UWORLD 9 Flashcards
1
Q
Thyroid nodules management
A
2
Q
Biliary Colic
What is it due to?
How does the patient present?
How long does the entire episode usually last for?
A
Due to hormonal or neural stimuli that contract the gall bladder and force gallstones or sludge into the cystic duct.
The increase pressure within the gallbladder causes pain, which is usually decreased as the gall bladder relaxes and the stone moves back into the cystic duct.
Patient typically develop a constant epigastric or RUQ dullness or discomfort. Pain can radiate to the right shoulder.
The entire episode usually lasts for <6 hours.
Abd. exam is usually benign without peritoneal signs or guarding.
3
Q
What is initally perferred for diagnosing gallstones?
When is it ideally done?
What if patients have a negative result?
A
Transabdominal UltraSound is initally preferred for diagnosing gallstones as it is readily available.
Ideally done after an 8-hour fast and can show gallstones (echogenic foci with shadow) or sludge (echogenic foci without shadow)
Patients with negative US and suspected biliary colic usually have a repeat US in a few weeks.
If the repeat is negative, they likely need further testing (ex: endoscopic US) to evaluate for missed gallstones or microlithiasis.
4
Q
Why is CT less sensitive than ultrasound when it comes to gall bladder disease?
It is frequently done for what purpose?
A
Gallstones can appear isodense with bile and are difficult to distinguish on CT scan of the abdomen.
As a result CT are less sensitive (~55-80%, in most studies) than Ultrasound (which is ~85% sensitive, > 95% specific).
Abd. CT is frequently done to exclude other causes of abdominal pain (ex: pancreatitis, ischemic colitis)
5
Q
Pancreatitis versus Biliary colic presentation
A
Pancreatitis does not usually cause pain that radiates to the shoulder (unlike bilary colic)
Both has midepigastric pain that radiates to the back.
6
Q
Dyspepsia
How does it present?
Treatment for patients <55?
Treatment for patients >55?
A
Can present with > or =1 of the following symptoms:
Postprandial fullness, epigastric pain or burning and early satiety.
<55: PPI therapy; can also benefit from H.pylori testing with treatment if positive
>55: Upper GI endoscopy is indicated for patients >55 or those with alarm feature (ex: odynophagia, dysphagia, unintentional weight loss).
7
Q
Management of gallstones:
Asymptomatic
Typical biliary colic symptoms & Confirmed gallstones
Atypical biliary colic symptoms & Confirmed gallstones
Typical Bililary Colic & NO confirmed gallstones
A
Asymptomatic: No treatment
Typical biliary colic symptoms & Confirmed gallstones: Acute pain management (ex: NSAIDS) and prophylatic elective cholecystectomy (usually laproscoic) to prevent recurrence.
Poor surgical candidates or refuses surgery - can receive a trial of ursodeoxycholic acid (UDCA)
Atypical biliary colic symptoms & Confirmed gallstones - Patients who respond to UDCA undergo cholecystectomy; nonresponders are evaluated for other causes of abdominal pain.
Typical Bililary Colic & NO confirmed gallstones - Cholecystokinin-stimulated cholescintigraphy. Evaluates gall bladder ejection fraction, which is low in patients with functional gall bladder disease.
Patients with a positive test undergo cholecystectomy; those with a negative test are treated empirically for dyspepsia or IBS.
8
Q
Lithotripsy uses what?
When is it used?
It is not as effective for?
A
uses shock waves to fragment and remove difficult bilary and pancreatic duct stones.
However, it is not as effective for gallstones within the gallbladder.
9
Q
choledocholithiasis
where is the stone located?
Presentation - Uncomplicated vesus Complicated
A
Common bile duct stone
Can present with typical biliary colic symptoms (ex: RUQ pain, N/V), but have longer duration of pain and elevated serum liver function studies (elevated bilirubin, ALP, GGT, elevated transaminases)
Uncomplicated - Afebrile, symptomatic, have normal CBC and pancreatic enzymes (amylase, lipase)
Complicated
- complete obstruction of the CBD can cause acute cholangitis (ex: fever, hypotension, mental status changes, leukocytosis)
- Obstruction to the pancreatic duct can cause acute biliary pancreatitis with elevated serum amylase and lipase >3 x normal
10
Q
What is used to diagnose cholelithiasis versus choledocholithiasis?
A
Transabdominal ultrasound is sensitive and specific for diagnosing cholelithiasis, but has lower sensitivty for diagnosing choledocholithiasis.
Patients with uncomplicated choledocholithasis and CBD stone visualized on abdominal US should have endoscopic retrograde cholangiopancreatography (ERCP) for stone removal followed by elective cholecysteomy.
Ultrasound showing dilated CBD without an apparent CBD stone suggests choledocholithiasis but is not specific. As a result, these patients should also have ERCP to confirm the diagnosis and possibly provide therapy for a confirmed CBD stone before undergoing elective cholecystectomy.
11
Q
Cholescintigraphy
What does it use?
When is it used?
A
Uses technetium-labeled heaptic iminodiacetic acid (HIDA) to evaluate for patency of the cystic duct, common bile duct, and ampulla.
Useful for diagnosing suspected cholecystitis in patients with negative or inconclusive ultrasound findings.
12
Q
Management of acute cholecystitis
How does patients present?
A
IV antibiotics & supporitve care (ex: IV fluids, pain control) and immediate cholecystectomy.
Presents with gall bladder inflammation, Fever, RUQ pain and leukocytosis.
13
Q
Thormbotic thrombocytopenia Purpura
Pathophysiology
Presentation
A
Formation of autoantibodies against ADAMTS13, a plasma metalloprotease responsible for cleaving ultralarge strings of vWF off the vascular endothelial wall.
When levels of ADAMTS13 become severely deficient, uncleaved strings of vWF trap and activate platelets, resulting in diffuse microvascular thrombi.
This causes the following:
- Platelet consumption, leading to severe thrombocytopenia
- Intravascular RBC shearing, leading to signs of MAHA, such as schistocytes and elevated indirect bilirubin, lactate dehydrogenase and aminotransferase.
-Organ ischemia, leading to neurologic and renal dysfunction (classically)
14
Q
Treatment of Thrombotic thrombocytopenic purpura
A
Patients who have clinical and laboratory data that supports the diagnosis of TTP require urgent treatment with plasma exchange.
This removes the autoantibody against ADAMTS13 and replenishes the enzyme with ADAMTS13 from donor serum.
15
Q
Von Willebrand disease versus Thrombotic Thrombocytopenic Purpura
Presentation
Treatment
A
VDW has easy brusing and petechaie, but microangiopathic hemolytic anemia is uncommon (unlike TTP)
VWD - Desmopressin increases serum concentration of vWF and is often used in VWD to stop minor episodes of bleeding.
TTP- Plasma exchange
16
Q
DIC versus TTP
A
patients with DIC usually have signs of thrombocytopenia and MAHA due to coagulation cascade activation.
However DIC is usually associated with prolong coagulation testing.
17
Q
TTP versus Immune Thrombocytopenia
A
Antibodies against platelet antigens are responsible for immune thrombocytopenia, which may cause thrombocytopenia, bruising and petechiae.
However, immune thrombocytopenia is not associated with MAHA.
18
Q
For patients with increased risk due to family history of sporadic colon cancer, what is the screening colonoscopy recommendation?
A
beginning at age 40 (or 10 years before the age of cancer diagnosis in the relative, whichever comes first) and should be repeated 3-5 year intervals depending on the finiding.
19
Q
Daily low-dose aspirin is associated with what?
According to the United States Preventive Services Task Force, aspirin can be considered for colon cancer?
A
small decrease risk in colon cancer, as well as cardiovascular events.
However, it is associated with significant upper GI toxicity.
Aspirin can be considered for prevention of colon cancer in individuals whose 10-year risk of cardiovascular events is > or =10%
20
Q
When is bariatric surgery appropriate?
A
patients with BMI > 40 kg/m2 or
with obesity-related comorbidity and BMI > 35 kg/m2
21
Q
Treatment of DVT or PE
A
> or = 3 months of an oral factor Xa inhibitor (ex: rivaroxaban) for patients with DVT or PE who do not have cancer.
Factor Xa inhibitors are considered the first-line therapy because they are administered orally (unlike LMWH) and do not require a heparin bridge or laboratory monitoring (unlike warfarin).
Those with underlying malignancy who develop DVT or PE, a LMWH is considered more efficacious than other Factor Xa inhibitors.
22
Q
Antiplatelet and DVT
A
Antiplatelet therapy such as aspirin is often used for primary and secondary prevention of cardiovascular disease (ex: coronary artery disease, heart attack, stroke).
Antiplatelet therapy is not commonly used in the treatment of DVT.
23
Q
Management of patients who develop DVT while on menopausal hormone therapy (MHT)
A
Should discontinue the MHT and begin an alternative treatment such as SSRI (ex: escitalopram) or SNRI (ex: venlafaxine).
Although the exact mechanism for these medications improve hot flashes is currently unknow, 50-70% of women who receive this therapy have a reduction in symptoms.
24
Q
Primary Biliary Cirrhosis (PBC)
What is it?
Affects mostly?
Disease onset is usually?
Major pathologic feature is?
A
Chronic and progressive liver disease, that is autoimmune in nature
90% are women
Disease onset is usually around 30-65 years of age.
Destruction of small-and mid-sized bile ducts.
There is progressive fibrosis, and end-stage liver disease can supervene 5-10 years after diagnosis.
25
Signs and symptoms of primary billary cirrhosis
How do you diagnose?
**Progressive cholestatsis** and **liver failure** evolving over several years.
Other clinical characteristics include **hyperlipidemia** with **xanthomas**, **bone** disease (osteoporeosis and/or osteomalacia), and **autoimmune** manifestations
**Elevated alkaline phosphatase levels** and **unexplained pruritis**
**Liver biopsy**
26
What antibodies has high sensivity and specificty for PBC?
**Antimitochondrial antibodies (AMA)** have **high sensitivity (\>90%)** and **98% specificity** for **PBC**
27
How does PBC differ from Type I autoimmune hepatitis?
**Anti-mitochondrial antibodies** are specific for **PBC**.
**Anti-smooth muscle antibodies** are mostly associated with **type I autoimmune hepatitis.**
PBC **-** elevation of aminotransferases, **Elevated ALP**
Type I autoimmune hepatitis - elevation of aminotransferases is typical. **ALP level is either normal or elevated.**
28
**Iron overload**
How can it occur?
What does it cause?
How does this differ from PBC?
Can be **primary** (genetic hemochromatosis) or **secondary** (due to excess exogenous sources of iron such as repeated transfusions).
Can cause **liver disease, skin pigmentation, diabetes mellitus, arthropathy, cardiac involvement and hypogonadism.**
**More elevated levels of aminotransferase than ALP** levels (unlike PBC)
29
Wilson disease
Have low levels of what?
How does it differ from PBC?
**low serum cerulopasmin levels.**
**Elevatd levels of ALT and AST, along with hepatomegaly,** are commonly present in **Wilson disease**
where as **elevated ALP levels** are more commonly seen in **cholestatic** diseaes.
30
Treatment of PBC?
What is the curative treatment?
**Ursodeoxycholic acid**
**slows progression** of PBC, **improve** overall survival and maybe transplant-free survival.
**Curative treatment** is **liver transplant.**
31
What is a frequent complication of PBC?
**Bone disease.**
It is important to screen reguarly for osteoporosis and osteomalacia.
32
Clinical features of impaired gastric emptying related to gastric outlet obstruction or delayed gastric motility.
**Nausea, bloating, postprandial fullness and a succession splash**
*\*Succession splash is a splashing sound aucscultated with a stethoscope placed over the LUQ and is suggestive of retained gastric materal.*
33
What is the first step in evaluating impared gatric emptying?
You want to first exclude a mechanical obstruction (intrinsic first)--\> if neg. then rule out (exernal) --\> then finally motility
**Upper Gastrotintestional study** can diagnose an intrinstic obstruction and may show signs of external compression as well.
If **endoscopy is nondiagnostic,** but external malignant compression is still a concern, **abdominal imaging with CT or MRI** can be performed.
**Once mechanical obstruction is ruled out,** confirmatory tests for gastric motility disorders, such as **scintigraphic gastric emptying study**, can be performed.
34
What are your differentials and diagnostic test for delayed gastric emptying?
_Intrinsic obstruction_ - peptic ulcer stricture, gastric malignancy, foreign body, gastric volvulus
Dx: Endoscopy, Upper GI contrast imaging
_Extrinstic obstruction_ - Usually malignant,
Dx: CT, MRI
_Impaired motility -_ Medication (esp. anticholinergic effect), Autonomic neuropathy (esp. diabetic), nerve injury (esp. post-surgical) and idiopathic.
Dx: Nuclear gastric emtpying study, Gastroduodenal manometry
35
What is the first step in management of diabetic gastroparesis?
What can then be used if this is ineffective?
**Dietary modification -** smaller, more frequent meals. Foods that are high in fat or fiber can slow gastric emptying and should be avoided.
**Promotility medications** can be used if dietary changes are no effective or in those with acute worsening of gastroparetic symtoms - **erythromycin** and **metoclopramide**.
36
What medication is used in the treatment of painful diabetic peripheral neuropathy that can worsen diabetic gastroparesis?
Amitriptyline - TCA
TCAs have significant anti-cholindergic effects and can worsen diabetic gastroparesis.
37
Receiver-operating characteristic (ROC) curve helps determine what?
What does the area under the curve (AUC) of a ROC curve reflect?
What does a larger AUC mean?
What would an ideal test have for AUC?
**best cutoff point** to use determine on the optimal desired parameters for **sensitivity and specificity.**
AUC - reflects **better** **discrimination** and **diagnostic accuracy.**
Larger AUC means better **higher diagnostic accuracy.**
Ideal: **AUC of 1.0** (100% sensitivity and specificity) and a non discriminating test would have an **AUC of 0.5** (similar to a coin toss).
38
Test of choice for diagnosing pneumothorax in the acute setting (ex: trauma bay, ICU)?
What does it allow visualization of?
**Bedside ultrasonography**
(Can be more rapidly performed than CXR or CT scan)
Allows visualization of the pareital and visceral pleura; **inability to detect lung sliding** and the 2 layers moving against one another during respiration, is consistent with pneumothroax.
\*Sliding of the pleural line indicates the lack of air between the visceral and parietal pleural, and "rules out" an anterior pneumothorax. When pathologic air accumulates in between the parietal and visceral pleura, ultrasound waves are able to image the superficial parietal layer, but cannot visualize the visceral layer. This is because of the small collection of air in the pleural space that causes ultrasound waves to scatter.
40
When do you highly suspect tension pneumothorax in a patient?
Next step in management?
**Chest trauma with hypotension, tracheal deviation**
Diagnostic confirmation is not needed and urgent treatment can be given with **needle decompression or chest tube placement.**
41
What is the inital test of choice where there is suspicion for **pneumothorax** in the **nonacute** setting (low risk of tension physiology)?
Upright PA CXR.
42
First line agent for treatment for the treatment of childhood
43
Chest radiograph for Allergic Bronchopulmonary Aspergillosis (ABPA) reveals?
upper lobe opacities, atelectasis due to mucus plugging
signs of bronchiectasis such as bronchial wall thickening
44
**Allergic Bronchopulmonary Aspergillosis (ABPA)**
When does it occur?
Inital Evaluation for ABPA should include?
Current diagnostic criteria?
patients with either **underlying asthma or CF** become **sensitized to Aspergillus antigens**, resulting in an **intense IgE and IgG-mediated immune response.**
Skin testing for **Aspergillus** or analysis of **total and specific IgE** concentrations.
Diagnosis:
- Elevated Aspergillus-specific IgE & total IgE,
- positive Aspergillus specific IgG,
- eosinophilia
- a positive skin test reactivity for Aspergillus.
46
Mainstay treatment of Allergic Bronchopulmonary Aspergillosis (ABPA)
What is used to monitor and assess clinical response?
What therapy should also be considered?
Treatment is directed at **acutely stopping the underlying inflammation** and **decreasing fungal burden** to reduce the risk of recurrence.
**Systemic glucocorticoids** are the mainstay therapy and have been shown to improve symptoms during acute exacerbations.
-Speed up the **resolution of lung opacities on radiographic imaging, normalize eosinophil levels, and significantly reduce total IgE**, which is used to monitor and assess clinical response.
Antifungal therapy with **itraconazole** or **voriconazole** should be considered as it has been shown to **reduce the Aspergillus load** and therefore, the antigenic stimulus for ABPA.
It also been shown to **decrease the glucocorticoid** requirements.
47
Acute Hep B infection Management?
Most patients can be managed with **supportive care** and appropriate patient **outpatient follow-up.**
Even symptomatic patients are at **low risk of fulminant hepatic failure or other significant complications.**
**Hospitalization** is generally recommended for **significant fever or hemodynamic instability, impaired hepatic synthetic function** (ex: abnormal coagulation markers), **or signs of fulminant liver failure** (ex: encephalopathy, bilirubin \>10 mg/dL).
48
As patients recover from acute hepatitis B infeciton, there is normally a steady drop in ?
When are they considered chronic HBV infection?
**Both aminotransferase and HBV DNA levels.**
Aminotransferase levels typically normalize within **2-8 weeks.**
Patients who do not clear hepatitis B surface antigen **after 6 months** are diagnosed with progression to chronic HBV infection.
49
When do you give Hepatitis B immunoglobulin and Hepatitis B vaccine?
Administered as postexposure prophylaxis to health care workers exposed to contaminated blood or other body fluids.
Must be given as son a possible (ideally within 12-24 hours of exposure) for maximal efficacy.
50
Approproximate likelihood a patient with acute hepatitis B will develop chronic hepatitis B?
How does this differ from hepatitis C and A?
HEP B:
Patients infected at **age 1-5** have 20-50% progression rate.
**Adults** have **\< or = 5%** progression rate to chronic HBV infection.
HEP C:
**Approx. 75-85%**
HEP A:
**Not known to cause chronic hepatitis**
51
When should levothyroxine be administered on an empty stomach with water **at least how long before breakfast** to ensure adequate and consistent absorption?
What are common offenders that can affect its absorption?
When should it be seperated from levothyroxine?
at least **30-60 minutes** before breakfast
Common offenders include **calcium and iron preparation**.
Supplements should be seperated from levothyroxine by **3-4 hours.**
52
What can decrease levothyroxine absorption?
- bile acid-binding agents (ex: cholestyramine)
- iron, calcium, aluminum hydroxide
- PPI, sucralfate
53
**Thyroid** **Nodules** management?
**Thyroid nodules** should be evaluated using **TSH level** and **thyroid** **ultrasound**.
Patients with **normal or high TSH** and a **confirmed nodule \>1cm** in diameter on ultrasound should undergo **fine-needle aspiration** with nodule cytology.
Patients with **low TSH** should have a **radionuclide thyroid scan** to see if it's a hot nodule or a cold/indeterminate nodule.
54
What can increase TPG concentration?
What do you have to do in terms of levothyroxine reuirements?
- pregnancy, estrogen (oral), tamoxifen, raloxifene
- heroin, methadone
They can increase levothyroxine requirments due ot increased blood levels of thryoxine-binding globuin.
55
Classification of Multiple endocrine neoplasia (MEN)
56
What can decrease TBG concentration?
- androgens, glucocorticoids
- anabolic steriods
- slow release nicotinc acid
57
Management of **thyroid scan results**?
Low TSH levels should be evaluated using thyroid scan, usually with iodine 123.
A **hyperfunctioning (hot) nodule** (increased isotope uptake in the nodule) with decreased surrounding uptake) is **rarely malignant** and may be **treated as benign hyperthyroidism.**
**An indterminate or hypofunctioning ("cold") nodule** indicates a higher risk of cancer and requires further evaluation with FNA.
59
What does all patients with medullary thyroid cancer require?
Serum calcitonin and carcinoembroynic antigen,
neck ultrasound (evaluate regional metastases)
genetic testing for germline RET mutations
and evaluation for coexisting tumors (hyperparathyroidism, pheochromocytomas)
60
What is usually elevated in Pheochromocytoma?
How do you confirm this?
**Plasma-free metanephrines**
confirmed with **24-hour urinary fractionated metanephrines, catecholamines and abominal imaging.**
61
Management of breech presentation.
Breech presentaiton occurs when the feet or buttocks are the closest presentating part to the cervix.
Most preterm fetuses are in breech presentation; however, **most spontaneously convert to cephalic presentation by term** (ex: 37 weeks geestation)
**External cephalic version** (foward roll) is offered to patients with persistent breech presentation at 37 weeks gestation to **rotate the fetus to a cephalic presentation.**
62
What presentation is an absolute contraindication to vaginal delivery?
Footling breech presentation
63
Inital Management of palpable breast mass in those \<30 of age versus \>30?
\<30 - ultrasound
- If it has benign features, do mammography.
- if atypical features, do core needle biopsy.
\>30 - Diagnositic mammogram
\*Mammogram has a higher sensitivity and specificity in women over the age of 30.
A mammogram is not as sensitive or specific for inital eval in \<30 because breast tissue is usually denser ini those less than 30. An US has better sensitivity and specificity for inital evaluation
64
A score of less than what point is suggestive of dementia or delirium on the MMSE
Less than 24.
Highest score is 30.
65
What is the most effective oral emergency contraception?
When may it be taken?
How does it compare to levonorgestrel for emergency contraception?
What is the most effective form of emergency contraception? What is it contraindicated in?
**Ulipristal**, an antiprogestin, is the most effective oral emergency contraceptive
**may be take up to 5 days after unprotected intercourse.**
**OCP with progesterone doses** equivalent to levonorgestrel (second-line treatment) can be used as a form of emergency contraception.
However, OCP are **less** **effective** than ulipristal (75% compared to greater than 85%) and **have** **more** **side** **effects** (ex: nausea, vomiting)
**Copper IUD** is the most efficous form of emergency contraception, more effective than emergency oral contraceptives, 99% pregnancy prevention, but it is **contraindicated** **in acute** **cervitiis** (ex: friable cervix, multiple polymorphonuclear leukocytes on microscopy)
66
Postexposure prophylaxis for sexual assault
(infection and medication)
**HIV** (3-drug regimen (ex: tenofovir-emtricitabline with raltegravir)
**Hepatitis B** (vaccine & immune globulin)
**Chlamydia** (Azithromycin)
**Gonorrhea** (Ceftriaxone
**Trichomonas** **Vaginalis** (Metronidazole)
**HIV prophylaxis i**s offered up to **72 hours after the assault.**
67
**PEDIATRIC VACCINES**
**live attenuated**?
**Inactivated (killed)**?
**Toxoid (inactivated toxin)**?
**Subunit/conjugate?**
**Live attenuated - Rotavirus, MMR, Varicella**
*\*live virus that has been weakened to the point that it is incapable of causing disease*
**Inactivated (killed) - Polio and Hepatitis A**
*\*Virus that is killed and completely incapable of causing disease*
**Toxoid (inactivated toxin)** - **Diphtheria, tetanus**
*\*Toxoids are bacterial toxins that have been inactivated by heat/chemical. When injected, it stimulates production of antitoxins.*
**Subunit/conjugate - Hep B, Haemophilus Influenzae type B, Pertussis, Pneumococcal, Meningococcal, Influenza (injection)**
*\*connect outer sugar-like coatings found on bacteria to proteins to induce an immune response*
68
Varicella vaccine can be administered safely to a patient who lives with a pregnant women.
Isolation from a pregnant women is unnecessary unless?
The risk of post-vaccination rash is very low. Isolation from a pregnant patient is **unncessary unless the vaccinated patient develops a rash.**
69
What vaccine should pregnant women not receive?
what about household members?
**Pregnant women should not recieve LIVE vaccines**, but their **household members should get all** routine immunizations on schedule.
**Delaying vaccines is not recommended,** as vaccines make it less likely that children will contract the disease and expose pregnant women to wild-type infection.
70
Patients with suspected active TB require?
Patients with abnormal results need what?
What is the gold standard for diagnosing active TB?
**Chest imaging** to document findings consistent with pulmonary TB (ex: infiltrates, cavitation)
Abnormal imaging should **submit 3 sputum specimens** for **acid-fast bacillus smears and culture** (preferably in 8-24 hour intervals, with at least one earl-morning sputum specimen).
Sputum microscopy is the **easiest and least invasive** procedure for confirming suspected active pulmonary TB.
**GOLD standard** for diagnosing active TB (98% specific, 81% sensitive)
71
Bronchoscopy with bronchoalveolar lavage and TB
When is it used?
usually reserved for confirming the diagnosis in patients who
- **unable** to produce adquate expectorated or induced **sputum** **samples**,
- who have a **negative sputum studies with high suspicion for active TB** or
who have a **possible alternate diagnosis.**
72
Latent Tuberculosis infection can be diagnosed by?
Its effects on BCG vaccinated patients?
**Positive tuberculin skin test or interferon-gamma release assay (IGRA)** in the absence of active TB.
PPD testing can assess previous exposure, but can be negative in 10-25% of patients with active pulmonary TB.
In addition, **PPD may be difficult to interpret in Bacillus Calmette-Guerin (BCG)** vaccinated patients.
**IGRA has no interfernce in BCG vaccinated patients,** but also cannot differentiate between latent and active TB.
**Neither test would be helpful in patients with suspected active TB.**
73
PPV of 3 sputum samples for acid -fast bacilli (AFB) testing can range from ?
If a patient has clinical features for TB, do you wait for results?
90% for diagnosing active TB, but AFB has low sensitivity for ruling out TB.
**Patient will 3 negative smears are considered noninfectious.**
patients with clinical features of active TB should recieve empiric treatment while awaiting for sputum culture results which will provide the definitive diagnosis.
74
PPD Duration and when to treat patients
**\>or = to 5**
* HIV positive,
* Recent contacts of known TB
* Nodular or fibrotic changes on CXR consistent with previous healed TB
* immunosuppressed patients (Organ transplant)
**\> or = to 10**
* Recent immigrants (\<5 years)
* IV users
* Residents & employees of high risk settings
* Higher risk for TB reactivation (diabetes, corticosteriod therapy, leukemia, ESRD)
* Children \<4, or those exposed to adults in high risk categories
\> or = to 15
- Healthy individuals
75
PCP
What is it?
Symptoms?
First line treatment for intoxication?
**Hallucinogen, NMDA receptor antagonist.**
**(aka angel dust)**
**agitated, combative, HTN, tachycardia, ataxia, Prominant nystagmus (including horizontal, vertical or rotary nystagmus)**
**PCP intoxication l**eading to **severe agitation and violent behavior** should be immediately treated with **Benzodiazepines** (ex: lorazepam) to provide sedation.
If **mild** symptoms, a **low stimulation environment (with or without benzodiazpines)** is more appropriate with patients with milder symptoms of PCP intoxication.
76
What would you expect to see in a patient with chronic adrenal insuffiency?
What are characteristic lab findings?
**Increased pigmentation, decreased axillary and public hair, fatigue, weight loss, myalgias.**
**Hyponatremia, Hyperkalemia, and hyperchloremic metabolic acidosis**
\*Hyperpigmentation occurs due to increased production of ACTH/Melanocyte-stimulating hormone.
\***Hyponatremia** occurs as a result of both the loss of sodium and volume caused by **mineralocorticoid** **deficiency** and **increased vasopressin secretion (helps kidney reabsorb water)** due to **cortisol deficiency.** This at times results in significant salt craving.
**Hyperkalemia** is often associated with a **mild hyperchloremic acidosis** due to a deficiency in **mineralocorticoids**.
77
**Adrenal Insuffciency**
What is the most common etiology?
Diagnosis?
**Primary adrenal insufficiency** (Addison's disease)
Confirmed with **low morning plasma cortisol** and **elevated ACTH (**often performd with an ACTH stimulation test to expediate the evaluation)
78
Eating disorder versus adrenal deficiency
Both have weight loss and menstraul irregularities as well as electrolyte abnormalities.
**However**, **hyperpigmentation and signs of adrenal insufficency deficiency**, **would not be expected.**
79
Physician and informal treatment to friends
Physicians must consider ethical issues when asked to provide informal treatment to friends.
Treating friends should generally be **limited to emergency situations when no other care is available.**
80
Definition and calculation for sensitivity
The probability of a diseased person testing positive.
Sensitivity = TP/(TP+FN)
81
Definition and calculation of specificity
The probablity of a nondiseased person testing negative
Specificity = TN/ (TN+FP)
82
Definition and Calculation of PPV
The probablity that disease is present given a positive result
PPV=TP/(TP+FP)
83
Probablity and Calculation of NPV
The probablity that disease is absent given a negative result
NPV=TN/(TN+FN)
84
Defintion and Calculation of Positive likelihood ratio
A ratio representing the likelihood of having the disease given a positive result.
LR+ = Sensitivity / (1-Specificity)
85
Definition and Calculation of Negative Likelihood Ratio
A ratio representing the likelihood of having the disease given a negative result
LR - = (1-Sensitivity) / Specificity
86
What is (are) dependent on prevalence of the disease in the tested population?
What instrinstic test factors that are not affected by disease prevalence?
PPV & NPV.
Not affected: Sensitivy & Specificity
87
To exclude a disease in a patient, tests with high what would be helpful to help rule out a diagnosis?
Tests with High ****_S_**ensitivy** would be most helpful as ****_n_**egative** results on such tests help to rule **out** a diagnosis **(SnNout)**
88
General Guidelines for Likelihood Ratio Interpretation
**\> 10** - **Strong** evidence to **rule in** the disease
**5-10 - Moderate** evidence to **rule in** the disease
**2-5 - Weak** evidence to **rule in** the disease
**0.5-2 - No evidence** to **rule in or rule out** the disease
0. 2-0.5 - **Weak** evidence to **rule out** the disease
0. 1-0.2 - **Moderate** evidence to **rule** **out** the disease
\<0.1 - **Strong** evidence to **rule out** the disease
89
Odds Ratio
Where is it calculation?
What does it compare?
**Case-control studies**
compares the exposure of participants **with the disease (cases)** to the exposure of those **without the disease (controls)**
90
Relative Risk
What is it?
Where and how is it calculated?
Calculated in **cohort** studies
particpants are **followed over time** to **assess a risk factor** for developing a given disease.
Relative risk is the ratio of the probablity of an outcome occuring in the **exposed group** compared to the probablity of it occuring in the **non-exposed** group.
91
Verification Bias
What is it?
What is a possible method to reduce this?
a type of **merasurement bias** that occurs when a study **uses gold standard testing selectively** in order to confirm a positive (or negative) result of preliminary testing; this can **result in overestimates (or underestimates) of sensitivy (or specificity)**
To reduce this: Perform **gold standard testing** in a random sample of participants with negative results.
The results from this analysis can be used to extrapolate the likely number of cases that would have been found if all participants with negative screen tests had been fully investigated with gold standard testing
92
Contamination bias
Occurs when the **control group** **unintentionally receives the treatment or the invervention,** thereby reducing the difference in outcomes between the control and treatment group.
93
Observer bias
What is it?
How do you avoid this?
Occurs when an **observer** responsible for recording results is **influenced by prior knowledge** about participants or study details.
**Binded studies** usually avoid this bias by preventing observers from knowing which treatment or intervention the particpates are receiving; this leads to a **more objective measurement** of outcomes.
94
Selection bias
What is it?
What can reduce this?
Study participants are **selected or lost to follow-up.**
**Randominzation** in a clinical trial reduces selection bias
95
Susceptibility bias
Defintion and what type of bias is this?
Type of **selection** **bias**
Experimental and control groups differ from a prognostic standpoint, possibly due to **unforeseen confounding** **variables**.
*Groups being compared are not equally susceptible to the outcome of interest, for reasons other than the factors under study*
96
**Actinic Keratosis**
What is it?
Where does it commonly occur?
Lesions are characterized by?
**premalignant** condition to **squamous cell carcinoma** (SCC) caused by **excessive** **sunlight** (UV exposure).
Most commonly occur in **sun-exposed spots** (face, scalp, ears, upper chests, dorsal hands and forearms)
lesions are characterized by **small, rough, erythematous and keratotic** **papules**
97
A score of less than what point is suggestive of dementia or delirium on the MMSE
Less than 24.
Highest score is 30.
98
Basal Cell Carcinoma
Metastatic potential?
Typical Appearance?
Association with sunlight and actinic keratosis?
**Common skin malignancy** with **low metastatic potential.**
**Enlarging fleshy nodule with ulceration**
Also associated with **sun exposure**
Patients with history of heavy UV light exposure may develop both AK and BCC, but **BCC does nto arise from AK.**
99
Leser-Trelat sign
What is it?
How does the lesions look?
What is it associated with?
**acute** onset of **numerous seborrheic keratoses**
lesions are often **pruritic and inflammed.**
Associated with many **internal** **malginancies**, most commonly **adenocarcinoma of the gastrointestional tract**
100
Mycosis Fungoides
What is it?
How does it appear?
Extradermal spread may cause what?
**Cutaneous T-cell Lymphoma**
**Highly variable appearance** and may present as papules or plaques, hyper or hypo-pigmented patches, nonspecific ertyhema or subcuntaneous tumors.
Extradermal spread of the malignancy may cause **regional lymphadenopathy, infiltration of the lung, liver, or spleen, and occassionally, there can be bone marrow and CNS involvement.**
101
Malignant melanoma
Association?
What can also correlate with risk of melanoma?
Association with Actinic keratosis?
Associated with excessive UV exposure, especially in fair-skinned whites of non-hispanic origin.
Large number of **nevi and atypical nevi** also correlate with the risk of melanoma.
**Actinic keratosis does not predipose to melanoma.**
102
Management of Actinic Keratosis?
Why is it important?
**Individual** **lesions** can be destroyed with **liquid nitrogen cryosurgery** or by **surgical** **excision** or **curettage**.
**Field therapy** (ex: 5-flurorouracil cream, topical diclofenac, imiquimod) is recommended when **numerous small lesions** are present).
The **majority of Squamous Cell Carcinoma** arises from **pre-existing Actinic Keratosis.**
For this reason, any AK lesions that are detectd **should be removed or destroyed**
103
What is the most effective oral emergency contraception?
When may it be taken?
How does it compare to levonorgestrel for emergency contraception?
What is the most effective form of emergency contraception? What is it contraindicated in?
**Ulipristal**, an antiprogestin, is the most effective oral emergency contraceptive
**may be take up to 5 days after unprotected intercourse.**
**OCP with progesterone doses** equivalent to levonorgestrel (second-line treatment) can be used as a form of emergency contraception.
However, OCP are **less** **effective** than ulipristal (75% compared to greater than 85%) and **have** **more** **side** **effects** (ex: nausea, vomiting)
**Copper IUD** is the most efficous form of emergency contraception, more effective than emergency oral contraceptives, 99% pregnancy prevention, but it is **contraindicated** **in acute** **cervitiis** (ex: friable cervix, multiple polymorphonuclear leukocytes on microscopy)
104
Postexposure prophylaxis for sexual assault
(infection and medication)
**HIV** (3-drug regimen (ex: tenofovir-emtricitabline with raltegravir)
**Hepatitis B** (vaccine & immune globulin)
**Chlamydia** (Azithromycin)
**Gonorrhea** (Ceftriaxone
**Trichomonas** **Vaginalis** (Metronidazole)
**HIV prophylaxis i**s offered up to **72 hours after the assault.**
105
**PEDIATRIC VACCINES**
**live attenuated**?
**Inactivated (killed)**?
**Toxoid (inactivated toxin)**?
**Subunit/conjugate?**
**Live attenuated - Rotavirus, MMR, Varicella**
*\*live virus that has been weakened to the point that it is incapable of causing disease*
**Inactivated (killed) - Polio and Hepatitis A**
*\*Virus that is killed and completely incapable of causing disease*
**Toxoid (inactivated toxin)** - **Diphtheria, tetanus**
*\*Toxoids are bacterial toxins that have been inactivated by heat/chemical. When injected, it stimulates production of antitoxins.*
**Subunit/conjugate - Hep B, Haemophilus Influenzae type B, Pertussis, Pneumococcal, Meningococcal, Influenza (injection)**
*\*connect outer sugar-like coatings found on bacteria to proteins to induce an immune response*
106
Varicella vaccine can be administered safely to a patient who lives with a pregnant women.
Isolation from a pregnant women is unnecessary unless?
The risk of post-vaccination rash is very low. Isolation from a pregnant patient is **unncessary unless the vaccinated patient develops a rash.**
107
According to hte Organ Procurement and Transplant Network, what age do they consider an absolute contraindication for organ donation?
**Less than 18.**
There are ethical issues with allowing children to be organ donors because they are not capable of giving the appopriate consent required.
108
What vaccine should pregnant women not receive?
what about household members?
**Pregnant women should not recieve LIVE vaccines**, but their **household members should get all** routine immunizations on schedule.
**Delaying vaccines is not recommended,** as vaccines make it less likely that children will contract the disease and expose pregnant women to wild-type infection.
109
Patients with suspected active TB require?
Patients with abnormal results need what?
What is the gold standard for diagnosing active TB?
**Chest imaging** to document findings consistent with pulmonary TB (ex: infiltrates, cavitation)
Abnormal imaging should **submit 3 sputum specimens** for **acid-fast bacillus smears and culture** (preferably in 8-24 hour intervals, with at least one earl-morning sputum specimen).
Sputum microscopy is the **easiest and least invasive** procedure for confirming suspected active pulmonary TB.
**GOLD standard** for diagnosing active TB (98% specific, 81% sensitive)
110
Bronchoscopy with bronchoalveolar lavage and TB
When is it used?
usually reserved for confirming the diagnosis in patients who
- **unable** to produce adquate expectorated or induced **sputum** **samples**,
- who have a **negative sputum studies with high suspicion for active TB** or
who have a **possible alternate diagnosis.**
111
Latent Tuberculosis infection can be diagnosed by?
Its effects on BCG vaccinated patients?
**Positive tuberculin skin test or interferon-gamma release assay (IGRA)** in the absence of active TB.
PPD testing can assess previous exposure, but can be negative in 10-25% of patients with active pulmonary TB.
In addition, **PPD may be difficult to interpret in Bacillus Calmette-Guerin (BCG)** vaccinated patients.
**IGRA has no interfernce in BCG vaccinated patients,** but also cannot differentiate between latent and active TB.
**Neither test would be helpful in patients with suspected active TB.**
112
PPV of 3 sputum samples for acid -fast bacilli (AFB) testing can range from ?
If a patient has clinical features for TB, do you wait for results?
90% for diagnosing active TB, but AFB has low sensitivity for ruling out TB.
**Patient will 3 negative smears are considered noninfectious.**
patients with clinical features of active TB should recieve empiric treatment while awaiting for sputum culture results which will provide the definitive diagnosis.
113
PPD Duration and when to treat patients
**\>or = to 5**
* HIV positive,
* Recent contacts of known TB
* Nodular or fibrotic changes on CXR consistent with previous healed TB
* immunosuppressed patients (Organ transplant)
**\> or = to 10**
* Recent immigrants (\<5 years)
* IV users
* Residents & employees of high risk settings
* Higher risk for TB reactivation (diabetes, corticosteriod therapy, leukemia, ESRD)
* Children \<4, or those exposed to adults in high risk categories
\> or = to 15
- Healthy individuals
114
PCP
What is it?
Symptoms?
First line treatment for intoxication?
**Hallucinogen, NMDA receptor antagonist.**
**(aka angel dust)**
**agitated, combative, HTN, tachycardia, ataxia, Prominant nystagmus (including horizontal, vertical or rotary nystagmus)**
**PCP intoxication l**eading to **severe agitation and violent behavior** should be immediately treated with **Benzodiazepines** (ex: lorazepam) to provide sedation.
If **mild** symptoms, a **low stimulation environment (with or without benzodiazpines)** is more appropriate with patients with milder symptoms of PCP intoxication.
115
What would you expect to see in a patient with chronic adrenal insuffiency?
What are characteristic lab findings?
**Increased pigmentation, decreased axillary and public hair, fatigue, weight loss, myalgias.**
**Hyponatremia, Hyperkalemia, and hyperchloremic metabolic acidosis**
\*Hyperpigmentation occurs due to increased production of ACTH/Melanocyte-stimulating hormone.
\***Hyponatremia** occurs as a result of both the loss of sodium and volume caused by **mineralocorticoid** **deficiency** and **increased vasopressin secretion (helps kidney reabsorb water)** due to **cortisol deficiency.** This at times results in significant salt craving.
**Hyperkalemia** is often associated with a **mild hyperchloremic acidosis** due to a deficiency in **mineralocorticoids**.
116
**Adrenal Insuffciency**
What is the most common etiology?
Diagnosis?
**Primary adrenal insufficiency** (Addison's disease)
Confirmed with **low morning plasma cortisol** and **elevated ACTH (**often performd with an ACTH stimulation test to expediate the evaluation)
117
Eating disorder versus adrenal deficiency
Both have weight loss and menstraul irregularities as well as electrolyte abnormalities.
**However**, **hyperpigmentation and signs of adrenal insufficency deficiency**, **would not be expected.**
118
Physician and informal treatment to friends
Physicians must consider ethical issues when asked to provide informal treatment to friends.
Treating friends should generally be **limited to emergency situations when no other care is available.**
119
**Actinic Keratosis**
What is it?
Where does it commonly occur?
Lesions are characterized by?
**premalignant** condition to **squamous cell carcinoma** (SCC) caused by **excessive** **sunlight** (UV exposure).
Most commonly occur in **sun-exposed spots** (face, scalp, ears, upper chests, dorsal hands and forearms)
lesions are characterized by **small, rough, erythematous and keratotic** **papules**
120
Malignant melanoma
Association?
What can also correlate with risk of melanoma?
Association with Actinic keratosis?
Associated with excessive UV exposure, especially in fair-skinned whites of non-hispanic origin.
Large number of **nevi and atypical nevi** also correlate with the risk of melanoma.
**Actinic keratosis does not predipose to melanoma.**
121
Mycosis Fungoides
What is it?
How does it appear?
Extradermal spread may cause what?
**Cutaneous T-cell Lymphoma**
**Highly variable appearance** and may present as papules or plaques, hyper or hypo-pigmented patches, nonspecific ertyhema or subcuntaneous tumors.
Extradermal spread of the malignancy may cause **regional lymphadenopathy, infiltration of the lung, liver, or spleen, and occassionally, there can be bone marrow and CNS involvement.**
122
Leser-Trelat sign
What is it?
How does the lesions look?
What is it associated with?
**acute** onset of **numerous seborrheic keratoses**
lesions are often **pruritic and inflammed.**
Associated with many **internal** **malginancies**, most commonly **adenocarcinoma of the gastrointestional tract**
123
Basal Cell Carcinoma
Metastatic potential?
Typical Appearance?
Association with sunlight and actinic keratosis?
**Common skin malignancy** with **low metastatic potential.**
**Enlarging fleshy nodule with ulceration**
Also associated with **sun exposure**
Patients with history of heavy UV light exposure may develop both AK and BCC, but **BCC does nto arise from AK.**
124
Definition and calculation for sensitivity
The probability of a diseased person testing positive.
Sensitivity = TP/(TP+FN)
125
Definition and calculation of specificity
The probablity of a nondiseased person testing negative
Specificity = TN/ (TN+FP)
126
Definition and Calculation of PPV
The probablity that disease is present given a positive result
PPV=TP/(TP+FP)
127
Probablity and Calculation of NPV
The probablity that disease is absent given a negative result
NPV=TN/(TN+FN)
128
Defintion and Calculation of Positive likelihood ratio
A ratio representing the likelihood of having the disease given a positive result.
LR+ = Sensitivity / (1-Specificity)
129
Definition and Calculation of Negative Likelihood Ratio
A ratio representing the likelihood of having the disease given a negative result
LR - = (1-Sensitivity) / Specificity
130
What is (are) dependent on prevalence of the disease in the tested population?
What instrinstic test factors that are not affected by disease prevalence?
PPV & NPV.
Not affected: Sensitivy & Specificity
131
To exclude a disease in a patient, tests with high what would be helpful to help rule out a diagnosis?
Tests with High ****_S_**ensitivy** would be most helpful as ****_n_**egative** results on such tests help to rule **out** a diagnosis **(SnNout)**
132
General Guidelines for Likelihood Ratio Interpretation
**\> 10** - **Strong** evidence to **rule in** the disease
**5-10 - Moderate** evidence to **rule in** the disease
**2-5 - Weak** evidence to **rule in** the disease
**0.5-2 - No evidence** to **rule in or rule out** the disease
0. 2-0.5 - **Weak** evidence to **rule out** the disease
0. 1-0.2 - **Moderate** evidence to **rule** **out** the disease
\<0.1 - **Strong** evidence to **rule out** the disease
133
Odds Ratio
Where is it calculation?
What does it compare?
**Case-control studies**
compares the exposure of participants **with the disease (cases)** to the exposure of those **without the disease (controls)**
134
Susceptibility bias
Defintion and what type of bias is this?
Type of **selection** **bias**
Experimental and control groups differ from a prognostic standpoint, possibly due to **unforeseen confounding** **variables**.
*Groups being compared are not equally susceptible to the outcome of interest, for reasons other than the factors under study*
135
Management of Actinic Keratosis?
Why is it important?
**Individual** **lesions** can be destroyed with **liquid nitrogen cryosurgery** or by **surgical** **excision** or **curettage**.
**Field therapy** (ex: 5-flurorouracil cream, topical diclofenac, imiquimod) is recommended when **numerous small lesions** are present).
The **majority of Squamous Cell Carcinoma** arises from **pre-existing Actinic Keratosis.**
For this reason, any AK lesions that are detectd **should be removed or destroyed**
136
Selection bias
What is it?
What can reduce this?
Study participants are **selected or lost to follow-up.**
**Randominzation** in a clinical trial reduces selection bias
137
Observer bias
What is it?
How do you avoid this?
Occurs when an **observer** responsible for recording results is **influenced by prior knowledge** about participants or study details.
**Binded studies** usually avoid this bias by preventing observers from knowing which treatment or intervention the particpates are receiving; this leads to a **more objective measurement** of outcomes.
138
Contamination bias
Occurs when the **control group** **unintentionally receives the treatment or the invervention,** thereby reducing the difference in outcomes between the control and treatment group.
139
According to hte Organ Procurement and Transplant Network, what age do they consider an absolute contraindication for organ donation?
**Less than 18.**
There are ethical issues with allowing children to be organ donors because they are not capable of giving the appopriate consent required.
140
Verification Bias
What is it?
What is a possible method to reduce this?
a type of **merasurement bias** that occurs when a study **uses gold standard testing selectively** in order to confirm a positive (or negative) result of preliminary testing; this can **result in overestimates (or underestimates) of sensitivy (or specificity)**
To reduce this: Perform **gold standard testing** in a random sample of participants with negative results.
The results from this analysis can be used to extrapolate the likely number of cases that would have been found if all participants with negative screen tests had been fully investigated with gold standard testing
141
Relative Risk
What is it?
Where and how is it calculated?
Calculated in **cohort** studies
particpants are **followed over time** to **assess a risk factor** for developing a given disease.
Relative risk is the ratio of the probablity of an outcome occuring in the **exposed group** compared to the probablity of it occuring in the **non-exposed** group.
142
Toxic thyroid nodules are characterized by?
Definitive treatment?
Patients should be treated with?
What medication is preferred?
aka toxic adenoma
**increased radioiodine uptake** in the nodule and **suppressed uptake in the remainder of the gland**.
Definitive treatment with **surgery or raidoactive iodine ablation** is recommended for patients with overt hyperthyroidism. Surgery is preferred for those with large goiters, obstructive symptoms or suspected thyroid cancer.
Patients should be treated with **antithyroid** drugs to achieve **euthyoridism prior to surgery**
**methimazole** is preferred over pryopythiouracil for most paiients.
143
Methimazole versus propylthiouracil
Methimazole is preferred over PTU for most patients due to the risk of severe hepatotosicty with PTU.
PTU is preferred if hyptheryoidism is diagnosed in the first trimester of pregnancy as methimazole is associated with most severe teratogenic effects.
144
During treatment of unconjugated hyperbilirubinema, phototherapy should continue until?
Exchanged transfusions should be considered if bilirubin is at what levels?
**continued until bilirubin declines to below threshold levels.**
**Exchange transfusion** should be considered if bilirubin is at **toxic levels (\<20-25)**
145
Development dysphasia of the hip (DDH) is characterized by?
What are the classic symptoms and signs during the newborn period?
What is seen in adolescents if its missed in newborn period?
**abnormal acetabular development,** resulting in shadow hip socket and adequate support of the femoral head.
hip clunk, asymmetric leg creases
Misaligned and dysplastic hip undergoes **accelerated cartilate wear,** resulting in **chronic activty related hip pain** and **premature join degeneration** in adolescents and young adults.
146
Osteoid osteoma
benign tumor most commonly occuring in the proximal femur in adolescents.
Typical presentation is signifcant pain at night rather than with activity.
147
slipped capital femoral epiphysis
patients are classically overweight adolescents with limited internal rotation of the hip
148
Legg Calve Perthes disease
avascular necrosis of the femoral's head.
idopathic interuption of the blood supply can result in limp and /o rhip pain, typically at age 5-7
Age and leg-length discrepancy is not typical.
149
Pineal tumor
typically causes parinaud's syndrome (aka midbrain syndrome)
- **loss of pupllary reaction, vertical gaze paralysis and loss of optokinetic nystagmus and ataxia**
**headache** is the prominent feature due to obstructive hydrocephalus.
**Some** pineal tumors are **gernminomas** and **secrete HCG,** which can cuase precousious pubertyin prepubertal males.
*\*vertical gaze palsy, and Sunset Sign, is an inability to move the eyes up and down. It is caused by compression of the vertical gaze center at the rostral interstitial nucleus of medial longitudinal fasciculus (riMLF).*
150
Craniopharyngiomas
classically assocaited with diabetes insipidus and a defiency of one mor emore antierior pituitary hormones
151
eye findings in Multiple sclerosis
are due to the involvement of medial longitudinal fasciculus, which leads to internuclear opthalopegia.
*INO is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction*
Bilateral or unilateral optic neuritis can also occur.
152
Frontal lob tumors
can be silent
when symptomatic, these tumors present with headaches, focal neurological deficits, or seizures.
**Loss of inhibition** from the frontal lobe can cause the release of **primitive reflexes** such as **glabellar tap, grasp or plamomental reflexes.**
Frontal lobe tumors can be assocated with **Foster kennedy syndrome** (optic atrophy on the side of the tumor and papilledema on the contralateral side)
153
Pitutiary tumor with suprsellar extension can cause
bitemporal hemianopsia.
Patientss with pituitary tumors can present with hormonal dysfunction, depending on the secretory state and size of tumor.
154
Approach to childhood lead poisioning
155
Diagnosis of Brain death - clinical criteria
156
If clinical criteria of brain death is present, what is the next examination done?
What is this followed by?
157
Children with blood levels in the mid intoxication range (\<45) should have a
repeat venous blood level within 1 month to confirm that the value is not increasing
158
What is preferred first line treatment in patietns with alopecia areata
Topical or intralesional corticosteriods.
159
Immune thrombocytopenia
160
ITP is characterized by?
What is it due to?
normal coagulation factors and isolated thrombocytopenia without any obvious etiology.
antiplatelet autoantibodies that remove circulating platelets.
161
DIC versus ITP
DIC is a consumptive coagulopathy (leading to bleeding and thrombosis) usually associated with sepsis, trauma, malignancy or obsteric complications.
DIC typically causes **elevated D-dimer** (due to accelerated fibrinolyis), **prolonged prothrombin time** (PT) **and activated partial thromboplastin time** (aPTT) due to depletion of clotting factors), often with **low fibrinogen** (due to consumption).
This patients normal d-dimer, PT and aPTT makes DIC less likely.
162
TTP versus ITP
TTP is characterized by **thrombocytopenia** and **microantigopathic hemotlytic anemia**, which manifests as **schistocytes on peripheral smea**r and **elevated lactate dehdyrogenase.**
Other features may include **acute renal failure, fever and neurologic abnormalities.**
163
Odds ratio
measure of assocation commonly used in case control
odds that a case was exposed/odds that a control was exposed
**Odds ratio = (A/C)/(B/D) or (a\*d) / (b\*c)**
164
Management of Heart failure (order of therapy)
165
Mutiple linear regression is used to evaluate associations
between **1 quantative** (ex: continuous) dependent variable and **\> or = 2 independent variables** (either quantitative or qualitative)
166
A chi square test determines whether a statistically signifcant association exists between
**qualitative (categorical) variables.**
For example, this test evaluates the association between obsesity, defined as BM \> or = 30) and type 2 DM.
Both variables are categorical.
167
Multiple logistic regression evaluates associations between
**1 categorical dependent varilable with 2 levels and \> or = 2 independent variables**
For example, this regression models evaluates the association between type 2 DM (categorical dependent variable) and obesity (BMI \> or = 30) while adjusting for age and gender (quantitative or categorical independent variables).
168
Stratifed analysis evaluates the association between
**a dependent and independent variable based on presence of absence of a third variable.**
For example, a stratified analysis evaluates the association between obesity (BMI \> or =30( and type 2 DM stratifed by gender.
169
T-test compares
**the mean of a quantitative dependent variable between 2 independent samples** (1 categorical independent varialble with 2 levels), but it does not adjust for other variables.
Ex: this test compares mean levels for Alc (quantitative dependent variable) between patients with or without type 2 DM (categorical independent variable with 2 levels).
170
First stage over labor consists of what two phases:
171
Protracted active phase of labor occurs at what cervical dilation when the rate of cervical change is what?
**occurs at \> or = 6cm cervical dilation when the rate of cervical change is slower than expected (\< or = 1cm/2 hr)**
The most common cause of protracted active phase of labor is **contraction inadequancy.**
First line therapy is **oxytocin and amniotomy** (artifical rupture of membranes)
172
Misoprostol versus oxytocin
Misoprostol, a prostaglandin E1 analog, cuases uterine contractions but is indicated for labor induction- stimulation of contractions prior to spontaneous labor- not for labor augmentation.
173
What is indicated for arrest of labor?
what is the criteria?
Cesarean delivery
## Footnote
**Active phase arrest: no cervical chagne for \> or = 4 hours with adequate contractions for \> or = 6 hours without contractions.**
174
Clinical manifestations of hereditary hemochromatosis
175
Preferred treatment for hereditary hemochromatosis
therapeutic phlebotomy
\*removal of approximately 1 unite of blood each week until iron stores normalize
176
Pemberton test
constis of having the patient raise his arms over his head for up to 60 seconds.
The presence of facial plethora or engorgement of neck veins is strongly suggestive that the thyroid is the source of the patient's obstructive symptoms.
177
Thyroid lymphoma usually presents as
**rapid enlargement of the thyroid gland** in patietns with **Hashimoto thyroiditis.**
**Pemberton's sign** is the presence of ficial plethora or neck vein distention when arms are raised and confirms an enlarged thyroid gland as the cause of esophageal obstructive symptoms.
*\*foliccular, medullary and papillary thyroid cancer does not progress this rapidly.*
