UWORLD 10 Flashcards
Chronic opioid use and endocrinopathy
Chronic opioid use leads to decreased gonadotropin-releasing hormone secretion and is a common cause of hypogonadism.
Patients can develop decreased libido and other manifestations of hypogonadism.
has low levels of testosterone with low FSH and LH levels (consistent with secondary (central) hypogonadism rather than primary gonadal dysfunction.
Calcium homeostasis involves blood transport as?
Patients with hypoalbuminemia can have decreased?
How does this correlate with the total plasma calcium?
ablumin bound calcium (45%)
Ionized calcium (40%) or
calcium bound to inorganic or organic anions (15%).
Patients with hypoalbuminemia can have decreased total plama calcium.
However the ionized serum calcium (phyisologlically active form) is hormonally regulated and remains stable.
As a result, these patients may be asymptomatic as the measured total plasma calcium does not correlate with the physiologically active calcium.
Correct calcium calculation
The serum calcium concentration decreases by 0.8 for every 1 decrease in the serum albumin concentration.
The corrected serum calcium level is calculated with the formula below (normal albumin level is 4.0):
Corrected calcium = (measure total calcium) PLUS 0.8 (4.0-measured serum albumin)
Juvenile myoclonic epilepsy
When should you suspected it?
What does the EEG classically demostrate?
should be suspected in healthy adolescent patients with upper-extremity morning myoclonus and subsequent generalized tonic-clonic seizures.
- *myoclonic jerks of the arm occurs within the first hour of waking and can be aggravated by sleep deprivation and alcohol intake*
- bilateral polyspike and slow discharge durng the interictal period*
first line treatment in Juvenile myoclonic epilepsy
valproic acid
Sleep deprivation is a common seizure precipitants and patietns should e educated on sleep hygiene.
Neuroimaging and Juvenile myoclonic epilepsy
Neurogimaing is not necessary when the patient’s presentation and EEG are classic for JME as MRI is typically normal in these patients.
However, children with seizures should undergo brain MRI to evaluate for structual abnormality (ex: tumor) if examination shows focal deficits or UMN signs (ex: hyper-reflexia/hypertonia).
MRI should also be cosnidered for first time GTC seizure if there is no hx of staring spells or upper extermity morning myoclonus.
What should be monitored in patients taking valproic acid?
thrombocytopenia and hepatotoxicity
it is also a known teratogen that has been linked to neural tube defects.
Gingival hyperplasia is an important side effect of which antiepileptic drug?
Phenytoin
It is not associated with valproate acid.
Hyponatremia is a side effect of which antiepileptic drug?
oxcarbazepine
due to inappropriate antiduretic hormone release
What is important to determine for adults with intellectual disability?
Guardianship status
it should be clarified early in the medical relationship to faciliate decision making
*When children reach age 18, their parents may pursue guardianship in order to continue to make decisions for those with intellectual disability, especially if an adult child’s disability is severe enough to impair global decision making capactiy or ability to communicate.
Nonoverlapping confidence intervials always imply?
What if it overlaps?
a statisically significant difference between groups.
However, the opposite is not necessarly true.
There is an increased risk for type I errors when
multiple simultaneous hypootheses are tested at set p-values.
Interpretation of findings in clinical trials when multiple outcome measures are used without adjustment of the significance level may result in spurious findings and invalid conclusions.
*type I error (alpha) is the probaliby of rejecting a nulll hypothesis when the null hypothesis is true.
Type 1 error - You are too bold.
Type 2 error - You are too timid.
The Genetic Information Nondiscrimination Act of 2008
prevents employers from requiring or requesting genetic testing results of their employees.
If an employer already has genetic testing information, the law prevents the employer from using the info to discriminate against the employee.
What is the most effective contraceptive with a >99% effiicacy rate with typical use?
Progestin subdermal implant
has high pregnancy prevention rate once inserted it is effective for 3 years and is not user dependent.
It is even more effective than the IUD (0.2-0.8 failure rate) and female sterilization (0.5 failure rate).
Contraception is achieved by progesterone-induced changes that result in cervical mucus thickening and decreased tubal motility, which inhibit sperm migration. In addition, progestin causes ovulation suppression via decreased FSH and LH secretion.
Copper IUD versus Levonorgesterol IUD
IgA nephropathy versus Acute postreptococcal glomerulonephritis
Gross hematuria following acute URI is a common presentation of IgA nephropathy.
Acute poststrep glomerulonephritis follows a streptococcal throat infection with a gap of more than 10 days between throat infection and onset of renal disease. Serum complements are also decreased (unlike IgA nephropathy which is normal)
Many patients with IgA nephtropahty have a benign course. There is no definitive treatment for IgA nephropathy.
Hemophilia A is what type of disorder?
what happens to daugthers born to an affected father and normal mother?
What about sons of carrier mother?
X-linked recesive disorder that occurs almost exclusively in males.
Affected father, normal mother - daugther will be carrier
Sons born to carrier mother - have 50% chance of having hemophilia
A unilateral headache presenting with associated horner syndrome should be considered what until proven otherwise?
What if anhidrosis is absent?
What is the next step in management?
A carotid artery dissection
Horner syndrome (ipsilateral miosis, ptosis)
results from disruption of sympthetic nerves innervating the face and eye.
These nerves travel along the carotid artery, as a result, a carotid artery dissection is one important cause of horner syndrome.
Anhidrosis may be absent in internal carotid artery dissection (parital horner syndrome) because sweat nerve fibers travel along the external carotid artery.
Head and neck vasculature imaging is the inital diagnostic modality of choice.
Lyme disease verus Horner syndrome with carotid dissection
Early disseminated lyme disease can be associated with headache and cranial nerve palsies (including facial nerve palsy leading to unilateral facial paralysis).
However, it is not associated with other horner syndrome symptoms.
What have been successfully used to control dyspnea that patients experience at the end of life?
systemic opiates
Opiates cause sedation and can cause respiratory depression, so patients and families should be educated on side effects and physicans should carefuly titrate dosing.
Achalasia versus Esophagel stricture
peptic stricture is a well known complication of GERD that results from the healing process of ulcerative esophagitis.
Dysphagia usually starts with solids followed by liquids.
Young age and lack of alarmaing symptoms argue against ta diagnosis of malignancy.
For achalasia, it usually causes dysmotility type dysphagia that is characterized by difficulting in swallowing both solids and liquids.
What is especially useful in the management of obese, diabetic patietns?
What improves nonalocholic steohepatitis?
What can cause weight gain?
‘What is too weak to be used as monotherapy?
Metformin (associated with some weight loss)
Metformin & pioglitazone (thiazolidnediones) decreases triglycerides, increases HDL and improves Nonalcoholic steohepatitis (NASH).
Thiazolidenidones, insluin and sulfonylureas can cause weight gain.
Acarbose’s action is stoo weak to be used as monotherapy.
*Sulfonylureas (ex: glyburide, glipizide or glimepiride)
Acute back pain management
Urethritis in young male patients.
What are the two types?
What can help differentiate it?
Young male patients are at greatest risk for urethritis, which often manifests with dysuria, itching at the urethral meatus and urethral discharge.
Urethral gluid gram stain can help categorize between gonococcal or nongonococcal (aspetpic) urethritis.
Nongonoccal urethritis is most comomly cuased by Chlamydia trachmomatis and is treated empircally with azithromycin. All patients should also receive nucleic acid amplification testing of the urine to confirm the diagnosis of the pathologic organism.
Patients with nongonococcal urethritis with continued symptoms after azithromycin therapy - Management
Patients with nongonoccocall urethritis frequently have continued symptoms after azithromycin therapy due to reinfection or infection with an organism (ex: mycoplasma genitalium) not susceptible to azithromycin.
Patients should receive repeat urethral gram stain and nucelic acid amplification testing of the urine for common urethritis organisms.
Parvovirus B19 arthritis
Parvovirus B19 can cause viral arthritis, sometimes with a rash, following a nonspecific flu-like illness.
Acute onset pain, swelling and stiffness of the symmetric small joints of the hand are typical.
SLE presentation
Acute rheumatic fever verus Lyme arthritis
Acute rheumatic fever- erythema marginatum and suctuaneous nodules
Lyme arthritis - monoarticular and associated with erythema migrans.
Modified wells criteria for pretest probability of PE
Diagnostic strategy in suspected PE
Ventilaiation perfusion scintigraphy may be considered as an alternative test if the patient is unable to recieve IV contrast agents (ex; renal insuffiency, contrast allergy)
What is associated with a worse prognosis with PE?
Troponin can be elevated in the setting of large pulmonary emboli with resulting right heart strain and would not indicate acute cardiac ischemia.
Elevated troponin in the setting of PE is associated with a worse prognosis.
Patients with suspected PE should be initated on anticoagulant therapy and undergo urgent CT pulmonary angiography.
Management options for PE
Anticoagulation is the mainstay of treatment for PE, with most patients initally receiving LMWH or Unfractionated heparin followed by initation of warfarin.
Fibrinolytic therapy is used in patietns with persistent hypotension and IVC filters may be used in patietns with a CI to anticoagulation.
Patient on anticoagulant treatment of PE and has half a teaspoon of dark blood on an occassion - management?
a small amount of hemopthysis is normal in patients with PE, particulary if pulmonary infraction has occured.
The treatment regimen need not be latered if the patient is otherwise stable.
Breast cyst management
Breast cysts that are simple can be managed with observation (in asymptomatic patients) or with FNA (in symptomatic patients)
Nonbloody benign cysts that resolve with aspiration are then followed with clinical breast examination and repeat US.
simple - thin walled and fluid filled without septations are beign
Tetanus prophylaxis
what is a common cause of clinically significant heart failure?
What does patients often have?
What is shown on echo & xray?
Obesity and B-type Natriuretic peptide relationship?
Heart failure with preserved ejection fraction due to left ventircular diastolic dysfunction
comorbid systemic HTN and obesity
Chest xray can aid in the diagnosis and may show pleural effusion or pulmonary edema often manifested as kerley b lines (horzontal lines representing intersititual edema or linear densities at eh margins of the lung fields).
Echo provides an estiaimate of LEVEF and can identify impaired filling.
B-type NAP<100 is often usefully in ruling out clinically signficant heart failure, however obesity lwoers BNP levels, making htis test unreliable in such patients.
Restless legs syndrome may be as symptom of?
What should be obtained?
iron deficiency
a serum ferritin level should be obtained as iron deficiency is frequently present in the absence of anemia.
First line treatment for daily restless legs syndrome of moderate to severe intensity include?
dopamine agonists such as pramipexole or ropinirole
Management?
Flail chest is the result of double rib fractures in more than one site, resulting in paradoxical movement of the flail segment during inspiration.
The diagnosis may be obvious on examination, but many are occult.
Management includes supplemental oxygen, pain control (invasive or noninvasive), Positve pressure ventilation and surgical stabilization for more severe cases.
medications to avoid in mystenia gravis
Causes of Oligohydramnios? What is its AFI?
Causes of Polyhydramnios? What is it’s AFI?
Management of suspected adrenal insuficency?
Vaccines for adults with HIV
At the onset of symptoms, priapism may be terminated with simple interventions such as?
But symptoms lasting >4 hours require?
urination, cold compresses
invasive treatment. Management includes aspriation of the corpora cavenosa and intracavernosal injection of an alpha agonist (ex: phenylephrine)
As an α1-adrenergic receptor agonist, phenylephrine causes α-mediated vasoconstriction within the corpora cavernosa
Second-degree AV block
Distinguishing features of Mobitiz type I and Type II AV block
- level of block
- ECG findings
- Exerciase or atropine
- Vagal maneuvers
- Risk of complete heart block
Herbal supplement (use and side effects)
Ginkgo biloba
Ginseng
Saw palmetoo
Black cohosh
St Johns wart
Kava
Licorice
Echinacea
Ephedra
Casues of acute, painless vision loss
Proliferative retinopathy
due to DM typically results in progessive visual loss in its late stages.
has evidence of neovascularization or hemorrhage on funduscopy
Optic neuritis verus Central retinal artery occlusion
causes subacute (hours to days) monocular vision loss associated with eye pain that worsens with eye movement.
Patients can have afferent pupillary defect, but funduscopy characteriscally shows optic disc edema.
Central reintal artery occlusion
most commonly caused by carotid artery atherosclerosis and presents with acute painless monocular vision loss
patients typically have affferent pupillary defect on examination and funduscopy may show a pale, ischemic fundus with a “cherry” red spot.
Fundoscopy shows this:
Fundus with retinal hemorrhages & opic disc edema (blood & thunder)
Fundoscopy
retinal detachment
fundus with vitreous hemorrhages and marked elevation of retina
surgical repair necessary
What are classic findings of endometriosis?
What exactly is endometriosis?
What can it cause?
pelvic pain with exacerbation by bowel movement (dyschezia) and rectovaginal nodularity on pelvic examination
Extrauterine implantation of endometrial tissue that causes inflammation and fibrosis as it immplants cyclically shed in the ectopic location.
Endometrosis casues pelvic adhesions and inlfmmation, which can cuase infertility and chronic pelvic pain.
TUBEROUS SCLEROSIS
Pathophysiology
Clinical features
- Dermatologic
- Neurologic
- Cardiovascular
- Renal
genetic syndrome that leads to benign tumors throughout the body.
What is an important risk factor for UTI in tolddlers?
Chronic functional constipation can prevent full bladder emptying -> urinary stasis -> UTI
Evaluation and treatment of constipation is ncecessary to prevent dysfunctional voiding and recurrent UTI.
Differential diagnosis of travel associated diarrhea
Short term versus long term illness and their notable characterisitcs
Diagnosis of acute Hepatic C
Diagnosis is confirmed with HCV ribonucelic acid detection by polymerase chain reaction as anti-HCV antibodies can take up to 122 wweks or longer to become positive in acute HCV.
various type of twin placentation
What happens in monochorionic monoaminiotic gestation?
What are they at increased risk of?
two twins share 1 placenta and 1 amniotic sac.
Because the twins grow and evelop in 1 sac, monochorionic monoaminotic gestations can be complicated by cord enlargement.
Short stature
Etiology
Bone Growth
Growth Velocity
Short stature is height is what percentile?
Evaluation begins with calculating?
How do you calculate mid-parental height?
< or = 2%
mid-parental height and determining bone age
*Bone age study is a radiograph of th epatient’s hand and wrist used to assess the rate of skeletal maturation
Management of PPROM
Patients with PPROM at <34 weeks are managed conservatively witih prophylactic antibitoics (ampicillin plus erthyromycin) to prolong hte interval between membrane rupture and delivery, thereby improving neonatal outcomes.
*antibotics are to prevent overt intrauterine infection (ex: chorioamnionitis), which can result from progression of the sublinical infection that caused PPROM or from the ascent of vaginal bacteria through the ruptured membranes.
Ampicillin covers Group B strep, aerobic gram neg bacilli and anerobes; erythromycin covers ureaplasma
Erythema infectiosum
also known as?
Caused by?
Presentation?
What does it cause in adults and tin those with underlying hematologic disorders (ex: sickle cell disease)
or fifth disease
common benign childhood illness caused by parvovirus B19.
Presentation begins with fever and nonspecific prodrome (ex: cough, malais, followed by a bright red facial rash (slapped cheek” and reticulated rash on the trunks and extremities
*slapped cheek can also present as face appeared flushed
caues arthritis in adults and a transient aplastic crisis in those with Sickle cell disease.
