UWORLD 5 Flashcards
1
Q
Anemia and pregnancy
managment?
A
During pregnancy, plasma volume increases more rapidly than RBC mass, resulting in mild dilutional anemia that resolves spontaneously in the postpartum period.
Patients with physiologic anemia do not require treatment or futher evaluation.
2
Q
Gingival bleeding during pregnancy versus disorders of hemostasis.
A
Gingival bleeding during pregnancy is due to hyperplasia and inflammation that occurs as a result of the hormonal changes of pregnancy.
Disorders of hemostasis (ex: hemophilia, VWB disease) can present with gingival bleeding.
However, disorders of hemostatis also present with bleeding complications during surgery and ecchymosis or petechia on examination, not seen in those who are pregnant.
3
Q
Schaphoid fracture
A
Most common carpal bone fracture, commonly occurs due to falling onto an outstretched hand with a dorsiflexed wrist.
Findings include decreased grip strength, decrease range of motion in the wrist and tenderness to palpation of the scaphoid within the anatomic snuffbox.
Xrays of the wrist in full protonation and ulnar deviation to better expose the scaphoid.
4
Q
Colles fracture
A
common fracture falling onto an outstretched hand
dorsally angulated or displaced distal radius fracture that is typically associated with visible angulation proximal to the wrist joint (dinner fork deformity).
Lateral radiographs can confirm colles fracture diagnosis
5
Q
Hamate fracture
A
9
Q
Sprain of the wrist ligaments
How does it differ from scapholid fracture?
A
typically associated with mild pain or stiffness with normal range of motion and resolves with conservative or supportive care.
A wrist sprain causes pain that worsens with flexion and extension of the ligaments.
Scaphoid fracture has severe point tenderness with palpation.
10
Q
Management of scaphoid fractures
A
Patients with suspected scaphoid fracture should be evaluated further with either an immediate MRI or CT scan, repeat x-ray in 7-14 days or bone scan in 3-5 days.
Non displaced fractures should be treated with a short arm thumb spica cast, but other fractures should be referred to an orthopedic surgeon for evaluation.
Patients with a fracture should have wrist immobilization until there is evidence of radiographic union..
11
Q
Scaphoid fractures that are not properly treated or in a timely fashion can result in what?
A
avascular necrosis and increases the risk of nonunion.
12
Q
dupuytren contracture
what is it associated with?
A
characterized by progressive fibrosis of the plamer fascia of unknown etiology
associated with DM, exposure to repetitive vibration to the hands, CRPS, alcohol consumption and occassionally malignancy.
13
Q
Multiple Myeloma
What is it due to?
What does the patients typicall develop?
Serum and/or urine protein electrophoresis will show what?
A
Malignent monoclonal proliferation of plamsa cells
Patients develops back and bone pain, renal insufficiency, hypercalemia, and hyperproteinemia.
Serum and/or urine protein electrophoresis will show a monoclonal protein, and bone marrow biopsy will show >10% monoclonal plasma cells in most cases.
14
Q
What should be performed once a patient has been diagnosed with multiple myeloma?
What should be avoided in myeloma patients with renal insufficiency?
A
Complete x-ray skeletal series (ex: skull, long bones and spine)
*typicall revels punched-out lytic lesions, diffuse osteopenia, or fractures in nearly 80% of patients.
Other imaging modalities (CT, MR( and Positron emission tomography) are usually reserved for patients with bone pain and negative inital x-ray skeletal surveys.
Studies requiring iodinated radiocontrast agents should be avoided in myeloma patients with renal insufficiency.
15
Q
Hyperviscosity syndrome can be seen in which two conditions?
How do they differ?
How do they present?
What is the treatment?
A
Waldenstrom’s macroglobulinemia (due to elevated IgM)
and
Multiple Myeloima (due to increased plasma cells)
*More common in Waldenstrom’s macroglobulinemia.
Findings:: headache, dizziness, vertigo, nystagmus, hearing loss and visual impairment
Prompt plasmapheresis for symtom relief
16
Q
Prophylaxis for stress ulcers
A
Enteral or IV PPI are preferred , but H2 blockers can be used as alternate therapy.
*Small studies have shown effiicacy of PPI over H2 receptor antagonists.
17
Q
Complete rupture of the Achilles tendon is a clinical diagnosis that can be supported with what test?
A
Thompson test, which is >90% sensitive and specific.
The thompson test observes for plantar flexion of the food when the calf muscle is squeezed.
The absence of plantar flexion significes complete rupture and positive test result.
18
Q
What carries the highest teratogenticity risk of all Antiepileptic drug use (AED)?
What is preferred?
What is the management of patients on AEDs?
A
Valproate
changing to an alternate regimen should be tried 6 months prior to attempts to conceive.
However, no changes to the AED regimen should be made after conception as abrupt changes may trigger seizure activity.
Mgmt includes initating high-dose folic acid supplementation and screening for congenital anomolies (ex: neural tube defects) with serum alpha-fetoprotein and an anatomy ultrasound.
19
Q
Breastfeeding and women with epilepsy
A
Breastfeeding should be encouraged as the benefits of breasfteeding outweigh the risk of exposure of the infant to antiepileptic drugs.
Studies show that neurodevelopment outcomes in thsese breasfed infants are either better than or no different from those who are not breastfed.
20
Q
Hyperthyroidism in older versus younger patients
A
Hyperthyroidism in older patients often presents with atypical manifestations.
In contrast to younger patients, older individuals may not have classic hyperadrenergic findings (ex: palpations, tachycardia).
Older patients are also more likely to have lethargy, apathy, decreased appetitie and weight loss or have muscle weakness (myopathy)
21
Q
Foodborne disease and vommiting predominant (3)
A
Staph. Aureus
Bacilleus Cereus
Noroviruses (Norwalk)
22
Q
Foodborne disease and watery diarrhea predominant (6)
A
Clostiridum perfingens
Enterotoxic E.coli
Enteric viruses
Cryptosporidium
Cyclospora
intestional tapeworm
23
Q
Foodborne illnesses and inflammatory diarrhea predominant (6)
A
Salmonella (both typhi and non-typhi)
Campylobacter
Shiga toxin producing E.Coli
Shigella
Enterobacter
Vibrio (usually parahaemolyticus)
24
Q
What is the most common cause of gastroenteritis, including epidemic gastroenteritis, in adults and children?
What is more prominent?
How does this differ from Enterotoxigenic E.coli?
A
Norovirus
Vomiting is more prominent
Outbreaks are common and can occur in restuarant, travel and health care setting.
Enterotoxigenic E.coli is the most common cause of traveler’s diarrhea, but is much less frequently a cause of diarrhea in outbreaks.
It classically presetns with malaise, anorexia, abd. cramps, followed by acute onset of predominant watery diarrhea.
25
Q
Food borne disease and non-gastrointestional symptoms (7)
A
Botulism (descending paralysis)
Ciguatera toxin (paresthesia)
Scombroid (flushing, urticaria)
Listeria (meningitis)
Vibrio vulnificus (cellulitis, sepsis)
Hepatitis A (jaundice)
Brucellosis (fever, athralgias)
26
Q
How does camplyobater infection commonly present?
How do you diagnoise?
A
acute onset of cramping abdominal pain and inflammatory diarrhea (ex: mucus, blood)
Diagnosis is by stool culture
27
Q
How does clostridium perfringens is typically associated with but is also an important cause of?
clostridium perfringens and foodborne disease?
What are uncommon?
A
Typically associated with traumatic gas gangrene, but is also an important cause of watery diarrhea.
The spores of C perfringens germinate in warm food; once ingested, the bacteria produce a toxin in the GIT that cause disease.
Fever and vomiting are uncommon
28
Listeria monocytogenes and gastroenteritis
What does the patient get?
How do you diagnoise?
Rare cause of epidemic gastroenteritis (usually associated with **deli meats and soft cheese**).
In addition to **watery diarrhea, fever and nausea/vomiting**, L monocytogenes gastroenteritis may also present with non-gastrointestional symptoms such as **myalgia, arthralgia and headache.**
Diagnosis can be confirmed from special **stool culture** media.
29
Norovirus versus Enterotoxigenic E.coli
**Norovirus - most common cause of gastroenteritis**, including epidemic gastroenteritis, in adults and children. **Vomiting is more prominent.** Outbreaks can occur in restaurant, travel and health care setting.
**Enterotoxigenic Ecoli**- most common cause of **traveler's diarrhea,** but is much less frequently a cause of diarrhea in outbreaks. **Watery diarrhea** is more prominent.
30
**21 hydroxylase deficiency**
symptoms
hormone abnormalities
**Symptoms**:
Ambiguous genitalia in girls
Salt wasting (vomiting, hypotension, Decrease in Na+, increase in K+), hypoglycemia from lack of cortisol
**Hormone abnormalities:**
Decrease in cortisol & aldosterone,
Increase in testosterone,
Increase in 17-hydroxyprogesterone
31
**11 B- hydroxylase deficiency**
Symptoms
Hormonal abnormalities
**Symptoms**
Ambigugous genitalia in girls
Fluid & Salt retention, hypertension.
**Hormonal abnormalities**
Decrease in cortisol & adosterone
Increase in testosterone
Increase in 11-deoxycorticosterone (weak mineralocorticoid) & 11-doexycortisol
32
**17 a-hydroxylase deficiency**
Symptoms
Hormone Abnormalities
**Symptoms**
All patients are phenotypically female
Fluid & salt retention, hypertension
**Hormone Abnormalities**
Decrease in cortisol & testosterone
Increase in mineralocorticoids
Increase in corticosterone (weak glucocorticoid)
36
Galactosemia
Inheritance pattern?
deficency in?
Presentation?
**AR**
inability to digest galactose due to **def. of galactose-1-uridyl transferase.**
Patients are **hypoglycemic** and become v**ery ill and dehydrated** due to vomiting after ingestion of breast milk or cow's milk-based formula.
37
Steroid 5-a-reductase deficiency
**cause** 46 XY invidividuals to have **external female appearig genitalia with clitoromegaly** in some patients.
**46, XX** patients have **normal external femal genitalia.**
38
The most common cause of morbidity and mortality in SLE patients is?
what is needed?
**renal involvement.**
When the kidney is involved, a **renal biopsy** is needed to help guide the treatment.
**Type of therapy** is directed by the **pattern of glomerular involvement.**
Type I, II - require no treatment.
III, IV - requires immunosuppression
V - requres treatment.
IV methylprednisolone is usually use. Immunosuppresive agents may be needed when the response to steroids is inadequate.
39
**Lumbar spinal stenosis**
Who does it affect?
What is it characterized by?
**degenerative** disease that affects the **elderly** population.
**increased lumbar pain on extension of the spine.**
**Pain improves when the patient sits down or when he bends forward** (ex: using a grocery cart)
*\*People complain of pain when leaning backward (or even standing upright) because this makes the spinal canal and the foramen smaller.*
40
What can be used to monitor the disease activity in SLE patients?
**Anti-ds DNA and complement levels**
Renal involvement in SLE is due to immune complex mediated glomerular injury.
These immune complexes are primiarly composed of anti-dsDNA antibodies, and are deposited in the mesangium or subendothelial space, where they are fixed with the resultant influx of neutrophils and mononuclear cells.
The titers of anti-dsDNA correlate well with the disease activity of lupus nephritis.
Complement def. is not the inital event and results from complment activiation of immune complexes deposited in the glomerulus.
41
Sexual relationships with former psychiatric patients are
ALWAYS unethical.
42
Diagnosis of spinal stenosis
MRI of the spine
43
Stress hyperglycemia pathogenesis
How does it differ from Diabetes mellitus?
During illness & stress, hyperglycemia can result from the **release of high levels of stress hormones** (ex: cortisol, catecholamines and pro-inflammatory cytokines).
Patients with stress hyperglyemica, has normal hemoglobin A1c (rules out chronic hyperglycemia) and has no hx of weight loss, polyuria, polydipsia or polyphagia.
45
Disc herniation versus lumbar spinal stenosis
Disc herniation pain worsens with lumbar flexion (unlike Lumbar spinal stenosis)
46
**_Acute Tubular Necrosis_**
**Etiopathology?**
**Findings?**
- BUN/Cr Ratio
- Fractional excretion of sodium
- Urine osmolatility
- Microscopy
**-Management**
**Tubular inury from renal ischemia, sepsis or nephrotoxins** *(ex: aminoglycosides, tenofovir, radiocontrast media)*
- BUN/Cr Ratio: **Typically normal 10-15**
- Fractional excretion of sodium: **\>2%**
- Urine osmolatility: **~300 mOsm/kg**
- Microscopy: **Muddy brown cast**
**Management: Supportive care, treatment of underlying cause**
47
Treatment of lumbar spinal stenosis
conservative or lumbar epidural block.
Surgical decompression through a laminectomy is an option when other therapies fail.
49
**Sarcoidosis**
What is it?
What does clinical investigation often reveal?
**systemic inflammatory disorder** characterized by the formation of **noncaseating granulomas** against an unknown antigen.
**Bilateral hilar adenopathy with/without diffuse interstital infiltrates**
-**mixed restrictive** (reduced capacity for CO) **and obstructive pattern** (Reduced FEV1 and FEV1/FVC) pattern on PFT
**Hypercalemia and elevated inflammatory markers** (ESR)
50
Treatment of sarcoidosis
**Asymptomatic** patients often require **no treatment**
those with **symptoms or pulmonary function impairement** usually reeive 1**2-24 months of oral glucocorticoids.**
**Most cases (~75%) resolve over time and do not recur.**
51
**Aspiration pneumonia versus Aspiration pneumonitis**
Pathophysiology?
Clinical features?
Treatment of both?
**_Aspiration pneumonia_** - due to infection of the lung parenchyma due to **aspiration of oral cavity microbes** (gram +, gram - & anaerobes)
- patients with dypshia or gastric dysmotility
- **1-5 days after aspiration event**
- **Clindamycin** *(great against gram+ and anerobics)*
**_Aspiration pneumonitis_** - inflammation of the lung parenchyma due to **aspiration of foreign contents** (ex: gastric contents with subsequent acid injury)
- depressed level of consciousness, hx of vomiting and respiratory distress **2-5 hours after an aspiration event.**
- there is generally **no signs of infection** and tx is **supportive (no antibotics)**
53
**Pre-renal**
**Etiopathology?**
**Findings?**
- BUN/Cr Ratio
- Fractional excretion of sodium
- Urine osmolatility
- Microscopy
**-Management**
**Decreased renal perfursion** from **volume depletion** (hypovolemia/hemorrhage) **or decreased effective circulating volume** (ex: heart failure)
BUN/Creatinine Ratio: **Typically \>20**
- Fractional excretion of sodium: **\<1%**
- Urine osmolatility: **\>500 mOsm/kg**
- Microscopy **Bland**
**Management: IV fluids (responds to fluid challenge with improved urine output)**
54
What is the gold standard in distinguishing prerenal azotemia from ATN?
What else differentiates it from one another?
Response to IV fluid challenge - .Pre-renal responds, ATN does not.
Muddy brown casts and high franctional excretion of sodium differentates ATN from prerenal azotemia.
55
Red cell casts in the urine are indicative of?
glomerulonephritis
56
What is performed in high-risk patients to prevent future episodes of aspiration?
Speech and swallowing evaluation, followed by diet modification.
57
NPH versus long-acting insuling analogs
NPH and long acting insulin analogs (detemir, glargine, degludec) are **effective in lowering hemoglobin A1c i**n patients with type 2 diabetes mellitus.
However **NPH is associated with a higher risk of hypoglycemia** compared with long-acting insulin analogs.
*basal insulin = insulin that is intended to work continously through the day.*
58
The most important first step in the management of septic shock is?
WHat else can be added?
**aggressive fluid resuscitation** to a **Central venous pressure of 8-12 mmHg.**
**Vasopressors such as norepinephrine or dopamine** should be added if the patient's hypotension is poorly responsive to fluid resuscitation.
59
Criteria for systemic inflammatory response syndrome (SIRS)
Temp greater than 38.5C,
HR \>90 beats/min
RR \>20
WBC \>12,000
Need two out of the four
60
Patients on longstanding corticosteriods often have what?
What may be exacerbated should they develop septic shock?
How should these patients be managed?
suppression of pituitary-adrenal axis secondary to negative feedback.
Hypotension may be exacerbated
unless stress dose steriods are given during acute iillness
61
Asthma verus Coup
Treatment and PE
Nebulized beta agonist, such as albuteol are the first line for asthma exacerbations as they relax smooth muscle to relieve lower airway bronchoconstriction.
Asthma presents with wheezing rather than stridor and beta agonist are ineffective for coup as it is an upper airway disease.
62
Epiglottis versus coup
Endotracheal intubation is critical for a child with epiglottis, which also presents with fever and stridor.
However, cough is absent in epiglottis and patients appear toxic (high fever, drooling, leaning forward, severe respiratory distress)
64
Accepting gifts from patients
Accepting gifts from patients is generally considered appropriate if the gift is not excessive and not intended to influence future care.
Decisions to accept or decline gifts should be based on the patients best interest.
65
**Hemophilia A**
What is it?
Inheritance pattern?
Inherited bleeding disorder that is due to a deficit in coagulation factor VIII.
X-linked recessive disease that affects mainly males; heterozygous females are silent carriers.
66
If a father is affected by an X-linked recessive disease and the mother is NOT a carrier, what will be in the inheritance pattern for their children?
Their children will not be affected by the disease, although all their female children will be carriers.
(Male will receive fathers's Y chromosome and healthy X from his mother who is not affected)
67
What are certain patterns of calcification within the pulmonary nodule are strongly suggestive of benign lesions?
What raises suspicion for malignancy?
Benign - Popcorn, concentric or laminated, central and diffuse homogeneous calcifications.
Malignancy - Eccentric calcification (area of asymmetric calcification), as well as reticular or punctate calcification
68
Earliest sign of hypovolemia
tachycardia
70
Hoarseness of voice is suspicious for?
recurrent laryngeal nerve entrapment, causing vocal cord paralysis.
71
Brain death
What is it?
Neurological examination typically shows?
Diagnosis requires what?
**irreversible absence of cerebral and brain stem function.**
**including pupillary, oculocephalic, oculovestibular (caloric), corneal, gag, sucking, swallowing and extensor posturing.**
There is no spontaneous breathes, regardless of hypercarbia or hypoxemia.
Diagnosis requires a **CNS catastrophe of known etiology** with an **absence of counding factors** (ex: endocrine or electrolyte disturbance, drug intoxification) **and hypothermia.**
72
Patients with brain death can have what?
spontaneous movements, but these originate from peripheral nerves or the spinal cord.
73
**Sporothrix schenckii**
What is it?
How do humans acquire it?
Clinical manifestations?
Treatment?
**dimorphic fungus** found in **soil and decaying plant matter.**
Humans acquire the infection when the organism is **inoculated into the skin** or subcutaneous tissue.
**Gardeners & landscapers**
**Skin papule --\> ulceration with nonpurulent, odorless drainage**
over days, similar lesions usually develop along the **proximal lympathic chain.**
Tx: **3-6 months of itraconazole**
74
Blastomycosis versus Sporothrix
Blastomycosis is a fungal infection that primarily affect hte lungs (pneumonia) but may occasionally cause verrucous skin lesions with heaped up borders (not papular ulcerative lesions)
75
Cervicofacial actinomycosis
How does this differ from sporothrichosis?
**bacterial infection at or near the jaw**
**slow-growing, nontender mass** that evetnually evolves into **multiple abscesses, fistulas and sinus tracks** that drain a **thick, yellow, serous discharge with granules.**
Sporothrichosis- nodular papular lesions and similar lesions along the lymphatic chain.
76
Coccidoidomycosis
Fungal infection that affects primilary the lung (CAP) and CNS but my occassionaly cause skin manifestations.
Skin lesions are typicall soft tissue abscesses, not slow growing papules that drain nonpurulent, odoorless fluid (unlike sporotrichosis)
77
Rh(D) alloimmunization occurs when?
Alloimmunization can lead to what?
**Rh(D) negative mother develops antibodies against Rh(D) antigen.**
**hemolytic disease of an Rh(D)-positive newborn and/or fetus;** maternal IgG anti-D antibodies cross the placenta and destory fetal RBCs
When severe anemia developsin the fetus, it can lead to **heart failure and subsequent hydrops fetalis.**
78
Antibody screening for Rho(D)
When is it done?
What does a positive/negative test mean?
What reduces the risk of alloimmuniztion?
What if an early dose of anti-D immunoglobulin was already given?
Is performed in all pregant women at the **first prenatal visit** and **at 28 weeks gestation** to identifcy antibodies that increase the risk of hemolytic disease (typically anti-D).
Positive antibody screening test indicates that alloimmunization has already occured, and anti-D immune globulin is not administered.
Negative anti-D antibody screening test confirms a lack of antigen exposure and is an **indication to proceed with anti-D immune globulin prophylaxis at 28 weeks gestation**.
The postparum doese of anti-D immune globulin, administered \<72 hours after delivery, reduces teh risk of alloimmunization from fetomternal hemmorhage associated delivery.
The **postpartum dose, with the addition of antental dose at 28 weeks** reduces the risk of alloimmunization to \<1%.
Even when an early dose of anti-D immuneglobui has been given, **another dose is still indicated at at 28 weeks** (since it has a short half-life)
83
Histoplasmosis versus Sporothroix
Histoplasmosis is a **fungus that affects primilary the lungs** but may occasionaly cause progressive extrapulmonary infection.
Disseminated histoplasmosis may be assoicated with **nodular, papular or plaque-like skin slesions,** but patients **usually have systemic symptoms (**ex: fever, fatique, weight loss) **and are clinically ill.**
84
CKD is associated with?
**Phosphate retention, reduced free serium calcium levels and decreased 1,25 dihydroxyvitamin D levels.**
Leads to **compensatory rise in PTH levels** (secondary hyperPTH).
Overtime, this can lead to **autonomous PTH secretion** (tertiary hyperPTH) unresponsive to rising calcium levels, resulting in hypercalemia with very high PTH levels.
85
Carpal tunnel syndrome diagnosis
Clinical and several physical exmination maneuvers can be used for confirmation.
**Phalen Test (hyperflexion of the wrist).** Compresses the median nerve in the carpal tunnel and a positive test repdorudctions characteristic symptoms within one minute.
**Tinel sign** (tapping over the nerve in the carpal tunnel elicits tingling sesation)
**Elevation above the head** to help confirm
86
Dequervain tenosynovitis
overuse of extensor pollcis brevis and abductor pollicis longus tendons and presents with **sharp pain at the base of the thumb.**
Pain is produced by **ulnar devation at the wrist,** especially when the **thumb is held in oppostion across the palm (**finkelstein test)
87
Indications for parathyroidectomy in tertiary hyperPTH include?
**persistent hypercalemia or hyperphosphatemia,**
**very high PTH levels (\>800),**
**soft tissue calcification or calciphylaxis** (vascular calficiation with skin necrosis)
**Intractable bone pain**
88
Acute treatment of severe hypercalemia
IV hydration.
89
Preterm labor is defined as?
What is indicated?
Why?
**regular uterine contractions resulting in cervical change at \<37 weeks gestation.**
**IM corticosteriods (ex: betamethasone)** are indicated at \<37 weeks gestation to **decrease the risk of neonatal respiratory distress, necrotizing enterocolities and intraventicular hemorrhage** associated iwth prematurity
90
Preterm labor and magnesium sulfate
Used for fetal neuroprotection at \<32 weeks gestation as it has been shown to decrease the incidence of cerebral palsy.
91
time period of patients with herpes zoster transmission of varicella zoster virus to other individuals?
how?
Advice for patients?
from the **onset on the lesion** **until it is completely crusted over.**
Most tranmissio**n occur via direct contact, but aerosolized virus from active lesions has occasionally caused infections**.
patients treated as an outpatient basis for herpes zoster should be advised to **keep a lesion covered until it is completelly crusted over.**
92
Treatment of postherpetic neuralgia?
persistant pain and allodynia \>4 months after rash of resolved are considered to have postherpetic neuralgia.
Treatment requires chronic treatment.
First line - TCA's (ex: amitriptyliine), but should be used with caution in older patients or those with cognitive impairements
Second line - Gabapentine
95
Inital treatment of carpal tunnel syndrome
What if this doesn't work?
**Start with Spints to hold the wrist in neural position.**
Splinting prevents excessive flexion or extension that could narrow the tunnel and worsen medial nerve compression.
Nighttime splinting is usually adequate, although patients may opt for full time use.
**Corticoid injections later for those who fail inital treatment** (can provide short term relief)
**Surgical decompression** is efffective but is usually reserved for patients with **more severe or chornic symptoms who fail conservative measures.**
96
Presentation of urethral diverticum
Physical examination will reveal?
**dysuria**, postvoid dripping, **dyspareunia** and an **anterior vaginal mass.**
a tender anterior wall vaginal mass that expresses bloody, purulent fuild on manipulation of the urethra.
97
What is indicated for patients with chronic or refractory carpal tunnel syndrome who are being considered for surgury.
**Nerve conduction studies.** They are not usually needed in the inital diagnosis (which is clinical dx) but can be considered if diagnosis is uncertain.
\*compression of the median nerve in CTS results in loss of myelination. Nerve conduction studies can confirm the diagnosis and assess the severity of CTS by **demonstrating slowed condutction along the nerve at the level of carpal tunnel)**.
98
Bell's Palsy
What is it?
Common findings?
What is very important that patients be assessed for?
**idopathic neuropathy of cranial nerve VII**
**Rapid** onset of **unilateral upper and lower facial weakness.**
Afflicted side include **inabilty to raise eyebrow or close the eye,** **drooping of the mouth corner,** and **disappearance of the nasolabial fold.**
Symmetry by raising their eyebrows due to bilateral UMN innervation to the forehead.
Forehead sparing is suggestive of an intracranial lesion and would warrant brain imaging to evaluate for ischemia or tumors
99
Treatment for Bell's palsy
**Corticosteriod and supportive eye care are the mainstays of treatment.**
patients have poor eyelid closure and patients are at risk of dryness and abrasions. Therefore **artifical tears and eyepatching** should be prescribed.
100
Treatment of Clostridium difficile colitis -
Mild/moderate
Severe
Subsequent relapses
second recurrence
**Mild/moderate** - **Oral metronidazole**
**Severe c.difficile colitis with** **systemic toxicity** (high fever, WBC \> 15,000, creatinine \>1.5x baseliine) - **Oral vancomycin**
**Subsequent relapses- similar treatment as inital.**
**second recurrence - Vancoymycin**
101
SVC presentation
Best diagnostic test
Suspected in patients who have a **high risk of malignancy (**ex family hx or smokers) and presents with **dyspnea, orthopnea, neck pain and swellling and has cervical and upper extremities venous dilation.**
**CT contrast of the chest and neck,** which will reveal an obstruction of hte SVC due to the pulmonary mass, metatstic nodes or IV thrombus.
102
Classic presentation for SVC
**Dyspnea, persistent cough, facial fullness and neck pain and progresses into hoarseness, dyspnea, CP and syncope.**
Pertinent physical findings are **edema, erythema of the neck, and dilated veins of the arm and neck.**
103
Relative risk of an outcome calculation
If the relative risk of an outcome in Group A as compared to Group B is x, then the relative risk in Group B as compared to Group A is 1/x.
104
First line for treatment for sulfonylurea poisoning?
What if they have severe sulfonylurea overdose?
Sulfonylureas cause **increased insulin secretion** which can cause hypoglycemia.
**Inital treatment with dextrose** - however, dextrose administration can cause transient hyperglycemia that may elicit an higher level of insulin secrretion and subsequent **rebound hypoglycemia.**
**Octreotide** is a somatostatin analogue that decreases insulin secretion in patients with a large sulfonylurea overdose, particularly if the patient is unable to say how much medication was ingested.
106
Presentation of posterior urethral valve
congental malformation that obstructs the flow of urine;
typical presentation includes recurrent urinary tract infections, incontinence, strained voiding and bilateral hydronephrosis.
This malformation is most common in male infants.
107
Stress urinary incontinence
verus
Urethral diverticulum
loss of urine with increased intrabdominal pressure (ex: Valasalva manuever).
There is no associated dysuria, dyspareunia or vaginal wall mass.
108
Damage to the corpus callosum can result in
problems with learning, hand-eye coordination and visual/auditory memory
109
Epiglottis versus coup
Endotracheal intubation is critical for a child with epiglottis, which also presents with fever and stridor.
However, cough is absent in epiglottis and patients appear toxic (high fever, drooling, leaning forward, severe respiratory distress)
110
Diagnosis of Urethral diverticulum
Confirmed with MRI of the pelvis or transvaginal ultrasound
111
Internal capsule is composed largely of?
Damage to this area results in?
composed largely of the **corticospinal tract**, which brings information from the **primary motor cortex to the lower motor neurons in the spinal cord.**
Damage to this area typically results in **contralateral hemiparesis or hemiplegia.**
112
Q tip test is performed to diagnose?
urethral hypermobility, a common cause of stress urinary incontinence.
A cotton swab is placed inside the urethra to measure the extent of urethra mobility during the valsalva maneuver; a positive test has a \>30 degree angle of movement.
113
What is used to diagnose urinary incontinence due to a vesicovaginal fistula?
**Methylene blue is instilled into the bladder.**
Vesicovaginal fistulas present with painless, continuous leakage of urine from teh vagina.
The test is positive if a tampon placed in the vagina become blue after the dye is instilled in the bladder
114
What are certain patterns of calcification within the pulmonary nodule are strongly suggestive of benign lesions?
What raises suspicion for malignancy?
Benign - Popcorn, concentric or laminated, central and diffuse homogeneous calcifications.
Malignancy - Eccentric calcification (area of asymmetric calcification), as well as reticular or punctate calcification
115
Polymyalgia rheumatica characterization?
Treatment?
What is it frequently associated with?
PMR affects **patients \>50** and is characterized by **elevated ESR (\>40)** and **pain** and **stiffness** in the **neck, shoulders and pelvic girdle.**
SIgns of inflammation are absent.
**Low dose glucocorticods.**
Frequently assoicated with **giant cell arteritis** (aka temporal arteritis). If this is suspected, need to edo **expediated temporal arterial biospy** and receive **significantly higher doses of glucocorticods.**
116
Classic features of Wernicke encephalopathy?
**Life threatening disorder** of **thiamine deficiency** seen most commonly in patients with heavy alcohol use and/or severe malnutrition
**Encephalopathy** - disorientation and confusion
**oculomotor dysfunction** - lateral rectus palsy
**Gait ataxia** - wide based gait or complete gait impairment.
117
Treatment of Wernicke encephalopathy
**IV thiamine**
IV thiamine usually improves ocular abnormalites within hours, but confusion and gait ataxia may persist for days or weeks; many patients never fully recover.
118
Hepatic encephalopathy versus encephalopathy with Wernicke encephalopathy
Treatment for both
Both causes **confusion**, but **hepatic encephalopathy** is **not** typically associated with **ophthalmophlegia**.
Treatment for **hepatic** is **Lactulose** and **Wernicke** is **Thiamine**
119
Asthma verus Coup
Treatment and PE
Nebulized beta agonist, such as albuteol are the first line for asthma exacerbations as they relax smooth muscle to relieve lower airway bronchoconstriction.
Asthma presents with wheezing rather than stridor and beta agonist are ineffective for coup as it is an upper airway disease.
120
**Sporothrix schenckii**
What is it?
How do humans acquire it?
Clinical manifestations?
Treatment?
**dimorphic fungus** found in **soil and decaying plant matter.**
Humans acquire the infection when the organism is **inoculated into the skin** or subcutaneous tissue.
**Gardeners & landscapers**
**Skin papule --\> ulceration with nonpurulent, odorless drainage**
over days, similar lesions usually develop along the **proximal lympathic chain.**
Tx: **3-6 months of itraconazole**
121
Blastomycosis versus Sporothrix
Blastomycosis is a fungal infection that primarily affect hte lungs (pneumonia) but may occasionally cause verrucous skin lesions with heaped up borders (not papular ulcerative lesions)
122
Cervicofacial actinomycosis
How does this differ from sporothrichosis?
**bacterial infection at or near the jaw**
**slow-growing, nontender mass** that evetnually evolves into **multiple abscesses, fistulas and sinus tracks** that drain a **thick, yellow, serous discharge with granules.**
Sporothrichosis- nodular papular lesions and similar lesions along the lymphatic chain.
123
Coccidoidomycosis
Fungal infection that affects primilary the lung (CAP) and CNS but my occassionaly cause skin manifestations.
Skin lesions are typicall soft tissue abscesses, not slow growing papules that drain nonpurulent, odoorless fluid (unlike sporotrichosis)
124
Earliest sign of hypovolemia
tachycardia
125
Antibody screening for Rho(D)
When is it done?
What does a positive/negative test mean?
What reduces the risk of alloimmuniztion?
What if an early dose of anti-D immunoglobulin was already given?
Is performed in all pregant women at the **first prenatal visit** and **at 28 weeks gestation** to identifcy antibodies that increase the risk of hemolytic disease (typically anti-D).
Positive antibody screening test indicates that alloimmunization has already occured, and anti-D immune globulin is not administered.
Negative anti-D antibody screening test confirms a lack of antigen exposure and is an **indication to proceed with anti-D immune globulin prophylaxis at 28 weeks gestation**.
The postparum doese of anti-D immune globulin, administered \<72 hours after delivery, reduces teh risk of alloimmunization from fetomternal hemmorhage associated delivery.
The **postpartum dose, with the addition of antental dose at 28 weeks** reduces the risk of alloimmunization to \<1%.
Even when an early dose of anti-D immuneglobui has been given, **another dose is still indicated at at 28 weeks** (since it has a short half-life)
126
Rh(D) alloimmunization occurs when?
Alloimmunization can lead to what?
**Rh(D) negative mother develops antibodies against Rh(D) antigen.**
**hemolytic disease of an Rh(D)-positive newborn and/or fetus;** maternal IgG anti-D antibodies cross the placenta and destory fetal RBCs
When severe anemia developsin the fetus, it can lead to **heart failure and subsequent hydrops fetalis.**
127
Patients with brain death can have what?
spontaneous movements, but these originate from peripheral nerves or the spinal cord.
128
Brain death
What is it?
Neurological examination typically shows?
Diagnosis requires what?
**irreversible absence of cerebral and brain stem function.**
**including pupillary, oculocephalic, oculovestibular (caloric), corneal, gag, sucking, swallowing and extensor posturing.**
There is no spontaneous breathes, regardless of hypercarbia or hypoxemia.
Diagnosis requires a **CNS catastrophe of known etiology** with an **absence of counding factors** (ex: endocrine or electrolyte disturbance, drug intoxification) **and hypothermia.**
129
Hoarseness of voice is suspicious for?
recurrent laryngeal nerve entrapment, causing vocal cord paralysis.
130
Histoplasmosis versus Sporothroix
Histoplasmosis is a **fungus that affects primilary the lungs** but may occasionaly cause progressive extrapulmonary infection.
Disseminated histoplasmosis may be assoicated with **nodular, papular or plaque-like skin slesions,** but patients **usually have systemic symptoms (**ex: fever, fatique, weight loss) **and are clinically ill.**
131
CKD is associated with?
**Phosphate retention, reduced free serium calcium levels and decreased 1,25 dihydroxyvitamin D levels.**
Leads to **compensatory rise in PTH levels** (secondary hyperPTH).
Overtime, this can lead to **autonomous PTH secretion** (tertiary hyperPTH) unresponsive to rising calcium levels, resulting in hypercalemia with very high PTH levels.
132
Carpal tunnel syndrome diagnosis
Clinical and several physical exmination maneuvers can be used for confirmation.
**Phalen Test (hyperflexion of the wrist).** Compresses the median nerve in the carpal tunnel and a positive test repdorudctions characteristic symptoms within one minute.
**Tinel sign** (tapping over the nerve in the carpal tunnel elicits tingling sesation)
**Elevation above the head** to help confirm
133
Dequervain tenosynovitis
overuse of extensor pollcis brevis and abductor pollicis longus tendons and presents with **sharp pain at the base of the thumb.**
Pain is produced by **ulnar devation at the wrist,** especially when the **thumb is held in oppostion across the palm (**finkelstein test)
134
Indications for parathyroidectomy in tertiary hyperPTH include?
**persistent hypercalemia or hyperphosphatemia,**
**very high PTH levels (\>800),**
**soft tissue calcification or calciphylaxis** (vascular calficiation with skin necrosis)
**Intractable bone pain**
135
Acute treatment of severe hypercalemia
IV hydration.
136
Preterm labor is defined as?
What is indicated?
Why?
**regular uterine contractions resulting in cervical change at \<37 weeks gestation.**
**IM corticosteriods (ex: betamethasone)** are indicated at \<37 weeks gestation to **decrease the risk of neonatal respiratory distress, necrotizing enterocolities and intraventicular hemorrhage** associated iwth prematurity
137
Preterm labor and magnesium sulfate
Used for fetal neuroprotection at \<32 weeks gestation as it has been shown to decrease the incidence of cerebral palsy.
138
time period of patients with herpes zoster transmission of varicella zoster virus to other individuals?
how?
Advice for patients?
from the **onset on the lesion** **until it is completely crusted over.**
Most tranmissio**n occur via direct contact, but aerosolized virus from active lesions has occasionally caused infections**.
patients treated as an outpatient basis for herpes zoster should be advised to **keep a lesion covered until it is completelly crusted over.**
139
Treatment of postherpetic neuralgia?
persistant pain and allodynia \>4 months after rash of resolved are considered to have postherpetic neuralgia.
Treatment requires chronic treatment.
First line - TCA's (ex: amitriptyliine), but should be used with caution in older patients or those with cognitive impairements
Second line - Gabapentine
140
If a father is affected by an X-linked recessive disease and the mother is NOT a carrier, what will be in the inheritance pattern for their children?
Their children will not be affected by the disease, although all their female children will be carriers.
(Male will receive fathers's Y chromosome and healthy X from his mother who is not affected)
141
**Hemophilia A**
What is it?
Inheritance pattern?
Inherited bleeding disorder that is due to a deficit in coagulation factor VIII.
X-linked recessive disease that affects mainly males; heterozygous females are silent carriers.
142
Inital treatment of carpal tunnel syndrome
What if this doesn't work?
**Start with Spints to hold the wrist in neural position.**
Splinting prevents excessive flexion or extension that could narrow the tunnel and worsen medial nerve compression.
Nighttime splinting is usually adequate, although patients may opt for full time use.
**Corticoid injections later for those who fail inital treatment** (can provide short term relief)
**Surgical decompression** is efffective but is usually reserved for patients with **more severe or chornic symptoms who fail conservative measures.**
143
Presentation of urethral diverticum
Physical examination will reveal?
**dysuria**, postvoid dripping, **dyspareunia** and an **anterior vaginal mass.**
a tender anterior wall vaginal mass that expresses bloody, purulent fuild on manipulation of the urethra.
144
What is indicated for patients with chronic or refractory carpal tunnel syndrome who are being considered for surgury.
**Nerve conduction studies.** They are not usually needed in the inital diagnosis (which is clinical dx) but can be considered if diagnosis is uncertain.
\*compression of the median nerve in CTS results in loss of myelination. Nerve conduction studies can confirm the diagnosis and assess the severity of CTS by **demonstrating slowed condutction along the nerve at the level of carpal tunnel)**.
145
Bell's Palsy
What is it?
Common findings?
What is very important that patients be assessed for?
**idopathic neuropathy of cranial nerve VII**
**Rapid** onset of **unilateral upper and lower facial weakness.**
Afflicted side include **inabilty to raise eyebrow or close the eye,** **drooping of the mouth corner,** and **disappearance of the nasolabial fold.**
Symmetry by raising their eyebrows due to bilateral UMN innervation to the forehead.
Forehead sparing is suggestive of an intracranial lesion and would warrant brain imaging to evaluate for ischemia or tumors
146
Treatment for Bell's palsy
**Corticosteriod and supportive eye care are the mainstays of treatment.**
patients have poor eyelid closure and patients are at risk of dryness and abrasions. Therefore **artifical tears and eyepatching** should be prescribed.
147
Treatment of Clostridium difficile colitis -
Mild/moderate
Severe
Subsequent relapses
second recurrence
**Mild/moderate** - **Oral metronidazole**
**Severe c.difficile colitis with** **systemic toxicity** (high fever, WBC \> 15,000, creatinine \>1.5x baseliine) - **Oral vancomycin**
**Subsequent relapses- similar treatment as inital.**
**second recurrence - Vancoymycin**
148
SVC presentation
Best diagnostic test
Suspected in patients who have a **high risk of malignancy (**ex family hx or smokers) and presents with **dyspnea, orthopnea, neck pain and swellling and has cervical and upper extremities venous dilation.**
**CT contrast of the chest and neck,** which will reveal an obstruction of hte SVC due to the pulmonary mass, metatstic nodes or IV thrombus.
149
Classic presentation for SVC
**Dyspnea, persistent cough, facial fullness and neck pain and progresses into hoarseness, dyspnea, CP and syncope.**
Pertinent physical findings are **edema, erythema of the neck, and dilated veins of the arm and neck.**
150
Relative risk of an outcome calculation
If the relative risk of an outcome in Group A as compared to Group B is x, then the relative risk in Group B as compared to Group A is 1/x.
151
First line for treatment for sulfonylurea poisoning?
What if they have severe sulfonylurea overdose?
Sulfonylureas cause **increased insulin secretion** which can cause hypoglycemia.
**Inital treatment with dextrose** - however, dextrose administration can cause transient hyperglycemia that may elicit an higher level of insulin secrretion and subsequent **rebound hypoglycemia.**
**Octreotide** is a somatostatin analogue that decreases insulin secretion in patients with a large sulfonylurea overdose, particularly if the patient is unable to say how much medication was ingested.
152
Accepting gifts from patients
Accepting gifts from patients is generally considered appropriate if the gift is not excessive and not intended to influence future care.
Decisions to accept or decline gifts should be based on the patients best interest.
153
Presentation of posterior urethral valve
congental malformation that obstructs the flow of urine;
typical presentation includes recurrent urinary tract infections, incontinence, strained voiding and bilateral hydronephrosis.
This malformation is most common in male infants.
154
Stress urinary incontinence
verus
Urethral diverticulum
loss of urine with increased intrabdominal pressure (ex: Valasalva manuever).
There is no associated dysuria, dyspareunia or vaginal wall mass.
155
Damage to the corpus callosum can result in
problems with learning, hand-eye coordination and visual/auditory memory
156
Diagnosis of Urethral diverticulum
Confirmed with MRI of the pelvis or transvaginal ultrasound
157
Internal capsule is composed largely of?
Damage to this area results in?
composed largely of the **corticospinal tract**, which brings information from the **primary motor cortex to the lower motor neurons in the spinal cord.**
Damage to this area typically results in **contralateral hemiparesis or hemiplegia.**
158
Q tip test is performed to diagnose?
urethral hypermobility, a common cause of stress urinary incontinence.
A cotton swab is placed inside the urethra to measure the extent of urethra mobility during the valsalva maneuver; a positive test has a \>30 degree angle of movement.
159
What is used to diagnose urinary incontinence due to a vesicovaginal fistula?
**Methylene blue is instilled into the bladder.**
Vesicovaginal fistulas present with painless, continuous leakage of urine from teh vagina.
The test is positive if a tampon placed in the vagina become blue after the dye is instilled in the bladder
160
Polymyalgia rheumatica characterization?
Treatment?
What is it frequently associated with?
PMR affects **patients \>50** and is characterized by **elevated ESR (\>40)** and **pain** and **stiffness** in the **neck, shoulders and pelvic girdle.**
SIgns of inflammation are absent.
**Low dose glucocorticods.**
Frequently assoicated with **giant cell arteritis** (aka temporal arteritis). If this is suspected, need to edo **expediated temporal arterial biospy** and receive **significantly higher doses of glucocorticods.**
161
Classic features of Wernicke encephalopathy?
**Life threatening disorder** of **thiamine deficiency** seen most commonly in patients with heavy alcohol use and/or severe malnutrition
**Encephalopathy** - disorientation and confusion
**oculomotor dysfunction** - lateral rectus palsy
**Gait ataxia** - wide based gait or complete gait impairment.
162
Treatment of Wernicke encephalopathy
**IV thiamine**
IV thiamine usually improves ocular abnormalites within hours, but confusion and gait ataxia may persist for days or weeks; many patients never fully recover.
163
Hepatic encephalopathy versus encephalopathy with Wernicke encephalopathy
Treatment for both
Both causes **confusion**, but **hepatic encephalopathy** is **not** typically associated with **ophthalmophlegia**.
Treatment for **hepatic** is **Lactulose** and **Wernicke** is **Thiamine**
164
Korsakoff Syndrome
what is it?
what do you see on an MRI of the brain?
How does this differ from Wernicke Encephalopathy?
late stage **complication of chronic thiamine deficiency** due to repeated or prolonged episodes of **significant retrograde and anterograde amnesia**, often with **confabulation**.
**KS** has **Mammillary body atrophy** on the MRI on the brain.
Unlike WE, the neurocognitive changes of KS rarely improve; most patients require long-term supervision and social support.
165
**Basal ganglia**
Important for?
What disease primilary affects this?
Important for **voluntary movement, procedural learning and routine behaviors** (ex: teeth grinding)
**Parkinson disease** primarily affects the basal ganglia and is associated with **"pill-rolling" tremor, bradykinesia and cogwheel rigidity.**
166
Frontal Lobes contribue to?
voluntary movements and high-level cognition that integrates emotions with memory.
167
Kappa Statistic
**Measure of inter-rater reliability**
Items such as physical exam findings, radiographic interpretations, or other diagnostic tests often rely on some degree of subjective interpretation by observers.
Studies that measure the agreement between two or more observers should include a statistic that takes into account the fact that observers will sometimes agree or disagree simply by chance.
The kappa statistic (or kappa coefficient) is the most commonly used statistic for this purpose. A **kappa of 1 indicates perfect agreement,** whereas a **kappa of 0 indicates agreement equivalent to chance**.
168
Power of a diagnostic test
the **ability to detect a difference between when one actually exists.**
**depends on sample size**
Power is given **(1-B)**, where **B is the probabilty of making a type II error** (failue to reject a null hypothesis when it is false)
169
Level of statistical significance
denoted by a (alpha), which is usually set at 0.05.
An a=0.05 means that investigators are willing to accept a 5% chance that the null hypothesis is being rejected incorrectly (type 1 error).
If the p-value of a measurement is
170
Cessation of what at least for weeks prior to surgery decreases risk of post operative pulmonary complications?
Smoking
171
3 common causes of Vertigo?
Give cause of each.
_Meniere disease_ - increased pressure and volume of endolymph
_BPPV_- otoliths in semicicular canal
_Vestibuilar neuritis (labryrinthiits)_ - inflammation of vestibular nerve (viral or postiviral)
172
Clinical features of Meniere Disease
Diagnosis
Recurrent vertigo
Ear fullness/pain
**unilateral hearing loss & tinnitus \*THINK menEAR disease\***
**Dx: Clinical - head thrust test**
Patient focuses on examiner's nose while the examiner quickly rotates the patients head 10-15 degrees to the side; normally the eyes remain fixed on the target, but in a paptient with peripheral vestibular disorder, the eyes rotation with the head before voluntarily redirecting back to the target (corrective sccade)
174
Clinical features of BPPV
Brief episodes brought by head movement
**No auditory Symtoms** (unlike Meniere and labyrinthitis)
175
Clinical symptoms of Vestibular neuritis (labyrinthitis)
single episode of severe vertigo that can last for days
if it occurs in association with hearing loss, it is termed labryinthitis.
Benign, self limited disorder that typically follows a viral infection.
176
Acoustic neuroma versus Vestibular neuritis
Acoustic neuroma (schwannoma of the auditory nerve CVIII) causes vertigo, sensorienural hearing loss and tinnitus.
BUT symptoms are typically chronic and progressive rather than acute (unlike acoustic neuroma)
177
Cerebellar hemorrhage is characterized by?
usually occurs in what type of patients?
**headache, neck stiffness, ataxia, and often disabling vertigo.**
Symptoms occurs **over minutes to hours**, and hematoma expansion can lead to cranial neuropathies and altered mental status.
Usually occurs in **patients \>50 with chronic, poorly ocntrolled HTN.**
178
Meniere disease versus vestibular neuritis
Menieres disease is characterized by chronic, episodic vertigo (lasting minutes to hours) associatd with low-freq tinnitus and sensorineural hearing loss.
Acute, persistant symptoms following a recent viral infection is more consistent with vestibular neuritis.
179
Clinical manifestations of Community Acquired pneumonia in HIV-infected and HIV uninfected individuals
What does the labs and chest imaging show?
**Fever, chills, cough and sputum production, dyspnea and pleuritic chest pain.**
**Neurotrophilic leuckocytosis** (except when CD4 counts is very low) and chest imaging typicall revelas a l**obar pulmonary infiltrate.**
180
Legionella versus CAP
Legionella usually causes high fever and prominent gastrointestional symptoms prior to the development of pulmonary symptoms.
181
Myocbacterium tuberculosis infection versus Strep. Pneumo in HIV patients.
Pulmonary tuberculosis usually manifests with subacute fever, cough, weight loss and malaise.
Acute symptoms, cough productive of brown sputum and lobar infiltrate is more S. Pneumo.
182
Mycoplasma pneumonia versus S. Pneumo
Mycoplasma pneumonia cuases **subacute (not acute)** illness with headache, fever, sore throat, cough and dyspnea.
Chest imaging reveals **patchy interstital infiltrates** (unike a lobar infiltrate in S. Pneumo)
183
Pnemocystic pneumonia versus S. Pneumo in HIV patients
Pneumocystis pneumonia usually causes pulmonary disease in patients with **CD4 counts \<200** and **develops slowly over weeks (not days).**
Manifestations usually include fever, dyspnea, cough and an **intersititlal (not lobar) pulmonary infiltrate.**
184
Pernicious anemia
What is it?
What is characteried by?
What are the two major implicated autoantibodies?
Inital testing?
What is second line if this test is negative?
Pernicious anemia is a **decrease in red blood cells** that occurs when the **intestines cannot properly absorb vitamin B12.**
Characterized by **autoimmune destruction of parietal cells.**
Two major implicated autoantibodies that have ben described are the **anti-parietal and anti-intrinstic factor (IF) antibodies.**
**Anti-IF testing** is the recommended inital test for detection of pernious anemia has 100% specificity (anti-parietal testing is much less specific).
**Schiling tes**t is a classic diagnostic test of pernicious anemia that uses **radio-labeled cobalamin**. More cumbersome than antibody testing and can be used as **second-line if the anti-IF test is negative.**
185
Pernicious anemia is associated with a type of gastritis called?
Where does it attack?
What are the three main components?
**autoimmune metaplastic atrophic gastritis (AMAG)**
caused by autoimmune agression against **gastric mucosa**
**glandular atrophy, intestional metaplasia and inflammation**
Atrophy affects mainly the **gastric body and fundus.**
In advanced stages, the mucosa becomes thin and atrophic, and endoscopy may demostrate **absent gastric rugae in the body and fundus.**
186
**bacterial conjunctivits**
presentation?
most common causes?
Treatment?
How does this differ with contact lens wearers?
**Highly contagious** and **presents with conjunctival ertyhema** and **mucopurulent discharge.**
Discharge is often thick and accumulates quickly.
**Usually self-limited**, but topical antibotics are prescribed to shorten symptom duration and **reduce person to person transmission.**
**Staph A., Strep pneumo, Moraxella Catarrhalis, Haemophilius influenza.**
**First Line treatment:** **Erythromycin ointment or polymxin-trimethoprim drops**
However incidence o**f Pseudomonas aeruginosa conjunctivitis** is much **higher among contact lens wearers. Use topical fluoroquinolones** (ex: ciprofloxacin, ofloxacin).
187
Bacterial conjunctivitis can progress to?
**Bacterial keratitis - inflammation of the cornea** *(the clear tissue covering the pupil and iris, borderd by bulbar conjunctivae)*
(which most commonly occurs in patients who wear contact lenses improperly (ex: overnight use) or have decreased immunity (ex: corticosteriod use)
188
Endopththamalmitis is?
Baterial infection of the **deep eye (vitreous)** due to **direct inoculation into the globe** (ex: surgery or trauma) **or hematogenous spread.**
It is not a complication of bacterial conjunctivits (which is keratitis)
189
Hordeolum
a.k.a
What is it?
How does patietns present
also known as **Style**
**bacterial infection of the sebaceous gland in the eyelid**
patients have **tenderness, redness and swelling at the eyelid margins.**
It is not a complication of bacterial conjunctivitis (which is keratitis)
190
Virual conjunctivitis treatment
warm or cold compresses
can use antihistamine/decongestant drops
191
Allergic conjunctivitis presentation and treatment
how does presentation differ from infectious conjunctiivitits
watery discharge and usually invovlves both eyes.
Prominent pruritis can also help distinguish allergic conjunctivitis from infectious conjuncitivitis
OTC antihistamine/decongestant drops for intermittent symptoms
Mass cell stabilizer/antihistamine drops for frequent episodes
193
**Coup**
a.k.a
usually affects who?
Clinical manifestations
Dx?
**parainfluenza** viral infection of the **larynx and trachea** that peaks in the **fall and early winter**
Usually affects children \< or = to 3
rhinnorhea, cough, fever, which progresses to the **sudden onset of a harsh, barking cough, inspiratory stridor and hoarseness.**
**Dx; clinical**
P-A neck xray can be order for uncertain cases and may reveal the steeple sign due to subglottic narrowing
195
Uveitis
is an infection of the middle eye (ex: choroid, vitreous, iris, lens and ciilary body) due to autoimmune disease or systemic infection
196
How does keratitis present?
Dx?
next step in management
**photophobia, blurred or impaired vision, and foreign body sensation** with difficulty opening the affected eye
**Refer to opthalmologist**
Slit-lamp exmaination showing cornea ulceration
**Can cause scarring or ulceration of the corena and subsequent blindness if not aggressively treated.**
197
Patients with fracture following minor trauma such as ground-level fall should be tested for?
How does the scoring go?
osteoporosis using dual energy x-ray absorptiometry (DEXA).
Postmenopausla osteoporosis can be diagnosed with DEXA based on **T-score** (number of standard deviations above + or below (-) the mean for a healthy 30 year old of the same gender and ethnicity)
Tscore
**-1 = normal**
**-1 to -2.5 = osteopenia**
**-2.5 or lower = osteporosis**
198
First line for postmenopausal osteoporosis
Alendronate
plus supplemental calcium and Vitamin D to ensure adequate daily intake
200
Treatment of Coup
Mild and severe
self-limited and usually resolves within a week.
MILD COUP
**humidifed air** to soften secetions and decrease drying of inflammed mucosal surfaces.
**A single dose of corticosteriods** (either as an oral liquid or intramusclar injection) can be given to reduce stridor which often worsens at night.
MODERATE/SEVERE COUP
**Corticosteriods plus nebulized epinephrine** can be adminstered to relieve upper airway obstruction. Improves significally after treatment.
201
Anal abscesses arise when?
How do patients typically present?
What does PE reveal?
Treatment?
arises when one more more of the several **glands that encircle the anus become blocked** and the **bacteria within grow** unchecked.
Patients with anal abscesses typically present with **severe, constant pain** that **may be accompanied by fever or malaise.**
PE. reveals **erythematous, indurated skin, or a fluctant mass** over the **perianal or ischiorectal** space.
**Prompt incision and drainage of the abscess.** Perianal and small ischiorectal abscesses are often drained in the office, but larger ischiorectal abscesses typically require
202
Anal abscesses arise when?
How do patients typically present?
What does PE reveal?
Treatment?
arises when one more more of the several **glands that encircle the anus become blocked** and the **bacteria within grow** unchecked.
Patients with anal abscesses typically present with **severe, constant pain** that **may be accompanied by fever or malaise.**
PE. reveals **erythematous, indurated skin, or a fluctant mass** over the **perianal or ischiorectal** space.
**Prompt incision and drainage of the abscess.** Perianal and small ischiorectal abscesses are often drained in the office, but larger ischiorectal abscesses typically require
203
50 patient of patients with anal abscesses will go on to develop what?
chronic fistual from the involved anal gland to the overlying skin.
Such fistulas require surgical repair.
204
**Toxic Shock Syndrome**
Presentation
Pathophysiology?
**History of packing** (nasal, tampons, etc)
**Fever, chills, myalgias that evolves into a multisystem syndrome** (eg, hypotension and shock with dermatologic, gastrointestional, muscular, renal and /or neuro findings); some patients can become abrupting ill within hours.
Widespread activation of T cells by **bacterial** **exotoxins** acting as superantigens *(ie, can active T-cells directly without needing to be processed by antigen recognition cells)*
**Massive cytokine production and release occur.**
205
Treatment of TSS
**Remove any associated foreign bodies (**ex: tampons, nasal packing).
May require **extensive fluid replacement** that can reach up to 20 L per day.
Physicans generally administer **clindamycin** (which prevents toxin synthesis) **with or without antistaphylococcal antimicrobial therapy** (vancomycin, or oxacillin or nafcillin if succeptible) to eradicate the organism and prevent the TSS reccurence.
206
Testing for what is indicated in patients who have suggestive symptoms of SLE?
What is most specific for diagnosis of SLE?
Testing for **antinuclear antibodies (ANA)** is indicated in patients who have suggestive symptoms and is positive in nearly all patients with SLE. However, ANA can also be positive in many patients who are healthy or who have CT diseases other than SLE.
Antibodies to **double-stranded DNA (dsDNA),** a type of ANA (has a sensitivity of approx 70%) is **most specific** for dx of SLE.
**Anti-smith antibodies** are also highly specific for SLE, but have a senstiivity of only **25%.**
207
What is most sensitive for the detection of the CREST variant of scleroderma
Anti-centromere antibodies
208
What antibodies are senstive to detect primary billiary cirrhosis?
Anti-mitchodrial antibodies
209
What antibodies are seen in some patients with SLE but are most sensitive for Sjogren's syndrome
Anti-Ro/SSA antibodies
210
What is used to follow the course of SLE?
**Anti-dsDNA**
can be used to follow disease activity in SLE patients and is associated with the **development of lupus nephritis** - immune complexes containing these antibodies are actually seen iwthin the glomeruli of patients with lupus nephtiritis.
211
Treatment of SLE
**Prednisone and Hydroxychloroquine**
**Hydroxychloroquine** is an anti-malarial agent which is particularly effective at improving **athralgisits, serositis and cutaneous symptoms.**
May also help prevent further damaage to kidneys and CNS.
**Low dose prednisone** may be helpful in the **short term** to improve the patient's symptoms **until the hydroxychlorquine takes effect.**
More serious (nephritis, CNS and vasculitis) use prednisone and cyclophosphamide.
212
Anterior epistaxis that does not cease after nose pinching is next treated with?
What if this method doesnt work?
**topical vasoconstriction.**
**Oxymetazole** is the preferred agent in children and should be applied with a squirt bottle (nasal spray) or cotton pledget.
Direct pressure should then be applied to the nasal alae for addtional 5-10 mins.
Parents should be advised to **use topic decongestants for \<3 days to avoids rebound congestion.**
Chemical or electrical cauterization can be performed if direct compression and topical vasoconstrictor therapy are unsuccessful.
**Silver nitrate** is the most commonly used agent for chemical cautery and topical lidocaine is applied to minimize cauterization pain. However, smimultaneous bilateral cauterization should be avoided due to the risk of spetal ulceration and perforation.
213
Erectile dysfunction (ED) is often caused by?
What is it a strong predictor of and what should they receive prior to initiating therapy for sexual dysfunction?
ED is often caused by **peripheral artery disease**, and is also a strong predictor of **coronary artery disease.**
Patients with **ED and atherosclerotic risk factors** should receive **appropriate diagnostic testing** (ex: **ankle-brachial index, cardiac stress testing**) _prior_ to initiating specific therapy for sexual dysfunction.
214
C. difficile colitis can range from what to what?
How is Colostidium difficile colitis usually diagnosed?
Patients with negative laboratory testing and high clinical suspicion should undergo what?
**Watery diarrhea to fulminant colitis with toxic megacolon**
C. difficile colitis is usually diagnosed by stool studies for C. difficile toxin such as **polymerase chain reaction (PCR) or enzyme immunoassay (EIA) for C. difficile toxins A and B.**
**PCR** is usually the prefered due to **higher sensivity** than EIA.
Patients with **negative laboratory testing** and **high clinical suspicion** for C. difficile colitis should undergo **colonoscopy or sigmoidscopy** to document **pseudomembranous colitis** and confirm the diagnosis.
***\*Stool culture** on selected medium with assay for C. difficile toxin is a very sensitive and specific diagnostic test. **However, it is** **too slow (48-96 hours) to be practical for clinical use.***
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What medications are frequently associated with the development of C. difficile infection?
Fluroquinolones
Enhanced-spectrum penicillins
cephalosporins
clindamycin
216
Manifestations of Clostridium difficile associated infections are due to?
**intestional colonization with cytotoxin production.**
**Normal intestinal flora** **inhibits the growth of C difficile** and this balanced is **altered by antibotics** (sometimes chemotherapeutic agents).
For example, 90% of the total bacteria in feces is comprised of **Bacteroides** species and thse species **disappear** in many patients with **C difficile-associaed infection.**
217
Clinical features of RA
Diagnosis?
**symmetric polyarthritis** (involving MCP and PIP joints) associated with **morning stiffness lasting more than 30 minutes** to several (**more than six) weeks**
**DX: Clinical,** but presence of positive **rheumatoid factor and/or anti cyclic citrullinated peptide (CCP)** i**s helpful** for confirmation.
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RA versus SLE arthritis
Antibodies?
Duration?
Treatment?
**Anti-ds DNA** antibodies for **SLE**
**positive Rheumatoid factor** and **anti-cyclic citrullinated peptic (CCP)** antibodies for **RA**
**Arthritis in SLE** is typically more **migratory** *(lasting only a few days in any location***)** and has a **shorter** **duraiton** of morning stiffness *(few mins in SLE but usually hours for RA).*
SLE patients also generally have **manifestations in other organs systems,** paticularly the skin and kidneys, in additon to the musculoskeletal system.
**SLE** patients have **steriods** as first line treatment where as in **RA,** **NSAIDs** are the first line treatment with aggressive use of **DMARDS** for patients at higher risk of disease progression.
219
Parvo virus versus RA arthritis
Both symmetrical.
But parvovirus infection only causes systems for less than a few weeks.
where as in RA (it is more than six weeks).
220
What are highly effective in patients who have refractory disease with methotrexate?
What must be done prior to starting therapy?
**TNF inhiibtors (etanercept and infliximab)**
Classificed as **biological DMARDs**, as opposed to drugs like methotrexate which are referred to as nonbiologic.
They are **very** **expensive** are not indicated as the first line drugs of treatment.
**PPD test** is indicated **before treatment with TNF inhibitors** is started
221
How does acute pancreaitis differ from chronic pancreatitis in terms of laboratory values?
What is the hallmark of CP?
Unlike **acute pancreaitis,** which can be effectively diagnosed in the appropriate setting by **elevations in serum lipase or amyase**, **CP does not regularly result in laboratory abnormalities.**
**Pancreatic calcifications** are the hallmark of CP
222
Rheumatoid Factor versus Anti-CCP in R.A
**RA** is a **clinical diagnosis.**
RF levels may be **negative in approximately 20% of patients.**
**Anti-CCP antibodies** (anti-citrulline containing peptide antibodies) have some value in patients with negative RF levels; besides they **carry a higher specificity.**
223
How do you diagnoise chronic pancreatitis
**magnetic resonance cholangiopancreatography** or **abdominal CT scan,** which can identifiy pathognomonic findings (ex: pancreatic calcifications)
**Computed tomography** demonstrating enlarged head of pancreas with **coarse calcification and a dilated main pancreatic duct (**A), **magnetic resonance cholangiopancreatography** showing a **tortuous, dilated pancreatic duct** (B), inflammatory stricture of the distal common bile duct (C), endoscopic retrograde cholangiopancreatography showing a stent placed in a dilated pancreatic duct (D).
224
How does fat malabsorption differ from carbohydrate malabsorption?
_Fat malasorption_ - **voluminious** and **difficult to flush** stool; pain is **relieved by sitting up and leaning forward,** positions that displace the other abdominal organs away from the inflamed pancreas.
_Carbohydrate malabsorption (_ex: lactose intolerance) - **fltatulence** and **watery diarrhea** and the assoicated **pain is not positional** or **not severe** enough to warrent hospitalizaiton.
225
First line treatment of chronic pancreatitis?
What if it is not successful?
**Alcohol and tobacco cessation, along with dietary modifications.**
**Pancreatic enzyme replacement and analgesics** should be considered if conservative measures are unsuccessful.
226
**Androgen insensitivity Syndrome**
What is strongly suggestive?
This condition is related to?
Genotype and phenotype?
**Primary amenorrhea, bilateral inguinal masses , and breast development without pubic or axillary hair**
**No mullerian structure** is present (uterus, fallopian tube) **and** the **vagina ends with a blind pouch.**
**Mutation of the androgen receptor gene**, making peripheral tissues unresponsive to androgens that are typically available in normal concentrations in these patients.
Ahough the **genotype is 46, XY**, a **female phenotype** develops.
Breast development is present because testosterone is converted to estrogen, however there is no pubic or axillary hair.
227
Consitutional delay versus Androgen insensitivity
Consititutional delay rarely results in 'asynchronous' delay in puberty (breast development with no pubic hair growth and amenorrhea)
228
Amenorrhea beyond what age is considered abnormal, even if secondary sexual characteristics are present?
15.5 years old
229
Klinefelters syndrome versus androgen insensitivy
_Klinefelters syndrome_ - **chromosomal** abnormality, produces a **male** **phenotype**; however, **small testes and gynecomastia** are common
_Androgen insensitivty_ - mutation of Androgen **receptor** gene, **female** **phenotype; amorrhea, breast development without pubic or axillary hair, baterial inguinal masses**
230
What does the chest radiograph of a patient with Sarcoidosis usually show?
How do you diagnosis?
Bilaeral hilar adneopathy with or without paratracheal lymph node enlargement
Biopsy sites for sarcodisos include **lacrimal glands, salvary glands i**ncluding **parotid glands,** **skin lesions _other_ than erythema nodosum** and **palpable superfical lymph nodes.**
*\***Erythema nodosum,** an inflammatory involvement of the septa of subcutaneous **adipose tissues (panniculitis),** It does _not_ represent any **granulomatous involvement of the skin or subcutaneous tissue** and its biopsy is therefore **not useful i**n the diagnosis.*
231
Erythrasma
What is it caused by?
Appearance?
What do you use to diagnose?
Infection of the skin that occurs most often in intertriginous spaces and is caused by Corynebacterium minutissimum.
The appearance of erythrasma includes a confluence of pruritic, reddish brown, finely wrinkled papules.
The use of Wood lamp reveals a coral-red fluorescence caused by the Corynebacterium porphyrins.
232
Pityriasis Rosea
**self limited condition** of **unknown etiology** that first manifests as a s**ingle primary plaque ("herald patch")** with fine collarette scale.
A g**eneralized eruption** develops **1-2 weeks later**, with **fine, scaling papules and plaques** in the **"christmas tree" decoration**
233
Rosacea
**Chronic inflammatory disease** that causes **erythema** to the **central face.**
It first manifests as easy flushing and later results in persistent erythema and telangiectasia.
Patients are **sensitive to chemical and physical insults and should limit exposure to the sun.**
234
Seborrheic dermatitis
**chronic superfical inflammatory** process that arises in **areas rich in sebacous glands.**
The condition worses during infancy and puberty when the sebacous glands are more active.
In adults iwth seborrheic dermatitis, erythema with fine scale is evident on the scalp ("dandruff"), eyebrows, nasolabial cres, ears, sternal area, axillae, umbilicus, groin and gluetal crease.
235
In absence of advance directives or appointed power of attorney, many states allow physicans to use the patient's relatives as surrogates in what order of priority?
spouse, adult child or majority of adult child reasonablity available, parents, sibilings and nearest living relative of the parent.
The hospital's ethics committee can be consulted in cases of irresolvable disagreements among family members.
236
Ehrlichiosis
**Tick-borne bacterial illness** characerized by fever, nonspecific symptoms (ex: malaise, headache), N/V and cough
althrough **arthralgia** may occur, most patients also have signicant laboratory abnormalities (ex: **leukopenia, thrombocytopenia, elevated aminotransferase)**
237
How does Boerhaave's syndrome present?
Where does most tears occur?
What happens to 75% of the cases?
Radiologic finding?
Why is urgent management needed?
**chest pain after repeated episodes of vomitting.**
Other associated symptoms are **dyspnea,epidgastric pain or shoulder pain.**
Most tears occur in the **distal third of the esophagus**, and this leads to pleural effusion.
**Pneumomediastinum** and **pneumothroax** can be part of the presentation.
In **75%** of the cases, **pleural effusion** will develop 6 hours after perforation.
The effusion is located on the left side in 66% of the cases and **can be accompanied by pneumomediastinum, pneumothorax, or both.**
Radiological findings: **radiolucent band adjacent to the cardiac border**
**Mediastinitis** carries a **mortality rate of more than 40%** if not properly diagnosed within the first 24 hours.
238
Best diagnostic test for esphogeal perforation?
What if this test is negative, but clinical suspicion is high?
**esophaogram with water-soluble contrast**
Provides a definite diagnosis in 90% of the cases.
Barium contrast can then be used, but water-soluble contrast is perferred to barium because the latter can produce further mediastinal irritation and injury.
*\*CT scan of the chest is helpful, but may not detect small tears or ruptures. Upper Gi endoscopy has no role and should not be used.*
239
Sarcoidosis is what type of disease?
Characterized by?
**Chronic granulomatous disease** more frequently seen in **young african american** patients.
characterized by **formation of non-caseating granulomas** in various involved tissue and organs.
**Usually involved the lungs,** but **can also include other organs**.
**Usually asymptomatic** and is frquently detected as **incidental finding** on routine chest xray.
240
Chikungunya Fever
What does it cause?
Transmission?
Management?
**Mosquito borne virus** that casues **high fever** and **severe polyarthralgia.**
Arthralgia is typically **bilateral and symmetric** and affects **distal** **joints** (ex: hands, wrist, ankles) preferentially.
**Transmission** occurs via the **Aedes mosquito,** which also transmits dengue fever and zika virus.
Supportive care. **Most cases resolve spontaneously**, but approx. 30% of patients may have chronic athralgia or arthritis.
241
Acute pancreatitis and predictor of severity
The prediction of the severity of acute pancreatitis is largely based on well defined **multiple factor scoring systems** as well as **several single risk factors.**
**APACHE II score**
**Systmic inflammatory response syndrome (SIRS) score,** and
single indicators have been found to correlate with severity include **older** **age, obesity, hematocrit, C-reactive protein and BUN.**
An elevated hematocrit (\>44%) on admission is predictive of more severe disease, as it reflects greaer hemoconcentration from third space losses.
Similarly a BUN. or = to 20 mg/dl at the time is associated with increased death.
A elevated C-reactve protein level (\>150 mg/dL) which rises more slowly than BUN or other acute markes (ex: hemocrit), has also been shown to correlate with severe AP 24-48 hours after admission.
242
Typhoid fever
bacterial illness caused by **salmonella**.
**manifestations progress slowly** and begin with a **week of fever** (often with temperature pulse dissociation), **followed by abdominal pain and cutenaous "rose spots"**
**By week 3 hepatosplenomeglay, intestinal bleeding and intestinal perforation often occur.**
243
Malaria
**mosquito-borne protozol** illness that typically causes **fever and flu-like symptoms** (ex: shaking chills, headache, maylagia, maliase0.
Laboratory abnormalities such as **anemia** and **hyperbilirubinema** are common due to **red blood cell lysis.**
