UWORLD 7 Flashcards
1
Q
Patients with obstructing uterolithiasis associated with infection, acute kidney injury or severe pain that has failed initial measures require?
A
decompression of the upper urinary tract with percutaneous nephrostomy ureteral stent placement.
2
Q
Clinical features of patients highly suggestive of cushing’s syndrome?
Screening test done?
A
diabetes, osteoporosis, hypertension and hypokalemia
Overnight dexamethasone suppression test or measurement of 24-hour urinary free cortisol level.
In normal individuals, serum cortisol is typically supressed.
3
Q
Symptoms of fatigue and depression in lithium-treated bipoloar patietns should prompt a workup for?
Management?
A
hypothyroidism
When lithium induced hypothyroidism develops, it should be treated with levothyroxine and does not typically require lithium discontinuation.
4
Q
What has been associated with increased lithium levels?
A
Thiazide diuretics,
Nonsteriodal anti-inflammatory drugs (except aspirin)
and Ace inhibitors.
5
Q
Cerebral venous sinus thrombosis - most cases are associated with?
Patients with this suually develop what?
A
pregnancy, OCPs, malgiancy, infection or head trauma.
As the dural sinsus drain CSF and venous blood from the brain, obstruction usually causes
- increased ICP, leading to gradual worsening headache that is maximal on awakening and with Valsalva0-like maneuvers (ex: coughing or sneezing).
- Venous congenstion of the brain, leading to focal deficits (ex: hemiparesis), seizures and/or confusion.
6
Q
Diagnosis of Cerebral venous sinus thrombosis?
Patients are typically treated with?
A
MRI
LMWH to recanalize the obstructed sinus and prevent thrombus propagation.
*As CVST is primarily medatiated by the activation of the coagulation cascade, antiplatelet therapy isnot typically used for treatment.
7
Q
Clinical findings of SLE
A
8
Q
Laboratory findings of SLE
A
9
Q
Psychosis in SLE versus Urinary Porphobilinogen
A
Urinary porphobilinogen is elevated in acute intermittent porphyria, a hereidtary disorder charazterized by intermitten neurovisceral symptoms that can present with acute psychosis.
This person’s lack of acute abdominal patin (the most common symptom) and the lack of family hx of similar symptoms make this condition unlikely.
10
Q
Psychosis in SLE versus Wilson’s diase
A
A slit-lamp eye examination can be used to look for copper deposits in the cornea (Kayser-Fleischer rings), a possible sign of WIlson disease, a disorder of copper transport in which copper accumulation causes hepatic, psychiatirc and neurologic dysfunction.
Findings include dysarthria, dystonia, tremor and parkinsonism.
Depression, not psychosis, is the most common psychiatric manifestation.
11
Q
MEN 1 is characterized by?
A
Parathyorid adenomas/hyperplasia
Pancreatic and gastriointestional neuroendocrine tumor (ex: gastrinoma/Zollinger-Ellison syndrome)
Pituitary adenoma (ex: prolactionoma)
12
Q
MEN 2A verus MEN 2B
A
13
Q
Indications for parathyroidectomy in patients with MEN 1
A
similar to those for sporodic primary hyperparthyoridism
including symptomatic hypercalcemia (or calcium >1 above normal),
end-organ complications (ex: osteoporosis, CKD, nephrolithiasis)
and increased risk for complications (ex: urinary calcium excretion >400 mg/day)
14
Q
What is a variant of asthma and how does it present?
A
Cough-variant asthma
presents with chronic nonproductive cough that is typically worse at night and triggered by exercise, forced expiration, and allergen exposure.
The diagnosis can be challenging as these patietns typically lack classic asthma symptoms (ex: wheezing, shortness of breath) and physical examination is often largely unremarkable, even during active symptoms.
15
Q
Tracheomalacia verus cough variant asthma
A
describes weakness of the walls of the trachea leading to expiratory airway collapse.
Patients often have coughing and SOB as well as stridoer on physical examination
Chest tightness is not typical.
16
Q
Recommended dose of Folic acid for generation population versus women who ahve anticonvulsants or have child with neural tube defect?
A
17
Q
What is recommended for patients who have contraindications to estrogen (ex: antiphospholipid syndrome)
A
Progestin-relasing intrauterine device
long acting, reversible contraceptive
*Copper containing IUD is associated with increased menstrual bleeding and dymeorrhea,and is not recommended for patients with heavy menstral flow or on anticoagulation.
18
Q
What is teh best diagnostic test for suspected subprenic or other abdominal abscess?
A
Abdominal ultrasound
19
Q
Lesions of the nondominant pariental lobe lesions presents with
A
Right parietal hemisphere (nondominant parietal lobe)
constructional and dressing apraxia.
patients have difficulty copying simple line drawings. or difficulty in wearing clothes.
20
Q
Damange to the dominant parietal lobe
A
Left side, presents as Gerstmann syndrome
difficulty in performing simple arthrmetic tasks (acalculia),
inability to name individual fingers (finger agnosia),
impaired writing (agraphia) and
righ/left confusion (difficulty in identifying or distiguisting the right or left side of the body)
21
Q
Lesions of the dominant temporal lobe causes?
A
Aphasia
Wernicke aphasia is usually seen
Characterized by impairement in comphresion of spoken or written lanaguate.
Patients have diffculty in expressing their thoughts in a menainingful manner.
22
Q
Nondominant parietal lobe lesion versus dominant temporal lobe lesion
A
Nondominant parietal lobe lesion presents with constructional and dressing apraxia.
Aphasia is typically seen in dominant temporal lobe lesions
23
Q
First line for prolactinomas?
What if it’s large?
A
Dopaminergic receptor agonists (bromocriptine and cabergoline) are the first-line treatment for prolactinomas, including large prolactinomas.
Treatment generally leads to a decrease in tumor size within a few days.
Visual symptoms usually improve before the tumor’s decrease in size is seen on MRI.
*Transpenodial and transcranial surgery is rarely required even in patietns with visual or other compressive symptoms as they may respond to treatment with dopaminergic receptor agonists.
24
Q
Patients with negative exercise stress test indicates what?
A
<1% risk of cardiovascular events within the next year.
25
Anterior uveitis is characterized by inflammation of the?
Most cases are due to
iris and ciliary body
Underlying infection (ex: AIDS) or systmic inflammatory disease (ex: sarcoidosis)
26
American diabetic association guidelines for diagnosing diabetes in symptomatic patients?
Asymptomatic patients with an abnormal screening test require?
Symptomatic patients hyperglcemia and abnormal tests?
_Symptomatic patients_
**Hb A1C \> or = 6.5**
**Fasting (\> hours) blood sugar is \> or = 126**
**Glucose \>200 after oral glucose tolerance test**
**or random glucose \> or = to 200**
_Asymptomatic patients with an abnormal screening test require:_
**repeat measurement** with the same test to confirm the diagnosis
_Symptomatic patients **hyperglcemia and abnormal test**s:_
can be diagnosed with diabetes **without repeating** confirmatory testing.
27
Ecthyma gangrenosum is most commonly seen in?
Manifestations typically include?
**immunocompromised patients** with **Pseudomonas** aeruginosa bacteremia.
**rapid evolution of \> or =1 skin lesion from an erythematous macule to pustule or bullae and then into a _nonpainful_ gangreous ulcer**
28
Pyoderma versus ecthyma gangrenosum
Pyoderma gangreosum is a neutrophillic dermatosis that is usually associated with IBD or an arthritides.
Lesions typically begin as inflammatory nodules, pustules or vesicles that quickly evolve to ulcers; however thye are **usually quite painful.**
*\*Pyoderma gangrenosum is typically associated with autoinflammatory disorders.*
29
Management of patients with eecthyma gnagrenosum
Patients likely have **Pseudomonas aeruginosa bacteremia.**
**Urgent blood and would cultures** are required.
Patients should then receive **empiric IV antibidotics** with 2 medications against Pseudomas.
Commonly, platients receive **beta-lactam** (ex: piperacillin-tazobactam) and **aminoglycoside** (ex: gentamicin)
30
Management of patients with clostridal myonecrosis versus ecthyma gangrenosum
Patients with clostridal myonecorsis usually requires **extensive surgical debridement,** but this condition is **associted with signficant pain.**
Surgical debridement is not typically required for ecthyma gnagrenosum.
31
Clostridal myonecrosis versus Ecthyma gangrenosum
**Clostridial myonecrosis**, also called **gas gangrene**, is associated with **fever, severe muscle pain, and purple colored bullae.**
This patient does not have pain, making this condition unlikely.
32
Invasive Candida infection versus Ecthyma gangrenosum
Invasive candida infection frequently cause endophthalmitis and necessitate opthalmologic evalulation.
however, skin lesions due to hematogeneous dissemination of Candidia usually manifest as **grouped pustules on a erythematous base** **with or without necrositc centers (not bullous, ulcerative lesions)**
33
Under-anticoagulation can lead to worsening of thrombotic disease and such patients should be started on?
IV hepatrin (r subcutneaous LWMH) until a therapeutic INR is achieved with warfarin.
34
Group B streptococcus bacteriuria in pregnant women requires
both immediate treatment to prevent OB complications and intrapartum prophylaxis to prevent Group B Strep. disease
35
Indications for preventing neonatal Group B STrep. infection
36
Presentation of cherry angiomas?
Management?
Multiple, small, vascular and dome-shaped papular lesions in adults.
CA are benign lesions that crease increase number with age and do not regress spontaenously. Most lesions do not require treament.
37
Strawberry hemangiomas
**Infantile** strawberry hemangiomas.
**Grow rapidly but spontaenous regress by age 5-8.**
Most infantile hemangiomas may be **managed conservatively,** through **beta blockers may occasinally be needed for ulcerating lesions.**
38
Management of patients with Renal Cell Carcinoma?
**Surgical management** is the **only chance of cure** for patients with RCC.
IF the renal mass is **confined within the renal capsule (stage 1)**, **partial nephrectomy** can be offered.
If the processs **extends through the renal capsule but not beyond Gerota fascia (stage II**), **radical nephrectomy** is the best treatment option.
_Partial nephrectomy:_ remove the cancer within the kidney and some of the tissue around it. A partial nephrectomy may be done to prevent loss of kidney function when the other kidney is damaged or has already been removed.
_Radical nephrectomy_: A surgical procedure to remove the kidney, the adrenal gland, surrounding tissue and, usually, nearby lymph nodes.
39
Management of this patient?
On a standard 10 second ECG tracing the HR can be estimated by multiplying hte nubmer of QRS complexes by 6 (23x6 = 138).
**Narrow QRS, abscence of organized P waves** and **irregular irregular Rhythm** with **varying R-R intervals (brackets)** is considered **Atrial fibrillation with rapid ventricular response.**
**BB or nondihydropyridine CCB** to control the ventricular rate in patients with rapid Afib.
40
After adjusting for age, what remains as the single most important factor in determining the prognosis of patients with COPD?
FEV1
41
Various types of twin placentation?
42
Criteria for operative vaginal delivery include?
complete cervical dilation (10cm) and at least +2 fetal station
operative vaginal delivery (ex: forceps)
43
Delivery mode for diamniotic twin gestation
44
How does hyperkalemia present on EKG?
**intially** manifests as **peaked T-waves** and **subsequently** as prolongation of the PR interval and QRS complex, **disappearance of the P waves** **and eventally a sine wave.**
45
First line treatment for hyperkalemia if severe ECG manifestations are present?
**Calcium Gluconate or calcium chloride**
**Beta agonist or a combination of glucose and insulin** are then typically given to reduce serum potassium by driving potassium intracellularly.
*\*Calcium gluconate is shorte lived so other treatments are subsquently necessary to loswer the potassium level.*
46
Long term complications of IVC filter placement include?
**recurrent DVTs and IVC thrombosis.**
*\*The fliter can prevent clot progression to a PE, but does not prevent future DVTs or treat the underlying thrombotic predisposition.*
47
evaluation of suspected myelopathy
48
What suggests acute myelopathy?
These patients should be evalulated immediately with?
Treatment?
**acute paralysis with the presence of sensory or bowel/bladder dysfunction.**
**MRI**
**Steroids** should be administered after the diagnosis is estabilished or empirically if suspicion or compressive myelpathy is high, as in malignancy.
49
GBS verus traverse myelitits
Flaccid paralysis and hyporeflexia with a hixtory of URI may also suggest Guillian-barre syndrome.
However, **a sensory level and bowel/bladder dysfunction after a URI make transverse myelitis (TM) more likely.**
50
Correlation coeffection (r) values indicate what?
What indicates a stronger association?
indicates a positive or negative direction of association between 2 variables.
The closer the r value is to its margin (-1, +1), the stronger the association.
51
Which patients are at high risk for preeclampsia recurrence?
In these patients, what is used for prevention?
renal disease, DM, HTN, or prior preeclampsia
Aspirin is used for preeclampsia preventing and is started at 12 weeks gestation.
\*Apsirin inhibits platelet aggregation and prevents plcental ischemia.
52
What would qualify as polycthemia?
What is a good inital diagnostic test for the evaluation of polycythemia?
What does a high/low value mean?
**hemoglobin \> than 16.5 in a women or 18.5 in a man.**
**Serum eythropoietin**
A **low erythropoietin** level suggests **polycythemia vera**, whereas
a **high erythopoeitin level** suggests **secondary cause** of polycythemia, such as **chronic hypoxia** or **hormone producing neoplasm** (commonly Renal cell carcinoma)
*\*A high serum eyrthropoietin level is expected in a compensatory mechanism to correct for hypoxia in a patient with hypoxia.*
53
Manigment of incidentally detected adrenal mass
Before deciding to medically, surgically or conservatively manage it, an **evaluation for hormone production** should first be completed
**(serum electrolytes, dexamethasone suppression testing, 24 hour urine catechoalmine, metanephrine, VMA and 17-ketosteriod measurement (not 17-hydroxprogesterone)**
All functional masses, masses with raidographic evidence of maligancy or masses greater than 4cm should be removed.
*17-hydroxprogesterone - is seen in congenital adreanl hyperplasia, would not be seen as an adult.*
54
Pregnant women with clinically suspected acute cystitis require empiric antibotics with?
**nitrofuratoin, cephalexin or amoxicllin-clavulanate for 3-7 days.**
\*Fluoroquinolones and tetracyclines are CI in pregnancy and TMP should be avoided in teh first and third trimesters.
55
Treatment for pyleoneprhtis in pregnant women
hospitalization and broad-spectrum b-lactam antibiotics (ex: ceftriaxone)
56
Patients with preterm premature rupture of membranes are at risk for?
umbilical cord prolapse
57
Clinical features of umbilical cord prolapse
fetal heart abnormalities (ex: recurrent variable decelerations, bradycardia)
diagnosis is confirmed by palpating a apulsatile umbilical cord in the vagina or cervix
58
Management of relieving compression off prolapsed cord
**elevation of the presenting fetal part to prevent compression** of the umblical cord and **emergency cesarean delivery.**
59
Diagnosis of acute bacterial rhinosinusitis is typically made when?
one or more of the following is present
- **persistent symptoms/signs of rhinosinusitis** for \> or = 10 days
- **severe symptoms, high fever** (\>39 C (102.2F), **purulent nasal discharge , and/or facial pain \> or = 3 consecutive days.**
- **Double sickening**- inital imporvement of viral upper respiratory symptoms for 5-6 days, followed by clinical deterioration (ex: worsened fever, headache, nasal discharge).
60
Acute rhinosinusitis is mostly commonly due to?
What if it's persistent? What is the management?
**viral pathogens** and usually resolves within 10 days.
Patietns with persistent symptoms **\> or = 10 days**, **severe symptoms or deteroriation after several days of improvement** often have acute **bacterial rhinosinusitis,** which is usually treated **empirically with 5-7 days of oral amoxicillin-clavulanate.**
61
Early orchioplexy helps to prevent?
What risk still remains increased after orchioplexy?
**testicular torsion and possibly infertility.**
Although the risk of **malignant transformation** may decrease a little after the surgery, it remains higher than that of the general population.
62
Perioperative medical management
Selective estrogen receptor modulators such as raloxifene are asosciated with increased risk of venous thrombembolism and should be discontinued 4 weeks prior to any surgical procedure associated with moderate to high rsik of venous thrombembolism.
63
Patietns with CKD develop?
Inital treatment is?
**elevated serum phosphorus levels** and **hypocalcemia** leading to **secondary hyperparathyroidism.**
1. Inital treatmetn is **dietary phosphate restriction**
**2. Phosphate binding agents** may be added if serum phosphate is still elevated.
64
Renal osteodystrophy
How does it occur?
Patients with CKD are at risk for **renal osteodystrophy**, a **disorder** in the **homeostasis of the bone and mineral metabolism.**
As GFR rate decreases iwth CKD progression, the kideny's availbity to excrete phosphate falls, leading to hyperphosphatemia and hypocalcemia (as serum phosphorus binds with free calcium).
**Hyperphosphtememia and worsening renal failure** also inhibits the formation of calcitriol (1,25 dihydroxyvitamin D) exacerbating hypocalemia.
The body responds to these abnormaliteis by increasing serum parathyroid hormone levels (**secondary hyperPTH)** which stimulates **renal phophate excretion and increases bony turnover** to relase free calcium, the increased bone turnover leads to weaking of the bone and replacement wth fibrosis tissue **(osteitis fibrosa cystica)**
65
Length-time bias
suggests that screening is **more likely to detect slowly progressive diseases,** while **rapidly progressing and potenitally lethal diseases are less likely to be detected**, leading to **an apparant increase in survial rates.**
66
Treatment of lead intoxication
67
herbal supplement (uses and side effects)
ginkgo biloba
ginseng
saw palmetoo
black cohosh
st. johns wort
kava
licorice
echinacea
ephedra
68
Injury of the hypoglaossal nerve causes?
tongue deviation to the site of the injury.
69
Evaluation of renal colic during pregnancy
70
Changes in maternal thyroid axis during pregnancy
T3 serum levels are not useful in the management of most hypothyroid patients including those who are pregnant as they are an insenstivitve marker of thyroid stauts.
T3 levels often remain normal disepite undder replacement of thyroid hromone.
71
Patients with primary hypothyroidism and management during pregnancy
The doeser equirement of levothyroxine increases during pregnancy by 25-50% primilary in the first trimester.
TSH and total thyroxine levels should be monitored and kept in the normal reference range for pregnancy.
72
What can occur in meta-analysis?
**publication bias**
this occurs when studies with a positive result are prublished but studies with negative/null results are not.
meta-analysis yields an accurate synthesis of the studies included in the analyiss, but a biased sample of all revelant studies in the literature distorts the true mean effect computed by the meta-analysis and leads to publication bias.
73
Initial evaluation of BPH
74
Diphtheria is caused by?
Manifeistations of respirta include?
System absorption may casue?
caused by toxigenic strains of **Corynebacterium diphtheria.**
Manaifestations of respiratory infection include sy**stemic symptoms (ex. fever), sore throat, and pharyngitis with grey exudates that may colesce into a pseudomembrane (bleeds with scraping).**
System absorption of exotoxins may cause toxin-mediated damage to the **heart (myocarditis), CNS, and kidneys.**
**Myocardiits occurs in up to 2/3 of patients; severe cases are associated with complete heart block and failure**
75
Tuberculosis pleural effusions are typicallly?
Findings on smears and what is required for diagnosis?
**lymphocytic and exudative with an elevated adenonsime deaminase level.**
**Smears are often negative** **for acid fast bascilli** and diagnosis usually requires **pleural biopsy** with histopathologic demostration of pleural granulomas.
*\*although malignancy may present with similar findings, an elevated adenosine deaminase level strongly suggests TB.*
76
Seborrheic keratosis versus Leser-trelat sign
SK can be asymptomatic or cause puritis, pain or bleeding (expecially with friction against clothing or jewelry).
Explosive onset of multiple pruritic SK's (Leser-trelat sign) has been associated with malignancies (expecially lung & GI tumors):
77
Management of skin abscess
78
Spontaneous abortion is due to?
pregnancy loss \<20 weeks gestation
Risk factors include prior spontenous abortion, advanced maternal age, extremes in BMI and maternal substance abuse.
79
Myelomeningocele is also known as?
All almost all patietns with this have an associated?
**spina bifida**
result of the spinal cord and meninges herniated through a defect in the vertebral column.
Almost all patients with spina bifida have assocaited **neurogenic bladder** due to distrubtion of the spinal cord control of normal urinary function.
80
Spina bifida is caused by?
failure of the caudral neuropore to close preoplerly during fetal development.
81
Biospy proven Squamous cell carcinoma should be treated with?
Mohs micrographic surgery or by an excsion of 4mm margins
82
Intention-to-treat analysis (ITT)
analyzes each subject based on randomization group (even if subjects stop the intervention or shift to a different intervention).
This tends to prvide a conservative but more valid estimate of the intervention effect.
ITT is used to help preserve the benefits of randomization in superirity trials.
83
As treated analysis
subjects are evaluated based on teh intervention they received rather than the intervention to which they were randomized. Therefore the benefit of randomization is lost.
84
Solitary pulmonary nodule on routine chest xray
85
Management of the following
Low risk pulmonary nodule
High risk
Intermediate risk
_Low risk pulmonary nodule_ - **serial CT scans**
_High risk_ - **surgical excision**
_Intermediate risk_ - **serial CT scans** (\<0.8 cm) or **fluorodeosyglcouse-positron-emission tomography scan** (\> or = 0.8 cm)
86
Henoch-Schonlein Purpura
What is it?
How does it present?
Diagnosis
HSP is a **pediatic vasculitis** that results from **systemi IgA deposition**
commonly presents with **purpura** in gravidty dependent areas (ex: legs, buttoocks) and a**bdominal pain** from **small-bowel intussception.**
**Athralgis and IgA nephropathy** are also common but manifests later.
**The diagnaosis is primarily clinical.**
87
HSP versus HUS
HUS consists of microangiopathic hemolytic anemia, throbmocytopenia and acute RF that thypciall occurs in patietns age \<5 after an acute bloodly diarrheal illness.
THis patietn has had no precediing diarrhea, making this diagnosis unlikely.
88
HSP versus ITP
Immune thrombocytopenic purpura presents with petechiae or purpura that develop in any skin area spontaneously or with low impact.
Although it often follows an upper respiratory infection, the **abdominal pain and extension distrubtion of the purpura on this patietn's legs are more consistent with HSP than ITP.**
89
TTP versus HSP
TTP is a serious disorder charazterized by the pentad of fever, microangiopathic hemolytic anemia (pallor) thrombocytopenia , renal failure and neurologic impairement (ex: confusion).
This patietn is afebrile and neurologically intact, making htis diagnosis unlikely.
90
Treatmetn of Henoch Schonlein purpura
Suppporitve (hydration & NSAIDS) for most paients
hopsitilization and systemic glucocortioids in patietns with severe symptoms.
91
Management of acute otitis externia
92
What is a charactertisis finding of Otitis Externia?
pain caused by tragal pressure or traction on the auricale
93
Treatment of symptomatic Peripheral artery disease
94
Rash started 3 days ago under her breats and has gradually spread to her chest. No associated pruritis.
What is the most likely organism?
What is the treatment?
**Intertrigo** is most commonly due to **Candidia** infection and causes erythematous plaques and erosions in intertrignious regions (ex: ignuinal, perineal, genital, intergluteal).
**Topical antifungals** (ex: miconazole, nystatin, terbinafine) are the perferred inital therapy.
95
**Corynebacterium minutissimum** is a gram positive bacillus found in normal skin flora that can cause erythrasma, a superficial skin infection affecting intergriginous areas.
Erythrams casues **well defined erythematous patches or thin plaques with fine wrinkling** in the groin, axille, inframmammary region or umbilicus.
96
Cellulitis versus Interigo
**Staph. Aureus causes cellulitis**, which usually presents with **acute-onset erythema, edema and warmth.**
The duration fo the rash and abasence of teh warmth makes this less likely.
97
Tinea cruris versus Intertrigo
**Trichophyton rubrum** casues **tinea curis,** which presents as erythematous patches with sharply demarcated borders, most commonly on the inner thighs.
The patch typically spreads with partial central clearing and can be slightly elevated.
98
Standardized mortality ratio
SMR = observed number of deaths/expected number of deaths
Ex: An SMR of 1.75 indicates that the observed number of deaths amongh the miners in the study is 1.75 times (or 75%) higher than would be expected if these miners had the same death rate as the standard population.
99
Angiodysplasia and colonic ischemia
Angiodysplasia is an uncommon cause of gastrointestinal bleeding and is characterized by painless hemorrhage.
Risk factors include aortic stensos, von willebrand disease and chronic kidney disease.
100
Triad of pulmonary aspergillosis?
common cause of pulonary disease with?
Chest imaging shows?
**cough, pleuritic chest pain, and hemoptysis**
**severe immunocompromise,** particulary those with **prolonged neutropenia or on chronic corticosteriods.**
**Nodules with surrounding ground-glass opaticities** ("halo sign") or **cavitation with air fluid levels.**
101
CMV versus Invasisve aspergillosis
CMV casues fever, cough, dyspnea and diffuse ground glass opacitis (not a nodular infiltrate).
This patient is on CMV prophylaxis iwith valgancicolovir, makign this infection unlikely.
102
Strep pneumo verus invasive pumonary aspergillosis
Strep. Pneumo is the most common bacterial cause of pneumonia, but is usually assocaited with lobar (not a nodular) pulmonary infiltrate and is less likely to occur in the setting of prophylactic levofloxacin.
103
Pneumocystis pneumonia versus Invasive aspergillous
Pnemocysitis Pneumonia is a common infection in patients with **recent stem cell transplant** and usually manifests with diffuse intersitial pulmonary infiltrates and fulminant respiratory failure.
This patient is receiving prophylaxis for Pneumocystis with trimethoprim-sulfamethoxazole.
104
Legionella versus invasive aspergillous
LEgionella can cause cough, chest pain, hemoptysis and a nodular pulmonary infiltrate (although a lobar or an interstitial infiltrate is more common).
However, patietns usually have **high fever and gastrointestional symptoms** (ex: N/V/D) **prior to the onset of the pulmonary symptoms.**
In addtion, this patient is on **levofloxacin**, which is an effective treatment for legionella.
105
Empiric treatment of CAP:
Outpatient
Inaptient (non-ICU)
Inpatient ICU
106
Patients with community acquired pneumonia require risk stratification with what to determine if hospitalization is needed
CURB-65 score of 2 or 3 indicates a need for hospitalization
107
Developmental milestones during toddlerhood
12 months
18 months
2 years
3 years
4 years
5 years
108
What is an important resik factor for acute otitis media
Exposure to cigarette smoke
109
Patient with 3 days of cough, wheezing and SOB and has a drop in peak expiratory flow \>20%
consistent with asthma exacerbation
110
Treatment of Samonellosis
**Does not need to be treated with antibiotics in immunocompetent individuals age 12 months or older.**
Since the gatroenteritis is usually cell limited and anttibiotic use has not been shown to hasten the resolution of symptoms or improve the rate of salmonella clearance from stool, antibiotic usuage is not recommended for immunocompetent adults or children older than one year of age.
\*Think raw egs
111
Indications for implantable cardioverter-defibrillator placement
112
Current guidelines recommend biventricular pacing devices for patietns with
sinus rhythm with a combination of symptomatic heart failure, left ventricular ejection fraction \<35%, and left BBB with QRS duration \> 150 msec.
113
Deep Q waves in leads V1-V4 typically indicate?
previous anterior MI
114
Rhionocerebral mucormycosis is most commonly seen in which type of patients
**is most commonly seen in patients with DKA..**
The organism possesses an enzyme (ketone reductase) that catalzyes growth in high-glucose, acidic environment.
As such , \>70% of patients with mucomycosis have underlying diabetes mellitus, most often with keotacidosis.
115
Rhinocerebral mucomycosis
Presentation?
Treatment?
Acute/agressive
fever, nasal congestion, purulent nasal discharge
**necrotic invasion of the palate, orbit, brain**
**Surgical debridement and IV liposomal amphotercin B.**
116
Actinomyces infection
presentation
treatment
slow-growing, painless mass near the jaw with multiple draining sinus tracts
High dose pencillin treatment
117
Aspergillous versus Rhinocerebral mucomycosis
**Aspergillosis** is ovften treated with **IV voriconazole** and may occasionally present with a clinical profile similar to that of rhino=orbital mucomycosis; however, patietns are **typically neutropenic, not diabetic.**
118
Hand-foot-mouth-disease
caused by **group A coxsackievrus**
that can manifest as an enanthem (herpangina), exanthem, or both.
The enanthem consists of vesicles in the posterior oropharynx, but the exanthem can occur in the palms, soles, buttocks and/or genitalia.
119
Major depression is an independent risk factor for
increased morbidity and mortality in cardiovascular diseaase
120
What is the first linet reatmeent for actute gout flares?
It is contraindicated in patients with?
What should be given instead?
**NSAIDS are first line**
CI in patients with **renal failure.**
Instead give **corticosteriods** - can be injected locally in patients with monoarticular arthritis or given orally in patients with multiple joint involvement.
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Management of choking in children
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Pituitary incidentaloma
Incidentally discovered small lesions in the sellar region are very common.
Patients with a small mass or lesion without any hormonal dysfunction can be safely followed by periodic assessment of the pituitary gland with MRI
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Patients with a single episdoe of MDD should continue antidepressants for how long?
at the same dosage for an additional 6 months following the acute response to reduce the risk of relapse.
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Glucose-6-phosphate dehydrogenase deficiency
presents in the neonatal period on **day of life 2-3** with **unconjugated hyperbilirubinemia and anemia**
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G6PD defiency versus breast milk jaundice
Breast milk jaundice prsents with indirect hyperbilirubinemia over the first few weeks of life and results from increased enterohepatic circulation.
**Breast milk jaundice** **rarely requires therapy, and anemia would not be expected.**
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G6PD deficiency versus Hemolytic disease of the newborn (ABO incomopatibility)
The timing of jaundice development
first 24 hours = Hemolytic disease of the newborn and with a positive direct coombs test, tpyocally in an infant with blood type A or B born to amother with blood type O.
Day 2-3 = G6PD
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Genetic of G6PD
X-linked RBC enzyme defect commonly found in patients of african, middle eastern and southeast asian descent.
This defect increases the susceptibilty of RBCs to hemolyze, which typically occurs on exposure to oxidative stress (ex: sulfa drugs, fava beans).
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G6PD deficiency versus Physiologic jaundice
Physiologic jaundice occurs in almost every newborn due to an increased RBC count with a shorter RBC life span, decreased hepatic bilirubin clearance and icnreased enterohepatic circulation.
Physiologic jaundice is not associated with anemia.
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Meidcal therapy for BPH
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Effect modification
Effect modification is all about **stratification** and occurs when an **exposure has a different effect among different subgroups.** Effect modification is associated with the outcome but not the exposure.
## Footnote
*For example: Aspirin use is associated iwth Reye syndrome in children but not in adults. therefore age (effect modifier) modifies the effect of aspirin (exposure) on Reye syndrome development (outcome)*
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Effect Modification versus Confounding
With confounding (unlike with effect modification), no change in the strength or direction of the effect is typically seen with stratification.
Randomization usually helps remove confounder effects.
**The effect modification is ONLY related to the outcome, but NOT to the exposure.**
**Confounding is related to BOTH the exposure and the outcome.**
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What is the most reliable method for verification of ETT placement in the trachea rather than the esophagus
**Capnography (measurement of CO2 concentration over time).**
Clinical findings, including auscultation of breath sounds over both lung fields, chest wall rise with assisted ventilation, visualization of the ETT passing through the vocal cords, and fogging of the ETT on exhalation, are not reliable indicators of correct placement in the trachea.
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Benign paroxysmal positional vertigo should first be treated with?
Canalith repositioning procedure, which is a series of maneuevers that moves particles o out of the posterior semicircular canal and into the utricle.
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What is benign paroxysmal positional vertigo?
abnormal feeling of motion triggered by certain provocative positions.
the condition is most often attributed to canalithiasis or the presence of calcium "rocks" within the posterior semicircular canal.
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Children with latent TB infection require treatment to prevent converstion to active disease. what is the treatment?
Daily isoniazid for 9 months is the standard of care.
If isonaizid resistance is suspected, the best alternate therapy is daily rifampin for 4-6 months.
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Precocious purbery versus precocious pesudo-puberty
**Precocious puberty** is caused by **premature activation** of the hypothalmaus-pituitary gonad **(HPG) axis. Less dramatic in presentation. Sequential development** of the following is typically present: testicular enlargement, penis enlargement, pubic hair growth and **lastly, a growth spurt.**
**Precocious pseduo-puberty** is caused by a gonadotropin-independent process, typically an excess of sex steriods. has **severe signs of androgen excess (ex: severe cystic acne, significant growth acceleration).**
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Symptoms of Serotonin syndrome
Mental status changes
autonomic dysregulation
neuromuscular hyperactivity
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What is the washout period from switching from a SSRI to an MAOI?
**5 week washout**
* \*The recommended washout period for most antidepressants prior to beginning treatment of MAOI is 14 days.*
* However, due to fluoxetine's long half life, it is recommneded that **at least 5 weeks** elapse between stopping fluoxetine and starting MAOI treatment.*
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Lyme disease is transmitted by Ixodes tick after how many hours of attachment?
Patients with tick attachment less than this should be managed how?
**36-48 hours**
Patients with tick attachment **\<36 hours or with unengorged ticks** are at **low risk for lyme disease. No specific treatment needed.**
Tick saliva may cause **cutaenous irritation** several hours after tick removal; this should not be confused with **erythema migrans,** which takes **three day**s to develop.
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Maternal Thyroid testing in pregnancy, first semester
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Recommended vaccines for adults
The tetanus-diphtheria toxoid booster (Td) vaccine should be given every 10 years to all adults after age 18.
On one occasion, the tetanus diphtheria-pertussis (Tdap) vaccine should be provided in place of Td.
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Clinical clues to renovascular disease
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Marked increased in serum creatinine after initation of ACE inhibitor therapy is highly suggestive of?
Renal artery stenosis (typically bilateral or unilateral stenosis of a solitary kidney or a transplant).
RAS leads to stimulation of the RAAS, which results in HTN\>
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MMR vaccination is contraindicated in?
patients with anaphylaxis to neomycin or gelatin
Severe immunodeficiency or pregnancy.
\*live attenuated vaccine
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The decreased ability to discriminate speech in patients with presbycusis is especially obvious in?
a noisy, distracting environment
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Evaluation of hypoglycemia
To **differentiate from insulinoma from surreptitious medication ingestion** is to obtain a **serum assy for oral hypoglycemic agent**.
If **no medications are detected**, insulinoma becomes mroe likely and **US or CT imaging** can localize the tumor for subsequent surgical resection.
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Nested case control study versus Prospective and restrospective
Proespective and retrospective cohort studies identify 2 groups of individuals (cohorts), based on their exposure status to a risk factor.
These 2 cohorts are then followed over time to assess development of the outcome of interest.
In this example, the cases and controls were selected from indivdiuals within a established follow-up (ex: cohort) study
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Nested case control study
cases and controls from a group of individuals participating in a follow up study (ex: cohort or experimental);
it is subtype of case control study.
The main advantage is that exposure data has arleady been collected for both cases and controls.
This reduces the likelihood of recall bias.
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Risk factors for CRC
family hx
polyposis syndromes (ex: FAP)
IBD
african american race
smoking
alochol
obesity
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Protective factors for CRC
high fiber diet, rich in fruits and vegetables
regular NSAIDs
Hormone replacement therapy
regular exercise
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Absolute contraindication to receiving additional doses of diphtheria-tetanus-acellular pertus
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If Pap testing reveals a high-grade squamous intraepithelial lesion, the next step in management is with either?
**colopsocopy or a diagnostic excisional procedure**
Copposcopy - cervix is magnifed so that the abnormal areas are more easily identified and biopsied.
LEEP - exceision of the cervical transformatin zone and surrounding endoscervix. These are for women \> or = 25 , are not pregnant and have completed childbearing
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Earliest sign for phenytoin toxicity
presence of nystagmus on far lateral gaze.
Initally managed by altering the drug dosage or treatment schedule to minimize drug peaks.
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What is recommended for patients with latent tuberculosis?
Isoniazid treatment for 9 months.
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Differenital diagnosis of neuromuscular weakness
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Degerneration of anterior motor horns
describes spinal muscular atrophy, which causes flaccid paralysis, hyporeflexia and fasciculations.
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Treatment of infant botulism
IV botulism immune globulin should be provided as soon as possible while waiting for confirmatory stool studies.
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Primary ovarian insufficiency refers to?
How do they present?
Diagnosis is confirmed by?
What is it associated with?
POI refers to **loss of ovarian function** (ie, hypoestrogenemia) i**n patients age \<40** and typically presents with **infertility** **and/or irregular menstrual cycles (**ex: secondary amenorrhea).
Diagnosis is confirmed by an **elevated FSH level** **(hypergonadotropic hypogonadism).**
Because POI is associated with **Turner syndrome,** these patients undergo **karytype analysis.**
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