UWORLD 5 Flashcards
Anemia and pregnancy
managment?
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.
Gingival bleeding during pregnancy versus disorders of hemostasis.
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.
Schaphoid fracture
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.
Colles fracture
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
Hamate fracture
Sprain of the wrist ligaments
How does it differ from scapholid fracture?
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.
Management of scaphoid fractures
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..
Scaphoid fractures that are not properly treated or in a timely fashion can result in what?
avascular necrosis and increases the risk of nonunion.
dupuytren contracture
what is it associated with?
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.
Multiple Myeloma
What is it due to?
What does the patients typicall develop?
Serum and/or urine protein electrophoresis will show what?
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.
What should be performed once a patient has been diagnosed with multiple myeloma?
What should be avoided in myeloma patients with renal insufficiency?
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.
Hyperviscosity syndrome can be seen in which two conditions?
How do they differ?
How do they present?
What is the treatment?
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
Prophylaxis for stress ulcers
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.
Complete rupture of the Achilles tendon is a clinical diagnosis that can be supported with what test?
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.
What carries the highest teratogenticity risk of all Antiepileptic drug use (AED)?
What is preferred?
What is the management of patients on AEDs?
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.
Breastfeeding and women with epilepsy
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.
Hyperthyroidism in older versus younger patients
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)
Foodborne disease and vommiting predominant (3)
Staph. Aureus
Bacilleus Cereus
Noroviruses (Norwalk)
Foodborne disease and watery diarrhea predominant (6)
Clostiridum perfingens
Enterotoxic E.coli
Enteric viruses
Cryptosporidium
Cyclospora
intestional tapeworm
Foodborne illnesses and inflammatory diarrhea predominant (6)
Salmonella (both typhi and non-typhi)
Campylobacter
Shiga toxin producing E.Coli
Shigella
Enterobacter
Vibrio (usually parahaemolyticus)
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?
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.
Food borne disease and non-gastrointestional symptoms (7)
Botulism (descending paralysis)
Ciguatera toxin (paresthesia)
Scombroid (flushing, urticaria)
Listeria (meningitis)
Vibrio vulnificus (cellulitis, sepsis)
Hepatitis A (jaundice)
Brucellosis (fever, athralgias)
How does camplyobater infection commonly present?
How do you diagnoise?
acute onset of cramping abdominal pain and inflammatory diarrhea (ex: mucus, blood)
Diagnosis is by stool culture
How does clostridium perfringens is typically associated with but is also an important cause of?
clostridium perfringens and foodborne disease?
What are uncommon?
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
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.
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.
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
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
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)
Galactosemia
Inheritance pattern?
deficency in?
Presentation?
AR
inability to digest galactose due to def. of galactose-1-uridyl transferase.
Patients are hypoglycemic and become very ill and dehydrated due to vomiting after ingestion of breast milk or cow’s milk-based formula.
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.
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.
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.
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.
Sexual relationships with former psychiatric patients are
ALWAYS unethical.
Diagnosis of spinal stenosis
MRI of the spine
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.
Disc herniation versus lumbar spinal stenosis
Disc herniation pain worsens with lumbar flexion (unlike Lumbar spinal stenosis)
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
Treatment of lumbar spinal stenosis
conservative or lumbar epidural block.
Surgical decompression through a laminectomy is an option when other therapies fail.
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)
Treatment of sarcoidosis
Asymptomatic patients often require no treatment
those with symptoms or pulmonary function impairement usually reeive 12-24 months of oral glucocorticoids.
Most cases (~75%) resolve over time and do not recur.
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)
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)
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.
Red cell casts in the urine are indicative of?
glomerulonephritis
What is performed in high-risk patients to prevent future episodes of aspiration?
Speech and swallowing evaluation, followed by diet modification.
NPH versus long-acting insuling analogs
NPH and long acting insulin analogs (detemir, glargine, degludec) are effective in lowering hemoglobin A1c in 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.
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.
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
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
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.
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)
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.
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.
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)
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
Earliest sign of hypovolemia
tachycardia
Hoarseness of voice is suspicious for?
recurrent laryngeal nerve entrapment, causing vocal cord paralysis.
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.
Patients with brain death can have what?
spontaneous movements, but these originate from peripheral nerves or the spinal cord.
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
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)
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.
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)
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.
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)
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.
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.
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
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)
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
Acute treatment of severe hypercalemia
IV hydration.
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
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.
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 tranmission 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.
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
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.
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.
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).
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
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.
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
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.
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.
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.
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.
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.
Damage to the corpus callosum can result in
problems with learning, hand-eye coordination and visual/auditory memory
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)
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.
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
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
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)
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.
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)
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
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)
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.
Damage to the corpus callosum can result in
problems with learning, hand-eye coordination and visual/auditory memory
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.
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)
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)
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)
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)
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)
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
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
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).
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 including 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 in the diagnosis.
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.
Pityriasis Rosea
self limited condition of unknown etiology that first manifests as a single primary plaque (“herald patch”) with fine collarette scale.
A generalized eruption develops 1-2 weeks later, with fine, scaling papules and plaques in the “christmas tree” decoration
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.
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.
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)
