UWORLD 3 Flashcards
Infertility is defined as?
Initial evaluation includes?
a couple’s inability to conceive after one year of appropriately timed unprotected intercourse.
Initial evaluation includes a semen analysis, a noninvasive, low cost test to detect male factor infertility.
What is common adverse effect of topical antibotic use?
What does it also increase the risk for?
Allergic contact dermatitis
*may range from mild reactions (erythema) to vesiculation or eczematous changes
Antibotic-resistant organisms
Dermatits Herpetiformis
what is it?
Associated with?
What is usually performed?
Autoimmune disroder characterized by crusting & vesicles in a widespread distrubtion, primiarly on the elbows, knees, buttocks.
Severe itching
It is assoicated iwth celiac disease.
Skin biopsy is usually performed to differentiate DH from other autoimmeune vesitcular/bullous disorders.
Pemphigus vulgaris characterstic features
Flaccid bullae
Soughing of skin
oral lesions
Bullous pemphigold characteristics
tense bullae
itching
Erythema & urticaria
LgA bullous dermatosis
Group lesions,
linear or annular pattern
Lewy body dementia
2nd most common degenerative cause of dementia after Alzheimer disease
chacterized by progessive dementia, visual hallucinations, parkinsonian features, early gait dsyfnction and neuroleptic hypersensitivity.
Prominent flucatations in symptoms are also suggestive of this diagnosis.
Allzheimer disease versus lewy body dementia
Parkinsonism is not seen in AD and dementia associated with AD progresses over a much longer period.
Frontotemporal dementia
manifests as personality changes that initalily dominate over cogntive dysfunction.
Patients typically present with disinhibition, personality changes, extreme agitiation and urinary incontinence.
Treatment of Lewy Body dementia
What medication can exacerbate the visual hallucination in these patients?
tx overlaps with that of both alzheimer disease (AD) and parkinson dementia (PD)
LBD is treatd with cholinesterase inhibitors (also used for AD) and antiparkinson medication such as levodopa and dopamine agonist (also used for PD).
Exacerbated by therapy with dopamine agonists.
Patients who have preeclampsia with severe features
presentation?
What do they require?
Blood pressure > or = to 160/110 and signs of end organ damage (ex; headache, visual symptoms)
stabilization with blood pressure control (ex: hydralazine, labetalol) and magneisum sulfate for seizure prophyalxis.
At > or = to 34 weeks gestation, delivery is initated after maternal stabilization is established.
Pre-eclampsia without severe features are delivered at?
what if they have severe features?
> or = to 37 weeks gestation
> or = to 34 weeks
What is the strongest known factor for male breast cancer?
Klinefelter’s syndrome
abnormality caused by an additional X chromosome (47, XXY).
Carries af 50% fold increase in the risk of breast cancer compred to the men in the normal genotype.
Transportation of an amputated part
should be wrapped in sterile gauze, moistened withs aline and placed in a sealed, sterile plastic bag.
Bag should be placed in a ice mixed with saline container.
Pregnancy induced pruritis
How does it present?
treatment?
common benign condition that typically presents with localized, focal pruritis over the abdomen without an associated rash.
Treatment options include oatmeal baths, UV light exposure and antihistamines.
Not at increase risk for pregnancy complications.
Intrahepatic cholestasis of pregancy versus Pregnancy -induced skin changes
ICP has similar presentation to pregnancy-related pruritis: pruritus in the absence of a rash.
However, in ICP there is generalized prurutis that is often most intense on the palms and soles.
The diagnosis is confirmed with elevated bile acid levels.
ICP is associated with an increase risk for intrauterine fetal demise and managment includes delivery at 37 weeks gestation.
Pempigold gestationis
what is it?
Inital presentation?
what is characteristic spared?
pregnancy related autoimmune disease (antibody reaction to basement membrane)
typically abdominal pruritis.
After the prurtis, the rash develops around the umbilicus and trunk of the urticarial papules and plaques that eventually form tense bualle.
the mucous membranes are characteristic spared.
Treatment of pemphigod gestationis
symptom control: relieving pruritis and limiting bullae formation
High-potency topical corticosteroids (ex: triamcionolone)
Antihistamines (ex: loratidine, cetirizine) can be added for pruritis release.
Travel to an endemic region, peripheral eosinophilia and positive fecal occult blood?
What are the common ones?
How is diagnosis made?
What is the treatment?
Intestinal helminths
largely a disease of developing world where water and sewage sanitation is poor.
Most common helminhts include Ascaris lumbricoides (roundworm), Trichuris Trichiura (whipworm) and Ancylostoma duodenale (hookworm).
Diangosis is made with stool ova and parasite testing
Oral abendazole is typically curative.
Testes that have not descended by what age rarely descend sponstaneously?
What also happens?
Next steps?
6 months
spermatogonia degeneration begins in the undescended testicles at this age as well.
Orhiopexy is optimally performed during infancy to improve fertility and testicular growth.
also decreases torion resk as the testis is surgically affixed to the scrotal wall.
Skin conditions and associated diseases
acanthosis nigricans
insulin resistance
GI malignancy
Skin conditions and associated diseases
Porphyria cutanea tarda
Cautenous leukocytoclastic vasculitis (palpable purpura) secondary to cryoglobulinemia
Hepatitis C
Dermatitis Herpitformis and associated diseases
Celiac disease
Sudden osnet severe psoriasis, recurrent herpes zoster and disseminated mollucsum contagiosum and associated diseases
HIV infection
Severe seborrheic dermatitis and associated condtions
HIV infection, parkinson disease
Pyoderma gangrenosum and associated condition
inflammatory bowel disease
What strongly suggests NF-2?
How does it differ frm NF-1?
Hypopigmented spots, in combination with family hx of bilateral deafness
NFI has hyperpigmented spots; can also present with acoustic neuroma (typically unilateral) but cutaneous neurofibromas, axillary freckling and other symptoms are usually present.
Tuberous sclerosis
hypopigmented maculae (ash-leaf spots)
glial proliferation
several organ harmatomas/cysts
Tuberous - think Tumors
Sturge-Weber syndrome
facial port-wine stain and leptomeninngeal angiomatosis
Sturge = Stain
Osler-Rendu-Weber Syndrome
multiple telangiceastia and vascular lesions of the CNS
Aspirin toxicity versus Meniere disease
Asprin toxicity may manifest as tinnitus and vestibular symptoms, but unilateral hearing loss does not occur with this condition.
Patients found to have aortic root disease and/or family hx of aortic dissection or sudden death should be counseled against
any strenous activity.
They can participate in low-to-moderate intensity recreational noncompetitive sports (ex: bowling, golf, doubles tennis)
What is a common precipitant of SIADH through a poorly understood mechanism?
What else has been associated with SIADH?
Pneumonia
A number of psychiatric medications (ex: SSRI, carbamazepine, valproic acid)
hyponatremia due to SIADh is characterized by
low serum osmolaity (<275),
inappropriately high urine osmolality (>100)
high urine sodium concentration (>40)
in the setting of clinical euvolemia
Pseudohyponatremia versus SIADH
pseudohyponatremia describes an artifical lab result that occurs in patients with increased fraction of the nonaqueous component of the serum (ex: paraproteinemia, hypertriglycermeida).
The measured serum osmolaity is normal in patients with pseudohyponatremia
SIADH versus excessive water ingestion
In Excessive water ingestion, Urine osmolality is low (<100) as the kidneys attempt to excrete large amounts of free water.
Absolute contraindiaction to OCPS
Migraine headaches (increased risk of ischemic stroke due to estrogen in the contraceptives)
Blood pressure > or = 160/100 and
women > or = to 35 who smoke > or = 15 cigarettes per day
Patient has brief and shoot back pain provoked by bending forward and straining, diminishes on lying down, what is it?
What test will you do to confirm?
nerve root irritation
Positive straight leg test at 60 or less is usually present
Good confirmatory tests must have high what?
specificity
as specifity increases, PPV also increases and the number of FP decrease
Highly _______ tests are useful for screeing; highly ________ tests are useful for confirmation.
Highly sensitive tests are useful for screening; highly specific tests are useful for confirmation.
Given a test with high sensitivity, a negative result would help rule out a diagnosis (SnNout)
High specificity, a positive results would help rule in a diagnosis (SpPin)
*For example, Anti-CCP antibodies have some value in patients with a negative RF levels. They carry a higher specificity.
A technietium-99 nuclear scan is highly specific for meckel’s diverticulum
A screening test must have high?
Sensitivity.
Sensitivity = TP / (TP/FN)
Probablity of a disease person testing positive
This high sensitivy helps “RULE OUT” the disease by decreasing the number of false-negative results and by increasing the negative predictive value (SnNOut)
NPV = TN/ TN +FN
ACL versus PCL injury
ACL injuries are common in atheltic activities.
Unlike patients with ACL, PLC patients do not complain of a typical “popping” sound
CSF analysis
The classic dashboard injury results from?
posteriorly directed force on the anterior aspect of the proximal tibia with the knee in a flexed position
This results in distruption of the PCLda
Sample size and power realtionship
Sample size is related to power, which is the ability to detect a diff between groups in a study.
Larger sample size results in more power.
How do you tell the difference between normal grief from major depressive disorder?
Persistent sadness, persvasive anhedonia and functional impairement can help differentiate normal grief from major depressive disorder.
Grieving individuals tend to have intermittent periods of sadness that revolve around reminders of the deceased.
Drug of choice for immediate treatment of metoclopramide-induced acute dystonia?
Dihphenhydramine IV
aside from having anithistamine properties, it has anticholinergic properties as well.
Diffuse esophagel spasm
what is it?
Gold standard for diagnosis?
First line treatment?
motility disorder
esophageal manometry - premature contractions of the distal esophagus with normal distal esophagel sphincter relaxation.
Calcium channel blockers (ex: dilitiazem)
Achalsia
is caused by?
Secondary achalsia can be caused by?
What does esophagogram typically reveal?
lower esophageal spincter cannot relax due to degeneration of the ganglia in the auerbach plexus
infection with Trypansoma cruzi (Chagas disease)
Dilated esophagus with bird’s beak narrowing of the distal esophagus
Patients with brain death would have absence of reflexes associated with?
cortical and brainstem function
(pupillary, oculocephalic, oculovestibulor (calcoric), corneal, gag, sucking, swallowing and extensor pospturing)
Patients with brain death can have reflexes and movement, but these orginiate from peripheral nerves or the spinal cord.
Prophylatic therapy of choice for preventing DVT in patients with hip fracture?
what if the patient is schduled for surgery?
LMWH and should be started on admission even if the patient is scheduled for surgery.
This can be stopped 12 hours before surgery.
Non-overlapping confidence interval suggests
statistically significant differences between the groups.
What sports are not recommended during pregnancy?
scuba diving (risk of fetal decompression sickness from air embolus formation)
expercise associated with a high risk of falling (skiing, sky diving, horsback riding)
and contact sports
Major treatable risk factors for ischmic stroke include?
Most important modifable risk factor for stroke?
HTN, diabetes, smoking and dyslipidemia.
HTN
*some sttudies have shown modest benefit with smoking cessation and control of blood sugar and lipids
First line therapy for premenstrual syndrome/premenstrual dysphoric disorder?
What if this is ineffective?
Patients with this is ast an increased risk for?
SSRI
Another SSRI or OCP may be tried
psychiatric disoders such as Depression
*80% lifetime risk. This includes primary mood and anxieity disorders
TSH security pituitary adenomas cause?
What may these tumors also secrete?
central hyperthyroidism with elevated TSH and thyroid hormone levels.
biologically inactive alpha subunit and other pituitary hormones (ex: GH leading to acromegaly) and can cause mass effect symptoms (ex: headaches, visual field defects)
What are the indications for implantable cardioverter-defibrilator placement in HCM patients?
Prior hx of cardiac aarrest or sustained VT
Family hx of sudden death
syncope (recurrent or exertional)
nonsustaned VT on holter monitering
hypotension with exercise
Extreme LVH (>3 cm maximal septal wall thickeness)
First line treatment of HTN in patients with HCM
betablockers
Patient suspected of Pagets disese of the bone
what is it due to?
Next step in management of a patient?
Treatment?
increased bone turnover
obtain calcium and alkaline phoshatase levels
(elevated ALP and normal calcium).
Bisphosphonates (reduce bone turnover)
Pagents disease of the bone versus Multiple myeloma
Serum protein electrophoresis is useful screening test for patients with suspected monoclonal gammopathy, such as in multiple myeloma
MM usually involves bones with scattered lytic lesions or occansionally diffuse osteopenia.
The thickened, sclerotic bone in patients with PDB would not be seen in myeloma.
Hearing loss in patients with Paget disease
Hearing loss is a common complication
Treatment with calcitonin or bisphosphonates can slow the progression of hearing loss but is unlikely to reverese hearing loss that has already occured
Indications for IVC filter placements in patients with PE or DVT.
patients who have complications of anticoagulation, contraindications to anticoagulation or failure of anticoagulation
What the most common pathogens responsible for acute otitis media include?
What may cause otitis-conjunctiviits syndrome?
Streptococcus pneumoniae,
Nontypeable Haeomophilus influenzae (may cause otitis-conjuncitivitis syndrome, which is purulent conjunctivitis that occurs the same time as acute otitis media)
Moraxella catarhalis
*M. catarrhalis less common than S. pneumo and H. influenzae and does not cause otits-conjunctivitis syndrome
Uncomplicated acute otitis media should be treated with?
Recurrent AOM?
high dose oral amoxicillin
recurrent AOM should raise concern for beta-lactamase resistant and warrants treatment with amoxicillin-clavulanci acid.
HIV lipodystrophy presentation?
What is suggestive of this?
What are closely interrelatd with HIV lipodystrophy?
lipoatrophy, fat accumulation or both in different areas.
A pattern with increased fat tissue deposition on the back of the neck and abdomen along with thin extremities and face
Insulin resistance and dyslipedemia
*cause and effect is unclear
Cushing disease versus HIV lipodystrophy
Icnreased fat deposition in the neck and abdomen could be confused with cushing’s disease from adrenal hyperplasia.
However, only adrenal insufficiency has a correlation with HIV infection.
Mycotic aneurysms
aka
Can occur due to?
can present as
a.k.a infected arterial aneurysm
metastic infection from Infective endocarditis, with steptic embolization and localized vessel wall destruction in the cerebral (or systemic) circulation.
expanding mass with focal neurologic findings or with aneurysm rupture and suarachnoid hemorrhage
consituational pubertal delay is characterized by?
management?
delayed puberty
retarded bone age
postive family hx without any evidence of systemic disorder
these patients develop puberty without any intervention
management of patients wth poor response to methotrexate?
What must patients be screened for first?
switching or adding an anti-cytokine drug (ex: infliximab, entanercept)
Use of anti-cytokine therapy is associated with higher incidence of opportunisitc infections, particular reactivation of TB; therefore, all such patients hould be screened for latent TB by PPD testing.
Any monoarticular arthritis in patients with RA should be considered as what until proven otherwise?
mgmt?
septic arthritis
especialy when accompanied by systemic signs of infeciton such as fever
do joint aspirations
Lung cancer screening by annual low dose CT is recommended for?
patients 55-80 who have > or = 30 pack year smoking history and are current smokers or quit within the last 15 years.
Managment of patients with suspected TB menigitis
should be initated on treatment prior to bacteriologic confirmation
Treatment involves 2 months of 4 drug therapy with isonaizd, rifampin, pyrazinamide ad eitehr fluoroquinolone or injectable aminoglycoside, followed by 9-12 months of continued therapy with isoniazide plus rifampin.
Patients should also receive adjuvant glucocorticoids to reduce treatment-associaed CNS inflammation
Screening for pheochromocytoma should be considered in paients with?
Biochemical Diagnosis?
What is the next step for localizing a pheochyromocytoma after biochemical confirmation of the tumor?
What if it’s negative?
episodic symptoms (headaches, diaphoresis and tachycardia), early onset or refactory hypertension and paraosymal hypertension.
Measuring plasma free metanephrine levels or 24 hour urine collection for measurement of catecholamine and metanephrine.
Abdominal imaging (CT or MRI) to help localize pheochromocytomas, which are usually located in the adrenal glands.
If negative, metaiodbenzylguanine (MIBG) scan, which is a functional scintigraphhy with iodine labled MIBG.
MIBG resembles NE, is taken up by adrenergic tissue and can detect tumors not detected by MRI or CT.
Removal of pheocytomchroma tumor is performed only after what?
adrequate prepoperative control of blood pressure for 10-4 days with an alpha blocker, and intravascular fluid volume repletion with liberal fluid and salt.
BB are given only to patients with adequate and complete alpha blockade.
*BB started before alpha blockade can lead to paradooxical increase in BP.
Late neurosyphilis can present with
tabes dorsalis (sensory ataxia and lacinating pains) and Argyll Robertson pupils (consriction with accommodation (reduce in size on a near object) but not with light)
Diminished pain and temp sensation, areflexia.
lancinating pains (brielf shooting or burining back in the face, back or extremities)
instability during the Rhomberg test
*Tabes dorsalis is a neurogenative disorder that inolves the poserior spinal column and nerve roots.
HHS versus DKA
Both HHS and DKA occur in patients with poorly controlled diabetes.
Patients with Type 2 DM tend to develop HHS as opposed to DKA which is ruled out by patient negative serum ketones.
HHS - has serum bicarbonate near lower limits of normal
DKA - have anion gap acidosis (secondary to ketoacid production)
*Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of blood glucose, hyperosmolarity, and little or no ketosis.
Chronic alcohol use, DM and Lyme disease versus Tabes Dorsalis
Chronic aclohol use and DM can result in symmetric sensory peripheral nuropahty that presents similarly to Tabes dorsalis.
Lyme disease has high incidence in Mid-Atlantic region of the US and can also have variable neurolgic manifestations.
However, Argyll Robertson puppils are not associated with these conditions.
Standarized incidence ratio (SIR)
used to determine if the occurance of cancer in a small population is high or low relative to an expected value derived from a larger comparison population.
It is calculated by dividing the observed cases by the expected cases.
Management of HHS
Aggressive volume resuscitation since they are generally severely volume depleted.
IV insulin should be started after the patient has been partially resusciated.
Aggressive management of Hyperkalemia should be avoided in these patients since these patients generally have a total body potassium deficit (that would become unmasked with fluids and insulin).
* Analysis of the physiopathology of the HHS syndrome points to sodium and water deficits as the principal cause of symptoms. A rapid lowering of the blood glucose level may be detrimental, since this leads to an osmotic gradient between the central nervous system and the intravascular space. Treatment should be directed at the rapid replacement of sodium and water with minimal administration of insulin.
Patients who are actively suicidal and refusing treatment should be placed on?
1:1 observation and hospitalization under involuntary status.
Patellofemoral pain syndrome
More common in?
Diagnosis?
Treatment?
most common cause of knee pain in young adults, especially women
*women have greater angle btw the main axis of the quadriceps and the vertical axis of the patellofemoral grove
Clinical diagnosis
Patients may have a reproduction of pain by extension of the knee with anteior pressure on the patella (patellofemoral compression test)
Treatment is primarily stretching and streghening exercises of the thigh
Hereditary hemochromatosis
Which joints does it common affect?
Joint aspriation will show?
Treatment?
What does the treatment usually not improve?
affects the second and third metacarpophalangeal joints, knees, ankles and shoulders.
Joint aspiration can identify calcium pyrophosphate dihydrate crystals in approx. 50% of patients. These crystals have a rhomboid shape and positive birefringence under polarized light.
Treatment: phlebtomy usually does not improve the arthropathy
Gout versus arthropathy in Hereditiary hemochromatosis
Gout typically cause episodic, acute inflammatory arthritis affecting the 1st MCP joint (2nd and 3rd in HCC).
Microscopy shows needle-shaped, negatively birefringent crystals.
(rhomboid shape and positive birefringence in HCC)
Osteoarthritis verus HCC joint aspiration
OA synvoivd fluid is typically bland, with less than <2,000 cells, <50% neutrophils and no crystals
RA versus HCC joint aspiration
RA causes arthritis in inflammatory synovial effusion, however no crystals are present.
Patients with hereditary hemochromatois have a increased risk for
HCC due to associated chronic liver disease.
Treatmetn with phelbotomy can lead to improved HCC function, with reduced progression to cirrhosis and an associated reduction in the risk of HCC.
Thyroglossal duct
PE
How is it formed?
What is needed before subjecting the patient to surgery?
midline neck mass that moves with protrusion of the tongue
(thyroid is formed as an outpouching from the base of the tongue and then descends to the base of the anterior neck. The Thyroglossal duct connects the tongue and the thyroid gland and a cyst can develop from the epithelial remnants within the duct.)
Ectopic thyroid tissue is present in a large nubmer of patients within the thyroglossal duct cysts, but sometimes this is the only functional tissue present.
Therefore imaging studies, like thyroid nuclear scan, ultrasound or CT is mandatory before subjecting patient to surgery.
What is the most common adverse event in patients i not undergoing sugery?
Most common adverse event not undergoing surgery - adverse drug event
Functional hypothalamic amenorrhea triad?
oligomenorrhea/amenorrhea
relative caloric deficiency
decrease bone mineral density
*cayses decrease levels of GnRH resuling int decreased LH and FSH levels, supressed ovarian function and low estrogen levels.
Tick paralysis
what is it caused by?
Manifestations?
Neuroglic examination usually reveals?
WHat is uncommon?
What is required?
rare, potentially life threatening disorder caused by neurotoxins found in the tick salivia.
Manifestations typically arise 4-7 days of tick attachment and include rapaidly progressive gait ataxia and ascending paralysis.
Neurologic examination usually reveals absent deep tendon reflexes and normal sensation.
Fever is uncommon.
A teticulous skin examination is required.
Clostridium botulinum toxin versus Tick paralysis
Colstridium Botulinum toxin can be found by serum analysis.
Botulism usually causes a afebrile, descending paralysis, starting with the cranial nerves.
This patient with motor weakness of the legs and normal cranial nerves is unlikely to have botulism
Guillian-Barre syndrome versus Tick paralysis
Electrodiagnostic studies and CSF (elevated protein with normal leukocytes) are often obtained to support Guillian-barree syndrome.
This syndrome casues ascending paralsysis with absent deep tendon relfexes, but usually follows a GI or respiratory ifection and typically progresses over sveral days or weeks (rather than hours).
This child who recently camped in the woods should first be examined meticulousy for ticks to rule out ticks paralysis.
Treatment of tick paralysis
meticulous skin exam. Tick removal usually significally improves symptoms within a few hours.
Most patietns recover completely without further intervention.
Early neurosyphillis may present with?
When does it commonly occur?
Late neurossyphilis presents with?
Early neurosyphillis - symptomatic meningitis, ocular syphillis and otosyphillis.
*early neurosyphillis most commonly occur during the secondary stage of syphillis (as indicated by the generalized maculopapular rash and lymphadenopathy)
Late neurosyphilis (tertiary)- General paresis & tabes dorsalis (uncommon)
Disseminated gonococcemia versus early neurosyphillis
Disseminated gonoccocemia presents as eitehr a combination of a rash with tenosynovitis and a non-purulent polyarthraiga or lone purulent polyarthritis.
Meningococal infection versus early neurosyphillis
Meningococcal infections may present with rash and miningitis, but would progress rapidly (usually over a period of hours rather than days) to severe and life-threaning meningitis.
Patients presumptively diagnosed with prostatitis should first be evaluated with?
urinalysis and urine culture
pyuria and positive urine culture are consistent with prostatitis.
What is the mainstay therapy for diabetic patietns with renal failure?
What medications is recommended to stop in diabetic patients with renal failure?
What are alternatives to continue oral therapy.
Insulin
Metformin and other sulfonylureas (ex: glyburide) since they are metbolized by the kidney, in order to avoid toxicity and adverse events.
Rosiglitazone, pioglitzone, acarbose or repaglinide are alternatives.
*Rosiglitazone, pioglitzone are metabolized by the liver.
What should you suspect in any individual who has been exposed to smoke or superheated air?
airway injury and edema
(ex: supragloggic damage stems from inhaling hot air, steam or smoke).
Intussusception
What is it?
Occurs at what age?
How do they present?
What is the gold standard for diagnosis and treatment?
Telescoping of the proximal portion of the intestine into a distal portion.
Children ages 6 months to 3 years
severe, episodic, crampy abdominal pain, emesis and “current” jelly
Air or water soluble enema
*barium contrast enemas are traditionally used for reduction of intussusception, but are no longer preferred given the risk of peritionitis if perforation occurs
Potential complication of enema reduction of intussception?
What should patients with acute pain after reduction undergo?
Intestinal perforation
Radiographs of the abdomen to rule out intestional perforation.
*Air (pneumatic) enema is generally preferred for intial reduction as it tends to be fast, thereby minimizing radiation exposure. In addition, perforation from air enemas tend to be smaller than those occuring with water soluble (hydrostatic) or barium enmas.
Air, unlike contrast mediums, is not harmful to the contents of the peritoneal cavity.
Renal cell caricinoma is typically associated with?
Patients usually have?
What paraneoplastic syndrome is common?
What does diagnosis require?
Smoking, obesity and hypertension
hematuria, abdominal mass, and/or flank pain.
Paraneoplastic syndrome (ex: erythropoietin secretion) are common
CT of the abodmen to evaluate for renal mass
Eythrocytosis in RCC versus myeloproliferitive disorder (ex: myelofibrosis)
myeloproliferative disorder (ex: myelofribrossi) are diagnosed by Bone marrow biopsy and can cause erythrocytosis.
However, hematuria is not a common typical feature of these disorders (unless patients have severe thrombocyopenia).
Eythrocytosis in Polycythemia vera versus RCC
PCV is a chronic myeloproliferative neoplasm often associated with JAK2 mutations.
Erythrocytosis is a defining feature, patietns also have aqugenic pruritis, HTN, and arterial or venous thrombosis.
This patient with long-term cigarette use and hematuria is more likely to have erythrocytosis due to RCC
Erythrocytosis in Anabolic steriods verus RCC
Anabolic steriods can stimulate erythropoiesis and stimulate erythrocytosis.
THis patietn with hematuria and chronic cigarette use is more likely to ahve RCC
CT imaging of the abdomen for RCC shows?
Management of RCC?
enhancing kidney mass with thickened, irregular walls or septa.
If the tumor is localized within the kidney, nephectomy is usually curative.
Simple and complex kidney cysts versus polycystic kidney disease and RCC
Simple and complex cysts as well as cyts for PCKD do not enhance with contrast.
RCC mass enhances with contrast.
Cardiac auscultation in patients with MVP
nonejection click due to snapping of the mitral chordae as the valves cusps extend into the atrium during systole, followed by systolic mumur of mitral regurg
The timing of the click during systole varies depending on LVEDV.
In the setting of increased venous return (ex: squatting, supine leg raise), LVEDV is relatively high and the critical point at which prolpase occurs is reached late in systole or may not be reached at all (disappearance of the click).
In contrast, maneuvers that decrease venous return (ex: standing, valsalva) result in relatively low LVEDV, earlier reaching of the critical prolapse during systole and an earlier click and murmur.
How does MVP cardiac auscultation differ from Aortic/Pulmonary Stenosis?
An ejection click followed by midsystolic murmur is heard in patients with aortic or pulmonic valve stenosis.
The murmor is typically crescendo-decresendo and increases in intensity with increased venous return.
MVP - nonejection click and systolic mumur of mitral regurg. murmur becomes less promiment in the setting of increased venous return
Increased Venous return –> increases LVEDV –> proplase occurs late in systolic or may not be reached at all (disppearce of click)
Most murmurs become more prominent with increased venous return except
MVP and HCM
Murmur of mitral stenosis
accentuated S1 (mitral valve closure), an opening snap heard after S2 and a low pitched mid-diastic meumur best heard at cardiac apex
The allergen most frequently associated with asthma is
house dust mites
Hirschsprung disease causes?
Inital workup typically shows?
What is the gold standard?
delayed meconium passage and abdominal distension due to lackof innervation in the rectosigmoid colon
distal bowel obstruction on xray and a transition zone (normal versus narrow) on contrast enema.
rectal suction biopsy - absence of ganglion cells
Midgut volvulus versus Hirschspring
what is used for diagnsos and what does abdominal xray show
Upper GI series is the best test for diagnosing malrotaiton of midgut volvulus, which can cuase bilious emesis but is not associated with delayed meconium passage.
In addition, abdominal xray may show a nasogastric tube in a displaced duodenum rather than dilated loops of large bowel.
Vibrio vulnificus
What is it?
where is it found?
How do you acquire the infections?
presentation?
Dx?
free living, gram neg. bacteria found in coastal water and marine environments.
infections are acquired primarily through consumption of raw oysters or through wound contamination during recreational activities or raw seafood handling.
Patients with certain characteristics (ex: liver disease or DM) are at high risk for fatal infection, incuding rapidly progressive cellulitis, hemorrhagic bullae and septic shock.
Dx: blood & Wound cultures
Treatment with IV antibotics should not be delayed
Pseudomonas skin infections versus V. vulnificus
Pseudomonas skin infections are associated with hot tub exposure and usually result in folliculitis (tender papules or nodules).
Rapidly progressive celluluitis with hemorrhagic bullae after injury in a marine enviroment is more likely to have V. vulnificus.
Staph. Aureaus versus Vibrio vulnificus
Staph. Aureus is a common cause of skin abscess and cellulitis.
However this infeciton usually arises over a few days (not hours) and is typically not associated with marine environments.
Classic dengue fever clinical featurs
flu-like febrile illness with marked myalgias & joint pains (break bone fever)
retro-orbital pain
rash (white islands in sea of red)
Dengue hemorragic fever clinical features
increased vascular permeability
thrombocytopenia (<100,00
Spontatenous bleeding –> Shock
Positive tourniquet test (petechiae after cuff inflation for 5 mins)
Treatment of dengue fever
supportive
Dengue shock syndrome
Respiratory/Circulatory failure can develop with signficant plasma leakage due to increased capillary permeability.
Plasmodium falciparum malaria versus Dengue Fever
Cerebral edema can occur in Plasmodium falciparum malaria, which sually presents with fever, anemia and splenomegaly.
This patietns absence of anemia makes it less likely. In addition, patients that took advised prophylaic medications can rule out malaria.
In an normal bell shaped distribution curve, what is the the standard deviation breakdowns
68% lie within the 1st standard deviation of the mean
95% of observations lie within 2 S.D of the mean
99.7 lie within 3 standard deviations of hte mean.
Preventation medicine strategies
Primary
Secondary
Tertiary
Quatenary
Primary - before pt. develops disease; prevention
Secondary -halt the progression of a disaease before irreversible change takes place (ex: statins use with hx of angina)
Tertiary - disease has advanced, limit impairments and disabilities (ex: CABG)
Quatenary - set of health activities that limit the conseq. of unncessary or excessive intervention by the health system (ex shared EMR to lmit unncessary repeated cardiac catherization procedures)
Tamoxifen screening
symptomatic versus asymptomatic
selective estrogen receptor modulator
increses the risk for endometrial hyperplasia/cancer and uterine sarcoma in postmenopsual women.
However, asymptomatic patients on tomixfien do not rrequire routine screening for these complications.
Endometrial biopsy is indicated only for symptomatic patients
CLL
What is associated with a worse prognosis?
monoclonal b-cell leukemia
has significant lymphocytosis
that causes lympahdenopahty, organomegaly (liver, spleen) and anemmia/thrombocytopenia, all of which are associated with worse prognosis
CLL is confirmed by?
peripheral smear (smudge cells) and flow cytometry
*LN and bone marrow biopsies are generally not needed!
First line treatment for toxic megacolon
medical mgmt to lessen the degree of colitis, with glucocorticoids used for patients with underlying inflammatory bowel disease and appropriate antibotics used for patients with infectious colitis.
5-ASA compounds and opiods should be avoided in patients with toxic megacolon as they can precipitate attacks. 5-ASA can be retarted at a later time after the patient’s condition has improved with glucocorticoids.
Empiric antibotic treatment for catheter related infections
Vancomycin with the addition of gram neg. coverage (cephalosporin cefepime) if the patient is neutropenic or septic
Majority of catheeter associated infections are due to coagulaase negative staph and in the majority of cases, the isolates are methicillin resistant.
Imaging modlaity for suspected vertebral osteomyelitis
MRI
Management of Suspected epidural spinal cord compression
treated as an emergency with empiric high dose corticosteriods
MRI should be ordererd to confirm the diagnosis and assess spine stablilty
Patietns with highly radiosensitive tumors may be treated with radiation.
Patients with radioresistant tumors and those with an unstable spine should undergo surgical evaluation.
Medial collateral ligament (MCL) tears
direct impact to the lateral knee causing valgus stress to the joint
laxity of the knee joint occurs when valgus stress is applied
UMN versus LMN lesions - how to tell in a patient
UMN - contra, lower face only afected (as seen in strokes)
LMN- Ips, cannot raise eyebrows (as seen in bell’s palsy)
*beLl -brow, Lower, Ipsi
Acrochordons are?
What is it associated with?
aka skin tags are benign outgrowth of normal skin that appear as pedunculated, skin-colored papules in areas of friction.
Associateed with obesity, insulin resistance, overt diabetes and metabolic syndrome.
Celiac disease is assocaited with?
Dermatitis herpetiformis
which appears as pruritic, erythematous, group papulovesicular lesions.
Crohn disease is associated with?
Perianal skin tags (unlike acrochordon which is axillary skin tags) and pyoderma gangrenosum (which presents as a purlent ulcer.
Hepatitis C is associated with
lichen planus, porphyria cutanea tarda and cryoglobulinemia causing leukocytoclastic vasculitis.
CI and sample size
CI and accuracy
Sample Size: Smaller sample sizes generate wider intervals. There is an inverse square root relationship between confidence intervals and sample sizes.
Histologic findings of celiac disease
villous atrophy, loss of normal villus archtiecture, intrapeithelial lymphocytic infiltrates and crypt hyperplasia.
Treatment of pagets disease
bisphosphonates
Pagent’s disease findings on the following:
Xray
Technetium bone scan
Routine lab
Xray - thickening of the outer cortex, sclerotic leasions, mild bowing
Technetium bone scan - increase uptake
Routine lab - creatinine and calcium levels are normal
Management superficial infantile hemangiomas
most common vascular tumors of childhood, affecting ~5% of all infants.
Most superfiical infantile hemangiomas are small or clincially insignificant and can be observed.
Evident at birth, goes through a period of proliferation and then spontenaous involution by 7-10 years.
Propanolol therapy should be considered for lesions that are disfiguring or located at sites of potential function impairement (ex: eyelid or airway)
Glucagonoma
rare pancreatic tumor associated with mild diabetes and a classic skin rash (necrolytic migratory eryhtemia)
Erythemaous, scaly rash which appears to be clearing from the center. Borders appear slightly elevated and crusty. Angular chielosis is also noted.
Light’s criteria for transudative
Intial treatment for transudative pleural effusion?
What if its refractory?
sodium restriction and diuretics.
Transjuglar intrahepatic portosytemic shunt placment may be prursed in refractory cases.
*TIPS placment creates a fistula between the portal vein and the hepatic veins, which decreaes the hdyrostatic pressure in the portal venous system.
Rotator cuff tendionpaty versus adhesive capsulitis
Rotator cuff tendionpathy with partial or complete tear may cause pain with mild (partial) or severe (complete) decreased active ROM.
However, unless tehre is concurrent adhesive capsulitis, pssive ROM is not affected.
*Rotator cuff has pain with abduction, external rotation
Bicepts thenndionpathy/rupture - anterior shoulder pain
Number needed to harm (NNH) is a measure that indicates what?
what is the formula?
indicates how many patients need to be exposed to a particular risk factor over a specific period before a harmful event occurs in 1 patient.
NNH is the inverse of the absolute risk increase (or attributable risk), which is the difference in incidence rate between exposed and non exposed.
Odds ratio is a measure of ?
association between an exposure and an outcome.
IT can be calciulated on a 2 x 2 contingency table, using the formula OR = ad/bc
First line therapy for plantar warts?
Other options include?
Dx?
Topical salicylic acid (takes 2-3 weeks to beecome apparent)
other option: liquid nitrogen cyrotherapy
Dx: single or multiple hyperatotic papules on the sole of the foot. Scrapings of hyperkeratoci debris can confirm the diagnosis by showing thrombosed capillaries (also called seeds).
Gout versus Peusedogout
