UWorld Flashcards
Bone lesion in child w/ pain worse at night and better /w NSAIDs
Also will be unrelated to activity = Osteoid osteoma
What are porphyrias?
Porphyrias = acquired or congenital disorders in heme synthesis
Enzyme deficiency early in porphyrin synthesis => acute intermittent porphyria
Enzyme deficiency late in porphyrin synthesis => porphyria cutanea tarda
Membranous vs. membranoproliferative glomerulonephritis
(a) Renal biopsy findings
(b) Clinical presentation
Membranous GN
(a) basement membrane thickening
(b) Nephrotic in adult
Membranoproliferative GN
(a) Mesangial hypercellularity
(b) Nephritic in adult
Three diagnostic requirements for acute liver failure
- severe acute liver injury, ALT and AST over 1000
- synthetic dysfunction INR > 1.5
- hepatic encephalopathy (confusion, asterixis)
Differentiate typical presentating features of Patau vs Edwards syndrome
Patau (trisomy 13) = midline deficits: cutis aplasia (no epidermis over skull), micropthalmia, holoprosencephaly, omphalocele
Edwards (trisomy 18): closed fists w/ overlapping fingers, rocker bottom feet, micrognathia (undersized jaw
Inhibin A
(a) Produced where?
(b) Level in Turners pts
(c) Relevance in the quadruple screen
Inhibin A
(a) Released by ovaries
(b) Low in Turners pts (ovarian dysgenesis/streak ovaries)
(c) Elevated inhibin A on quadruple screen associated w/ increased risk of Down syndrome
Ecthyma gangrenosum vs. pyoderma gangrenosum
Ecthyma gangrenosum = hemorrhagic pustules that => necrtoci ulcers, 2/2 pseuomonas in pts w/ neutropenia and pseudomonal bacteremia
-tx w/ abx
Pyoderma gangrenosum- usually systemic disease like IBD, RA
-tx w/ steroids
CXR finding of pulmonary contusion
= Parenchymal bruising in the lung causing intra-alveolar hemorrahge and edema => patchy, irregular (nonlobular) alveolar infiltrate not restricted by anatomical borders
Age to introduce
(a) Cow’s milk
(b) Puree food
(a) Cow’s milk at one year age
- too early associated w/ increased risk of iron deficiency
(b) Puree food at 6 months
- too early associated w/ increased risk of GI infection
Drugs that decrease warfarin effect
Decreased warfarin effect (reduce its activity) = Cyp 450 inducers
“chronic alcoholics steal phen-phen and never refuse greasy carbs”
- chronic EtOH
- St. John’s wart
- phenytoin
- phenobarbitol
- nevirapine (NNRTI)
- rifampin
- griseofulvin (antifungal)
- carbamazepine
Clinical manifestations of acute intermittent porphyria
Usually after exacerbating factor (usual meds, fasting) get GI symptoms (N/V/D) and neuropsych (weakness, pain, psychosis)
Malignant otitis externa
(a) What is it?
(b) At risk populations
(c) Tx
Malignant otitis externa = necrotizing infxn of external auditory canal and base of skull
(a) Caused by pseuodomonas
(b) Elderly often w/ poorly controlled diabetes or otherwise immunocompromised
(c) IV cipro
HIV ppx based on CD4 count
- CD4 under 200: trim-sulfa for PCP
- CD4 under 150: itraconazole for Histo
- CD4 under 100 W/ IgG positive for toxo: trim-sulfa for toxo
- CD4 under 50: azithromycin for MAC
Note: no fluconazole for candidiasis ppx b/c don’t want drug resistance and it’s relatively easy to treat
What derm abnormality do the following treat
(a) Oral dapsone
(b) Topical clobetasol
(a) Oral dapsone (type of abx) used for dermatitis herpetiform in addition to gluten-free diet
(a) Clobetasol = high potency glucocorticoid used to tx bullous pemphigoid
MC cause of
(a) AL amyloidosis
(b) AA amyloidosis
(a) AL amyloid = light chains, MC cause is multiple myeloma
(b) AA amyloid = abnormal proteins, MC cause is rheumatoid arthritis
How to determine dose of anti-D immune globulin required
Give standard dose at 28 weeks of gestation, then repeat w/in 72 hrs of delivery
-about 50% of Rh- F will need a higher dose after delivery, placental abruption, or procedures, so use the Kleihauer-Betke test to determine dose to give to mother
Reversal agent for
(a) Heparin
(b) Warfarin
(a) Heparin reversal w/ protamine sulfate
b) Warfarin reversal w/ prothrombin complex concentrate to quickly decrease INR (by replacing vit-K dependent factors
Tx of torsades
If stable- IV Mg
If unstable- immediate defibrillation
What is Duputren’s contracture?
Fibroblast proliferation and collagen deposition => fourth and fifth digits contracted, deforming the hand
D/o associated w/
(a) FSGS
(b) Membranous nephropathy
(c) MPGN
(d) Minimal change disease
(a) FSGS associated w/ HIV, obesity, AA/Hispanic, heroin use
(b) Membranous- adenocarcinoma (breast, lung)
(c) MPGN: hep B and C
(d) Minimal change seen in lymphoma (liquid tumors, solid associated w/ membranous) and NSAID use
Conditions associated w/ pulsus paradoxus
Pulsus paradoxus = drop in systolic BP by 10 mmHg w/ inspiration
- cardiac tamponade/pericardial effusion classically
- BUT ALSO: severe asthma and COPD
9 yo F p/w unstead gait and weakness in lower limbs
- decreased vib/position sense in LE
- absent ankle jerks b/l
- deformed high plantar arches
- T wave inversions on ECG
- MRI: atrophy of spinal cord
Dx
Dx = Freidreich ataxia
- aut recessive
- frataxin gene = mitochondrial protein, so needed in super active muscle tissue specifically heart and skeletal muscle
Gait/limb ataxia
Loss of vib/position sense, areflexia
T wave inversions from cardiomyopathy
Describe classic presentation of laryngomalacia
Laryngomalacia (floppy supraglottic structures that collapse during inspiration) presents at age 4-8 months w/ inspiratory stridor (‘noisy breathing’) worse when supine/better when prone
Clinically distinguish methanol and ethylene glycol poisoning
Both present w/ anion gap metabolic acidosis
Main difference: methanol damages the eyes (vision loss, see optic disc hyperemia), where ethylene glycol damages the kidneys
Relation btwn cholinergic agents and gluacoma
Anticholinergic agents (ex: trihexyphenidyl, benztropine, tropicamide, scopolamine) can precipitate acute angle-closure glaucoma
38 yo M w/ sarcoidosis on extended course prednisone p/w 6 wk h/o progressive R hip pain
(a) Dx
(b) Diagnostic test
(a) Dx = avascular necrosis of the hip
- Osteonecrosis (AVN) = not uncommon complication of chronic steroid use
(b) Xrays will be normal, need MRI
Changes in fetal heart tracing caused by
(d) Umbilical cord compression
(e) Chorioamnionitis
(d) Umbilical cord compression => variable decels = abrupt drops in fetal HR of varying depth and duration
(e) Maternal infection => fetal tachycardia (baseline over 160)
Significance of red reflex
If red reflex is absent (aka eye will look white) think
(1) Opacity of lens = congenital cataracts
(2) Tumor = retinoblastoma
Rules for meningococcal vaccine
Meningococcal vaccine: primary vaccine at 11-12, then booster at 16-21 (if got primary vaccination before 16)
High-risk pts (asplenia, military recruits, college students in residential housing)
Nitrate vs. esterase on UA
- Esterase = pyuria (presence of bacteria in urine)
- Nitrates = presence of Enterobacteriaecae (aka E. Coli which obv is the MC), b/c they convert urinary nitrates to nitrites
4 antihypertensives that are safe during pregnancy
“Hypertensive moms love nifedipine”
Hydralazine
Methyldopa
Labetalol
Nifedipine
Even asymptomatic pregnant F should be screened for what during first prenatal visit
Increased risk of pyelo in pregnancy => screen for asymptomatic bacteriuria and tx if UA has over 100k CFUs of a single organism
Differentiate clinical picture of clostridial myonecrosis vs. vascular compromise s/p full thickness burn
Clostridial myonecrosis (gas gangrene) p/w crepitus, fever
While vascular compromise (compartment syndrome) can result from eschar that constricts venous and lymphatic drainage
Age of presentation of
(a) Fanconi anemia
(b) Diamond-Blackfan anemia
(a) Fanconi- around 8 yoa w/ progressive pancytopenia
(b) Diamond-Blackfan = presents w/ pallor in neonatal period
- congenital hypoplastic anemia, only low RBC
- associated w/ short stature, webbed neck, cleft lip, shielded chest, triphalangeal thumbs
Compare the facial features of Fetal alcohol syndrome, Downs, and Fragie X
Fragile X: macrocephaly, long narrow face
Downs: flat facies w/ slanted palpebral fissues, small low set ears
FAS: smooth philtrum (space btwn nose and mouth), thin vermillion border (gap btwn lips and skin), small palpebral fissures, microcephaly
Distinguish clinical features of niacin and selenium deficiency
Selenium deficiency = cardiomyopathy (JVD, LE edema), thyroid dysfunction, immune dysfunction
Niacin (B3) deficiency = pellagra = dermatitis, dementia, diarrhea
Distinguish clinical features of zinc and copper deficiency
Zinc deficiency = alopecia, impaired taste, pustular skin lesion, hypogonadism, immune dysfunction
Copper deficiency = brittle hair, skin depigmentation, neurologic signs, sideroblastic anemia
Pt who presents w/ mono-like picture but negative heterophile antibody test
CMV mononucleosis: get the same fever, malaise, and fatigue w/ lymphocytosis and atypical lymphocytes on peripheral smear
Discharge and Lab findings seen in
(a) BV
(b) Trichomoniasis
(c) Candida vaginitis
(a) BV = gardnerella
- thin white discharge w/ fishy odor
- clue cells
- positive whiff test
(b) Trich = thin, yellow-green malodorous discharge
- motile trichomonads
(c) Candida- thick ‘cottage cheese’ discharge
- pseudohyphae w/ normal pH
First line tx for IIH
Pseudotumor cerebri first line = acetazolamide (carbonic anhydrase inhibitor) to reduce CSF production
+/- furosemide
Which primary care issue can OCPS increase risk of?
OCPs increase risk of worsening HTN
-not of diabetes, endometrial/ovarian cancer etc
Key: link btwn OCPs and HTN (mechanism unclear)
Contrast use of bethanechol and oxybutynin in bladder d/o
Bethanechol = cholinergic agent (enhances vagal tone) used for urinary retention or atonic bladder
Oxybutynin = anticholinergic agent used to block parasymp tone of bladder during filling => used to tx overactive bladder by improving bladder filling capacity
(a) 3 main features of B12 deficiency
(b) Cancer screening for ppl w/ B12 deficiency
(a) Macrocytic anemia, glossitis, neurologic symptoms (peripheral neuropathy
(b) Periodic stool testing for blood b/c of 2-3x increased risk of gastric cancer in ppl w/ pernicious anemia as cause of their B12 deficiency
- b/c pernicious anemia => atrophic gastritis => intestinal type gastric cancer or gastric carcinoid tumor
Which psych drugs are known to cause
(a) Wt gain
(b) agranulocytosis
(c) Nephrogenic diabetes insipidus
(d) Amenorrhea from hyperprolactinemia
(a) Wt gain: olanzapine and clozapine
(b) Agranulocytosis from Clozapine
(c) Nephrogenic DI from Lithium therapy
(d) Amenorrhea from risperidone
First line tx for DVT in pt on dialysis
Renal impairment contraindicates enoxaparin (LMWH) and DOACs (ex: rivaroxaban) b/c they’re metabolized by the kidney => high bleeding risk in CKD
Use unfractionated heparin to bridge to warfarin (need bridge b/c of transient hypercoagulable state of warfarin and takes time to therapeutic dose)
Hereditary spherocytosis
(a) Mode of inheritance
(b) Clinical presentation
(c) Abnormality on CBC
(d) Gold standard diagnostic test
(a) Aut dominant
(b) Hemolytic anemia w/ jaundice and splenomegaly
(c) Elevated MCHC 2/2 cellular dehydration and membrane loss
(d) Increased osmotic fragility on acidified glycerol lysis test, abnormal eosin-5-maleimide binding test
Differentiate trichinellosis from strongyloidiasis
Both are parasitic infxn from nematodes, both have GI symptoms (abd pain, N/V/D) w/ eosinophilia
But trichinellosis has muscle phase => significant myositis: muscle pain, weakness, tenderness, swelling
(not seen in strongyloidiasis)
Nematode you get from undercooked pork
Trichinellosis
Clinically: GI symptoms (abd pain/N/V/dio) first w/ eosinophilia, then comes muscle phase when larvae infect skeletal muscle = myositis, tenderness, weakness
46 yo in DKA p/w foul smelling nasal discharge and necrotic nasal turbinate
-KOH stain from nasal turbinates w/ hyphae
(a) Dx
(b) Tx
(a) Tx = mucormycosis
- invasive fungal infxn by Rhizopus or mucor in immunocompromised (esp poorly controlled DM2)
- necortic spread (due to infarction of infected tissues) to palate, orbit, and brain is common
(b) Tx = surgical debridement w/ amphotericin B
What is mixed cryoglobulinemia?
(a) Clinical features
(b) Lab findings
Mixed cryoglobulinemia = small to medium vessel vasculitis due to deposition of of cryoglobulin-containing immune complexes
-cryoglobulin = mixture of immunoglobulins and complement
(a) Palpable purpura, myalgia, arthralgia
- also hematuria and proteinuria
(b) Anti-HCV positive (strong association w/ HepC), low serum complement, elevated Cr 2/2 kidney involvement
Differentiate clinical presentations of Ehrlichiosis and Lyme disease
Ehrlichiosis = tick bite w/ NO rash, associated leukopenia and/or thrombocytopenia, elevated LFTs and LDH
Lyme: erythema migrans rash (targetoid), heart block b/l facial palsy, encephalopathy
Clinical features of amniotic fluid embolism
a
Rapid onset respiratory failure in F during labor or immediate postpartum period
-severe hypotension and DIC
(a) Tx: correct hypxemia (intubation) and hypotension (pressors)
Epigastric pain promptly relieved by a glass of water and a piece of bread, also w/ intermittent melena
(a) Dx
(b) Mgmt
(a) Duodenal ulcer = epigastric pain improved w/ food
(b) Both abx and PPI
- abx for H. pylori eradication
Define preeclampsia
New HTN after 20 weeks plus either proteinuria or end organ damage
Then eclampsia = preeclampsia + seizure, often have proteinuria
Rubella vs. Measles
(a) Where does the rash start
(b) Location of lymphadenopathy
Both have similar prodrome and rash
Rubella (German measles)- rash starts on face and quickly spreads to body, posterior auricular LN
Measles- rash starts on face and spreads to body over a few days, cervical LN
Maltese cross
Peripheral blood smear finding of Babesiosis = tick borne protozoal illness p/w flu symptoms and anemia/intravascular hemolysis and thrombocytopenia
Which conjunctivitis comes first in neonates?
Gonorrhea first in first 3-5 days, then later (5-14) days think chlamydial
Dietary recommendations for pts w/ renal calculi
- High fluid intake
- Decreased sodium intake (increased Na intake enhances calcium excretion => hypercalciuria, reduced Na stimulates Ca and Na reabsorption)
- Normal calcium intake (don’t want a lot of Ca in urine)
Lab abnormalities of primary hyperaldo
Pt w/ HTN (maybe young pt w/ FHx) w/ metabolic alkalosis (peeing out H+), mild hypernatremia, either baseline hypokalemia or very prone to diuretic induced hypokalemia
So 35 yo pt comes in w/ HTN, starts low dose diuretic and becomes symptomatic from hypokalemia
Choice of tx for breast abscess 2/2 mastitis
So first line is needle aspiration w/ abx (dicloxacillin, cephalexin b/c usually S. aureus that enters thru the nipple during breast feeding)
Then second line, if abscess is not responsive to needle aspiration and abx, suspected presence of necrotic material, and large (over 5cm) pus collection = I & D (surgical draining)
NF 1 vs. NF2
(a) Clinically
(b) Mode of inheritance
(a) NF 1 = cafe au lait spots, axillary freckling, cutaneous neurofibromas, optic glioma
NF 2 = b/l vestibular schwannomas
(a) Both aut dom inheritance
Major cause of morbidity in Behcet syndrome
Recurrent oral and genital ulcers (Behcets)- major cause of morbidity is thrombosis
Ascitic fluid features c/w SBP
Diagnostic is ascitic fluid w/ > 250 PMNs
- then gram stain usually shows G- bacteria (E. Coli, Klebsiella)
- SAAG over 1, protein under 1g
First line tx for plt dysfunciton in uremia
DDAVP which stimulates release of vWF and factor VIII from endothelial storage sites
(don’t transfuse plts b/c they’ll just quickly be inactivated)
26 yo w/ chronic diarrhea x2 wks, colonoscopy w/ dark brown mucosal pigmentation in proximal colon
Laxative abuse causing melanosis coli = dark brown discoloration of colon seen either on gross pathology or histologically (pigment in macrophages of lamina propria)
Clinical features of Hairy cell leukemia vs. CLL (chronic lymphocytic leukemia)
Both in adults >50 w/ leukocytosis
Hairy cell: WBCs w/ ‘hairy’ like projections on peripheral smear, oftne pancytopenia (anemia and low plts 2/2 bone marrow infiltration), splenomegaly, no B symptoms
-BRAF mutation
CLL: prominent B symptoms w/ significant leukocytosis (>100k), smudge cells on peripheral smear
Clinical features of Waldenstrom macroglobulinemia vs. Multiple Myeloma
Both: Ig spike, plasma cell malignancy (MM) vs. B cell malignancy (WM)
Waldenstrom (B cell malignancy): hyperviscosity syndrome, neuropathy, bleeding, hepatosplenomegaly (from infiltration into tissue), lymphadenopathy
MM: CRAB
vs. MGUS: lower IgM spike and no end organ damage (no HSM)
Cushing’s reflex
Indicates elevated ICP
Triad:
- Hypertension
- Bradycardia
- Respiratory depression
42 yo F w/ 4 children is nervous b/c her mom got dx w/ breast cancer at 67, best recommendation for her?
Decrease alcohol intake
- EtOH is a dose-dependent risk factor for breast cancer
- genetic testing not indicated unless mother was under age 50
The number of trinucleotide repeats in Friedreich’s ataxia correlates w/ what?
Friedreich’s ataxia: aut recessive loss of frataxin (mitochondrial enzyme) gene used in highly active muscle (so skeletal muscle and heart)
- age of onset of limb/gait ataxia
- shorter time to loss of ambulation (median age 25 yo)
- increased risk of cardiomyopathy (what causes death in 30/40s)
Breastfeeding failure jaundice vs. breast milk jaundice
Breastfeeding jaundice: see signs of dehydration on exam (fewer wet diapers- should be a wet diaper for every day of age during the first week), get jaundice b/c reduced bowel movements = reduced bilirubin excretion so more in recycled, within first week of life
Breast milk jaundice: no signs of dehydration, starts 3-5 days peaks at 2 weeks, due to high beta-glucoronidase in breast milk
Key clinical features of fibromyalgia
(a) 1st line tx
FIbromyalgia = noninflammatory (so normal ESR/CRP- hence why NSAIDs/steroids aren’t helpful) pain syndrome in young to middle aged F adults
-fatigue, widespread pain, cognitive/mood disturbance
(a) TCAs (amitriptyline) w/ exercise and good sleep hygiene
PPSV23 vs. PCV13 vaccines
(a) Immunologic response
(b) Who gets each?
PPSV23 = polysaccharide vaccine
(a) T-cell independent B cell response b/c polysacc alone (no proteins) can’t be presented to T cells
(b) Immunocompromised, adults under 65 w/ diabetes cirrhosis, all > 65
PCV13 = pneumococcal conjugate vaccine
(a) T-cell dependent B cell response b/c capsular polysac are covalently attached to inactivated diptheria toxin
(b) To infants and young children
Differentiate SCFE and Legg-Calve-Perthes
SCFE = adolescent obese boy p/w altered gait w/o trauma
- Xray w/ ice cream separated from or falling off cone (displacement of capital femoral epiphysis from femoral neck)
- tx w/ immediate screw fixation to prevent AVN
Legg-Calve-Perthe = idiopathic AVN in boys 5-7 yoa
21 yo w/ point tenderness over second metatarsal
(a) Dx
(b) Tx
(a) Stress fracture
(b) RICE
Contraindications for yellow fever vaccine
Can’t give to immunocompromised (HIV w/ CD4 under 200) or on immunosuppressants (high dose corticosteroids, anti-TNF)
**Key here is to know you can’t give live attenuated virus to pts on anti-TNF agents (ex: adalimumab)
Deficiency in the following cause
(a) Aldolase B
(b) Galactosidase-1-phosphate uridyl transferase
(a) Aldolase B deficiency = hereditary fructose intolerance
- presents later as breast milk doesn’t contain fructose
(b) = Galactosemia
- p/w jaundice, hepatomegaly, failure to thrive after breast milk or regular formula
What is the Hawthorne effect?
Ppl change their behavior when they’re aware they’re being studied
Define fetal tachycardia
Fetal tachy = baseline over 160 bpm
22 yo F w/ vaginitis- microscopic exam shows flagellated motile organisms
Dx
Dx = trichomoniasis
-motile trichomonads
DIFFERENT from the clue cells seen from BV (gardnerella)
Sequelae of hyperestrinism in cirrhosis
Spider angiomata, palmar erythema (both are from high estrogen), testicular atrophy, decreased body hair, gynecomastia
Naltrexone vs disulfiram for EtOH cessation
Disulfiram- pt must be abstinent and very highly motivated
Naltrexone- first line to decrease craving and heavy drinking, can be initiated in pts who are still drinking (as long as they’re opioid free)
Vitamin A used in the tx of what severe viral illness?
Severe cases of measles (conjunctivitis, coryza, cough, Koplik spots)
Pt w/ diagnosed RA takes indomethacin- provides good relief but symptoms recur if dose is skipped
Next step in mgmt?
MTX!!! (need a DMARD)
-NSAIDs and COX2 inhibitors (celecoxib) are only for symptomatic relief, they do nothing to reduce disease progression
Drugs that can cause idiopathic intracerebral HTN
- growth hormone
- tetracyclines (minocycline, doxycycline)
- excessive vitamin A and its derivatives (isotretinoin, all-trans-retinoic acid)
Clinically distinguish leiomyomas and adenomyosis
Both cause heavy menses
Fibroids usually don’t come w/ pain, uterus nontender and non-uniformly enlarged
Adenomyosis (benign endometrial glands w/in uterine muscle) cause uniformly bulky, globular, TENDER uterus. Dysmenorrhea and pelvic pain
Eosin-5-maleimide binding and acidified glycerol lysis test
Used to identify hereditary spherocytosis = aut. dominant hemolytic anemia
Ophthalmic d/o associated w/
(a) Loss of peripheral vision
(b) Loss of central vision
(a) Loss of peripheral vision w/ eventual tunnel vision = open angle glaucoma
(b) Loss of central vision = macular degeneration
Typical MRI findings of brain mets
Brain mets: multiple, well-circumscribed lesions w/ vasogenic edema at the grey-white matter jxn
Lab value to differentiate iron deficiency anemia from thalassemia
Both microcytic anemia
- iron deficiency anemia will have elevated RDW (>20%): nutrient availability fluctuates => RBC fluctuates
- RDW normal in thalssemia (minors), also see target cells on peripheral smear of thalassemias
Symmetric arthritis in child associated w/ what hematologic abnormality?
Jeuvenile idiopathic arthritis = chronic autoimmune d/o of childhood w/ symmetric arthritis
-associated w/ anemia (of chronic disease b/c elevated hepcidin)
Explain swollen hands and feet in Turners pts
Lymphedema (nonpitting edema) in Turners pts due to dysgenesis of the lymphatic network
-can cause cystic hygroma of neck and fetal hydrops
Mgmt of variceal hemorrhage
Nonselective beta blocker (propranolol or nadolol) to reduce portal venous pressure
-blocks adrenergic vasodilatory response of mesnseteric arterioles => reduced portal flow
Endoscopic variceal ligation if varice is huge
Cyp p450 substrates
Drugs broken down by cytp450- so especially interact w/ oter cyt p450 inducers or inhibitors
“War on anti-terrorism”
Warfarin
OCPs
Anti-epileptics
Theophylline (PDE inhibitor for COPD)
Distinguish laryngomalacia from vascular ring
Both can present w/ chronic stridor
Laryngomalacia: improves w/ prone positioning
Vascular ring: stridor improves w/ neck extension
What is reactive arthritis?
(a) Classic triad
(b) Tx
Reactive arthritis = seronegative spondyloarthropathy usually from an enteric or GU infxn
(a) Triad: urethritis (UTI), conjunctivitis, asymmetric oligoarthritis
- also common to have mucocutaneous lesions and enthesitis
(b) First line tx = NSAIDs
Ex: 31 yo M w/ joint pain of R knee, R heel, lower back, recent trim-sulfa for urethral discharge, mouth ulcers, sterile synovial fluid
When does sinusitis need abx vs. CT scan of sinuses?
Uncomplicated- give augmentin (amox clavulanate), then if becomes complicated (periorbital edema, vision abnormality, AMS) get CT
Drugs that cause anemia 2/2 deficiency in
(a) Vit B6
(b) Folate
(a) Vit B6 (pyridoxime) and isoniazid
(b) Folate deficiency associated w/ trim-sulfa, MTX, AEDs (phenytoin)
So pt w/ h/o seizures who p/w megaloblastic anemia = B12 deficiency anemia
Otherwise healthy 44 yo M w/ single episode of Afib w/ RVR and echo showing mildly dilated LA
No additional therapy- CHADSVASC of basically 0
CHF, HTN, Age over 75 2 pts, DM, Stroke/TIA, Vascular disease (prior MI), age 65-74 1 pt, Sex (F)
15 yo girl p/w short stature, no breast development, no menarche
Expected hormone abnormality
= Turners syndrome (45 X,O) = ovarian dysgenesis (streak ovaries)
-no estrogen/progesterone = no feedback on anterior pituitary => elevated FSH and LH
So see elevated FSH/LH and absent menarche and thelarche (breast development)
Prostaglandins administer for which congenital heart defect?
Transposition of the great arteries (arterial switch): give prostaglandins to keep open ductus arteriosus to optimize inter-circulatory mixing
Skin condition associated w/ underlying hepC
Porphyria cutanea tarda = painless blisters that heal as scars and super sensitive skin w/ hyperpigmentation
MC inherited hypercoagulable d/o in Caucasians
Factor V Leiden = aut dom point mutation in factor V that makes it unable to respond to activated protein C
= activated protein C resistance
Clinical features of NAFLD
(a) RF
P/w abnormal LFTs and hepatomegaly in obese pt w/ other features of metabolic syndrome (diabetes, HTN) who doesn’t drink EtOH excessively, has normal iron studies, negative autoimmune and hepatitis markers
(a) Obesity
(b) Tx geared towards wt loss: diet, exercise, bariatric surgery
Ovarian mass in 7 yo girl w/ s/s premature puberty
(a) Dx
(b) Tx
(a) Dx = granulosa cell tumor of the ovary
- secrete estrogen (get high serum estrogen) => precocious puberty
(b) Tx = surgical removal (they’re malignant)
43 yo F G6P5 at 39 weeks gestation has GTC seizure in delivery room
- BP 80/40, satting 75% on facebmask
- unconscious, purpuric rash and bleeding from IV line site
(a) Dx
(b) Next step
(a) Dx = amniotic fluid embolism
- presents as acute respiratory failure w/ hypotension during delivery or immediate postpartum period
(b) Tx to correct hypoxemia (intubation) and hypotension (pressors)
Changes in fetal heart tracings caused by
(a) Contractions
(b) Inactive fetal sleep
(c) Placental insufficiency
(a) Contractions can cause benign early decels = shallow decreases in HR 2/2 change in ICP
(b) INactive fetal sleep and hypoglycemia => nonreactive nonstress test (no accelerations seen on tracing)
(c) Placental insufficiency => late decels = smooth drops in HR after contractions from transient fetal hypoxia from placental hypoperfusion during contraction
Graft vs. host disease
(a) Mechanism of disease
(b) 3 MC target organs
(a) Recognition of host HLA by donor T cells causing activation of donor T cells => cell-mediated immune response
(b) Skin (macpap rash), intestines (+FOBT diarrhea), liver (abnormal LFTs, jaundice)
When to consider multiple system atrophy
MSA = Parkinsons + autonomic dysfunction
So when pt w/ Parkinsonism (cogwheel rigidity, shuffling gait, bradykinesia) also has orthostatic hypotension, impotence, incontinence, abnormal salivation/lacramation, gastroparesis etc
MC cause of urinary tract obstruction in newborn M
Posterior urethral valves => Potter sequence
Potter sequence = olioghydramnios causing facial and limb abnormalities
When is C-sxn indicated for arrest of active labor
Active labor is once already 10cm dilated, then arrest of active labor is either
- no cervical change for 4 hrs w/ adequate contractions (over 200 MVU)
- no cervical change for 6 hrs w/o adequate contractions
For arrest of active labor- C sxn is indicated
-oxytocin won’t help if contractions are adequate!
Differentiate infiltrating ductal carcinoma from intraductal papilloma
Both p/w unilateral bloody nipple discharge
Intraductal papilloma (more common), is benign: no associated mass of lymphadenopathy -imaging w/ normal breast tissue or single dilated breast duct
Infiltrating ductal carcinoma: has corresponding breast mass and lymphadenopathy, breast imaging shows lesions w/ microcalcifications
2 MC prodromes to reactive arthritis
Reactive arthritis usually causes
- acute GI infxn (ex: salmonella, yersinia)
- acute GU infxn (urethritis- E. coli or chlamydia)
Dose limiting side effect of hydroxyurea in sickle cell pts
Myelosuppression (neutropenia, anemia, thrombocytopenia)
When can’t tell by look- helpful hints for SCC vs. basal cell carcinoma
SCC: more common in immunocompromised (s/p transplant) or over a scar, more common on extremities, can display early perineural invasion causing regional neurologic symptoms (numbness, paresthesias)
BCC: MC overall, usually head or neck, upper lip
Management/tx of lichen sclerosis vs atrophic vaginitis
Tx atrophic vaginitis w/ low-dose topical estrogen
While lichen sclerosis can be premalignant (increased risk of vulvar SCC) so do punch biopsy to confirm dx and r/o malignancy. Once dx confirmed tx w/ high dose topical corticosteroids (it’s a chronic inflammatory condition, not estrogen deficiency)
Cyp450 inhibitors
CRACK AMIGOS
Cimetidine (H2 blocker like Ranitidine) Ritonavir (protease inhibitor) Amiodarone Ciprofloxacin Ketoconazole (and other azoles)
Acute EtOH use Macrolides (except Azithromycin) Isoniazid Grapefruit juice Omeprazole Sulfonamides (Bactrim)
How to prevent recurrence of uric acid kidney stones
Potassium citrate to alkalinize urine and low-purine diet
- uric acid stones are highly soluble in alkaline urine
- citrate = stone inhibitor, reduces crystallization
UA and serum findings findings of
(a) Post strep GN
(b) Drug induced AIN
(c) IgA nephropathy
(a) Hematuria, RBC casts, proteinuria on UA. Low serum C3 complement levels
(b) Hematuria, sterile pyuria, WBC cases (no RBC casts)
(c) Hematuria, normal serum complement
Deficiency in the following cause
(a) Aldolase B
(b) Galactosidase-1-phosphate uridyl transferase
(a) Aldolase B deficiency = hereditary fructose intolerance
- presents later as breast milk doesn’t contain fructose
(b) = Galactosemia
- p/w jaundice, hepatomegaly, failure to thrive after breast milk or regular formula
Tx for acute vs. chronic prostatitis
Acute prostatitis: Trim-sulfa or fluoroquinolone
Chronic pancreatitis: fluoroquinolone
Both for 4-6 weeks
Alzheimers vs. NPH
Can have overlapping features, but differ on what comes first and what is most prominent
AD: first and most prominent is the memory, other stuff comes later
NPH: gait impairment is most prominent, cognitive disturbance come much later
Impact of intensive glycemic control in DM2
No change in mortality or microvascular complications (acute MI/stroke)
Bt decreased risk of microvascular complications (retinopathy, nephropathy)
Mechanism of cyanoide toxicity
Cyanide binds to cytochrome oxidase => inhibits mitochondrial oxidative phosphorylation
=> lactic acidosis (metabolic acidosis) from shift to anaerobic metabolism
Differentiate CN III palsy that results from nerve compression vs. ischemic damage
Nerve compression (external) => loss of parasympathetics (mydriasis) in addition to ischemic findings
Ischemic nerve damage damages from the center, associated w/ poorly controlled diabetes, ptosis, down and out gaze, diplopia, but normal pupillary response (b/c parasympathetics intact)
25 yo F w/ amenorrhea x2 months w/ constant vomiting, wt loss
Hyperemesis gravidarum = persistent N/V during pregnancy that can cause weight loss from prepregancy weight
Differentiate from typical N/V by ketones in the urine (2/2 prolonged hypoglycemia)
Clinically differentiate lichen sclerosis from atrophic vaginitis
Lichen sclerosis = vulvar premalignant lesion of “cigarette” paper thinning of skin of vulvar and perianal region, spares vagina and cervix
-chronic inflammatory condition in women of all ages, associated w/ other AI d/o
While atrophic vaginitis involves vagina cervix and some vulva, no perianal region, less severe, less itchy, thinning of vagina not figure 8 w/ perianal region
-tx w/ topical estrogens
Differentiate factitious d/o from somatic symptom d/o
Factitious d/o = intentional falsification w/ goal to assume sick role (secondary gain)
Somatic symptom d/o = excessive anxiety and preoccupation w/ one or more unexplained symptom
Describe CT finding of invasive pulmonary aspergillosis
In immunocompromised pt: see “halo sign” = nodules w/ surrounding ground glass opacities
Locate the stroke:
65 yo M w/ sudden onset weakness of R arm/leg and R facial paresis
- otherwise normal exam
- no findings on CT
Pure motor stroke = lacunar stroke of contralateral internal capsule
Stroke = L internal capsule posterior limb
53 yo F s/p chemo for breast CA w/ R abd pain, lightly brushing skin on abd elicits intense pain
Dx
Dx = varicella zoster reactivation
Hyperesthesia/allodynia- pain can precede onset of vesciular rash by several days
What to do when a pt w/ chronic hep C (untreated) gets pregnant
Don’t treat (ribavirin is teratogenic), no need for C-section (not protective), and breastfeeding should be encouraged UNLESS maternal blood present (nipple injury)
One recommendation = Hep A and B vaccination
Anterior, middle, vs posterior mediastinal massese
Anterior mediastinal mass = thymoma
Middle mediastinal mass = bronchiogenic cyst
Posterior mediastinal mass = neurogenic tumors (ex: neuroblastoma)
Protocol for pts s/p splenectomy
- ppx penicilin for 3-5 years
2. vaccines: pneumococcal, haemophilus, meningococcal
Mode of inheritance
(a) Friedreich’s ataxia
(b) HOCM
(a) Aut recessive (trinucleotide repeats)
(b) Aut dom
3 cyanotic heart disease in newborns that present w/ single S2
(a) Accompanying murmur
- TGA
- Tricuspid atresia
(a) VSD murmur - Truncus arteriosus
(a) systolic ejection murmur (increased flow thru the truncal valve)
TGA is the only one that won’t have a murmur
2 common presentations of fibromuscular dysplasia
- HTN 2/2 renal artery stenosis
2. Headaches 2/2 carotid artery stenosis
What is Asherman syndrome?
Intrauterine adhesions from infection (severe endometriosis) or surgical intervention (D&C, endometrial ablation) that can cause infertility
Eczema + imunodeficiency
Eczema + immunodeficiency + thrombocytopenia = Wiskott Aldrich
- X-linked
- immunodeficiency is 2/2 hypogammaglobulins
67 yo w/ progressive vision loss where “vertical lines appear bent and wavy”
Grid test = early sign of macular degeneration- leading cause of blindness in developed countries
RF: age, smoking
Also Drusen spots
Danger of Graves pt s/p thyroidectomy during pregnancy
After delivery baby may have transient thyrotoxicosis 2/2 transplacental passage of anti-TSH antiobodies during the third semester
-highest risk if mother has anti-TSH receptor antibodies above 5 times ULN
50 yo w/ ESRD on dialysis x4 yrs w/ R carotid bruit on exam, most likely to die from what in the next 5 years?
Cardiovascular disease
-not stroke (despite bruit), CVD is the MC cause of death in dialysis pts, also MC cause of death in renal transplant pts
Risk of giving pt w/ megaloblastic anemia folic acid instead of B12
If they’re B12 deficient, giving folic acid may correct the anemia (no longer see megaloblasts on peripheral smear), but => rapid progression of neurologic complications
- loss of proprioception and vibration sense
- memory deficits, irritability, dementia
2 RF from hyperemesis gravidarum
- hytadiform mole
- multiple gestations (twins)
Tx for neonatal conjunctivitis: 3 days old vs. 10 days old
3 days old w/ purulent discharge = gonococcal => tx w/ single IM dose of ceftriaxone
10 day old w/ mucuopurulent d/c = chlamydia => tx w/ oral erythromycin (PO macrolide)
23 yo s/p MVA w/ pain and SOB, progressive drowsiness
-BP 160/90, HR 50, R. sided weakness
(a) Dx?
(b) Expect dysfunction of what cranial nerve?
(a) Transtentorial (uncal) herniation
- Cushing’s reflex indicating elevated ICP (HTN, bradycardia, resp depression)
- compression of contralateral cerebellar peduncle => ipsilateral hemiparesis
(b) CN III compression => mydriasis from loss of parasympathetics and eye down and out
Main clinical distinction btwn serotonin syndrome and NMS
Both w/ AMS and autonomic instability
NMS: rigidity and hyperthermia
SS: hyperreflexia and myoclonus**
Palpable breast mass in F, first step?
Depends on age!
Under 30: get ultrasound
30 or over: mammogram
Indication for negative-pressure wound therapy
= Vacuum assisted wound closure- applies sub-atmospheric pressure to accelerate healing
-ONLY in healthy, granulating wounds
NOT for infected or necrotic wounds
Newborn w/ CF w/ nonbilious vomiting
(a) Dx
(b) Next step
(a) Dx = meconium ileus
(b) Next step = contrast enema in stable pts to determine level of obstruction
Differentiate clinical presentation of Babesiosis and Ehrlichia
Both are tick borne p/w no rash and thrombocytopenia (and can have elevated LFTs)
Ehrlichae- leukopenia
But Babesiosis will have signs of intravascular hemolysis (jaundice, dark urine, high LDH) and leukocytosis
When is BRCA, HER2 testing indicated?
Genetic testing indicated when
- breast cancer in F under 50 yoa
- ovarian cancer at any age
When do use the following when assessing pt w/ possible PE
(a) D dimer
(b) Ultrasound of lower extremities
(c) TTE
(d) CTA
(a) D dimer if suspicion is low to rule it out, not helpful if high suspicion
(b) US of LE only if they have clinical manifestations in LE, also not that helpful b/c negative doesn’t r/o
(c) TTE in decompensating pts (too unstable for CTA) to see RV dilation/dysfunction if massive PE
(d) Gold standard = CT angiogram
Clinical presentation of cardiac myxoma
(a) Location
(b) Complications
Cardiac myxoma = MC intracardiac tumor
Clinically: constitutional symptoms (fever, wt loss), can cause acute HF 2/2 obstruction
(a) 80% in the left atrium
(b) CV complications (acute HF, arrhythmia, valvular disease, heart block)
- Embolization (stroke)
- Lung invasion => respiratory symptoms
Tx for actinic keratosis vs. BCC
Actinic keratoses can be tx topically w/ fluorouracil or liquid nitrogen cryotherapy
While basal cell carcinioma indicates excisional biopsy
First line tx for croup?
(a) When to intubate
Croup = laryngotracheitis- seal like barky cough, inspiratory stidor
Start w/ corticosteroids (single dose dexamthasone) to reduce airway inflammation
- If stridor present at rest or still respiratory compromised give nebulized racemic epinpehrine
- vasoconstricts mucosal arteries to decrease airway edema and reduce secretions
(a) Only intubate if corticosteroids and nebulized racemic epi fails
Pt w/ painless genital ulcerated lesion but negative RPR- what to do next
RPR and VDRL (nontreponemal tests) can be negative early in infection => empirically treat anyway w/ penicillin
Activity of protein C and protein S
They inactivate factors V and VIII
58 yo w/ h/o chronic hepC p/w hepatic encephalopathy and SBP has gradual increase in serum Cr throughout stay
- renal US: normal size kidneys w/o hydronephrosis
- no improvement w/ IV saline or albumin
(a) Dx
(b) Mechanism
(c) Tx
(a) Hepatorenal syndrome = gradual reduction in renal perfusion induced by increasing severity of severe hepatic injury
- represents end stage of step wise process
(b) Due to splanhcnic arterial dilation induced by portal HTN
(c) Tx by splanchnic vasoconstrictors (midodrine, octreotide, norepi) or liver tranpslant
PKU
(a) 2 hallmark clinical findings
(b) Diagnostic study
PKU = phenylanine hydroxylase deficiency => can’t metabolize phenylalanine to tyrosine so phenylalanine accumulates as neurotoxic byproducts
(a) Musty body odor, fair complexion (hypopigmentation)
(b) Quantitative amino acid analysis
42 yo F w/ 4 children is nervous b/c her mom got dx w/ breast cancer at 67, best recommendation for her?
Decrease alcohol intake
- EtOH is a dose-dependent risk factor for breast cancer
- genetic testing not indicated unless mother was under age 50
Differentiate typical pt that benefits from CBT vs dialectical behavioral therapy vs biofeedback
CBT: changes maladaptive behavior (I’m fat, I’m worthless)
Dialectical behavior therapy for boderline personality d/o: helps regulate emotion and manage self harm
Biofeedback for pts w/ prominent physical symptoms (pain d/o)
Differentiate the symptoms and first line tx for
(a) Open angle glaucoma
(b) Cataracts
(c) Macular degeneration
(a) Open angle glaucoma = loss of peripheral vision w/ eventual tunnel vision
- tx w/ beta-blocker eye drops = Timolol
(b) Cataracts = gradual blurring of vision and decreased night vision from progressive thickening of the lens
- definitive tx w/ lens extraction
(c) Macular degeneration = loss of central vision
- not much for tx
Urinary 5-HIAA elevated indicates what dx?
(a) Clinical features
Elevated 5-HIAA = Carcinoid syndrome, becomes sympatomatic when liver mets (so bypass portal circulation where histamine, serotonin, and VIP get metabolized)
(a) Episodic flushing/episodic pounding sensation, secretory diarrhea, wheezing tricuspid regurg 2/2 plaque-like deposits on R heart
Clinical presentation of abruptio placentae vs placenta previa
Abruptio placentae (placenta separating from uterine wall before delivery) = vaginal bleeding, abdominal/back pain, frequent contractions
While placenta previa is painless vaginal bleeding
Pt w/ N/V, pneumobilia, hyperactive BS, dilated loops of bowel on Xray
Dx
Dx = gallstone ileus = when gallstone passes thru biliary-enteric fistula into the small bowel, eventually stone to ileum (narrowest portion)
(pneumobilia is air in the biliary tree)
MC cause of congenital hypothyroidism
(a) Clinical presentation
(b) Mgmt
MC cause of congenital hypothyroidism = thyroid dysgenesis (not iodine deficiency which is super uncommon nowadays)
(a) P/w poor feeding, hoarse cry, jaundice
(b) Want to recognize early and give levothyroxine to prevent permanent neurodevelopmental injury
3 main manifestations of Friedreich’s ataxia
Autosomal recessive d/o, life expectancy 20 yoa
- Neurologic (degeneration of spinal tracts): gait ataxia, frequent falls, dysarthria (speech difficulty)
- skeletal deformities: scoliosis, hammer toes
- concentric hypertrophic cardiomyopathy
Name the 3 ddx for vaginitis
- Bacterial vaginosis = gardnerella
- Trichomoniasis
- Candida
MC brain tumor in children
Pilocytic astrocytoma = low grade astrocytoma (vs. high grade astrocytic tumor = glioblastoma which was much less common)
Amikacin
(a) Class of abx
(b) Mechanism
(c) Side effect
Amikacin
(a) aminoglycoside abx (like gentamicin, tobramycin, streptomycin
(b) Inhibits protein synthesis by inhibiting 30S ribosomal subunit
(c) Renal toxicity => carefully monitor renal fxn during therapy
Low maternal BMI/poor wt gain increases fetal risk for what?
Growth restriction and preterm delivery
-NOT anemia or cystic hygroma (Turner’s, lymphatic dysfunction)
4 parts of uncal herniation syndrome
- compression of ipsilateral PCA => ischemia to visual cortex => contralateral homonymous hemianopsia
- compression of ipsilateral oculomotor nerve (CN III) => mydriasis, eye down and out
- compression of contralateral cerebellar peduncle => ipsilateral hemiparesis
- compression of reticular formation => altered mental status, coma
Clinical presentation
(a) Suppurative thyroiditis
(b) Subacute thyroiditis
(c) Subacute lymphocytic thyroiditis
(a) Suppurative = uncommon, euthyroid, inflammatory condition so have high fever
(b) Subacute (de Quervain) = painful/tender goiter, post viral inflammatory process w/ prominent hyperthyroid symptoms
- elevated ESR/CRP
(c) Subacute lymphocytic = painless/nontender goiter, brief hyperthyroid phase
- variant of Hashimotos => TPO Ab +
Define hypertensive emergency and malignant hypertension
Hypertensive emergency = severe HTN (over 180/120) w/ presence of either malignant HTN or hypertensive encephalopathy
Malignant HTN = retinal hemorrhage, exudates, and/or papilledema
-renal findings (ARF) usually present but not required for dx)
Why is cyclophosphamide reserved for really bad SLE cases
(a) How to avoid complication
Cyclophosphamide (alkylating agent) reserved for SLE cases w/ significant renal or CNS involvement b/c of side effects: hemorrhagic cystitis/bladder cancer
(a) Lots of fluids and taking MESNA to clear it’s active meabolite (acrolein) from the bladder
Dermatomyositis
(a) Antibodies
(b) Key complication
Demrmatomyositis
(a) Anti-Jo1 (anti-synthetase) Abs
(b) Over 15% of these pts will have malignancy => age-appropriate cancer screening is key
72 yo presents in hypertensive emergency, started on O2 furosemide and nitroprusside drip
Complication?
Complication of prolonged nitroprusside (potent vasodilator) ggt = cyanide poisoning
P/w AMS (confusion, disorientation), flushing then cyanosis, arrhythmia, tachypnea, metabolic acidosis (from lactic acidosis), renal failure
HIV+ pt w/ neck stiffness and cervical lymphadenopathy, LP w/ low glucose high protein high whites
CSF fungal stain w/ encapsulated yeast
(a) Dx
(b) Tx
(a) Cryptococcal meningitis from cryptococcus neoformans
(b) Tx = amphotericin plus flucytosine
Differentiate osteosarcoma, Ewing sarcoma, osteoid osteoma
Osteosarcoma = spiculated sunburts on long bone, Codman’s triangle of periosteal elevation
-MC in children and young adults
Ewing Sarcoma = less common, osteolytic lesion w/ perisoteal rxn producing layers = onion skin appearance
Osteoid osteoma (benign) = sclerotic cortical lesion w/ central lucency, pain worse at night unrelated to activity and improves w/ NSAIDs
Popliteal cyst
(a) Chronic presentation
(b) Acute presentation
Popliteal (Baker) cyst
(a) Usually asymptomatic, chronic painless bulge behind the knee
(b) Can rupture (trauma like strenuous exercise) pushing fluid into connecting bursa of nearby muscles
- presents like DVT: posterior knee and calf pain, venous swelling (so usually do US to r/o DVT)
- give away is the crescent sign = arc of ecchymosis distal to medial malleolus
Tx of multiple system atrophy
MSA = Parkinsons + autonomic dysfunction, doesn’t usually respond to anti-Parkinson agents
Treatment aimed at increased intravascular volume w/ salt supplementation, fludrocortisone (mineralocorticoid), alpha agonist
