UWORLD 4 Flashcards
Most likely mechanism of injury?
People with this injury frequently have additional injuries including?
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
Management of Distal Colles fracture
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
Fractures in teh 4th and 5th metacarpals are frequently caused by?
punching with a closed fist (boxer fracture)
Twisting or torsional injury of the hand may cause?
metacarpal fracture or a spiral fracture of the radius.
A fall with wrist in flexion may lead to?
Hyperflexion in addition to a ventrally displaced radius fracture (Smiths Fracture).
These fractures have a higher risk of complications and usually require orthopedic consultation.
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For data that is normally distributed, what is the best choice for central tendancy?
How does that differ from data that is highly skewed?
Normal distribution: mean
Highly skewed: median
In a strongly skewed distribution, the mean is a better measure of central tendancy than the mean.
UTI antibiotic prophylaxis can be considered in young female patients who?
had at least two UTI in six months or 3 in one year.
First line imaging for ovarian torsion?
pelvic ultrasound with color doppler, which typically shows an enlarged, edematous ovary with impaired ovarian blood flow.
Stool microsocpy for Giardiasis will reveal?
Symptoms of acute infection include?
multiple cysts and several flagellated trophozoites with 2 nuclei
Bulky, greasy stools, bloating/flatus, weight loss.
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Treatment of Giardiasis
What else is recommended?
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.
Giardia transmission
fecal-oral rout or ingestion of contaminated food or water.
Exposure to untreated water during camping or hiking is a common source of infection.
Treatment of recurrent Clostridium difficile infection
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.
What is the likelihood ratio?
Postive LR
Negative LR
Both can be calculated from?
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.
Likelihood <1 indicates?
LR=1
LR>1
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.
Type 1 versus Type 2 Error
The failure to detect a difference between groups as it exists is referred to as type II error.
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The probablity of type II errors is related to?
Power of a study is increased with?
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.
Gifts and approach
Gifts of small value that are expressions of gratutide are acceptable.
Acute interstitial nephritis is characterized by?
It is frequently caused by?
inflammatory infiltrate within the glomerulus, causing WBC casts, pyuria, mild hematuria and proteinuria.
medications including NSAIDs, PPI, Pencillins and diuretics.
Post infectious IgA nephropahty versus Acute interstital nephritis?
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.
Post-strep glomerulonephritis versus AIN
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
Herbal medications and what they are commonly used for:
Saw palmetoo
Kava Kava
St. John’s wort
Ginkgo biloba
Ginseng
Saw palmetoo - BPH
Kava Kava - Anxiety & insomonia
St. John’s wort - Depression
Ginkgo biloba - Memory enhancement
Ginseng - Improved mental performance
Side Effects
Saw palmetoo
Ginkgo biloba
Ginseng
Kava Kava
St. John’s wort
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).
Treatment of acute asthma exacerbation in pregnant women versus nonpregnant patients.
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.
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?
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)
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.
Dementia prognosis
progressive illness characterized by functional decline and impairement across several cognitive demans. Medications can slow progression, but there is no cure.
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.
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.
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.
Treatment of Nonallergic Rhinitis
topical intranasal glucocorticoids (ex: fluticasone) or intranasal antihistamine (ex: azelastine).
Patients with more severe may require both.
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.
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.
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.
PMR versus statin induced myopathy
Stain induced myopathy - elevated CPK level and normal ESR
(PMR has elevated ESR and normal CPK)
Prognosis of Essential or familial tremors
generally do not cause significant disabilities or neurologic problems in patients.
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
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MOA of hypercalcemia in SCC?
PTHrP
Treatment of Hypercalemia seconary to sarcoidosis
Glucocoerticoids
Glucocorticoids decrease calcium by inhibiting the production of calcitriol, thereby decreasing GI absorption of calcium.
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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
What is most frequently associated wtih rosacea
Ocular symptoms.
Complications frequently inclucde burning or foreign body snsation, blepharitis, keratitis, conjunctivits, episcleritis and recurrent chalazion.
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.
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.
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.
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..
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.
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.
Anterior shoulder pain is seen in patients with?
acromioclavicular or glenohumeral joint osteoarthiritis and biceps tendonitis
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Rotator cuff tendonitis usually presents as?
lateral shoulder pain aggavated by movements requirement abduction and external rotation.
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
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.
Causes of papillary necrosis
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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.
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.
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.
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).
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.
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Desmoid tumor versus lipoma
slow-growing and locally agressive benign neoplasms 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
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.
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Desmoid turmos are rare but increased in patients with?
FAP (ex: gardner syndrome)
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
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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.
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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.
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.
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.
Normal fasting sugar range?
Any individual with blood sugar level less than what is considered to be hypoglyemic?
70-100
less than 60
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.
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.
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.
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.
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)
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.
Psychodynamic psychotherapy
traces problems back to their origins in childhood, which may provide the patietn with insight
Interpersonal psychotherapy
focuses on improving dysfunctional relationships and interpersonal functioning. It is used primarily in the treatment of depressive disorders.
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
Treatment of EBV
Supportive and NSAIDS.
symptoms generally resolve within weeks (other than fatigue which persists for months)