphasia).
Can be from orofacial trauma)
When to not use amitriptyline?
Patients >65 due to anticholinergic effects; also pt with pre-existing cardiac disease due to conduction abnormalities exacerbated
Erythema nodosum - what to look for?
Could be idiopathic. BUT always check for systemic things - TB, sarcoid, strep, coccidiodomycosis, IBD and Behcet
Wallenberg syndrome - site of infarct; artery involved; symptoms
Infarct - lateral medullary infarct
Artery - occlusion of posterior inferior cerebellar or vertebral artery
Symptoms - loss of pain and temp ipsilateral face and contralateral body; ipsi bulbar weakness, vestibulocerebellar impairment (vertigo, nystagmus), and Horner’s syndrome.
Motor - normal
First versus second line in BPH
1: alpha 1 blockers (terazosin, tamsulosin) - rapid response, relax bladder neck and prostate smooth muscle
2: 5 alpha reductase inhibitors - take 6-12 mo to work, inhibit conversion of T to dihydroT, reduces prostate size
Hard signs of vascular trauma; what to do about it
Signs: observed pulsatile bleeding, expanding hematoma, or signs of distal ischemia (cold limb, no pulses)
Do: urgent exploration (dont’ wait for imaging)
Main substrates for gluconeogenesis
alanine, lactate - these get converted to pyruvate
also glutamine and glycerol-3-phosphate involved
Fatigue, constipation, nephrolithiasis — think of?
Hypercalcemia - suggestive of hyperparathyroidism. Can also have pseudogout with CPPD - calcium pyrophoshate crystals. Rhomboids, positively birefringent. On joint x ray can see chondrocalcinosis in joint spaces.
hypoplastic fingers and nails + cleft lip + concern for bleeding at birth
Fetal hydantoin syndrome. Pregnant women on phenytoin. In final trimester, get vitamin K to prevent neonatal bleeding, since phenytoin increases rate of fetal vit K degradation
morning vomiting, nocturnal headaches - concern for?
Intracranial pathology
poor feeding, irritability, head circumference %ile increasing, decreased activity, vomiting
Hydrocephalus - see tense and bulging fontanelle, prominent scalp veins, wide sutures
Temporal pattern of paralysis in stroke
Start with flaccid paralysis. Eventually turns to spastic.
What are the extrapyramidal signs?
rigidity, bradykinesia, tremor, and chorea. lesions of subcortical nuclei like BG.
impaired abduction at the shoulder w/ pain and after falling on outstretched hand. And what if you do a drop arm test, and half way down, their arm falls?
rotator cuff tear! usually supraspinatus.
Drop arm test, and arm falls: complete supraspinatus tendon tear
inability to do extreme shoulder abduction
serratus anterior / long thoracic nerve, winged scapula problem. From penetrating trauma or chest tube insertion, etc
Transverse myelitis - when do you see it, and what does it look like?
In MS - see motor and sensory loss below lesion level, including bowel and bladder. First flaccid paralysis, then spastic.
Internuclear ophthalmoplegia
In MS (if bilateral) - demyelination of medial longitudinal fasciculus - cannot adduct affected eye, and contralateral eye abducts with nystagmus (says ‘come on!’ to the other eye)
Treatments for idiopathic intracranial hypertension (And other name)
Pseudotumor cerebri -
Acetazolamide (inhibits choroid plexus carbonic anhydrase, so makes less CSF)
Repeated LPs (short term only)
VP shunt + optic nerve sheath decompression
What is multiple system atrophy?
Shy Drager syndrome:
- Parkinonism (rigidity, bradykinesia)
- Autonomic dysfunction (orthostasis), incontinence, impotence, etc
- Widespread neuro sx (Cerebellar, LMN, etc)
Horner syndrome
Regional autonomic dysfunction - anhydrosis, miosis, and ptosis
Guillain barre - sx? muscles? reflexes? tx?
ascending polyradiculoneuropathy. Ascending flaccid paralysis, sometimes paresthesias. Weak or absent DTRs. Autonomic dysfunction, too.
Albuminocytologic dissociation
Tx: IVIG or plasmapheresis
Dementia with Lewy Body disease - sx
Visual hallucinations
Spontaneous parkinsonism - resting tremor, muscle rigidity (severe sensitivity to dopamine antagonists/antipsychotics)
Fluctuating cognition
Normal pressure hydrocephalus
ataxia early in disease
urinary incontinence
dilated ventricles
Frontotemporal dementia
early personality changes, apathy, disinhibition, compulsive behaviors
Name this syndrome: hypotension, pigmentation, hyponatremia, hyperkalemia, eosinophilia, high ACTH, low serum cortisol
primary adrenal insufficiency!
focal bone pain + elevated alk phos? - oh, and has a new hearing aid, and headaches
Paget’s disease! also look for hearing loss or enlargement of cranial bones
- from osteoclast dysfunction, increased bone turnover!
risk factors for brain abscess
cyanotic heart diseases, R to L shunts (bacteria bypasses pulmonary circulation, where a lot of macrophages live); recurrent sinusitis;
Brain abscess triad
fever, headache (nocturnal or morning), and focal neuro deficits
what do you do with a solid testicular mass?
Remove first, assess for cancer later. I.e. just radical orchiectemy
Pattern in essential tremor?
Parkinson’s tremor?
Essential - occurs during activity
Parkinson’s tremor - occurs at rest, better with activity - most common presentation is asymmetric, distal extremity
Open angle glaucoma - eye exam? sx? tx?
cupping of optic disk; loss peripheral vision; beta blocker drops like timolol
Nerve responsible for facial motor activity? Facial sensation?
VII facial nerve - motor (upper and lower face = lower CN VII lesion, below the pons) - will also see inability to close the eye) —- vs central lesion = forehead spared (since above eyebrows has bilateral upper motor neuron innervation and would be spared)
SENSATION = CN V, trigeminal
Menierre’s disease
increased volume or pressure of endolymph
- recurrent episodes >20 min, sensorineural hearing loss, tinnitus, fullness in ear
TX = restrict sodium, caffeine, nicotine, alcohol. Consider diuretic.
High fever; then rash (maculopapular) as the fever abates
Roseola (no vesicles
monocular vision loss in 60 yo; also has unilateral headache, jaw claudication - what test to get? then what?
Concern for Giant Cell Arteritis. Get ESR. Then get biopsy.
May also have polymyalgia rheumatica, fever, fatigue, etc
woman <50 yo with monocular vision loss, pain with eye movement - think of? how will pupils be?
Concern for optic neuritis (in woman with MS) - often with afferent pupillary defect, and optic disk swelling
enzyme mutated in galactosemia?
galactose 1 phosphate uridyl transferase deficiency!
Sx: FTT, bilateral cataracts, jaundice, and hypoglycemia
galactokinase deficiency =/= what condition
galactosemia. The kinase deficiency gets cataracts only, no other sx
main acid base disorder in diarrhea?
Metabolic ACIDosis - loss of organic anions and bicarbonate. Get hyponatremia and hypokalemia
xray and microscopy findings in pseudogout? What about in Gout?
xray - chondrocalcinosis - calcification of cartilage in joint space
micro - rhomboid pos biref crystals
GOUT - punched out erosions with rim of cortical bone; needle shaped neg biref crystals
where is broca’s area? supplied by what artery? associated physical sx?
dominant FRONTAL lobe - middle cerebral artery. Dominant cortex for verbal and written language function
- usually w/ right hemiparesis of face and UE
Where is Wernicke’s area? Sx? Associated physical sx? Artery involved?
dominant temporal lobe (receptive aphasia).
right superior visual field defect
Dominant (left) MCA - also get UPPER limb neuro deficits
(vs R MCA gets hemineglect)
Something to do for young woman with heavy vaginal bleeding, dysfunctional uterine bleeding from irregular/infrequent menstrual cycles?
high dose oral contraceptives (or IV estrogen). D&C + transfusion only if hemodynamically unstable
lab to check to confirm menopause?
FSH. Probably also get TSH to rule out hypothyroid
preferred imaging for presumed ureteral stone?
US, or CT WITHOUT contrast
main risk factor for endometrial cancer?
unopposed estrogen! (early menarche, no pregnancies, no OCPs, obesity)
name 2 aminoglycosides
tobramycin, gentamicin, amikacin, streptomycin, neomycin
notable missing feature in a lacunar stroke?
absence of cortical signs! (aphasia, agnosia, neglect, apraxia, seizure)
- do see pure motor or sensory stroke,, ataxic hemiparesis, etc
what can cause spinal stenosis? = neurogenic claudication = pseudoclaudication
congenital, degenerative disk disease, degenerative arthritis (spondylosis)
by what age should kids be walking?
17-18 months
Postpartum fever lasting >24 hrs is most likely?
postpartum endometritis ; it’s polymicrobial, so give clindamycin + gentamicin
Most likely area of pure sensory stroke
posterolateral thalamus! can have post stroke, deep thalamic pain syndrome
TImecourse for gestational diabetes? Preeclampsia?
Onset after 20 weeks gestation -
Preeclampsia is onset >20 weeks + proteinuria or end organ damage
Fever >5 days + what other symptoms = kawasako
4 of: conjunctivitis; mucositis (strawberry tongue, injected lips), cervical lymphadenopathy; rash (erythematous generalized or morbilliform); erythema of hands and feet
fever, sandpaper rash sparing palms/soles, and pharyngeal exudate?
scarlet fever in poorly treated strep throat
how to treat sarcoidosis when symptomatic?
(cough, dyspnea, chest pain, hypercalcemia with lithiasis, constitutional)
- use glucocorticoids
parvovirus b19 infection in older adult - main symptoms?
arthritis / arthralgia, symmetric = may mimic RA **(polyarticular and symmetric; hands, feet, wrists)
flushing, diarrhea, + bronchospasm - what syndrome? what primary site?
carcinoid syndrome. GI tract malignancy (small intestine)
- carcinoid cells make serotonin from tryptophan, which uses up your niacin
VIPoma syndrome = where is primary tumor site?
(pancreatic cholera) = diffuse watery diarrhea, muscle weakness (hypokalemia), and hypochlorhydria; also flushing
- primary tumor in pancreatic tail
Syndrome during gastrinoma?
Zollinger-Ellison syndrome; multiple gastric ulcers and dyspepsia (tumor is in pancreas)
PID treatment
ceftriaxone + azithromycin
can see pelvic sx and maybe RUQ liver from Fitz hugh curtis
Dry vs wet beri beri
Dry = symmetrical peripheral neuropathy w/ motor + sensory often
Wet = same plus cardiac involvement (myopathy, CHF, edema, etc)
- Thiamine deficiency
recently had URI, now with palpable purpura (lower extremity), arthritis/arthralgia, abd pain, renal disease/hematuria (+/- scrotal swelling)
HSP Henoch Schonlein purpura (immune mediated small vessel vasculitis)
- watch for IgA-like nephropathy; intussuception
antibody to post synaptic acetylcholine receptor
myasthenia gravis - fluctuating mm weakness worse w more use. Can have diplopia, ptosis. Proximal muscle weakness, normal reflexes.
antibody to presynaptic voltage gated calcium channel
Lambert Eaton = paraneoplastic = proximal mm weakness, dimished DTRs; autonomic dsfnx (dry mouth), ptosis
weight gain + proximal muscle weakness + HTN + agitation/insomnia/psych + hyperglycemia = syndrome. What other associated syndrome in women?
How to test?
Cushing syndrome (=hypercortisolism from steroids or from ACTH from tumor or adrenal)
Also see easy bruisability, dermal atrophy, striae
Some hyperandrogen in women
Test: late night salivary cortisol OR 24hr free cortisol OR overnight low-dose dexamethasone suppression test
female athlete triad, running a lot more lately, now has tenderness to palpation in foot
stress fracture!
first and final treatments for pituitary prolactinoma?
Med: bromocriptine or cabergoline (DA agonists)
Surgical: last, only if large and sx
old lady with visual flashers, floaters, and curtain of darkness coming down?
retinal detachment
most common cause nephrotic syndrome in kids? what to do about it?
minimal change disease (T cell mediated podocyte injury)- give prednisone
ptosis that improves with 2 minutes of ice pack on eyes?
Myasthenia gravis (cold inhibits breakdown of Ach) - antibody mediated degredation of Ach receptors
postpartum - now with seizure, coma, and hyponatremia - what med caused it?
oxytocin toxicity! cause low sodium, HTN
Magnesium toxicity
hyporeflexia, lethargy, headache, respiratory failure, cardiac arrest (everythign including reflexes SLOWS DOWN)
acute onset focal neurologic sx; followed by nausea, vomiting, headache, confusion? - cause?
acute stroke! Probably from hypertensive intracerebral hemorrhage, then increased ICP
inflammatory arthritis + splenomegaly + neutropenia +/- skin lesions
Felty syndrome! Long standing rheumatoid arthritis (10+ yrs)- then get severe joint disease, rheumatoid nodules, vasculitis with mononeuritis multiplex, necrotizing skin lesions
- the neutropenia is important here.
bonus - labs = anti-CCP and RF, very high ESR
headache, bilateral periorbital edema and bilateral CN 3,4,5 and 6 nerve deficits
(infectious) cavernous sinus thrombsis
when do you see anti-scl-70 (topoisomerase 1) and anti-RNA pol III?
diffuse cutaneous scleroderma / systemic sclerosis
adnexal mass with lack of doppler flow?
ovarian torsion! needs emergent surgery
most common primary immune deficiency ? what happens when they get blood transfusion?
Selective IgA deficiency. Can have severe reaction to transfusion (pt has anti- IgA antibodies!)
food borne illness, early onset (few hours) having nausea and vomiting - type of pathogen?
think staph aureus, pre-formed toxin. In dairy products (mayo in potato salad).
Also bacillus cereus if fast onset but from starch product
short stature + aortic coarctation makes you think…
Turner syndrome (estrogen deficient, risk of osteoporosis)
subclinical hypothyroid + miscarriages; name the dx and antibody involved
chronic Hashimoto’s thyroiditis
antithyroid peroxidase and antithyroglobulin antibodies
can’t see can’t pee can’t climb a tree
reactive arthritis but its usually chlamydia (vs in younger kids it’s often a diarrheal illness like salmonella)
thyroid stimulating immunoglobulins; disease; antibody name
Graves disease = hyperthyroid
Antibody: TSH receptor antibody
what nerve gets injured by anterior shoulder dislocation?
axillary nerve - innervates deltoid and teres minor; get weak shoulder abduction
deep axillary laceration / lymph node dissection may cause what nerve problem?
long thoracic injury, innervates serratus anterior - causes winged scapula
most common nephrotic syndrome in adults?
FSGS (localized mesangial sclerosis and BM changes)
subacute thyroiditis - other name? tx?
de quervain thyroiditis, post-viral, painful and hyperthyroid, high ESR and CRP
Tx: betablockers for thyrotoxic sx and NSAID for pain
CHARGE syndrome
Coloboma, Heart defect, Atresia (choanal), Retardation of growth, Genitourinary, and Ear problems)
triad: hemolytic anemia, thrombocytopenia, AKI
Hemolytic uremic syndrome HUS, from EHEC or Shigella with bloody diarrhea, e.g.. But 10% had strep pneumo
unopposed estrogen places pt at increased risk of what malignancy?
endometrial hyperplasia and cancer
immediate anaphylactic response to blood transfusion?
recipient probably has no IgA, and thus has anti-IgA antibodies.
Which 4 vaccines you cannot give in pregnancy
HPV, MMR, live attenuated flu (nasal), and varicella
most common extracranial solid tumor in childhood? urine markers?
Neuroblastoma - see urine HVA and VMA
Neural crest as precursor to sympathetic chain and adrenal medulla (tumors can be here)
signs of increased ICP and also focal neuro deficits
intracranial tumor! not just stroke
FTT + normal anion gap acidosis; urine alkalotic
Renal tubular acidosis! (inability to excrete H+ or to reabsorb bicarb)
Man with AIDS has blurred vision, floaters; funduscopy has fluffy yellow lesions along vasculature
CMV retinitis
tremor of hands with action, better after alcohol
essential tremor
resting tremor that decreases with movement
parkinson’s
alcoholic hallucinosis
occurs between 12-36 hrs after drinking; hallucinations with stable vitals
neonate with sensorineural hearing loss, cardiac defect (PDA), and cataracts
congenital rubella syndrome (in 1st trimester exposure)
eczema or ulcer on breast, by nipple, itching and burning - concerning for what?
Paget’s disease of breast - often adenocarcinoma (since it’s the most common type of breast cancer overall) - due to cancer blocking lymph drainage, inflammatory breast disease
signs of complicated small bowel obstruction (when do you need to operate)?
change in character of pain; new fever, hemodynamic instability, guarding, leukocytosis, metabolic acidosis
recurrent skin and mucosal bacterial infections (no purulence), severe periodontal disease? kiddo?
Leukocyte adhesion defect! Delayed umbilical separation. Low leukocytes (leukocytosis with lots of PMNs)
what immune deficiency gets recurrent sinupulmonary and GI infections? low b cell? oh, and they have low Ig levels?
x linked agammaglobulinemia - bruton’s. defective B cell maturation.
what bacteria are involved in chronic granulomatous disease?
catalase + organisms - staph aureus, serratia, burkholderia.
Impaired respiratory burst for intracellular killing in phagocytes.
baby with retinal hemorrhage?
almost pathognomonic for abusive head trauma. shaken baby. can have shearing of subdural veins causing subdural bleed, large head, and seizures
what if you have thyroid nodule with high calcitonin - what are you concerned about? what associated findings shoudl you look for?
get biopsy - see medullary thyroid cancer
Concern for MEN1 and MEN2 - look for pheo (plasma metanephrines) (and consider RET mutation testing) - if found, pheo should be removed prior to thyroid!
some causes of idiopathic intracranial hypertension?
young obese women; growth hormone; tetracyclines (Doxy, mino), excess vitamin A (Retinoids)
diagnose a patient with RA - they’re already taking ibuprofen. What do you do?
Start a DMARD like methotrexate! Always, early. Prevent future joint damage.
- before starting a DMARD (including biologic) test for TB, hep B and hep C
- step up therapy (after 6 months if not improved) - biologic
most common cause of corneal blindness in US?
HSV infection of the eye. Painful. Can cause retinitis and vision loss, too. With keratitis and conjunctivitis, too.
(vs CMV is painless)
macrocytosis in SCD patient?
Probably a folate deficiency - used up in compensation for anemia
24 hour old neonate, hasn’t passed meconium, signs of obstruction; CF in family; what to do
KUB to rule out obstruction. Concern for meconiium ileus - nearly pathognomonic for cystic fybrosis. Get contrast enema to break it up (and also to visualize). Could also show Hirschprung’s.
risk factors for cervical cancer
HPV, smoking, early sexual activity, OCPs, immunosuppression
main concern for untreated hyperthyroidism?
rapid bone loss, osteoporosis
old person, shoulder and hip pain, stiffness in morning for 1 hr; some systemic things - fatigue; high ESR/CRP - this is? what to do?
polymyalgia rheumatica. Give glucocorticoids/steroids!
Normal physical exam - no decreased ROM or focal inflammation.
name upper motor neuron signs
spasticity, bulbar symptoms, hyperreflexia
name lower motor neuron signs
fasciculations; atrophy; flaccid paralysis
recurrent UTI in young girl? young boy? (anatomic only, not social)
girl - vesicoureteral reflux
boy - posterior urethral valve(s) - only in boys!
patient with down syndrome presenting with unknown upper motor neuron signs
concern for atlantoaxial instability
- hyperreflexia, + babinski, dizziness, diplopia, vertigo, behavioral change, torticollis
how to differentiate lichen sclerosis from atrophic vaginitis from estrogen deficiency
lichen sclerosis spares the vagina; atrophy will show decreased vaginal rugae
hyperpigmentation of palmar creases, dehydration, hypotension
Addison’s - primary adrenal insufficiency, hypocortisolism - hyponatremia, thus hyperkalemia
glucose 6 phosphatase deficiency (=/= G6PD deficiency!)
can’t convert glycogen to glucose, get lots of glycogen, present at 3-4 months, hypoglycemia and seizure
after which antibiotic should you warn patients of a disulfiram like reaction?
metronidazole
hypercalcemia, and you already know PTH is low. How does phosphate help you?
if low phosphate, probably had high PTHrP
if high phosphate with high calcium, probably from high vitamin D problem (like in sarcoid)
most common cancer in kids?
ALL
what syndrome has “failure of follicle maturation” and infertility?
PCOS
triad: encephalopathy, ocular dysfunction, gait ataxia
Wernicke encephalopathy - chronic thiamine (b1) deficiency
bilateral abducens palsy, horizontal nystagmus
recurrent respiratory and GI infections, no response to vaccines? tx?
CVID - impaired B cell diff, hypogammaglobulinemia
Tx: IVIG
CD19 =? CD3 =?
what if you’re low on T cells and also have low IgG?
CD19 is B cells
CD3 is T cells
low on both is SCID - needs stem cell transplant
major toxicity of azathioprine?
dose-related diarrhea, leukopenia, and hepatotoxicity
major toxicity of mycophenolate?
bone Marrow suppression
cyclosporine toxicity?
How does tacrolimus toxicity differ?
cyclosporine: nephrotoxic, hyperkalemia, HTN, gum hypertrophy, hirsutism, tremor
Tacrolimus: all of above EXCEPT no hirsutism or gum hypertrophy
third world country, crowded, eye redness, follicular conjunctivitis?
trachoma - chlamydia trachomatis serotypes A,B,C - can cause scarring. Leading cause of blindness worldwide.
recurrent pulmonary abscesses, cutaneous abscesses with organism filled PMNs? what is it? how to test?
CGD chronic granulomatous disease - failure of oxidative burst (catalase + organisms, X linked dz)
Test PMN function for oxidative burst - use dihydrorhodamine 123 or nitroblue tetrazolium test)
test to determine total complement concentration?
CH50
rapid onset angioedema, without urticaria
hereditary angioedema
deficiency of C1 inhibitor - get high C2b and bradykinin
Pontine vs thalamic stroke?
Basal ganglia? (IC or putamen)
Pons has Pinpoint reactive pupils + deep coma. Not good.
Thalamus has eyes deviating Toward hemiparesis
Basal ganglia - contralateral hemiparesis and sensory loss, conjugate gaze deviation Toward lesion
short stature, primary amenorrhea, and no thelarche?
concern for turner syndrome - XO - premature ovarian failure - so low E, but high LH and FSH trying to turn it on
most common organisms in brain abscess (not immunosuppressed)?
staph aureus, viridans group strep
from direct extension of sinus infection, get ring enhancing lesion
three categories causing wernicke’s encephalopathy?
chronic alcoholism
chronic malnutrition (anorexia)
hyperemesis gravidarum
medication interaction risk with sildenafil or other PDE5 inhibitors?
hypotension combined with alpha blockers like doxazosin
also with nitrates - severe hypotension
signs of trigeminal neuralgia, but bilateral
concern for MS
what cranial nerves go through cavernous sinus?
III, IV, V (V1 and V2) and VI
what other things are in HELLP aside from its name?
severe variant of preeclampsia - n/v, headache; liver swelling, capsule distended - abdominal pain
HTN with signs of hemolysis
with preeclampsia, generalized arterial spasm - high afterload - concern for pulmonary edema
costochondral joint hypertrophy (rachitic rosary) + genu varum + large anterior fontanelle + craniotabes (soft skull)
concern for rickets, vitamin D or calcium deficiency
patient started on carbidopa/levodopa
early side effects?
late?
early - hallucinations, agitation, drowsiness
late - involuntary movements (after years)
lateral epicondylitis - common name? 2/2 overuse of what action?
tennis elbow. overuse of wrist extension.
On exam, reproduced by straight elbow with flexion of wrist
how is QT in HYPERcalcemia?
short QT
appears septic (hypotensive, tachycardic), febrile, diffuse macular rash on body and palms and soles
Toxic shock syndrome! tampon use, recent surgery
Bacteria (like staph aureus) have pre-formed toxins
kid has prolonged QT - what to do?
beta blocker + pacemaker
most likely adverse effect of having benign intracranial hypertension (see papilledema)?
blindness. Try weight loss, acetazolamide. Then may need shunting or optic nerve sheath fenestration to prevent blindness.
first and second line tx for enuresis in kiddo?
1: desmopressin
2: tricyclics (imipramine) just as effective, more SEs
hemorrhagic stroke / intracerebral bleed in a patient on warfarin? what to do?
reverse the warfarin urgently - okay to use PCC / Kcentra and vitamin K (Takes too long)
infant with meningococcemia, has sudden vasomotor collapse, hypotension… has skin rash with large purpuritic lesions on flank… what happened?
adrenal hemorrhage - Waterhouse Friderichsen syndrome. Almost 100% mortality.
contents of most common morning after pill
levonorgestrel. can use ulapristal
breast cancer risk factors - modifiable
alcohol, nulliparity, hormone replacement therapy (bad), older age at first birth
when to check BRCA?
relative with breast cancer <50 or any ovarian cancer dx
what birth control thing shouldn’t be given to a woman with migraines with aura?
estrogen containing OCPs
when to give corticosteroids with woman in early labor? what about magnesium sulfate?
steroids - before 37 (definitely if before 34 weeks) weeks, to reduce prematurity related m/m
Magnesium - before 32 weeks to reduce risk of cerebral palsy
arrest of labor - when is it, and what to do
no cervical change for 4 hours with adequate contractions, or 6 hours without - need C section
Rh - mother without antibodies - when to consider giving anti-D immune globulin (Rhogam)?
At 28-32 weeks gestation, and again within 72 hours of delivery if baby is Rh+
what to do about placenta previa?
pelvic rest (no sex, digital cervical exam; needs c section at 36-37 weeks)
metabolic acidosis, dehydration, polyuria, LOC, and diffuse abdominal pain.. is? recently had an infection?
what happens to urine solute levels?
total body potassium?
DKA, even in undiagnosed T1DM
urine solutes increase (osmotic diuresis, glucose, ketones)
Total body potassium is DOWN (net renal loss), but shifted extracellular due to acidemia and decreased insulin activity
infant, episodic abdominal pain, currant jelly stool, lethargy - what is it? what to do?
intussusception
get ultrasound-guided air contrast enema
EBV/mono - pharynx? lymphadenopathy?
What about gonococcal pharyngitis?
Strep throat - adenopathy?
EBV has exudative pharyngitis with TENDER lymphadenopathy cervical
GC pharynx with some edema, no exudate, and NONtender adenopathy - but likely to have PID symptoms
Strep - TENDER adenopathy
what does estrogen replacement therapy do for TBG / thyroxine binding globulin?
increase TBG levels - thus will have lower thyroid levels, and need higher dose of thyroxine
what can trigger crisis in pheochromocytoma?
surgical procedure, anesthetic agent, intra-abdominal pressure; nonselective beta blockers cause state of unopposed alpha - cause vasoconstriction and paradoxical hypertension
when do you see antithyroid peroxidase antibodies?
autoimmune / hashimoto thyroiditis, with palpable goiter, clinical hypothyroidism (sometimes transient hyperthyroid first)
new LBBB - what to be concerned of?
STEMI
Leads V1-V4?
II, III, aVF?
I, aVR, V6?
V1-V4 is LAD, LV
II, III, aVF is RCA, inferior
I aVR and V4-V6 is left circumflex
T2DM on metformin, A1c still high - what to add? what if they also want weight loss? what A1c would you add insulin?
sulfonylurea usually.
try GLP1 agonist like exenatide if want weight loss
add insulin >8.5, but may cause weight gain
large genital ulcers, deep, with severe lymphadenopathy that may suppurate - will there be pain? what is it?
chancroid - haemophilus ducreyi
painful
nevus flammeus (port wine stain, very red area, flat, usually since birth) - associated with what?
Sturge Weber syndrome, also get seizures. Congenital unilateral cavernous sinus hemangioma - get hemianopia, hemiparesis, etc. And intracranial calcifications.
axillary freckles and lisch nodules (on iris) in a kiddo?
Neurofibromatosis 1 - may get neurofibromas, even in brain
one week old, blotchy erythematous papules, move around, asymptomatic
erythema toxicum neonatorum - just supportive cares
CGG’ trinucleotide repeats plus macroorchidism - called? what else do you see?
fragile X - most common genetic MR
thrombocytopenia (with low MPV) in young male?
likely wiscott aldrich (cytoskeleton problem in both platelets and white cells, impaired cellular migration)
- – X linked recessive, eczema, recurrent infections
- – Tx: stem cell transplant
CD40 ligand mutation - can’t do what? causes?
T cells can’t induce B cell class switching - all stay IgM - hyper IgM syndrome
cherry red macula, loss of developmental milestones - main two things on differential?
- –Neimann Pick disease - also has areflexia and hepatosplenomegaly - sphingomyelinase deficiency
- –Tay Sach’s - hyperreflexia - b-hexosaminidase A deficiency
(both more in Ashkenazi Jew’s - think of Sarah Neimann, she was jewish and had Red food dye allergy) - and didn’t work out much, so was hypotonic
treatment for catatonia, even in a patient already with bipolar on antipsychotics?
benzodiazepine like lorazepam! even try ECT
- caution, antipsychotics can worsen it!
SSRI + what drug of abuse at a party can lead to serotonin syndrome?
Ecstasy
antipsychotics causing the most weight gain?
olanzapine, clozapine
on antipsychotic, now has amenorrhea - guess the drug
risperidone, causing hyperprolactinemia (or paliperidone)
new onset psychiatric symptoms and neuro abnormalities, also abdominal pain- concern for? (has a family history of same)
acute intermittent porphyria (GI + neuro)
dysphoria, yawning, myalgia, abdominal cramping? drug abuse hx?
opioid withdrawal
- see mydriasis (dilated), lacrimation, increased bowel sounds, piloerection
polyarthralgia, tenosynovitis, and painless vesicular/pustular rash ?
disseminated gonococcal arthritis
patient being treated for RA, now has oral ulcers = why?
methotrexate toxicity (GI sx, oral ulcers, hepatotoxicity, BM suppression, rash) - try adding folic acid
hypertension + hypokalemia = concern for? how to differentiate?
hyperaldosteronism! check renin and aldosterone levels
High renin activity: secondary hyperaldo -
Low renin: primary hyperaldosteronism (either adrenal hyperplasia or adrenal adenoma). Also mild hypernatremia, metabolic alkalosis
ACE inhibitor effect on K? Creatinine?
Increase K
Increase Cr
due to decreased GFR
should you combine niacin with a statin? what if someone has super super high triglycerides?
No. (Not for reducing trigs) Doesn’t add any benefit, and have more GI side effects.
= if needed, use fibrate, most effective, only if super severe
asian woman, <40 yo, has arm pain/claudication, fatigue, and weight loss?
Takayasu arteritis - inflammation of large vessels, aorta = arterioocclusive symptoms
gangrene of digits, superficial thrombophlebitis, in an old guy who is a smoker?
Thromboangiitis obliterans - Buerger disease
don’t forget about multifocal atrial tachycardia
normal or not?
3 or more distinct looking p waves
not a good sign
how to treat WPW? what not to use
procainamide
DON”T USE - AV nodal blockers like adenosine, digoxin, CCBs (verapamil and diltiazem), beta blockers
electrolyte stuff causing torsades?
low K, low Mg; Li or tricyclic overdose
other things associated with peaked T waves?
hyperkalemia -
widened QRS, short QT, prolonged PR
low voltage EKG + undulating things, pulsus paradoxus
electrical alternans - worry about cardiac tamponade; distant heart sounds
conus medullaris vs cauda equina syndrome? vs spinal cord?
Conus - symmetric motor weakness, hyperreflexia (UMN lesion), back pain
Cauda equina - asymmetric weakness, hyporeflexia, severe radicular pain
most common cause of vitreous hemorrhage?
diabetes (sudden vision loss, floaters, red glowing fundus)
kiddo with strabismus of left eye (left moves in when R is covered) - what to do?
Left is lazy - patch the GOOD eye! (or blur out the good eye)
old person with DIP joint involvement
Probably OA (not RA) even if PIP and DIP both involved.
which antibiotic class causes ototoxicity? what about isolated vistibulotoxicity?
aminoglycosides (amikacin, gentamicin, tobra, etc)
- for vestibulotoxicity, specifically think of gentamicin
14-3-3 protein?
Creutzfeldt Jakob, prion disease
hyperthyroidism + low TSH - what to check next?
thyroid radioiodine scintigraphy
low I uptake suggests release of preformed thyroid hormone, not chronic new production
name 4 things in hereditary hemochromatosis?
hyperpigmentation, diabetes, joint spaces (arthritis, arthralgia, chondrocalcinosis), cirrhosis, restricted cardiomyopathy
(iron goes to skin, pancreas, joints, muscles, heart, liver)
(a secondary cause of pseudogout!)
what is surveillance bias
exposed group has more surveillance - more likely to pick something up
acute rheumatic fever follows what?
UNtreated strep pharyngitis
fever, urticaria, and polyarthralgia - no mucosal involvement. 1-2 weeks after treatment with beta lactams, penicillin/amoxicillin, or bactrim
serum sickness - type III immune complex hypersensitivity
symptoms of mono - treated, now have morbilliform rash on trunk. what happened?
were treated with amoxicillin!
proximal muscle weakness + red/purplish rash over dorsum of fingers (Gottron’s sign)
dermatomyositis - but can also be a paraneoplastic syndrome - still get heliotrope rash
Patient has afib with HFrEF - new onset fatigue, memory loss, constipation, weight gain, dry skin — what happened? syndrome? med that caused this?
signs of hypothyroidism
- in this patient, look to amiodarone-induced hypothyroidism
- AMIO also causes chronic interstitial pneumonitis, blue/grey skin, heart block, and elevated transaminases, and eye problems
Patient is on amiodarone therapy - what things should you monitor (SEs)?
LFTs (hepatitis), TSH (hypothyroid)
- low threshold for CXR for pulmonary sx
- low threshold for ophtho
signs of a stroke, more pronounced in LOWER than upper limbs? maybe some urinary incontinence?
anterior cerebral artery (ACA) stroke
because lacunar infarcts equally impact upper and lower.. full side, since BG is so small
what do loop diuretics do to calcium?
loops lose calcium (thiazides save it)
treatment for psoriasis? what not to give?
DON”T use systemic steroids
OK to use PUVA, methotrexate, NSAIDs for arthritis
patient has several tiny waxy papules, central umbilication - what’s the likely cause - and what to go looking for?
poxvirus causing molluscum contagiosum - but watch out for HIV
which of the dermatophyte infections requires ORAL treatment?
tinea capitis needs systemic antifungal
neurologic consequence of prolonged seizure?
excitatory neurotoxicity - cortical laminar necrosis
niacin deficiency ?
dermatitis, diarrhea, and dementia (pellagra) with glossitis, angular stomatitis
Polymyositis - SIGNS?
proximal muscle weakness, elevated CK, autoantibodies (ANA, anti-Jo); muscle biopsy with endomyosial infiltrate
vs ESR and CRP more elevated in polymyalgia rheumatica (with stiffness)
carpal tunnel - which nerve involved?
MEDIAN nerve - can also get thenar weakness
foodborne botulinum - what to do?
equine hepatavalent botulinum antitoxin.
- improperly canned foods; cured fish
- onset within 36 hrs of eating
Bilateral cranial neuropathies, facial weakness, symmetric DESCENDING weakness
bone pain, history of malabsorption, muscle cramps or weakness. Concave vertebral bodies and pseudofractures of long bones
Osteomalacia - low vitamin D! (thus low Ca and low Phos - reflexively high PTH)
most common cause hypothyroidism?
chronic lymphocytic thyroiditis - Hashimoto’s
chronic alcohol and smoker, now with wide based gait, impaired heel to shin, normal finger to nose, poor coordination
alcoholic cerebellar degeneration - Tx: stop drinking! to stop disease progression
most common cause sub arachnoid hemorrhage without trauma?
ruptured berry aneurysm
name a BP med that wastes potassium? one that increases K?
thiazides lose K, cause hypokalemia
ACE inhibitors cause hyperkalemia
hyperpigmentation - why? what was cortisol doing?
cortisol deficiency causes ACTH production in response, and this shares cosecretion with melanocyte stimulating hormone
- will NOT see this in exogenous glucocorticoid suppression of ACTH (steroid induced adrenal insuff)
main side effect of hydroxychloroquine?
retinopathy
pronator drift downward suggests?
pyramidal tract lesions
lab findings with dermatomyositis?
high CPK, aldolase and LDH
anti-RNP, anti-Jo, anti Mi2
MEN1 has what 3 P’s?
Pituitary adenoma
Primary hyperParathyroidism (90% of patients, have hypercalcemia)
Pancreatic/GI tumors like gastrinoma, cause Zollinger Ellison
asymmetric POLYarthralgia?
gonoccoccal septic arthritis (usually w/ tenosynovitis and dermatitis)
vs nongonococcal usually single joint
(also consider rheumatic fever, a transient migratory arthritis of large joints)
enlargement of hands and feet (old person), coarsening of facial features, pharyngeal crowding - what is this? what happens to heart? what hormone is up?
Acromegaly
Heart - concetric hypertrophy, diastolic dysfunction
GH increases liver production of IGF-1
asymmetric thickening of IV septum is?
hypertrophic cardiomyopathy (HOCM)
why (proximal) muscle weakness in hypercortisolism (Cushing’s - either ACTH tumor/ectopic or primary adrenal dz)?
direct catabolic effect on muscles - get muscle atrophy
migratory, non-deforming arthritis, malabsorptive diarrhea, small intestine biopsy with PAS (periodic acid schiff) + macrophages - this is?
Whipple disease - tropheryma whippelii, g+ bacillusx
when to consider tPA in acute stroke?
within 4.5 hours of onset, and only after noncontrast CT shows no bleed
liver disease (even if mild) + some neuropsych things, even tremor, rigidity, paranoia, depression, catatonia, or drooling)
Wilson’s disease
medullary thyroid, marfanoid, pheo, and mucosal neuromas
MEN2B
superficial infantile hemangioma vs cherry angioma vs nevus simplex
superficial hemangioma - benign, appear in first few weeks, grow, then regress on own
Cherry angioma - benign, in adults, more palpable
Nevus simplex - cherry red port wine stain, usually nape of neck, blanchable
CVID vs bruton’s agammaglobulinemia
CVID has normal B cell count, but low IGG/Ms,
Bruton’s has low B cells, also low IGs
Tx acute dystonia? akathisia?
Dystonia - benztropine or diphenhydramine
Akathisia - B blocker or benzo
Tx drug induced parkinsonism? TD?
Parkinsonism - benztropine or amantadine
TD- maybe switch to clozapine?
anti-smooth muscle antibodies?
autoimmune hepatitis
name 2 DMARDs that can cause stomatitis?
oral ulcers
- methotrexate, sulfasalazine
patient has hyperkalemia (e.g. presumed from crush injury) and needs intubation - what med to not use for paralysis? what can you use?
Don’t use succinylcholine (depolarizing neuromuscular blocker)
Can use nondepolarizing - like rocuronium and vecuronium
several years post accident - now has loss of pain/temperature sensation of arms, as well as muscle weakness?
syringomyelia
name an infectious cause of nasopharyngeal carcinoma
reactivation of EBV - and note that NPC is endemic in China
what does aflatoxin 1 exposure predispose to?
hepatocellular carcinoma
chronic, nonhealing wound - concern for what type of cancer?
SCC - Marjolin ulcer if it’s from a burn
antipsychotic least likely to cause EPS like TD?
clozapine (Surprisingly)
how long of sx before diagnosing schizophrenia?
6 months
1-6 is schizophreniform
PPX in HIV:
<200: bactrim for PCP (and <100 bactrim for toxo)
<50: azithromycin for MAC
<150 and endemic ohio and mississippi river valey - itraconazole for histo
symptomatic prolactinoma - what to do?
try DA agonist (cabergoline, bromocriptime); only if needed, surgery
which pneumococcal vaccine for adults with chronic conditions?
PPSV23
Then PCV13 at 65, then PPSV23 again lafter that
how does dobutamine work?
beta 1 agonist; potent inotrope, increases contractility
