UWORLD 7 Flashcards
Patients with obstructing uterolithiasis associated with infection, acute kidney injury or severe pain that has failed initial measures require?
decompression of the upper urinary tract with percutaneous nephrostomy ureteral stent placement.
Clinical features of patients highly suggestive of cushing’s syndrome?
Screening test done?
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.
Symptoms of fatigue and depression in lithium-treated bipoloar patietns should prompt a workup for?
Management?
hypothyroidism
When lithium induced hypothyroidism develops, it should be treated with levothyroxine and does not typically require lithium discontinuation.
What has been associated with increased lithium levels?
Thiazide diuretics,
Nonsteriodal anti-inflammatory drugs (except aspirin)
and Ace inhibitors.
Cerebral venous sinus thrombosis - most cases are associated with?
Patients with this suually develop what?
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.
Diagnosis of Cerebral venous sinus thrombosis?
Patients are typically treated with?
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.
Clinical findings of SLE
Laboratory findings of SLE
Psychosis in SLE versus Urinary Porphobilinogen
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.
Psychosis in SLE versus Wilson’s diase
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.
MEN 1 is characterized by?
Parathyorid adenomas/hyperplasia
Pancreatic and gastriointestional neuroendocrine tumor (ex: gastrinoma/Zollinger-Ellison syndrome)
Pituitary adenoma (ex: prolactionoma)
MEN 2A verus MEN 2B
Indications for parathyroidectomy in patients with MEN 1
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)
What is a variant of asthma and how does it present?
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.
Tracheomalacia verus cough variant asthma
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.
Recommended dose of Folic acid for generation population versus women who ahve anticonvulsants or have child with neural tube defect?
What is recommended for patients who have contraindications to estrogen (ex: antiphospholipid syndrome)
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.
What is teh best diagnostic test for suspected subprenic or other abdominal abscess?
Abdominal ultrasound
Lesions of the nondominant pariental lobe lesions presents with
Right parietal hemisphere (nondominant parietal lobe)
constructional and dressing apraxia.
patients have difficulty copying simple line drawings. or difficulty in wearing clothes.
Damange to the dominant parietal lobe
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)
Lesions of the dominant temporal lobe causes?
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.
Nondominant parietal lobe lesion versus dominant temporal lobe lesion
Nondominant parietal lobe lesion presents with constructional and dressing apraxia.
Aphasia is typically seen in dominant temporal lobe lesions
First line for prolactinomas?
What if it’s large?
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.
Patients with negative exercise stress test indicates what?
<1% risk of cardiovascular events within the next year.
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)
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 tests:
can be diagnosed with diabetes without repeating confirmatory testing.
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
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.
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)
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.
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.
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)
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.
Group B streptococcus bacteriuria in pregnant women requires
both immediate treatment to prevent OB complications and intrapartum prophylaxis to prevent Group B Strep. disease
Indications for preventing neonatal Group B STrep. infection
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.
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.
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.
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.
After adjusting for age, what remains as the single most important factor in determining the prognosis of patients with COPD?
FEV1
Various types of twin placentation?
Criteria for operative vaginal delivery include?
complete cervical dilation (10cm) and at least +2 fetal station
operative vaginal delivery (ex: forceps)
Delivery mode for diamniotic twin gestation
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.
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.
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.
evaluation of suspected myelopathy
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.
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.
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.
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.
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.
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.
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.
Treatment for pyleoneprhtis in pregnant women
hospitalization and broad-spectrum b-lactam antibiotics (ex: ceftriaxone)
Patients with preterm premature rupture of membranes are at risk for?
umbilical cord prolapse
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
Management of relieving compression off prolapsed cord
elevation of the presenting fetal part to prevent compression of the umblical cord and emergency cesarean delivery.
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).
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.
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.
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.
Patietns with CKD develop?
Inital treatment is?
elevated serum phosphorus levels and hypocalcemia leading to secondary hyperparathyroidism.
- Inital treatmetn is dietary phosphate restriction
2. Phosphate binding agents may be added if serum phosphate is still elevated.
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)
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.
Treatment of lead intoxication
herbal supplement (uses and side effects)
ginkgo biloba
ginseng
saw palmetoo
black cohosh
st. johns wort
kava
licorice
echinacea
ephedra
Evaluation of renal colic during pregnancy
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.
Initial evaluation of BPH
Diphtheria is caused by?
Manifeistations of respirta include?
System absorption may casue?
caused by toxigenic strains of Corynebacterium diphtheria.
Manaifestations of respiratory infection include systemic 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
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):
Management of skin abscess
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.
Biospy proven Squamous cell carcinoma should be treated with?
Mohs micrographic surgery or by an excsion of 4mm margins
Solitary pulmonary nodule on routine chest xray
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)
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 abdominal pain from small-bowel intussception.
Athralgis and IgA nephropathy are also common but manifests later.
The diagnaosis is primarily clinical.
Management of acute otitis externia
Treatment of symptomatic Peripheral artery disease
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.
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.
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.
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.
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.
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.
Empiric treatment of CAP:
Outpatient
Inaptient (non-ICU)
Inpatient ICU
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
Developmental milestones during toddlerhood
12 months
18 months
2 years
3 years
4 years
5 years
Indications for implantable cardioverter-defibrillator placement
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.
Actinomyces infection
presentation
treatment
slow-growing, painless mass near the jaw with multiple draining sinus tracts
High dose pencillin treatment
Management of choking in children
Meidcal therapy for BPH
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.
Symptoms of Serotonin syndrome
Mental status changes
autonomic dysregulation
neuromuscular hyperactivity
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 days to develop.
Maternal Thyroid testing in pregnancy, first semester
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.
Clinical clues to renovascular disease
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.
Absolute contraindication to receiving additional doses of diphtheria-tetanus-acellular pertus
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
Differenital diagnosis of neuromuscular weakness
