UWORLD 4 Flashcards
1
Q
Most likely mechanism of injury?
People with this injury frequently have additional injuries including?
A
Fall on outstretched hand
Shows distal radius fracture with shortening and dorsal displacment.
This injury is known as Colles’ fracture.
Ulnar styloid fracture, scaphoid fracture and acute carpal tunnel syndrome
2
Q
Management of Distal Colles fracture
A
Most can be managed with conservative measures such as sugar tong splinting, with or without closed reduction.
More severe injuries, especially those with significant displacement or angulation >15-20 degrees may require urgent orthopedic consultation for possible surgical intervention
3
Q
Fractures in teh 4th and 5th metacarpals are frequently caused by?
A
punching with a closed fist (boxer fracture)
4
Q
Twisting or torsional injury of the hand may cause?
A
metacarpal fracture or a spiral fracture of the radius.
5
Q
A fall with wrist in flexion may lead to?
A
Hyperflexion in addition to a ventrally displaced radius fracture (Smiths Fracture).
These fractures have a higher risk of complications and usually require orthopedic consultation.
6
Q
For data that is normally distributed, what is the best choice for central tendancy?
How does that differ from data that is highly skewed?
A
Normal distribution: mean
Highly skewed: median
In a strongly skewed distribution, the mean is a better measure of central tendancy than the mean.
7
Q
UTI antibiotic prophylaxis can be considered in young female patients who?
A
had at least two UTI in six months or 3 in one year.
8
Q
First line imaging for ovarian torsion?
A
pelvic ultrasound with color doppler, which typically shows an enlarged, edematous ovary with impaired ovarian blood flow.
9
Q
Stool microsocpy for Giardiasis will reveal?
Symptoms of acute infection include?
A
multiple cysts and several flagellated trophozoites with 2 nuclei
Bulky, greasy stools, bloating/flatus, weight loss.
10
Q
Treatment of Giardiasis
What else is recommended?
A
Metronidazole
Hand hygenien is important to the spread of giardiasis - soap and water based agents are preferred (as giardia cysts are resistant to many alcohol-based hand sanitizers and disinfectants).
Affected individals with low risk do not require isolation.
Symptomatic individuals should be treated and refrain from attending recreational water venues to minimize disease transmission.
11
Q
Giardia transmission
A
fecal-oral rout or ingestion of contaminated food or water.
Exposure to untreated water during camping or hiking is a common source of infection.
12
Q
Treatment of recurrent Clostridium difficile infection
A
The management of a first relapse of Clostridum difficile infection is the same as as the inital episode.
Recurrent infection should be confirmed with stool studies.
Oral metronidazole is recommended for nonsevere and oral vancomycin is recommended for severe.
13
Q
What is the likelihood ratio?
Postive LR
Negative LR
Both can be calculated from?
A
the probability of a patient with the disease having a particular finding (ex: positive or negative test) divided by the probablity of a patient without the disease having the same finding.
Positive LR =sensitivity (1-specificity)
Negative LR = (1- sensivity)/specificity.
Positive and negative LR can be calculated from sensitivtity and specificty values or a contigency table.
14
Q
Likelihood <1 indicates?
LR=1
LR>1
A
LR<1 indicates decreased likelhood that the disease is present
LR = 1 indicates no change in the likelihood of disease
LR >1 indicates increased likelihood that the disease is present.
15
Q
Type 1 versus Type 2 Error
A
The failure to detect a difference between groups as it exists is referred to as type II error.
16
Q
The probablity of type II errors is related to?
Power of a study is increased with?
A
Power of the study.
larger sample sizes, so a smaller smaller study would be less effective in detecting differences between groups, increasing the chance of a type II error.
17
Q
Gifts and approach
A
Gifts of small value that are expressions of gratutide are acceptable.
18
Q
Acute interstitial nephritis is characterized by?
It is frequently caused by?
A
inflammatory infiltrate within the glomerulus, causing WBC casts, pyuria, mild hematuria and proteinuria.
medications including NSAIDs, PPI, Pencillins and diuretics.
19
Q
Post infectious IgA nephropahty versus Acute interstital nephritis?
A
Post-infectious IgA nephropathy commonly closely follows an upper respiratory infection (within 3 days); however urinalysis demostrates hematuria and often proteinuria
*pyuria, WBC casts and trace protein in AIN.
20
Q
Post-strep glomerulonephritis versus AIN
A
Post strep glomerulonephritis typically ocurs following Group A streptococcal infection.
Nephritis syndrome with hematuria, erythrocyte casts and proteinuria occurs weeks after infection.
*WBC casts is AIN
21
Q
Herbal medications and what they are commonly used for:
Saw palmetoo
Kava Kava
St. John’s wort
Ginkgo biloba
Ginseng
A
Saw palmetoo - BPH
Kava Kava - Anxiety & insomonia
St. John’s wort - Depression
Ginkgo biloba - Memory enhancement
Ginseng - Improved mental performance
22
Q
Side Effects
Saw palmetoo
Ginkgo biloba
Ginseng
Kava Kava
St. John’s wort
A
Saw palmetoo - increased bleeding risk
Ginkgo biloba- increased bleeding risk
Ginseng- increased bleeding risk
Kava Kava - severe liver damage
St. John’s wort - Hypertensive crisis, drug interactions: Antidepressants (serotinin syndrome), OC, Digoxin, Anticoagulants (decreased INR).
23
Q
Treatment of acute asthma exacerbation in pregnant women versus nonpregnant patients.
A
Treatment is similar to that in nonpregnant patients.
An inhaled or nebulized short-acting beta agonist (albuterol is preferred during pregnany) is given initally, usually in combination with inhaled ipratorpium.
If patients with persistent symptoms, the next step is the administration of systemic corticosteriods (ex: oral prednisone) wihout delay.
The risks of systemic corticosteriods (ex: premature birth) are outweighed by the benefits of effective asthma exacerbation management.
*inhaled corticosteriods (ex: fluticasone) are generally safe during pregnancy, but not appropriate for acute exacerbation. Following acute treatment, patient should be advised to resume fluticasone to prevent recurrent future exacerbation.
24
Q
ABG and pregnancy (chronic versus acute asthma exacerbation)
What suggest impending respiratory fialure and indication for intubation during asthma exacerbation in pregnant and non pregnant?
A
Pregnancy increases respiratory drive and leads to chronic respiratory alkalosis (PaCO2 of 27-32).
Acute asthma exacerbation causes acute respiratory alkalosis.
Respiratory acidosis PaCO2 >35 in pregnant or >40 in nonpregnant)
25
Management of infants born to mothers with active Hep. B infection
Should receive the Hep. B vaccine and immunologulin within 12 hours of delivery.
Exposed infants should receive the normal hep. B series (age 0, 2 and 6 months) and seriology should be obtained approx 3 months after the final Hep. B vaccine (usually 9 months).
Detection of HBsAg at the time is consistent with vertical infection. If HBs Ag is not detected at this time, the infant is uninfected.
26
Dementia prognosis
progressive illness characterized by functional decline and impairement across several cognitive demans. Medications can slow progression, but there is no cure.
27
Spontaneous bacterial peritonitis is dagnosed when there is ?
What must be started immediately?
**\> or = to 250 neutrophils** found in the peritoneal fluid.
**Empiric antibotic therapy** must be started immediately while waiting for the culture results, espeically if there are other indicators of infetion.
**IV albumin** has been asosciated with improved renal function and decreased mortality.
28
Rifaxamin what is it and what is it used for?
nonabsorbed oral antibotic used for addtional treatment of hepatic encephalopathy caused by bacterial overgrowth and ammonia formation in the gut.
29
The most commonly used calulation to predict mortality in patients with liver disease is the ?
What values does it look it?
**Model for Ends Stage Liver Disease (MELD) score.**
3 values are used to determine 90 day mortality in patients with advanced liver disease.
**serum bilirubin, INR and serum creatinine levels.**
THe MELD calcuation is commonly used in accessing candidates for transplant livers. Higher MELD takes precedence.
30
Treatment of Nonallergic Rhinitis
topical intranasal glucocorticoids (ex: fluticasone) or intranasal antihistamine (ex: azelastine).
Patients with more severe may require both.
31
How does Nonallergic rhinitis typically present?
after age 20 with nasal blockage, rhinorrhea and postnasal drip.
Patients have limited eye symptoms, are unable to find a clear trigger and can have symptoms throughout the year.
32
Polymyalgia rheumatica typical presentation?
Treatment?
affects patients \> 50 and is characterized by pain and stiffness in the neck, shoulders and pelvic girdle along with elevated ESR.
Treatmetn for PMR is low dose prednisone, which results in rapid relief of symptoms.
33
Polymyalgia rheumatica is frequently associated with?
What is the management when this is suspected?
giant cell arteritis (GCA) also known as temporal arteritis.
If GCA is suspected - expediated temporal artery biopsy and receive higher dose of glucocorticoids while evaluation is in progress.
34
PMR versus statin induced myopathy
Stain induced myopathy - elevated CPK level and normal ESR
(PMR has elevated ESR and normal CPK)
35
Prognosis of Essential or familial tremors
generally do not cause significant disabilities or neurologic problems in patients.
36
Sarcoidiosis - how does hypercalemia occur?
Sarcoid granulomas **produce enzyme 1-alpha-hydroxylase**, which converts 25-hydroxyvitamin D to 1,25-dhyroxyvitamin D, leading to increase in the GI absorption of calcium.
The resulting hypercalemia leads to suppresed PTH secretion and increased urinary calcium excretion
37
MOA of hypercalcemia in SCC?
PTHrP
38
Treatment of Hypercalemia seconary to sarcoidosis
**Glucocoerticoids**
Glucocorticoids decrease calcium by inhibiting the production of calcitriol, thereby decreasing GI absorption of calcium.
39
Flushes intensely in response to cold and hot temp and consumption of spicy food or alcohol.
PE shows redding of the central face, erythematous papules on the nose and sproradic telangiectasias on the nose and cheeks.
What does this patient have and what is the management?
Roseacea
characterized by erythema in the central face and is often assocaited with flushing, telangiectasis and pustules (occasionally).
Patietns with **only erythema and teclangiectasia** may be managed iwth **topical brimonidine** and **avoidance** of factors which trigger flushing.
Patients with **papular or pustular lesions** are treatment with **topical metronidazole or azelaic acid.**
Refractory or severe cases- oral antibiotics
40
What is most frequently associated wtih rosacea
Ocular symptoms.
Complications frequently inclucde burning or foreign body snsation, blepharitis, keratitis, conjunctivits, episcleritis and recurrent chalazion.
41
First line therapy for lactional mastitis?
**Oral dicloxacillin (antistaph pencillin) and cephalexin (first** generation cephalosporin); both are safe during breastfeeding.
\*most common organism is Staph. Aureus. Dx. is clinical.
42
Inaduately treated mastitis can lead to?
Next step in management?
Treatment?
breast abscess.
**Indurance** (skin thickening from edema and inflammation) and **fluctuance** (wavelight motion on palpation) on examination are evaluated by Ultrasound to distinguish mastitis from an abscess.
ANtiboticis and fluid drainage.
43
Use of mood stabilizers and antipsychoitcs during pregnancy
With the **exception of valproate and carbamazepine**, several mood stabilizers and antipsychotics can be utilized during pregnancy with minimal risk to the fetus and neonate in terms of major malformations.
General recommendations are to **avoid valproate and carbamazepine** in reproductive-aged women. With close monitoring, **lithium can be safely utilized in pregnancy.**
*\*risk of ebstein anomaly is very low due to the rarity of the condition.*
44
What is the most common cause of a palpable breast mass in adolescents?
What are its characterisitics?
Fibroadenoma
single, **rubbery**, **mobile**, **well-circumscribed** mass in the upper out breast quadrant.
Due to **hormonal fluctuation**, many patients may experience tenderness a few days prior to menstration..
45
Fibrocystic breast changes verus Fibroadenoma?
Fibrocystic breast changes are common and typically present as clusters of small masses or areas of thickening that are similar in both breasts.
The associated breast pain is bilaterial and generalized, with an increase in pain prior to menstrual onset.
In contrast, fibroadenomas are typically solitary and unilateral, rather than multiple and bilateral.
46
Management of any sharp object in the esophagus (ex: fish bone, toothpicks, needles, pins)
should be removed emergently by flexible endoscopy
Sharp printed objects have a high risk of esophagel perforation and should be removed urgently with endoscopy.
47
Anterior shoulder pain is seen in patients with?
acromioclavicular or glenohumeral joint osteoarthiritis and biceps tendonitis
48
Rotator cuff tendonitis usually presents as?
lateral shoulder pain aggavated by movements requirement abduction and external rotation.
49
Papillary necrosis
How do they present?
occurs with heavy long-term use of analgesics such as aspirin, phenacetin, acetaminophen and other NSAIDs.
hematuria, pyuria, proteinuria and renal colic.
Discontinuation of the analgesic usually stabilizes or improves the renal function
50
Acute glomerulonephritis versus papillary necrosis
Acute glomerulonephritis presents with elevated creatinine, HTN, hematuria with dysmorphic RBCs, RBC casts and proteinura.
Also, systemic involvement such as arthralgia or rash may be seen.
It does not cause flank pain or ureteric colic.
51
Causes of papillary necrosis
52
Papillary necrosis versus Pyelonephritis
Pyelonephritis have flank pain and costovertebral tenderness, but the presentation is not sudden.
Fever and dysuria are also commonly observed with pyleonephtriis.
53
Sensitivity analysis
Refers to **repeating** primary analysis after modifying certain criteria or variable ranges; the goal is to determine whether such modifications significantly affect the results initally changed.
54
Propensity scoring
Weighs diff. variables (ex: severity of diff. comorbidities) in both the treatment and the control groups to ensure that these variables are balanced between both groups.
An individual in the treatmetn group can be matched with an individual in the control group who has a similar propensity score.
55
Linear regression models
models the linear relationship between a dependent variable and one or more independent variables.
For example, multiple linear regression could be used to quantify the effects of alcohol use, tobacco smoking, and charred food consumption (independent variables) on the incidence of gastric cancer (dependent variable).
56
Attempting to grab a knife with a hand is likely to injuire what?
**tendons**
Digital arteries, nerves and veins run on the side, while flexor tendons run on the anterior surface of the phalanges.
57
Desmoid tumor versus lipoma
**slow-growing and locally agressive benign neoplasm**s with high rate of local recurrence, even after surgical excision.
arises from **fibroplastic** elements within the **muscle.**
**A lipoma** is asymptomatic and benign subcutnaeous collection of **fat cells**. It is usualy soft **without rapid enlargement or recurrence after resection**
58
Dermatofibroma
benign proliferation of fibroblasts that usually occurs after trauma or insect bite and can also be idiopathic.
It is usually a firm hyperpigmented nodule located on the lower extremities rather than the abdomen.
59
Desmoid turmos are rare but increased in patients with?
FAP (ex: gardner syndrome)
60
epidermoid cyst versus desmoid tumors
discrete nodule that is usually located on the skin and a result of the normal epidermal keratin becoming lodged in the dermis.
Epidermoid cysts can be seen in garder syndrome but are usually located on the extremities rather than the trunk or abdomen and resolve spontaneously without treatment
61
pyogenic granuloma
aka granuloma telangiectaticum
is caused by capillary proliferation after trauma and usually presents as **dome shaped papule with recurrent bleeding**.
It is more commonly seen in pregnant women.
62
What type of tests are useful for screening and which ones are useful for confirmation?
Highly senstive - useful for screening (SnNout) - a negative test helps rule out.
Highly specific tests are useful for confirmation (SpPin) - a positive results would help run in.
63
Patients with ACL injuries complain of?
What are the exam findings?
Dx?
**"popping"** sensation at the knee at the time of injury followed by **rapid onset hemarthrosis** and a **feeling of joint instability with weight bearing.**
Exam findings include laxity of anterior motion of the tibia relative to the femur and diagnosis is confirmed with MRI.
64
Patellofemoral pain versus ACL
PFS is associated with chronic overuse rather than acute trauma.
Patients report pain over the anterior knee, which can be produced by extending the knee while compression the patella (patellofemoral compression test).
Although they are some degree of swelling at the anterior knee, true knee effusions and hemarthrosis are not seen.
65
Normal fasting sugar range?
Any individual with blood sugar level less than what is considered to be hypoglyemic?
70-100
less than 60
66
Type 1 diabetes do not have endogenous insulin projection and require basal insulin by?
injection of twice-daily NPH or one injection of glargine insulin at bedtime.
67
Contrast-induced nephropathy is caused by?
contrast induced renal vasoconstriction
Patients with high risk of CIN should receive IV sodium chloride or sodium bicarbonate infustion before and after contrast exposure to reduce renal hypoperfusion.
68
Epiglottis presentation
What is it typically caused by?
Management
Unvaccinated chiild with acute onset of fever, stridor, drolling and dysphonia.
Tripod position (drooling, sitting fwd with his neck extended).
Haemophilius influenza Type B (less common now due to widespread vaccination)
Immediate Endotracheal intubation.
69
Coup versus epiglottis
Racemic ephinephrine and IM corticosteriods are beneficial for coup (layngotracheobronchitis) which can also present with stridor and respiratory destress.
However a **barking cough is a prominent feature of coup**.
In addition, feer is minimal and drooling is absent, in contrast to epiglottis.
70
What is any first line nonpharmacologic intervention for OCD
**exposure and response prevention**
Involves gradual and repetitive exposure to anxiety-provoking stimuli that produce obsessional thoughts (ex: contamination fears), followed by preventing of performing the assocated compulsion or ritual (ex: compulsive cleaning, repetitive showers)
71
Nonfpharmcologic intervention for Borderline Therapy
**Dialectical behavioral therapy**
Type of cognitive behavioral therapy that tries to identify and change negative thinking patterns and pushes for positive behavioral changes.
72
Psychodynamic psychotherapy
traces problems back to their origins in childhood, which may provide the patietn with insight
73
Interpersonal psychotherapy
focuses on improving dysfunctional relationships and interpersonal functioning. It is used primarily in the treatment of depressive disorders.
74
Pharmacological treatment for OCD
SSRis is first line (fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram).
TCA (clomipramine) can be used if they dont respond to SSRI
75
Treatment of EBV
Supportive and NSAIDS.
symptoms generally resolve within weeks (other than fatigue which persists for months)
76
Thyroid medications for pregnant woment
Propylthiouracil is preferred in first trimester (due to teratogenic effects of Methimazole - aplasia cutis),
but methimazole is preferred in second or third trimesters and in nonpregnant patients (due to hepatotoxicity of PTU)
77
What is indicated in unresponsive patients with large amounts of hematemesis?
**Endotracheal intubation** because of aspiration risk.
Upper endoscopy should be preferred early as it may be diagnostic and theraupetic.
78
In patients with cirrhosis in whom there is concern for variceal hemorrhage, what should be initiated after stabilization and while waiting for endoscopic therapy?
IV octreotide.
Octreotide is thought to decrease the elevated Portal venous pressure that causes varcieal formation and may stop the hemorrhage.
79
What can be used in the primary and secondary prevention of esophageal variceal hemorrhage?
**Nonselective BB** (ex: propanolol, nadolol) which reduces the pressure in the portal venous system, particularly in combination of **endoscopic surveillance and bind ligation.**
80
Guidelines for Chronic Obstructive Lung diseae recommend antibotic therapy for patients who have COPD exacerbation with any two of the following features?
increased sputum production, increased sputum volume or increased dyspnea.
81
Acute inferior wall MI often causes what?
**bradycardia**
* due to increase in vagal tone triggered by ischemia of the SA node and right ventricular wall ischemia.*
* Inferior wall MI is typically results from blockage of the RCA and may involve only the RV or both the Right and LV.*
* the SA node is supplied by the RCA in 60% of patietns; sinus bradycardia commonly occurs due to ischemia of the SA node and Right ventircular wall triggering an increase in vagal tone.*
82
Inital treatment of choice for patients with hemodynamically significant bradycardia due to inferior wall MI
**IV atropine**
results in increased CO and improvement in symptoms
83
What do you test at 24-28 weeks routine prenatal?
hemoglobin/hematocrit
Antibody screen if Rh(D) negative - and receive anti-D immune globuilin injection
50-g 1-hr Glucose Oral challenge test
\*if 50-g 1 hyr test is postive, then do confirmatory 100-g 3 hour glucose tolerace test prior to the diagnosis of gestational DM.
84
What do you test at 35-37 weeks visit
Group B Strep culture
85
Contraindications for Neuraxial analgesia
**severe thrombocytopenia** (\< than 70,000) or a rapidly dropping platelet count (often associated iwth preeclampsia with severe features).
These patietns there is a risk of spinal epidural hematoma.
86
Treatment of patients with focal dystonia (ex: involuntary eye closure provoked by external stimuli sch as bright light or irritants)
Boulinum toxin injections
87
Fibroadenoma
Adolescent with single, rubbery, mobile breast mass.
Breast tenderness preceding menses typically improves after the menstrual period has ended.
88
Fibrocystic versus Fibroadenoma
Fibrocystic breast changes are common and typically present as palpable clusters of small masses or areas of thickening that are similar in both breasts.
The associated breast pain is bilateral and generalized, with an increase in pain prior to menstrual onset.
**In contrast, fibroadenomas are typically solitary and unilateral, rather than multple and bilateral.**
89
WHat is an important cause of secondary hypertension in children and young adults?
renal parachymal disease
90
What is the most common cause of idiopathic nephrotic syndrome in adults, accounting for about 50% of cases of Africian American patietns?
Focal segemental glomerulosclerosis (FSGS).
Diagnosis is usually established by urinalysis and chem panel (proteinuria, increased serum cr) and confirmed by renal biopsy.
91
Relative risk reduction
versus
relative risk
RRR = (risk in unexposed - risk in exposed )/risk in unexposed
RR = risk of disease in exposed group/risk of disease in unexposed group
92
Found incidentally on imaging. What is this patient at risk for and what is the management?
associated withincreased risk of gallbladder cancer (due to chronic cholelithasis)
Patients with punctate calcifications or symptoms of biliary colic are usually referred for prophylactic cholecystecomy to reduce cancer risk.
93
Exercise induced amenorrhea is due to?
decrease inpulsatile secretion of LH, which leads to a decline in estrogen production.
It can lead to osteopenia, osteporosis, breast and vagina atrophy, mild hypercholesteremia and infertility.
*\*Paradoxically, there is a tendancy toward hypercholesteremia, not the oppposite.*
94
Focal nodular hyperplasia verus Hepatic adenoma
Focal nodular hyperplasia is a benign liver lesion due to hyperplastic liver cells. Most cases arise in young women and are disovered incidentally on imaging for other conditions.
## Footnote
**However CT scan with contrast usually shows uniform enhancement (no peripheral)**
**Hepatic adneoma is most commonly seen in young women on OCPs.**
95
CT scan of liver with Echinoccoccus infection
parasitic infection that often causes hepatic cysts.
Patients are frequently asympomatic for years after infection and CT scan typically reveals a cyst with fluid, peripheral calcificaiton and septation.
96
Case series
Group of case reports regarding individual patietns who had similar clinical manifestations or eceived similar treatment.
Each individual case is described in detailed.
97
What is the most serious adverse effect that is responsible for most of the deaths associated with amiodarone therapy?
pulmonary toxicity
\*can be seen in the form of chronic interstital pneumonitis, organizing pneumonia, ARDS, and rarely with a solidary pulmonary mass.
CIP is the most common presentation
98
The 3 diagnositc criteria for Acute Choliangitis:
If patients meet all all three dignostic criteria for AC, the most apporiate next step is?
**Fever** or other signs of inflammation (ex: leukocytosis , elevated CRP) and
**jaundice** or abnormal liver chemistries
**biliary diliation** or eviendence of etiology on imaging.
**Urgent endoscopic retrograde cholangiopancreatography.** ERCP can confirm the diagnosis and more important provide life saving biliary drainage.
99
Normal Grief versus MDD
Patients experiencing normal grief may report symptoms similar to those of a major depressive episode.
In normal grief, a patient may wish to die to join the deceased and may allso experience visions or hear the deceased person's voice.
**Pervasive anhedonia and suicidality feelings related to feelings of worthlessness and hopelessness are not present.**
100
Organophosphate poisoning presentation
What is used to confirm the diagnosis?
confusion, lethargy, bradycardia, skin flushing, miosis and wheezing.
Sudden onset of symptoms and **garlic-like odor from clothing** are also characterisitic.
RBC cholinesterase activity level.
101
What is used to help diagnosis salicylates, ehtylene glycol and methanol intoxications?
Arterial Blood Gas
102
How does Rubella present in the following:
Congenital
Children
Adolescents/adults
Rubella (German measles)
**Congenital**
- Sensorineural hearing loss
- cataracts
- PDA
**Children**
- Fever
- cephalocaudal spread of maculopapular rash (begins on face and spreads caudally)
**Adolescents/adults**
-Same as children + arthralgias/arthritis
103
Rubella versus Rubeola
Measles (Rubeola) and rubella have overlapping features, including prodrome of cough, conjunctivitis and coryza followed by cephalocaudal spread of maculopapular rash.
## Footnote
**However, patietns with measles are typically ill-appearinig with higher fevers.**
**In addition, the measles are darker (brick red) and spreads more gradually over a few days.**
104
Rash of Rocky mountain spotted fever
rickettsial disease transmitted by tick bite.
Characterized by fever, myalgias, headache and a petechial rash.
The rash classicaly involves the **distal extremities** (ex: palms and soles) and **subsequently spreads to the trunk.**
105
Lyme disease versus Rocky mountain spotted fever
106
Roseola (sixth disease) versus Rubella
Roseola (sixth disease) is a mild infection characterized by **high fever that resolves rapidly.**
The **fever is followed by eruption of a rosy, non-puritic rash that orginates in the trunk** and **spread to the extremities**
107
Management of patients with suspected Rocky Mountain spotted fever?
they should be treated empirically (without waiting for confirmation of the diagnosis).
Doxycycline is the treatment of choice in both children and adults.
Chloramphenicol is an alternative option for pregnant females and patients who are not able to tolerate tetracycline
*(Chloramphenicol irreversibly binds to a receptor site on the 50S subunit of the bacterial ribosome)*
108
What is typically used to monitor patients receiving cardiotoxic chemotherapy?
Radionuclide ventriculography
a.k.a MUGA (multigated acquisition) scan
It is highly accurate and reproducible test for quanitiating LVEF.
It is generally preformed at baseline before chemotherapy is initated and before each subsequent dose of chemotherapy.
109
Most common complication of cat-scratch disease?
suppuration of the lymph nodes (10%).
Other complications are: visual loss due to neuroretinitis, encephalopathy, fever of unknown origin and hepatosplenomegaly
\*Bartonella henselae
110
commonly found in infectious mononucelosis due to EBV
lymphocytes seen are **atypical reactive lymphocytes.**
(predominant cytoplasm with irregular nucleus)
111
Blasts (seen in leukemia
112
Reed Sternbergcells (with hodgkin lymphoma)
113
Complications for anorexia nervosa include
**dehydration, orthostatic hypotension and syncope** and are indications for inpatient stabilization.
Antiemetic therapy should not be administered as vomiting is due to purging behavior and can potentiate the risk of arrhythmia (ex: QA prolongation)
114
Nonfunctional pituitary adenomas presentation & treatment
**hypogonadism and low gonadotropin levels**; **serum a-subunit levels are characterisically increased.**
trans-sphenoidal surgery
Normal gonadotrophs secrete LH and FSH (which are dimeric hormones consistign of a common a-subunit and different b-subunit), but the **dysfunctional cells in most gonadotroph adenomas secrete primarily just the common a-subunit.**
The clinical symptoms of a-subunit overproduction are usually minimal ("nonfunctioning" adenoma), and the diagnosis is not apparent until the adenoma is large enough to cause headaches or visual disturbances due to mass effect.
115
Ocretide MOA on pituitary
acts on somatostain receptors in the pituitary inhibit release of GH.
Sometimes used in GH producing adenomas (acromegaly)
116
Treatment of Cat bites
Amoxicllin and clavulanic acid.
Doxyclycline can be used as an alternative drug if the adult patient is allergic pencilin.
117
Maternal to infant transmission of Chlamydia trachomatis
can cause neonatal conjuncivitis and/or pneumonia, occurs via direct contact with maternal secretions.
\*In addition, although topical erythromycin ophthalamic prophylaxis is effective in preventing gonococcal conjunctivitis in neonates, it has no effect on chlamydial conjunctivitis
118
Measles and influenza versus transmission of Chlamydia trachomatis via maternal-to-infant in neonate
Infections that are spread via airborne particles (ex: measles) or droplets (influenza) can also present with conunctivitis.
However, additional symptoms (ex: fever, rhinorrhea, cough) would be expected.
119
Treatment of neonatal chlamydial conujunctivitis
oral macrolide (ex: erythromycin, azithromycin).
Topical prophylaxis or therapy is not effective in preventing or treating chlamydial conjunctivitis.
120
Organisms & Treatment of the following:
Gonoccocal conjunctivitis
Empiric therapy for suspected neonatal sepsis
bacterial conjunctivitis in older children
**_Gonoccocal conjunctivitis_** - IM third generation cephalosporin (ex: cefotaxime, ceftriaxone)
**_Empiric therapy for suspected neonatal sepsis_** - *Group B Strep, E.choli & Listeria*
**IV ampicillin and gentamicin**
**_bacterial conjunctivitis in older children_** - commonly due to *staph. A, strep. pneumo or Haem. Influnenza.*
**topical trimethoprim-polymyxin**
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Management of newborns whos mother did not receive indicated Group B strep prophylaxis?
Must be observed for 48 thours.
A complete blood count with differential and blood cultures are indicated if the patietn is preterm or was exposed to prolonged rupture of membranes.
122
Primary CNS lymphoma is common malignant in patients with?
What is the major determinant of the survival in patients with Primary CNS lymphoma?
**advanced HIV infections and is strongly related to EBV.**Most patients with PCNSL have a persistently depressed CD4 count (\<50)
## Footnote
**the degree of immunosupression.**
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Aplastic crisis in Sickle cell disease
**transient failure of erythropoiesis most commonly due to parvovirus B19.**
Presentation includes a **sudden drop in Hemoglobin and a very low reticulocyte count (\<1%)**
*\*Parvovirus B19 preferes to attack erythroid precursors rather than other cell lines.*
124
Hyperhemolytic crisis versus apastic crisis in SCD
A hyperhemolytic crisis is a very rare complication of SCD that presents with acute, severe anemia and an **increased reticulocyte count,** which differentiates it from an aplastic crisis.
The etiology is unknown.
125
Splenic sequestration versus aplastic anemia
Splenic sequestration is due to pooling of RBCs in the spleen and presents with a rapidly enlarged spleen.
Lab findings include severe anemia and marked reticulocytosis.
The patients low reticulocyte count and normal abdominal exam make sequestration unlikely.
126
What is mixed cryoglobulinemia syndrome?
What is the triad of manifestations?
**vasculitis due to deposition of immune complexes** (polyclonal IgG and IgM rheumatoid factuor) within the vascular wall of small and meidum size vessels.
Palpable purpura
Fatigue
Arthralgias
127
Lab examination of Mixed cyroglobulinemia usually reveals
**elevated Rheumatoid factor and hypocomplementemia**
approx 20% of patients develop glomerulonephritis (red cells, red cell casts, proteinuria) with or without renal insufficiency.
128
Mixed cyroglobulimia syndrome is typically associated with?
What is the diagnosis?
chronic hepatitis C virus
measure the cyroglobulin levels
129
Treatment of Mixed cryoglobulinemia syndrome
immunosuppressive therapy (ex: corticosteriods and rituximab) followed by targeted therapy using the underlying condition that triggered the disease.
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Lesion is painful, red, edematous and elevated
what is the most common organism?
Erysipelas, a form of cellulitis.
A sharp demarcation from the uninvolved skin is usually present and a butterfly pattern involving the cheeks and the bridge of the nose may be seen. Other features are abrupt onset and presence of systemic symptoms (fever, chills, malasise)
Group-A streptococcus
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Overdose presentation on the following:
Anticholinergic agents
TCAs
Organophosphate or carbmate poisoning
Ethylene glycol
_Anticholinergic agents_ - **Dry skin and mucosal surfaces as well as dilated pupils.** *Common agents are TCA, mushrooms, certain plants.*
_TCAs_ - **Ventricular tachyarrythmias**
_Organophosphate or carbmate poisoning_ - **Excessive salviation.** *Common agents used in pesticides and insecticides.*
_Ethylene glycol_ - severe anion gap metabolic acidosis. **Rapid and deep breathing pattern** called kussmauls respiration
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Antidote for ethylene glycol and metanol intoxication.
**Fomeprizole (direct inhibitor of alcohol dehydrogenase)**
**Simultaneous use with ethanol is not recommneded.**
\*Ethanol can also be used for treatment. ADH actually has greater affinity for ehtanol than other alcohols; however fomepizole inhibits ADH more potently than ethanol is therefore the antidote of choice.
133
untreated chlamydia trachomas infection during pregnancy is assocaited with what obsteric complications and neonatal complicaitons?
First linet reatment
Obsteric complications: Preterm premature rupture of the membranes, preterm labor, postpartum endometrictis)
Neonatal complications (ex: blindness, pneumonia).
First linet reatment is azithromycin.
134
Secondary causes of HTN (8)
135
External validity
Or generalization
Defined as the the applicability of a study's result beyond the group that was initally assessed.
How generalizable are the results of the study to other populations?
136
What is a safe and effective treatment for severe bipolar mania during pregancy?
Other treatments include?
Haloperidol
Lithium and second generation antipsych (Quetiapine, risperiodone, olanzapine)
Valporate and carbamepine should be avoided.
ECT is effective but is typically reserved for treatment-resistant cases and for those at imminent risk to themselves or their fetus.
137
When do you need to treat asymptomatic bacteriuria?
138
Patients with PCOS, what is the best contraceptive option for them?
**Progestein-containing intrauterine device**
It simultaneous provides contraception and helps decrease risk for endometrial hyuperplasia or cancer due to unopposed estrogen excess).
139
PCOS and risk for endometrial hyperplasia and cancer comes from?
Chronic anovulation can lead to unopposed estrogen, resulting in uncontrolled endometrial proliferation and increaed risk for endometrial hyperplasia and cancer.
140
Iodine-induced thyrotoxicosis Management
**Self-limiting disorder** if the source of excess iodine is discountinue; however it can persist for months and is usually refractory to antithyroid medications.
**BB are used for mild symptoms and antithyroid medications** can be used for moderate to severe symptoms.
141
Heart failure on chest xray may show what?
Pleural effusion or pulmonary edema, often manifested as Kerley B lines (horizontal lines representing interstitial edema).
or linear densities at the margins of the lung fields
142
Leber hereditary optic neuropathy (LHON) inheritance pattern?
What other diseases follow this pattern?
Mitochondrial (mother to offspring). Males will acquire, but will not transmit it further.
Mitochondrian encephalopathies and myopathies (ex: MELAS).
\*Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a condition that affects many of the body's systems, particularly the brain and nervous system (encephalo-) and muscles (myopathy)
143
Restless leg syndrome may be a symptom of?
What should be obtained?
iron deficiency.
A serum ferritin level should be obtained as iron deficiency is frequently seen in the abscence of anemia.
144
Treatment of Restless leg syndrome
For moderate-to-severe intensity
First line: Dopamine agonist (pramipexole or ropinirole)
145
Flail chest
Usually the result of?
double rib fractures in more than one site, with pradoxical motion of the free segment of the chest wall during inspiration.
The diagnosis may be obvious on examination, but many cases are occult.
146
Cardiac contusion versus flail chest
Cardiac contusion, especially if massive, may lead to hemodynamic instability; however, disorder breathing (rapid, shallow breathing) with stable vital signs would not be typical.
147
Peeclampsia management for seizure prophylaxis in patients without Mystenia Gravis versus those with Mystenia Gravis.
**Magnesium sulfate,** commonly used in obsterics for seizure prophylaxis (ex: preeclampsia) and fetal neuroprotection, is **contraindicated in patients with mystehenia gravis** as it may trigger mystenia crisis due to the inhibition of acetylcholine release.
Use v
148
Life threatening hemorrhage in patients with warfarin therapy should be treated with?
**prothrombin complex concentrate and IV vitamin K.**
Prothrombin complex concentrate contains vitamin K-dependent clotting factors and normalizes INR \<10 minutes after administration.
**IV Vitamin K** - results in sustained warfarin reversal but **takes 12-24 hours for full effect.**
Because of this **delayed effect,** vitamin K is **always used with clotting factor replacement**.
\*FFP is typically used when prothrombin complex concentrate is unavailable.
149
When is IV desmopressin used in hematology?
it's a syntheic analog of ADH that increaes circulating levels of Factor VIII and Von willebrand factor.
It is often used to treat minor bleeding episode sin patients iwth von willebrand disease or uremic platelet dysfunction.
150
IV idarucizumab is used to reverse what?
it is a monoclonal antibody that is used to reverse anticoagulant dabigatran, a direct thrombin inhibitor.
151
A screening test must have what?
High sensitivity.
This high sensitivy helps to "RULE OUT' the disease by decreasing the number of flase-negative results and by increing the negative predictive valeu (SnNOut)
152
Rates of bacterial colonization in Cystic Fibrosis based on age?
What is the preferred empiric antibiotic regimen in patients experiencing severe pulmonary exacerbations?
**Staphlococcus Aureus and Pseudomonas Aeruginosa** are the most common pulmonary pathogens prsent in patients with CF.
Tobramycin (an aminoglycoside), ticarcillin-clavulante and vacomycin
*Tobramycin (an aminoglycoside) PLUS ticarcillin-clavulante for pseudomonas and Vanco for staph*
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schistosomiasis
Clinical presentation of urinary schistosomiasis
parasitic fluke infection commonly seen in sub-saharan africa
dysuria, urinary frequency, terminal hematuria, peripheral eosinophilia
\*terminal hematuria (blood in urine at the end of urination)
154
Schistosomiais diagnosis
Treatment
identifying parasite eggs by urine sedminet microscopy
Praziquantel
155
Best inital therapy for oral candidiasis
topical antifungal (ex: nystatin suspension or clotrimazole troches)
Oral antifungal such as fluconazole can be used for resistant cases.
\*plaques can typically be removed, although at times it may be difficult. A residual area of inflammation may be seen where the plaque has been removed. Most are asymptomatic, although some may complain of a strange cotton taste.
156
Atopic dermatitis (topical emollients and avoidance of hot/dry environments and harsh soaps and detergents.
Chronic pruritic rash with excorations and lichenification
157
When conservative measures do not work for atopic dermatitis, what is the next step in management?
topical glucocorticoids are effective in treatming mild-moderate atopic dermatitis.
Topical calcineurin inhibitiors (ex: tacrolimus) are an alternate therapy for areas where glucocorticoids are relatively contraindicated (ex: face, eyelids).
Severe atopic dermatitis may require phototherapy or systemic immunosuppressants.
158
Bile salt induced diarrhea occursin 5-10% of patients following cholescystectomy and in patients with short bowel syndrome.
Treatment of choice?
salt binding resins such as cholestyramine
\*Bile salts are conjugated bile acids. Primary bile acids produce din liver cells are secreted into the intestional lumen, where they are converted into secondary bile acids by the bacteria. These secondary bile acids can cause colonic stimulation if present in excess amounts.
Gallbladder surgery alters gut dynamics and leads to increased bile acid flux to the colon, resulting in an increased proportion of secondary bile acids and causing diarrhea.
Bile salt indiced dirrahea is also sseen in ileal resection or
159
**Meckels' diverticulum**
What does it result from?
How do they present?
What is highly specific for this condition?
Results from failure of the **vitelline duct** to obliterate during the first 8 weeks of gestation, leaving behind a blind pouch often containing **ectopic gastric tissue.**
**Painless rectal bleeding in children \<2.**
A **technetium-99 nuclear scan** is highly specific for this condition. It concentrates in the parietal cells of the diverticulum and the stomach.
160
Meckel's diverticulum versus Intussception
Children with intuessception have significant abdominal pain and poor appetitie (Meckel's is painless and appetite is normal)
161
Describe Xray findings of Silicosis
**many small round opacities** distributed **predominantly in the upper lobes.**
In **advanced** disease, the nodules can enlarge and **coalesce**, resulting in retraction of the hila, upper lobe fibrosis and hyperinflation in the lower lobes.
Radiograph may **occasionally** show **calcification of the rim of the hilar nodes (eggshell calcification)**. Cavitation can also be present with our wotihout superimposed mycobacterial infection, for which patients with silicosis are at increased risk.
162
Central retinal artery occlusion presents with?
Usually affects which patients?
Funduscopy shows what?
**acute, painless, monocular vision loss.**
\>60 with udnerlying **cardiovscular** risk factors.
Funduscopy shows **diffuse ischemic retinal pallor** and **cherry red macula** (due to preserved circulation via posterior ciliary arteries)
163
Management of Central Retinal Artery Occlusion
**Urgent opthalmology consultation and measures to lower intraoccular pressure.**
CRAO can cause irreveersible retinal damage within 90-100 minutes.
164
Presentation of acute angle-closure glaucoma?
typically presents with vision loss, severe eye pain, headache, nausea, and vomiting.
Patietns may resport seeing halos.
Examination shows conjuctival redness and dilated poorly reactive pupil.
165
Centeral retinal vein versus Centeral retinal artery occlusion
Central retinal vein occlusion can also present with painless, acute, or subacute monocular vision loss.
**Central retinal _vein_ occlusion** is usualy due to **nonembolic causes.**
Examination can show **tortous and dilated veins, diffuse hemorrhages, disk swelling and cotton wool spots.**
166
Macular degeneration presentation?
What are the two forms?
progressive distortion and loss of vision, primary in the center of visual field (Central scotomas)
The "**dry**" form can have cellular **debris** (**drusen**) accumulation between the retina and the choroid, which sometimes leads to retinal detachment.
The "**wet**" form is more **severe**, with **blood vessels growing** up from the choroid between teh retina, which can cause retinal detachment.
167
Retinal detachment presentation?
Usually associated with?
**vision loss** (peripheral followed by central) and **photopsia** with showers of **floaters**.
It is usually associated with **trauma**, p**revious eye surgery, agining and severe myopia.**
168
Subclinical hypothyroidism and pregnancy risk
Subclinial hypothyroidism is associated with increased risk for a number of pregnancy complications, including recurrent miscarriages, severe preeclampisa, preterm birth, low birth weight and placental abruption.
169
If analysis is between two categorical variables, what type of test would you use?
Chi-square test
170
Combination estrogen/progesterone menopausal hormone therapy increases the risk for?
stroke, coronary heart disease, breast cancer and venous thromboembolism.
171
Combination birth control effect in the breast versus the endometrium
**Endometrial cancer** is largely **eliminated** with combination estrogen/progesterone therapy.
In contrast, the **risk of breast cancer is increased** with combination therapy (although it may be lower with unopposed estrogen)
172
Epdiura abscess presents with?
Management?
Fever, focal spinal tenderness/back pain, and neurologic dsyfunction.
**Evaluation includes urgent MRI**, blood cultures, inflammatory markers (ESR and CRP), CT guided apsiration and culture and antiboticis.
Emergency surgical decompression and drainage of athe abscess are recommended for most paitns.
173
Medical contradictions to pregnancy
174
Management of previously vaccinated individual who are potentially re-exposed to rabies versus those without a history of immunization?
**Vaccinated + exposed** = receive only a **booster** course of rabies **vaccine (2 doses)**
**Nonvaccinated + exposed** = require both **immunoglobulin and full vaccination series (4 doses)**
175
What is Eisenmenger syndrome?
Complication of unrepaired VSD that leads to pulmonary HTN, Right to left shunting, cyanosis and eventual right and left sided heart failure.
176
Side effect of thiazolidnedione medications
result in **fluid retention** via PPAR-y agonist efects on the renal collecting trubules resulting in sodium reabsorption.
177
Guillian Barree patients are at a high risk of?
What must be frequently monitored?
Patients are at a **high risk of respiratory failure** and require frequent **monitoring of tidal volume** **and negative inspiratory force** to assess respiratory status.
## Footnote
*\*Peak expiratory flow is useful in obstructive lung disease. It is not typically used to access respiratory muscle weakness in GBS*
178
Manifestation of Guillain-Barre syndrome tend to evolve as follows?
How do you shorten this?
worsen over 2 weeks, plateau for 2-4 weeks and then spontaneously recover over months.
Time to recovery is shortened by the use of plasma exchagne or IV immunoglobulin.
179
Postoperative atelectasis
When is it common? How does it present?
Mgmt of those with secretions versus those without?
is **common 2-5 days** **following** thoracoabdominal **surgery** and typically presents with **hypoxemia or respiratory difficulty.**
Patients **without respiratory secretions** can be magned with **CPAP**, whereas those with **secretions** are best managed with **aggressive pulmonary hygeine**, including chest physiotherapy and suctioning.
180
UTI in children less than 24 months - management
**first time febrile UTI** should be treated with \> or = 7 days of **antibiotics** and **followed closely** for any recurrence.
**Renal and bladder US** should be performed to evaluate for any anatomic abnormalties.
**Voiding cystorethrogram** is inidicated in children with **abnormal findings on US or those with recurrent infection.**
181
Threshold for blood tranfusion in most stable patients with upper GI bleed?
\< 7 as it is associated with fewer complications and reduced mortality.
A hemoglobin level \> or = to 8 is recommned in patient with stable coronar artery dsiease or those planned for some large surgery (ex: certain orthopedic procedure)
182
Management of patietns with suspected acute coronary syndrome but unremarkable iniutal ECG and serum tropinin levels?
should be observed with **serial ECG and troponin levels** to confirm or rule out the diagnosis.
*(serum troponin levels remain undeteected for 6-12 hours following the onset of MI symptoms)*
183
Benzodiazepine withdrawal treatment
Give them benzo (ex: diazepam)
184
Organophosphate poisoning results in?
What is the management?
**cholinergic toxicity**
treated with two medicaitons: **atropine**, which reverses muscarinic receptor effects and **pralidoxime**, which is a cholinesterase activator.
185
Pyridoxine is used to treat what overdose?
This is another term for B6 and is usaed for treated **isonazid overdose**.
186
What is iused to treat acetamiophen overdose?
N-acetylcysteine
187
Delivery Management of mother who has HPV?
Cesaran delivery does not prevent vertical transmission of HPV.
Women with condyloma acuminanta can proceed with vaginal delivery unless the condyloma are large and obstruct the birth canal.
188
Variable decelerations, abrupt drops in the fetal HR that lasts \<2 minutes are the result of?
Umblical cord compression
189
