UWorld All Subjects 3 Flashcards
Pt and management of gender dysphoria
Pt: experiences persistent (>/= 6 months) incongruence between assigned + felt gender
- desires to be another gender
- dislikes own anatomy, desires sexual trains of another gender
- believes feelings/reactions are of another gender
- feels significant distress/impairment
Management: assessment of safety, support w/ psychotherapy (individual or family); referral to specialist services (medical + mental health multidisciplinary)
Mechanism, Pt, Dx, and management of optic nerve injury
Mechanism: indirect: shearing forces from facial trauma
direct: penetrating eye trauma
Pt: acute vision loss, decreased color vision, afferent pupillary defect
Dx: CT scan of the orbit
Management: urgent ophthalmology referral; +/- surgical decompression
Pt, Dx, and complications of prader-willi syndrome
Pt: hypotonia, weak suck/feeding problems in infancy; hyperphagia/obesity, short stature, hypogonadism, intellectual disability, dysmorphic features (narrow forehead, almond-shaped eyes, downturned mouth)
Dx: deletions on paternal 15q11-q13
Complications: sleep apnea, T2DM, gastric distension/rupture, death by choking
What is the MOA of flushing as a side effect of niacin? How can this be managed?
flushing and generalized pruritus are side effects of high-dose niacin therapy due to niacin-induced peripheral vasodilation via drug-induced release of histamine and prostaglandins
low-dose aspirin can greatly reduce or prevent sx if taken 30 min before niacin; flushing and pruritus usually improve after 2-4 weeks of therapy
Risk factors, Pt, and management of pubic symphysis diastasis
Risk factors: fetal macrosomia, multiparity, precipitous labor, operative vaginal delivery
Pt: difficulty ambulating, radiating suprapubic pain, pubic symphysis tenderness, intact neurologic examination
management: conservative, NSAIDs, physical therapy, pelvic support
Risk factors, Pt, and management of ABO hemolytic disease
Risk factors: infants with blood types A or B born to a mother with blood type O
Pt: jaundice within 24 hours of birth, anemia, increased reticulocyte count, hyperbilirubinemia, positive Coombs test
Management: serial bilirubin levels, oral hydration + phototherapy for most neonates; exchange transfusion for severe anemia/hyperbilirubinemia
acalculous cholecystitis path, pt, dx, and tx
Path: cholestasis danders gallbladder ischemia leading to secondary infection by enteric organisms and resultant edema and necrosis of the gallbladder
Pt: severely ill patients in the ICU with multi organ failure, severe trauma, surgery, burns, sepsis, or prolonged parenteral nutrition; fever, leukocytosis
Dx: gallbladder wall thickening, distension, and presence of pericholecystic fluid
Tx: Abx followed by percutaneous cholecystectomy with drainage of any associated abscesses
Path, Pt, Dx, and management of Ogilvie syndrome
Path: major surgery, traumatic injury, severe infection; electrolyte derangement (decreased K+, decreased Mg, decreased Ca2+), medications (opiates, anticholinergics), neurologic disorders (dementia, stroke)
Pt: abdominal distension, pain, obstipation, vomiting; tympanic to percussion, decreased bowel sounds; if perforation: guarding, rigidity, rebound tenderness
Dx: X-ray: colonic dilation, normal hausfrau, noldilated small bowel
CT scan: colonic dilation without anatomic obstruction
Management: NPO, nasogastric/rectal tube decompression; neostigmine if no improvement within 48 hours
Path, Pt, Dx, and Tx of sporotrichosis
Path: sporothrix schenckii (dimorphic fungus), decaying plant matter/soil, gardeners + landscapers
Pt: subacute/chronic; skin papule -> ulceration with non purulent, odorless drainage; proximal lesions along lymphatic chain; LAD, deeper spread + systemic sx are rare
Dx: cultures (aspirate fluid or biopsy)
Tx: 3-6 months of oral itraconazole
hypertrophic osteoarthropathy (HOA) vs hypertrophic pulmonary osteoarthropathy (HPOA)
Pt; digital clubbing + sudden-onset arthropathy, commonly affecting the wrist and hand joints
Hypertrophic pulmonary osteoarthropathy is a subset of HOA where the clubbing and arthropathy are attributable to underlying lung disease like lung cancer, TB, bronchiectasis, or emphysema
What do you expect the plasma renin and plasma aldosterone to be in secondary hyperaldosteronism? What can cause this?
elevated plasma renin and elevated plasma aldosterone
causes of secondary hyperaldosteronism:
- diuretic use
- cirrhosis or CHF
- renovascular HTN
- renin-secreting tumor
- malignant HTN
- coarctation of the aorta
What do you expect the plasma renin and plasma aldosterone to be in primary hyperaldosteronism?
decreased plasma renin, increased plasma aldosterone
what causes of HTN and hypokalemia would have decreased plasma renin and plasma aldosterone?
- CAH
- glucocorticoid resistance
- exogenous mineralocorticoid
- Cushing’s syndrome
- altered aldosterone metabolism
What is included in post exposure prophylaxis for sexual assault?
chlamydia: azithromycin
gonorrhea: ceftriaxone
Trichomonas vaginalis: metronidazole
HIV: multidrug regimen (tenofovir-emtricitabine with raltegravir)
Hep B: hep B vaccine +/- Hep B immunoglobulin
Dx and Tx of social anxiety disorder
Dx:
- marked anxiety about >/= 1 social situations for >/= 6 months
- fear of scrutiny by others, humialtion, embarrassment
- social situations avoided or endured with intense distress
- marked impairment (social, academic, occupational)
- subtype specifier: performance only
Tx: SSRI/SNRI, CBT, beta blocker or benzodiazepine for performance-only subtype
Human bite with possible rabies exposure in a low-risk wild animal (squirrel, chipmunk, mouse/rat, rabbit)?
no post exposure prophylaxis
Human bite with possible rabies exposure in a high-risk wild animal (bat, raccoon, skunk, fox, coyote)?
If available for testing: euthanize + test; start PEP if rabies test is positive
Not available for testing: start PEP (post-exposure prophylaxis)
Human bite with possible rabies exposure in a pet (dog, cat, ferret)?
If available for quarantine: observe for 10 days; no PEP if animal is healthy
Not available for quarantine: start PEP
Generalized convulsive status epileptics path, dx, and tx
Path: structural brain abnormality (brain tumor, stroke), metabolic abnormality (hyponatremia, hypoglycemia), infection (meningitis), or drug withdrawal (alcohol, benzos), epilepsy esp with noncompliance
Dx: seizure lasting >/= 5 mins OR >/= 2 seizure events in which the patient does not completely regain consciousness
Tx: ABC, IV benzos (lorazepam, m diazepam) for seizure termination, then a nonbenzo anti epileptic med should be administered to prevent seizure recurrence (fosphenytoin, phenytoin, levetiracetam, or valproic acid)
Path, Risk factors, Pt, and Management of primary dysmenorrhea
Path: excessive prostaglandin production Risk factors: 1. age <30 2. BMI < 20 3. tobacco use 4. Menarche at age < 12 5. Heavy/long menstrual periods 6. sexual abuse Pt: pain first 2-3 days of menses, N/V/D, normal pelvic examination Management: NSAIDs, combo OCPs
Pt of prolapsing leiomyoma uteri
a uterus with irregular enlargement on exam suggests uterine liomyomata; speculum and bimanual examination confirms the firm, smooth, round mass at the cervical os consistent with an aborting sub mucous myxoma
What is the Cushing triad? tx?
HTN, bradycardia, and irregular expirations (indicates elevated ICP); immediate tx is hypertonic saline to decrease the ICP and reduce the risk of cerebral herniation
Precipitating factors, Pt, and Tx of myasthenic crisis?
Precipitating factors: infection or surgery, pregnancy or childbirth, tapering of immunosuppressive drugs, medications (ahminoglycosides, beta blockers)
Pt: increased generalized and oropharyngeal weakness, respiratory insufficiency/dyspnea
Tx: intubation for deteriorating respiratory status; plasmapheresis or IVIG as well as corticosteroids
Path, Pt, and Complications of Sjogren syndrome
Path: immune-mediated destruction of the lacrimal and salivary glands; can occur as primary disease or secondary with other autoimmune disorders (SLE, RA)
Pt:
- dry eyes (keratoconjunctivitis sicca)
- dry mouth (xerostomia), salivary hypertrophy
- dry sin (xerosis)
- Raynaud phenomenon
- Cutaneous vasculitis
- Positive anti-Ro (SSA) and/or anti-La (SSB)
Complications: non-hodgkin lymphoma; corneal damage, dental caries
Risk factors for avascular necrosis
- steroid use
- alcohol abuse
- SLE
- Antiphospholipid syndrome
- Hemoglobinopathies (sickle cell)
- Infections (osteomyelitis, HIV)
- Renal transplantation
- Decompression sickness
What steps are known to minimize the risk of long term opioid abuse?
- check the prescription drug-monitoring program data for undisclosed coprescription
- perform random urine drug screening
- schedule frequent follow-up visits (q 3 months min)
Wafarin-associated intracerebral hemorrhage Path and management
Path: use of over-the-counter cold meds, which often contain acetaminophen (potentiates anticoagulant effect of warfarin) and decongestants such as phenylephrine (may elevated BP)
Management: IV Vit K, prothrombin complex concentrate (PCC) (consider FFP if PCC not available)
subclavian steel syndrome Path, Pt, PE, Dx, and Tx
Path: severe atherosclerosis of the left subclavian artery proximal tot he origin of the vertebral artery (left more commonly affected than the right)
Pt: ischemia in the affected UE (pain, fatigue, paresthesias), vertebrobasilar ischemia with concurrent atherosclerosis of the circle of Willis (dizziness, ataxia, disequilibrium)
PE: lower brachial systolic BP (>15) in the affected arm and a systolic bruit in the suprclavicular fossa on the affected side; S4 may be present due to LVH
Dx: dopper u/s or MR angiography
Tx: lifestyle management (lipid-lowering meds, smoking cessation) and sometimes stent placement
In patients with abnormal uterine bleeding, what does bleeding after progesterone administration indicate?
confirms normal endogenous estrogen production and proliferative endometrium; rules out causes of estrogen deficiency (primary ovarian insufficiency), endometrial abnormalities (intrauterine adhesions), and outlet tract abnormalities (imperforate hymen)
Path, Pt, Labs and Tx of serum sickness-like reaction
Path: type III hypersensitivity, immune complex formation, Abx (beta-lactam, sulfa), acute Hep B
Pt: symptoms 1-2 weeks after exposure; fever, skin rash, polyarthralgia
Labs: nonspecific hypocomplementemia and elevated inflammatory markers (ESR, CRP)
Tx: remove/avoid offending agent, supportive care, steroids or plasmapheresis if severe
UTI with urinary alkalinization (pH > 8) indicates what causes? What other sx might you see?
urease-producing bacteria such as Proteus mirabilis (MC) or klebsiella pneumoniae; might also see struvite stones (magnesium ammonium phosphate)
Congenital contractural arachnodactyly Path and Pt
Path: autosomal dominant with mutations in fibrillin-2 gene
Pt: tall stature, arachnodactyly, multiple contractures involving large joints
Path, Pt, and Dx of pheochromocytoma
Path:
- arises from neuroendocrine cells in adrenal medulla
- 25% inherited: VHL gene, RET gene (MEN 2), NF1
- symptoms result from increased catecholamine secretion
Pt: HA, tachycardia/palpitations, sweating, HTN
Dx: elevated urinary and plasma catecholamines + metanephrines
What is the rule of 10s in pheochromocytoma?
- 10% bilateral
- 10% extraadrenal
- 10% malignant
Path, Pt, Dx, and Tx of pediatric septic arthritis
Path: age < 3 months: Staph aureus, group B strep, gram negative bacilli
- Age >/= 3 months: staph aureus, group A strep
Pt: acute-onset joint pain, swelling, limited motion; refusal to bear weight; fever >/= 101.3
Dx: increased WBC, ESR, CRP; blood culture; joint aspiration (synovial WBC of > 50,000), effusion on u/s or MRI
Tx: joint drainage + debridement; IV Abx
UTI in infants Risk factors, Pt, Labs, and Tx
Risk factors: female, uncircumcised males, vesicoureteral reflux, constipation
Pt: fever, fussiness, poor feeding, decreased urine output
Labs: pyuria, bacteriuria
Tx: Abx, renal u/s (if febrile), +/- voiding cystourethrogram
(third-get cephalosporin, such as cefixime)
Path, Pt, Dx, Tx of SIBO; what organisms would you expect?
Path: anatomical abnormalities (strictures, surgery); motility disorders (DM, scleroderma)
Pt: abdominal pain, diarrhea, bloating, flatulence; malabsorption, WL, anemia, vitamin deficiency
Dx: jejunal aspirate + culture showing >10^5 organisms; carbohydrate breath testing (lactulose, glucose)
Tx: Abx (rifaximin, amox-clav), avoid antimotility agents (narcotics), dietary changes (high-fat, low carb), promotability agents (metoclopramide)
Organisms: streptococci, bactericides, escherichia, lactobacillus
Dumping syndrome Pt
Path: complication of gastric bypass and occurs when high-carb foods are rapidly emptied into the small bowel, leading to osmotically driven fluid shifts from the plasma to the intestine
Pt: abdominal pain and diarrhea < 30 min after meals, sympathetic activation due to fluid shifts -> tachycardia, diaphoresis, flushing; hypoglycemia may also occur
Path, Risk factors, Pt, Dx, and Tx of adenomyosis
Path: abnormal endometrial tissue within the uterine myometrium
Risk factors: age >40, multiparty, prior uterine surgery
Pt: dysmenorrhea, heavy menstrual bleeding, chronic pelvic pain, diffuse uterine enlargement (globular uterus), +/- uterine tenderness
Dx: clinical presentation, MRI + u/s: thickened myometrium; confirm via pathology
Tx: hysterectomy
What is the difference between adenomyosis and leiomyomata uteri?
adenomyosis can cause chronic pelvic pain whereas leiomyomata uteri (fibroids) can cause pelvic pressure, but usually not chronic pelvic pain. Fibroids cause a firm, irregularly enlarged uterus whereas adenomyosis causes diffuse uterine enlargement (globular)
diplopia, right eye ptosis, ophthalmoplegia, and pupillary dilation - dx?
non-pupil-sparing oculomotor nerve palsy
What are the causes of non-pupil-sparing CN III palsies? Next step in management?
mass effect should be considered an intracranial aneurysm until proven otherwise; patients should undergo immediate MR or CT angiography
What are the causes of pupil-sparing CN III palsies? What is the next step in management?
typically caused by microvascular ischemia associated with diabetes, hypertension, hyperlipidemia, and advanced age; observation and supportive care may be appropriate
What are the potential side effects of lithium therapy?
hyperparathyroidism, nephrogenic diabetes insipidus, CKD, thyroid dysfunction (most often hypothyroidism), teratogenic effects in first trimester (Ebstein anomaly)
What are the symptoms of Lyme disease at the early localized stage (days to 1 month)?
- erythema migrans
- fatigue, HA
- myalgias, arthralgias
What are the symptoms of Lyme disease at the early disseminated stage (weeks to months)?
- multiple erythema migrans
- U/L or B/L CN palsy (CN VII)
- Meningitis
- Carditis (AV block)
- Migratory arthralgias
What are the symptoms of Lyme disease at the late stage (months to years)?
- arthritis
- encephalitis
- peripheral neuropathy
What is the definition of fetal tachycardia, and what are the common causes?
fetal baseline heart rate > 160/min
Common causes include maternal infection, poorly controlled maternal hyperthyroidism, medication use 9terbutaline), and abruptio placentae
Path, Pt, Dx, and Tx of esophageal perforation?
Path: instrumentation (endoscopy), trauma; effort rupture (Boerhaave syndrome), esophagitis (infectious/pills/caustic)
Pt: chest/back +/or epigastric pain, systemic signs (fever0; crepitus, harman sign (crunching on auscultation); pleural effusion with atypical (green) fluid
Dx: CXR or CT scan: widened mediastinum, pneumonmediastinum, pneumothorax, pleural effusion
CT scan: esophageal wall thickening, mediastinal fluid collection
EGD with water-soluble contrast: leak from perforation
Management: NPO, IV Abx + PPI; emergency surgical consultation
What murmur is associated with aortic dissection?
aortic regurgitation
What will you see on u/s of a tubo-ovarian abscess?
complex multiloculated adnexal mass with thick wall and internal debris
Toxic megacolon treatment
IVF, broad-spectrum Abx, and bowel rest; IV corticosteroids are preferred for treating IBD-induced toxic megacolon; emergency surgery may be required if the colitis does not resolve
posterior urethral injury
Pt: blood at the urethral meatus, inability to void (due to urethral discontinuity), perineal bruising, and a high-riding prostate on digital rectal examination
Dx:
urethrography - extravasation of contrast from the urethra is diagnostic
Tx: anterior urethral injuries (penile fracture, straddle injury) are typically repaired urgently (within 24 hours) whereas most PUIs are treated with temporary urinary diversion via suprapubic catheter, followed by delayed repair
Risk factors, Pt, Dx, and Tx of Takayasu arteritis
Risk factors: female, asian, age 10-40
Pt: constitutional (fever, WL), arterio-occlusive (claudication, ulcers) in upper extremities, arthralgias/myalgias
PE: BP discrepancies, pulse deficits, arterial bruits
Dx: elevated inflammatory markers (ESR, CRP); CXR: aortic dilation, widened mediastinum; CT/MRI: wall thickening, narrowing of lumen
Tx: systemic glucocorticoids
Pt, Dx and Tx of congenital hypothyroidism
Pt: initially normal at birth; symptoms develop after maternal T4 wanes: - lethargy - enlarged fontanelle - protruding tongue - umbilical hernia - poor feeding - constipation - dry skin - jaundice Dx: increased TSH + decreased free T4 levels; newborn screening Tx: levothyroxine
What are migraine preventive options that are acceptable during pregnancy?
beta blockers, such as propranolol or metoprolol; CCBs (verapamil) are also safe and effective in pregnancy
Pt and Dx criteria for acute liver failure
Pt:
- generalized symptoms (fatigue, lethargy, anorexia, nausea)
- RUQ pain
- pruritus + jaundice due to hyperbilirubinemia
- renal insufficiency
- thrombocytopenia
- hypoglycemia
Dx criteria:
- severe acute liver injury (ALT + AST often > 1000)
- signs of hepatic encephalopathy (confusion, asterixis)
- synthetic liver dysfunction (INR >/= 1.5)
melena, RUQ pain, jaundice, anemia, and hyperbilirubinemia after recent livery biopsy - Dx? Tx?
hemobilia (u/s or CT scan can identify heamtomas and intraabdominal free fluid, and endoscopic evaluation may reveal oozing of blood from the papilla)
Tx: usually self-limited and managed conservatively
What is the treatment for toxoplasmosis encephalitis?
sulfadiazine + pyrimethamine (plus leucovorin)
involved site and pt of myasthenia gravis as a paraneoplastic syndrome
Involved site: acetylcholine receptor in postsynaptic membrane Pt: fluctuating muscle weakness: - ocular (ptosis, diplopia) - bulbar (dysphagia, dysarthria) - facial, neck + limb muscles
Involved site and pt of Lambert-eaton syndrome as a paraneoplastic syndrome
involved site: presynaptic membrane voltage-gated calcium channels
Pt: proximal muscle weakness, autonomic dysfunction (dry mouth), cranial nerve involvement (ptosis), diminished or absent DTRs
(~50% associated with an underlying malignancy, mostly small cell lung cancer)
Involved site and pt of dermatomyositis/polymyositis as a paraneoplastic syndrome
Involved site: muscle fiber injury
Pt:
- symmetrical + more proximal muscle weakness
- interstitial lung disease, esophageal dysmotility, Raynaud phenomenon
- polyarthritis
- esophageal dysmotility
- skin findings (Gottron papules, heliotrope rash) in dermatomyositis
Bell palsy Path, Pt
Path: peripheral neuropathy involving CN VII due to reactivation of a neurotrophic virus, most commonly HSV; results in nerve compression and degeneration of the myelin sheath
Pt: unilateral mouth drooping, disappearance of the nasolabial fold, involvement of the upper face (distinguishes from UMN disorders like stroke), decreased ipsilateral eye lacrimation, hyperacusis, and decreased sensation of taste of the anterior 2/3 of the ipsilateral tongue; weakness typically develops at night; sx progress over 2-3 weeks with gradual improvement over 3-6 months
Tx: glucocorticoids
migraine with aura involving the brainstem pt
vertigo, dysarthria, diplopia, and possible LOC, typically followed by a severe occipital HA
antipsychotic medication effect of the mesolimbic, nigrostriatal, and tuberoinfundibulnar dopamine pathways
mesolimbic: antipsychotic efficacy
nigrostriatal: extrapyramidal symptoms: acute dystonia, akathisia, Parkinsonism
tuberoinfundibulnar: hyperprolactinemia
humoral hypercalcemia of malignancy path/pt
Path: due to PTHrP; associated with squamous cell (lung, head, and neck), renal, bladder, breast, or ovarian carcinomas Pt: - very high (>14) calcium levels - polyuria, constipation, nausea - low PTH
Path and PT of cyclic vomiting syndrome
Path: personal or family hx of migraines; episodes often have identifiable trigger (infection, stress)
Pt: stereotypical vomiting episodes with acute onset of N/V/HA and abdominal pain; self-limited, lasting 1-2 days; asymptomatic between episodes; often regular intervals (2-4 weeks)
CSF rhinorrhea path, pt, dx, and management
Path: accidental trauma (MC), surgical trauma, non traumatic (elevated ICP)
Pt: U/L watery rhinorrhea with salty or metallic taste; possible complication: meningitis
Dx:
- test for CSF-specific proteins (beta-2 transferrin, beta-trace protein)
- imaging (with intrathecal contrast)
- endoscopy (+/- intrathecal fourescein dye)
Tx: bed rest, head of bed elevation, avoidance of straining; lumbar drain placement; surgical repair
description, normal result, and abnormal result of fetal non stress test
description: external fetal HR monitoring for 20-40 mins
normal: reactive: >/= 2 accelerations
abnormal: nonreactive: < 2 accelerations; recurrent variable or late decelerations
description, normal result, and abnormal result of fetal biophysical profile
description: non stress test plus u/s assessment of the following:
- amniotic fluid volume
- fetal breathing movement
- fetal movement
- fetal tone
(2 points per category if normal + 0 points if abnormal)
normal: 8-10 points
abnormal: equivocal: 6 points; abnormal: 0, 2, 4 points; oligohydramnios
description, normal result, and abnormal result of fetal contraction stress test
description: external fetal HR monitoring during spontaneous or induced (oxytocin, nipple stimulation) uterine contractions
normal: no late or recurrent variable decelerations
abnormal: late decelerations with >50% of contractions
description, normal result, and abnormal result of fetal doppler sonography of the umbilical artery
description: evaluation of umbilical artery flow in fetal intrauterine growth restriction only
normal: high-velocity diastolic flow in umbilical artery
abnormal: decreased, absent, or reversed end-diastolic flow
Pt, Dx, and Tx of vasovagal syncope
Pt: inciting event (stress, prolonged standing), prodrome (pallor, nausea, diaphoresis), consciousness regained rapidly (<1 minute)
Dx: mainly clinical; upright tilt table testing in uncertain cases
Tx: reassurance, avoidance of triggers, counter pressure techniques for recurrent episodes
acute poststreptococcal glomerulonephritis Pt & Labs
Pt: can be asymptomatic; if symptomatic:
- gross hematuria (tea- or cola-colored urine)
- edema (periorbital, generalized)
- HTN
Labs:
- U/A: + proteins, + blood, +/- RBC casts
- serum: low C3 and possible low C4, increased serum Cr, increased anti-DNase B + AHase, increased ASO and anti-NAD (from preceding pharyngitis)
acute hemolytic transfusion reaction Path, Pt, Labs, complications
Path: ABO incompatibility, intravascular hemolysis
Pt: onset within minutes to 24 hours of transfusion; fever, chills, hypotension; hemoglobinuria, flank pain
Labs: positive direct Coombs test; hemolysis (increased LDH, increased indirect bilirubin)
Complications: acute renal failure, DIC
Pt of acute PCP intoxication
- violent behavior
- dissociation
- hallucinations
- amnesia
- nystagmus (horizontal or vertical)
- ataxia
Pt of acute LSD intoxication
- visual hallucinations
- euphoria
- dysphoria/panic
- tachycardia/HTN
Pt of acute cocaine intoxication
- euphoria
- agitation/psychosis
- chest pain
- seizures
- tachycardia/HTN
- mydriasis
Pt of acute methamphetamine intoxication
- violent behavior
- psychosis, diahphoresis
- tachycardia/HTN
- choreiform movements
- tooth decay
Pt of acute marijuana intoxication
- increased appetite
- euphoria
- dysphoria/panic
- slow reflexes, impaired time perception
- dry mouth
- conjunctival injection
Pt of acute heroin intoxication
- euphoria
- depressed mental status
- miosis
- respiratory depression
- constipation
Path, Pt, Dx, and Tx of spinal epidural abscess
Path: staph aureus (65%); inoculating sources:
- distant infection (cellulitis, joint/bone)
- spinal procedure (epidural catheter)
- injection drug use
Pt: classic triad
- fever
- focal/severe back pain
- neurologic findings (motor/sensory change, bowel/bladder dysfunction, paralysis
Dx: elevated ESR, blood and aspirate cultures, MRI of the spine
Tx: broad-spectrum Abx (vancomycin plus ceftriaxone), aspiration/surgical decompression
What is the treatment of a pelvic fracture in a stable vs unstable patient?
in an unstable patient, they are at risk of life threatening hemorrhage from the venous plexus so rapid external stabilization with a pelvic binder should be performed as soon as possible to promote tamponade of venous bleeding
Path, Pt, Dx, and Tx of syringomyelia
Path: destruction of the crossing fibers of the spinothalamic tract int he ventral white commissure
Pt: progressive loss of pain and temp sensation (cape-like distribution)
Dx: MRI will show intramedullary cavity
Tx: usually requires surgical shunt placement
What can you infer from a HgA1c of >10% as compared to HgA1c of around 8%?
HgA1c of > 10% suggest significant hyperglycemia throughout the day, whereas lesser abnormalities are often due to elevation sin only postprandial glucose levels
uremic coagulopathy path, pt, labs, and tx
Path: abnormal hemostasis in the setting of chronic renal failure due to platelet dysfunction
Pt: ecchymoses and epistaxis are MC but GI bleeding, hemoperricardium, subdural hematoma, and bleeding from surgical or invasive sites can still occur
Labs: aPTT, PT, and TT normal, bleeding time (reflective of platelet function) is prolonged, normal platelet count
Tx: DDAVP, cryoprecipitate, and conjugated estrogens have been used to correct this
chronic suppurative otitis media
otorrhea and hearing loss for > 6 weeks and TM perforation one xam
otitis media with effusion
may cause hearing loss and poor TM mobility BUT in contrast to acute otitis media, there is a lack of acute inflammation (fever, TM bulging)
tinea versicolor
Path: malassezia globes skin flora grows in exposure to hot and humid weather
PT: hypo pigmented, hyper pigmented, or middle erythematous lesions, +/- fine scale, +/- pruritus
Dx: KOH prep shows hyphae and yeast cells in a “spaghetti + meatballs” pattern
Tx: topical ketoconazole, terbinafine, or selenium sulfide
bacterial conjunctivitis treatment options
- erythomycin ointment
- polymyxin-trimethoprim drops
- azithromycin drops
- preferred agent in contact lens wearers: fluroquinolone drops
viral conjunctivitis treatment
warm or col compresses +/- antihistamine/decongestant drops
allergic conjunctivitis treatment
- OTC antihistamine/decongestant drops for intermittent symptoms
- mast cell stabilizer/antihistamine drops for frequent episodes
Clinical manifestations of hemochromatosis based on body system
skin - hyperpigmentation (bronze diabetes)
MSK - arthralgia, arthropathy + chondrocalcinosis
GI - elevated hepatic enzymes with hepatomegaly (early), cirrhosis (late) + increased risk of hepatocellular carcinoma
Endocrine - DM, secondary hypogonadism + hypothyroidism
Cardiac - restrictive or dilated cardiomyopathy + conduction abnormalities
Infections: increased susceptibility to Listeria, Vibrio vulnficus + Yersinia enterocolitica
clinical associations of infective endocarditis with staph aureus
- prosthetic valves
- intravascular catheters
- implanted devices (pacemakers, defibrillator)
- IV drug use
clinical associations of infective endocarditis with viridans strep and which bugs belong in this group?
- gingival manipulation
- respiratory tract incision or biopsy
viridans group:
- strep sanguinis
- s mitis
- s oralis
- s mutans
- s sobrinus
- s milleri
clinical associations of infective endocarditis with staph epidermidis
- prosthetic valves
- intravascular catheters
- implanted devices
clinical associations of infective endocarditis with enterococci
- nosocomial UTIs
clinical associations of infective endocarditis with strep gallolyticus
- colon carcinoma
- IBD
clinical associations of infective endocarditis with fungi (candida)
- immunocompromised host
- intravascular catheters
- prolonged Abx therapy
PT, PTT, BT, platelet count, RBC count of von Willebrand disease
PT - normal PTT - high BT - high Platelet count - normal RBC count - normal **autosomal dominant (look for family hx)
PT, PTT, BT, platelet count, RBC count of hemophilia A/B
PT - normal PTT - high BT - normal Platelet count - normal RBC count - normal **x-linked recessive; A = low factor 8; B = low factor 9
PT, PTT, BT, platelet count, RBC count of DIC
PT - high PTT - high BT - high Platelet count - low RBC count - normal/low **appropriate history, low level of factor 8
PT, PTT, BT, platelet count, RBC count of liver failure
PT - high PTT - high BT - normal Platelet count - normal/low RBC count - normal/low **jaundice, normal factor 8 level; do not give vitamin K (ineffective), use FFP
PT, PTT, BT, platelet count, RBC count of heparin use
PT - normal PTT - high BT - normal Platelet count - normal RBC count - normal **watch for thrombocytopenia and thrombosis
PT, PTT, BT, platelet count, RBC count of warfarin use
PT - high PTT - normal BT - normal Platelet count - normal RBC count - normal **Vitamin K antagonist (factors 2, 7, 9, 10)
PT, PTT, BT, platelet count, RBC count of ITP (idiopathic thrombocytopenia purpura)
PT - normal PTT - normal BT - high Platelet count - low RBC count - normal **watch for preceding URI
PT, PTT, BT, platelet count, RBC count of TTP (thrombotic thrombocytopenia purpura)
PT - normal PTT - normal BT - high Platelet count - low RBC count - low **hemolysis (smear), CNS symptoms (hallucinations, AMS, HA, stroke); tx with plasmapheresis; DO NOT give platelets
PT, PTT, BT, platelet count, RBC count of scurvy
PT - normal PTT - normal BT - normal Platelet count - normal RBC count - normal **fingernail and gum hemorrhages, bone hemorrhages; caused by vitamin C deficiency
Lab findings of X-linked agammaglobulinemia
decreased or absent. cells
decreased immunoglobulines
Lab findings of common variable immunodeficiency
Normal B cells
decreased immunoglobulins
Lab findings of IgA deficiency
Normal B cells
decreased IgA
Lab findings of Hyper-IgM syndrome
normal B cells
decreased IgG + IgA
increased IgM
What is the next step in management after initial stabilization of acute MI with persistent pain, HTN, or heart failure?
IV nitroglycerin (not if hypotension, RV infarct, or severe aortic stenosis occurs)
What is the next step in management after initial stabilization of acute MI with persistent severe pain?
IV morphine
What is the next step in management after initial stabilization of acute MI with unstable sinus bradycardia?
Intravenous atropine
What is the next step in management after initial stabilization of acute MI with pulmonary edema?
IV furosemide (not if Patience’s tis hypotensive or hypovolemic)
Risk factors, Pt, and Tx of calcaneal apophysitis (Sever disease)
Risk factors: running/jumping sports, growth spurts, athletic cleat use or footwear without heel padding
Pt: heal pain (50% b/l), pain with calcaneal palpation or compression, decreased gastrocnemius/soleus flexibility
Tx: NSAIDs, ice, activity limitation
Path, Pt, Dx, and Tx of infant botulism
Path: ingestion of Clostridium botulinum spores (environmental dust/soil, honey), spores colonize GI tract + produce toxin; toxin inhibits presynaptic ACh release
Pt: age < 12 months; constipation, poor feeding, hypotonia; oculobulbar palsies (absent gag reflex, ptosis), symmetric descending paralysis, autonomic dysfunction (decreased salivation, fluctuating HR/BP)
Dx: clinical, confirmation by stool C botulinum spores or toxins
Tx: botulism immune globulin
Path, Pt, Dx, and Tx of neonatal thyrotoxicosis
Path: transplacental passage of maternal anti-TSH receptor Abs; Abs bind to infant’s TSH receptors + cause excessive thyroid hormone release
Pt: warm, moist skin; tachycardia; poor feeding, irritability, poor weight gain; low birth weight or preterm birth
Dx: maternal anti-TSH receptor Abs (>500% normal)
Tx: self-resolves within 3 months; methimazole PLUS beta blocker
What drugs are indicated in the treatment of preeclampsia to lower BP acutely to decrease stroke risk?
hydralazine IV (vasodilator), labetalol IV (beta blocker with alpha-blocking activity), or nifedipine PO (CCB)
Modified Wells criteria for pretest probability of pulmonary embolism
\+3 points = - clinical signs of DVT - alternate diagnosis less likely than PE \+1.5 points = - previous PE or DVT - HR > 100 - recent surgery or immbolization \+ 1 point = - hemoptysis - cancer Total score = 4 = PE unlikely > 4 = PE likely
Pt of ED due to vascular causes?
- cardiovascular risk factors (HTN, smoking, diabetes)
- abnormal vascular examination (bruits, decreased pulses)
Pt of ED due to neurologic causes?
- neurologic comorbidity (diabetic neuropathy, MS, spinal injury/surgery)
- gradual onset, loss of bulbocavernous reflex
Pt of ED due to psychogenic causes?
- suddent onset
- situational (ED with partner, normal erection during masturbation)
- normal nonsexual nocturnal erections
Pt of ED due to endocrine causes?
- additional symptoms due to underlying disorder
- abnormal hormone levels (TSH, prolactin)
Pt of ED due to medication causes?
- onset related to starting medication
- antihypertensives, SSRIs, anti-androgenic medications
Pt of ED due to hypogonadism causes?
- gradual onset
- decreased libido, gynecomastia, testicular atrophy
- low serum testosterone
DSM-5 criteria for schizoaffective disorder
- major depressive or manic episode concurrent with symptoms of schizophrenia
- Lifetime history of delusions or hallucinations for >/= 2 weeks in the absence of major depressive or manic episode
- mood episodes are prominent + recur throughout illness
- not due to substances or another medical condition
How do you differentiate major depressive or bipolar disorder with psychotic features from schizoaffective disorder?
major depressive or bipolar disorder with psychotic features: psychotic symptoms occur exclusively during mood episodes
How do you differentiate schizophrenia from schizoaffective disorder?
schizophrenia: mood symptoms may be present for relatively brief periods
Path, manifestations, and management of von hippel-lindau disease
Path: mutation in the VHL tumor suppressor gene on chromosome 3
Manifestations: cerebellar + retinal hemangioblastomas; pheochromocytoma; renal cell carcinoma (clear cell)
Management: surveillance for associated malignancies:
- eye/retinal examination
- plasma or urine metanephrines
- MRI of the brain + spine
- MRI of the abdomen
tumor resection
Path and Pt of tabes dorsalis
Path: increased incidence of syphilis in men who have sex with men + HIV-infected patients; HIV positive patients develop neurosyphilis more rapidly
Treponema pallidum spirochetes directly damage the dorsal sensory roots; secondary degeneration of the dorsal columns
Pt: sensory ataxia, lancinating pains, neurogenic urinary incontinence, associated with argyll Robertson pupils
What are risk factors for homicide?
young male unemployed impoverished access to firearms substance abuse antisocial personality disorder history of violence or criminality history of childhood abuse impulsivity
Name the drugs, indication, C/I, and side effects of bisphosphonates
Drugs: alendronate, risedronate
Indication: first-line tx for osteoporosis
C/I: not recommended for patients with renal impairment
SE: atypical fractures possible with prolonged use
*Take with water on an empty stomach an hour before food + other meds
Indication and SE of denosumab
Indication: osteoporosis
SE: risk of infection + skin reactions; close monitoring for hypocalcemia needed
Indication and SE of teriparatide
Indication: severe osteoporosis
SE: monitor serum calcium, uric acid, and renal function
Name and SE for selective estrogen receptor modulators as tx for osteoporosis
Name: raloxifene
SE: may lower risk of breast cancer, increased risk of DVT
**Less effective than bisphosphonates
Path, Pt, Dx, and Tx of fat embolism syndrome
Path: fracture of marrow-containing bone, orthopedic surgery, pancreatitis
Pt: 24-72 hours following inciting event; clinical triad: respiratory distress, neurologic dysfunction (confusion), petechial rash
Dx: based on clinical experience
Tx: early immobilization of fracture; supportive care (mechanical ventilation)
CD4 count + Pt of cryptosporidium diarrhea in AIDS
CD4: < 180
Pt: severe watery diarrhea, low-grade fever, WL
CD4 count + Pt of micros-iridium/Isosporidium diarrhea in AIDS
CD4: < 100
Pt: watery diarrhea, crampy abdominal pain, WL, fever is rare
CD4 count + Pt of mycobacterium avium diarrhea in AIDS
CD4: <50
Pt: watery diarrhea, high fever (>102.2), WL
CD4 count + Pt of CMV diarrhea in AIDS
CD4: <50
Pt: frequent, small-volume diarrhea, hematochezia, abdominal pain, low-grade fever, WL
Path, Pt, and Tx of severe combined immunodeficiency
Path: gene defect leading to failure of T cell development; B cell dysfunction due to absent T cells; X-linked recessive and autosomal recessive
Pt: recurrent, severe viral, fungal, or opportunistic (pneumocystis) infections, failure to thrive, chronic diarrhea
Tx: stem cell transplant
Path, Pt, and causes of fetal hydrops
Path: increased cardiac output demand causing heart failure, increased fluid movement into interstitial spaces (third spacing) Pt: pericardial effusion, pleural effusion, ascites, skin edema, placental edema, polyhydramnios Causes: immune: - Rh(D) alloimmunization Nonimmune: - parvo B19 - fetal aneuploidy - CV abnormalities - thalassemia (hemoglobin Barts)
Pt, Labs, and Tx of intrahepatic cholestasis of pregnancy
Pt: develops in 3rd trimester, generalized pruritus, pruritus worse on hands + feet, no associated rash, RUQ pain
Labs: increased total bile acids (>10), increased transaminases, +/- increased total + direct bilirubin
Tx: delivery at 37 weeks gestation, ursodeoxycholic acid, antihistamines
What are the obstetric risks of intrahepatic cholestasis of pregnancy?
intrauterine fetal demise
preterm delivery
meconium-stained amniotic fluid
neonatal respiratory distress syndrome
What are the risk factors for gout?
- medications (diuretics, low-dose aspirin)
- surgery, trauma, recent hospitalizations
- volume depletion
- diet: high protein foods (meat, seafood), high fat foods, fructose or sweetened beverages
- heavy alcohol consumption
- underlying medical conditions (HTN, obesity, CKD, organ transplant)
What factors decrease the risk of gout?
- dairy product intake
- vitamin C (>/= 1500 mg/day)
- coffee intake (>/= 6 cups/day)
Path, Risk factors, Pt, Dx, and Tx of onychomycosis
Path: trichophyton rubrum
Risk factors: advanced age, tinea pedis, diabetes, peripheral vascular disease
Pt: thick, brittle, discolored nails
Dx: KOH, periodic acid-Schiff stain, culture
Tx: first line: terbinafine, itraconazole; second line: griseofulvin, fluconazole, ciclopirox
What are the primary indications and features of cognitive behavioral therapy?
Primary indications: depression, GAD, PTSD, panic disorder, OCD, eating disorders, negative thought patterns
Features:
- combines cognitive and behavioral therapy
- challenges maladaptive cognitions
- targets avoidance with behavioral techniques (relaxation, exposure, behavior modification)
What are the primary indications and features of interpersonal psychotherapy?
Primary indications: depression
Features: links symptoms to current relationship conflicts and interpersonal skill deficits
What are the primary indications and features of supportive psychotherapy?
Primary indications: lower functioning; psychotic disorders, patients in crisis
Features:
- maintains hope; provides encouragement
- reinforces coping skills, adaptive defenses
What are the primary indications and features of psychodynamic psychotherapy?
Primary indications: higher functioning, personality disorders
Features:
- builds insight into unconscious conflicts + past relationships
- uses transference
- breaks down maladaptive defenses
What are the primary indications and features of motivational interviewing?
Primary indication: substance use disorders
Features:
- nonjudgmental; acknowledges ambivalence + resistance
- enhances intrinsic motivation to change
What are the primary indications and features of dialectical behavioral therapy?
Primary indications: borderline personality disorder
Features:
- improves emotion regulation, distress tolerance, mindfulness
- decreases self harm; builds skills
What are the primary indications and features of biofeedback?
Primary indications: prominent physical symptoms; pain disorders
Features:
- improves control over physiological reactions to emotional stressors
What are the absolute contraindications to combined hormonal contraceptives?
migraine with aura >/= 15 cigarettes/day PLUS age >/= 35 HTN >/= 160/100 heart disease diabetes mellitus with end-organ damage history of thromboembolic disease antiphospholipid-Ab syndromne - Hx of stroke - breast cancer - cirrhosis + liver cancer - major surgery with prolonged immobilization - use < 3 weeks postpartum
Path, Pt, Dx, and Tx of cutaneous larva migrans
Path: hookworm larvae; dog (ancylostoma canine) or cat (A braziliense); humans are incidental hostos
- barefoot contact with contaminated sand or soil
Pt: primarily lower extremity; cutaneous (deeper infection rare); erythematous, pruritic papule at site of entry; intensely pruritic, migrating, serpiginous, reddish-brown tracks
Dx: history and clinical findings; eosinophils usually normal
Tx: antihelmintic (ivermectin)
What effect do beta 1 blockers have on the RAAs system?
inhibit beta 1 sympathetic stimulation of the juxtaglomerular apparatus of the kidney (which would normally stimulate renin release)
What conditions predispose to aspiration pneumonia?
- altered consciousness impairing cough reflex/glottic closure (dementia, drug intoxication)
- dysphagia due to neurologic deficits (stroke, neurodegenerative disease)
- Upper GI tract disorders (GERD)
- Mechanical compromise of aspiration defenses (nasogastric + endotracheal tubes)
- protracted vomiting
- large volume tube feedings in recumbent position
Pt, Labs, U/sm and Tx of epithelial ovarian carcinoma
Pt:
- acute: SOB, obstipation/constipation with vomiting, abdominal distension
- subacute: pelvic/abdominal pain, bloating, early satiety
- asymptotic adnexal mass
Labs: increased CA-125
U/s: solid mass, thick separations, ascites
Tx: exploratory laparotomy
Pt and Dx of chronic granulomatous disease
Pt: majority of cases X-linked recessive; recurrent pulmonary and cutaneous infections with catalase-positive pathogens (Staph aureus, Serratia, Burkholderia, Aspergillus
Dx: neutrophil function testing (dihydrorhodamine 123 test, nitro blue tetrazolium test)
Path, Pt, and CXR of transient tachypnea of the newborn
Path: inadequate alveolar fluid clearance at birth results in mild pulmonary edema
Pt: tachypnea begins shortly after birth + resolves by day 2 of life
CXR: bilateral perihilar linear streaking
Path, Pt, and CXR of respiratory distress of the newborn
Path: surfactant deficiency result Sina alveolar collapse + diffuse atelectasis
Pt: severe respiratory distress + cyanosis after premature birth
CXR: diffuse, reticulogranular (ground-glass) appearance, air bronchograms, low lung volumes
Path, Pt, and CXR of persistent pulmonary HTN as a cause of neonatal respiratory distress
Path: high pulmonary vascular resistance results in right-to-left shunting and hypoxia
Pt: tachypnea + severe cyanosis
CXR: clear lungs with decreased pulmonary vascularity
Path, Pt, Labs, Tx of classic congenital adrenal hyperplasia
Path: autosomal recessive, 21-hydroxylase deficiency
Pt: ambiguous genitalia in girls, salt-wasting syndrome: affects most girls + boys; hypotension, dehydration + vomiting
Labs: decreased sodium, increased potassium, decreased glucose; increased 17-hydroxyprogesterone
Tx: glucocorticoids + mineralocorticoids; high-salt diet; genital reconstructive surgery for girls; psychosocial support
When should you expect to begin to see salt wasting in classic congenital adrenal hyperplasia?
1-2 weeks of age
Path, Management, complications of infantile hemangioma
Path: may present as patch of telangiectasia at birth
- proliferation: age 0-1; bright red, raised nodule
- involution: age 1-9; deeper red/violent, regression in size
Management: observation; topical beta blocker (propranolol) for ulcerated or cosmetically sensitive ares (face)
Complications: ulceration/scarring, vision impairment if near eye, life-threatening if near airway
Risk factors, Pt, Dx and Management of postpartum uriary retention
Risk factors: primiparity, regional neuraxial anesthesia, operative vaginal delivery, perineal injury, cesarean delivery
Pt: inability to void >/= 6 hours after vaginal delivery, incomplete bladder emptying, dribbling of urine
Dx: urethral catheterization; post-void residual volume of >/= 150 mL
Tx: self-limited; intermittent catheterization
Causes, Pt, Dx, and management of sciatica (acute lumbosacral radiculopathy)
Causes: herniated intervertebral disk (MC), degenerative spondylosis, malignancy, epidural abscess
Pt:
- pain in low back radiating down posterior leg to food
- positive straight-leg raising test
- possible dermatomal sensory loss and weakness of hip dorsiflexion
Dx: primarily clinical; MRI recommended for:
- significant/progressive or B/L neurologic deficits
- suspected malignancy or epidural abscess
Management: activity modification, NSAIDs, surgery for disabling symptoms
In what circumstances can minors provide thier own consent?
Medical emancipation:
- emergency care
- sexually transmitted diseases
- mental health + substance abuse tx
- pregnancy care
- contraception
Legal emancipation:
- financially independent
- parent
- married
- active military service
- high school graduate
Path, U/S, Pt, Dx, and Tx of congenital toxoplasmosis
Path: undercooked meat, unwashed produce, unprotected handling of cat feces
U/S: bilateral ventriculomegaly, diffuse intracranial calcifications
Pt: chorioretinitis, hydrocephalus, seizures, intellectual disability, sensorineural hearing loss
Dx: maternal: serology
fetal: amniotic fluid PCR
Tx: spiramycin
Path, pleural fluid analysis, pleural fluid gram stain + culture, Tx of uncomplicated parapneumonic effusions
Path: steroid exudate in pleural space
pleural fluid analysis: pH >/= 7.2, glucose >/= 60, WBC = 50,000
pleural fluid gram stain + culture: negative
Tx: Abx
Path, pleural fluid analysis, pleural fluid gram stain + culture, Tx of complicated parapneumonic effusions
Path: bacterial invasion of pleural space
Pleural fluid analysis: pH <7.2, glucose < 60, WBC > 50,000
pleural fluid gram stain + culture: negative
Tx: Abx and drainage
What are complications of excessive weight gain in pregnancy?
- gestational diabetes mellitus
- fetal macrosomia
- cesarean delivery
What are complications of inadequate weight gain during pregnancy?
- fetal growth restriction
- preterm delivery
Pt, Dx, Management, and Complications of acute diverticulitis
Pt: abdominal pain (usually lower left quadrant), fever, nausea, vomiting, ileus (peritoneal irritation)
Dx: abdominal CT (oral + IV contrast)
Management: bowel rest, Abx (ciprofloxacin, metronidazole)
Complications: abscess, obstruction, fistula, perforation
What are the indications for surgical repair of primary mitral regurgitation?
- surgery if LVEF 30-60% (regardless of sx)
- consider surgery if successful valve repair is highly likely:
- symptoms + LVEF < 30%
- asymptomatic + LVEF >60%
Path, Pt, Dx, and Tx of eosinophilic esophagitis
Path: chronic, immune-mediated esophageal inflammation
Pt: dysphagia, chest/epigastric pain, reflux/vomiting, food impaction, associated atopy
Dx: endoscopy + esophageal biopsy (>/=15 eosinophils per high-power filed)
Tx: dietary modification, +/- topical glucocorticoids
What protein level is considered high-protein ascites? What are the common causes of this? What about low-protein ascites?
> /= 2.5 (high-protein ascites):
- CHF, constrictive pericarditis, peritoneal carcinomatosis, TB, Budd-Chiari syndrome, fungal
<2.5 (low-protein ascites): cirrhosis, nephrotic syndrome
What SAAG ratio indicates portal HTN? What are the common causes? What about in the absence of portal HTN?
> /= 1.1 (indicates portal HTN): cardiac ascites, cirrhosis, Budd-Chiari
<1.1 (absence of portal HTN): TB, peritoneal carcinomatosis, pancreatic ascites, nephrotic syndrome
Characteristics and time frame of rotavirus + norovirus diarrhea
short-term
brief illness
vomiting common
Characteristics and time frame of enterotoxigenic E. coli and Enteropathogenic E coli diarrhea
short-term
contaminated food + drinking water
Characteristics and time frame of campylobacter diarrhea
short-term
prominent abodminla pain
pseudoappendicitis
bloody diarrhea
Characteristics and time frame of salmonella diarrhea
short-term
frequent fever
Characteristics and time frame of shigella diarrhea
short-term
fever
bloody diarrhea
abdominal pain
Characteristics and time frame of entamoeba histolytica
long-term (>2 weeks)
prolonged bloody diarrhea
Characteristics and time frame of giardia diarrhea
long-term (>2 weeks)
prolonged watery diarrhea
fat malabsoprtion, bloating common
asymptomatic patients may continue to shed organism for months
Characteristics and time frame of cryptosporidium, cystoisospora (formerly isospora), microscporidia species diarrhea
long-term (>2 weeks)
chronic watery diarrhea in immunosuppressed patients
Characteristics and time frame of cyclosporine diarrhea
long-term (>2 weeks)
may cause prolonged, relapsing infection
characteristics of focal nodular hyperplasia as a cause of a solid liver mass
- associated with anomalous arteries
- arterial flow + central scar on imaging
characteristics of hepatic adenoma as a cause of a solid liver mass
- women on long-term OCPs
- possible hemorrhage or malignant transformation
characteristics of regenerative nodules as a cause of a solid liver mass
acute or chronic livery injury (cirrhosis)
characteristics of hepatocellular carcinoma as a cause of a solid liver mass
- systemic symptoms
- chronic hepatitis or cirrhosis
- elevated alpha-fetoprotein
characteristics of liver metastasis as a cause of a solid liver mass
- single/multiple lesions
- known extra hepatic malignancy
What is ascertainment (sampling) bias?
type of selection bias: study population differs from target population due to nonrandom selection methods
What is nonresponse bias?
type of selection bias: high nonresponse rate to surveys/questionnaires can cause errors if non responders differ in some way from responders
What is Berkson bias?
type of selection bias: disease studied using only hospital-based patients may lead to results not applicable to target population
What is prevalence (Neyman) bias?
Type of selection bias: exposures that happen long before disease assessment can cause study to miss disease patients that die early or recover
What is attrition bias?
type of selection bias: significant loss of study participants may cause bias if those long to follow-up differ significantly from remaining subjects
What is recall bias?
type of observational bias: common in retrospective studies, subjects with negative outcomes are more likely to report certain exposures than control subjects
What is observer bias?
type of observational bias: observers misclassify data due to individual differences in interpretation or preconceived expectations regarding study
What is reporting bias?
type of observational bias: subjects over- or under-report exposure history due to perceived social stigmatization
What is surveillance (detection) bias?
type of observational bias: risk factor itself causes increased monitoring in exposed group relative to unexposed group, which increases probability of identifying a disease
characteristics of genital ulcers caused by HSV
painful
small vesicles or ulcers one erythematous base
mild LAD
characteristics of genital ulcers caused by haemophilus ducreyi (chancroid)
painful
larger, Depp ulcers with gray/yellow exudate
well-demarcated borders + soft, friable base
- severe LAD that may suppurate
characteristics of genital ulcers caused by treponema palladium (syphilis)
painless
single ulcer (chance)
regular borders + hard base
characteristics of genital ulcers caused by chlamydia trachoma’s serovars L1-L3 (lymphogranuloma venereum)
painless
small, shallow ulcers (often missed)
can progress to painful, fluctuant adenines (buboes)
What are risk factors for septic arthritis?
abnormal joint: OA, RA, prosthetic joint, gout
age > 80
diabetes
IVDA, alcoholism
intra-articular glucocorticoids injections
Pt, Dx, and Tx of septic arthritis
Pt: acute monoarthritis: hot, swollen, decreased ROM, fever, elevated ESR + CRP
Dx: blood cultures, synovial fluid analysis: leukocytosis (>50,0000), gram stain, culture
Tx: gram positive cocci: vancomycin
gram negative rod: third gen cephalosporin
negative microscopy: vancomycin (+ 3rd gen cephalosporin if immunocompromised)
fetal hydantoin syndrome path and pt
Path: due to in utero exposure to an anti epileptic (phenytoin, carbamazepine, valproate)
Pt: cleft lip and palate, wide anterior fontanelle, distal phalange hypoplasia, and cardiac anomalies (pulmonary stenosis, aortic stenosis), neural tube defects, microcephaly
Where are pressure ulcers most common?
bony prominences, such as the sacrum, ischial tuber-sixties, malleoli, heels, and 1st and 5th metatarsal head
What is used to correct hyponatremia? What is the goal for raising the Na?
patients with serum Na <130 with any symptoms of elevated intracranial pressure should be treated with hypertonic 3% saline boluses; the goal is to raise serum Na levels by 4-6 over a period of hours (maximum rate of correction is 8 in 24 hours to prevent ODS)
What is a serious risk of untreated infection of the retropharyngeal space?
retropharyngelal space drains inferiorly to the superior mediastinum; spread to the carotid sheath can cause thrombosis of the internal jugular vein and deficits in cranial nerves IX, X, XI, and XII; extension through the alar fascia into the “danger space” can lead to acute necrotizing mediastinitis (fever, chest pain, dyspnea, odynophagia, and requires urgent surgical intervention)
what is the difference between small fiber and large fiber nerve injury?
small fiber injury is characterized by the predominance of positive symptoms (pain, paresthesia, allodynia)
large fiber involvement is characterized by the predominance of negative symptoms (numbness, loss of proprioception and vibration sense, diminished ankle reflexes)
What can systemic blastomycosis cause? Where is it found?
found in Great Lakes, Mississippi River, and Ohio river basins (Wisconsin); systemic blastomycosis may cause characterizes ulcerated skin lesions and lytic bone lesions
what do you expect to see on peripheral smear of someone with CMV?
atypical lymphocytes
acute transverse myelitis path, pt, dx, and tx
path: infiltration of inflammatory cells into a segment of the spinal cord, leading to neuron and oligodendrocyte cell death and demyelination; most cases follow a recent infection but it’s also associated with MS and systemic disease (sarcoidosis); MC in teens and those age 30-40
Pt: inflammation localizes to >/= 1 contiguous spinal cord segments, leading to rapidly progressive myelopathy characterized by:
1. motor weakness that progresses from flaccid to spastic paraparesis with UMNS
2. autonomic dysfunction including bowel/bladder incontinence or retention and sexual dysfunction
3. sensory dysfunction including pain, paresthesia, or numbness with a distinct sensory level
Dx: MRI shows enhancement of the affected cord segments without evidence of compression
Lumbar puncture: CSF pleocytosis and elevated IgG
Tx: high dose IV glucocorticoids
What symptoms are typical of cauda equina?
associated with severe back pain and sensory loss that involves the thighs and buttocks
How is diverticulitis complicated by abscess treated?
- fluid collection < 3 cm can be treated with IV Abx and observation with surgery reserved for patients with worsening sx
- fluid collection >/= 3 cm should receive Abx and have Ct-guided percutaneous drainage; if the sx are not controlled within a few days, surgical drainage and debridement are recommended
pituitary apoplexy path and pt
path: sudden hemorrhage into an enlarged pituitary adenoma (prolactinoma)
Pt: sudden onset, severe HA as well as visual disturbances (diplopia, bitemporal hemianopsia) and eye dysfunction (ptosis); loss of all pituitary function; in the acute setting the loss of ACTH is most important and can lead to adrenal crisis
What bruises are suspicious of abuse?
patterned (belt buckle, hand) or located on the neck, ear, torso, and buttocks
retinal detachment path, pt, dx, tx
path: separation of the layers of the retina; age 40-70; inciting event usually occurs months before retinal detachment
pt: photo-Dia (flashes of light) and floaters (spots in the visual filed), sometimes a “curtain coming down over my eyes”
Dx: ophthalmoscopic exam revels a grey, elevated retina
Tx: laser therapy and cryotherapy
How does central retinal artery occlusion differ from retinal detachment in regards to the ophthalmoscopic exam?
central retinal artery occlusion = pallor of the optic disc, cherry red fovea, and boxcar segmentation of blood int the retinal veins
retinal detachment - grey, elevated retina
What CSF finding would you expect in a patient with suicidal behavior?
low levels of 5-HIAA (primary metabolite of serotonin)
diffuse 3-Hz spike and wave pattern on EEG - Dx?
characteristic of childhood absence seizures
generalized slowing with periodic sharp wave complexes on EEG and increased CSF 14-3-3 protein. - Dx?
Creutzfeldt-Jakob disease (progressive dementia, myoclonus, pyramidal/extrapyramidal dysfunction, mutism)
low concentration of hypocretin (orexin) int he CSF is found in what disorder?
narcolepsy
analgesic nephropathy path + pt
path: most common form of drug-induced chronic renal failure; most commonly seen in females (age 50-55 yo) who habitually use combined analgesics (aspirin + naproxen); generally seen after cumulative ingestion of 4.4-6.6lbs of the drug; papillary necrosis and chronic tuluointerstitial nephritis are the most common paths seen
Pt: polyuria, sterile pyuria with WBC casts; HTN, mild proteinuria, and impaired urinary concentration can occur as disease advances
right ventricular mI
Pt: RV failure leads to decreased preload and resultant hypotension, ST-segment elevation in inferior leads II, III, ave, JVD, Kussmaul’s sign (increase in JVD with inspiration), clear lung fields
Dx: confirmed with >/= 1mm ST-segmenet elevation in right-sided precordial leads V4R-V6R
tx: treated with IVF boluses to improve RV preload and facilitate LV filling
What anti-hypertensive commonly causes peripheral edema?
CCB - likely related to preferential dilation of precapillary vessels, which leads to increased capillary hydrostatic pressure and fluid extravasation into the interstitium (other side effects include HA, flushing, and dizziness)
Pt, PE, Dx, and Tx of fibromuscular dysplasia
Pt: 90% women Internal carotid artery stenosis: - recurrent HA -pulsatile tinnitus -TIA -stroke Renal artery stenosis - secondary HTN - flank pain PE: sub auricular systolic bruit, abdominal bruit Dx: imaging preferred (duplex u/s, CTA, MRA), catheter-based arteriography Tx: antihypertensives (ACE inhibitors or ARBs 1st line), PTA (percutaneous transluminal angioplasty), surgery (if PTA unsuccessful)
tachycardia, HTN, sweating, anxiety, neuropathy (weakness, numbness) and severe abdominal pain - Dx?
acute intermittent porphyria
dermatitis herpetiformis Pt, skin biopsy, immunofluorescence, associated disease, and Tx
Pt: intensely pruritic erythematous papules, vesicles, and bullae symmetrically grouped on extensor surfaces of elbows, knees, back and buttocks
Skin biopsy: sub epidermal micro abscesses at the tips of the dermal papillae
Immunofluroescence: deposits of anti-epidermal transgluatminase IgA in the dermis
associated with celiac disease
Tx: dapsone + gluten free diet
urethras diverticula
Path: recurrent periurethral gland infections that develop into an abscess that breaches the urethral mucosa -> tender anterior vaginal wall mass that can cause dyspareunia; can also have purulent discharge, dysuria, and postpaid dribbling
Dx: MRI
Tx: surgical excision
Pt, pediatric etiologies, adult etiologies of nephrotic syndrome
Pt: edema, fatigue, proteinuria, absence of hematuria, hypoalbuminemia
Peds: minimal change disease
Adults: FSGS, membranous nephropathy, membranoproliferative glomerulonephritis
Pt, pediatric etiologies, adult etiologies of nephritic syndrome
Pt: HTN, oliguria, hematuria, proteinuria, casts
Peds: poststreptococcal glomerulonephritis, HUS
adults: IgA nephropathy, membranoproliferazive glomerulonephritis, crescentic glomerulonephritis`
What is a significant risk factor for the development of membranous nephropathy? What labs would you expect?
hepB (can occur in children also); 24-hour urine sample with protein excretion >3g/day, and low serum C3
lower back radiucalr pain plus:
- motor deficits in the affected dermatome; reflex responses in the knee or ankle often absent
- patchy sensory loss in the affected dermatomes; saddle anesthesia
- rectal spinster, bladder, and/or sexual dysfunction
Dx?
cauda equina syndrome either due to lumbar disc herniation (L4-S1) or epidural tumors (metastatic squamous cell lung cancer), epidural abscess, or inflammatory diseases in the region (sarcoidosis)
Pt of pyromania
deliberate fire setting > 1 occasion
fascination with fire
tension/arousal prior to act; pleasure/relief when setting/witnessing fires
no external motivation (financial gain, political statement, recognition)
Complications, maternal management, and prevention of vertical transmission of hep C in pregnancy?
Complications: gestational diabetes, cholestasis of pregnancy, preterm delivery
Maternal management:
- ribavirin is teratogenic and should be avoided
- no indication for barrier protection in serodiscordant, monogamous couples
- hep A and B vaccination
Prevention of vertical transmission:
- vertical transmission strongly associated with maternal viral load
- C-section not protective
- breastfeeding should be encouraged unless maternal blood present (nipple injury)
Pt and biopsy of seborrheic dermatoses
Pt: velvety or greasy surface and well-demarcated border, stuck on appearance; benign although sudden onset of multiple SKs may indicate an occult internal malignancy (Leser-Trelat sign)
Biopsy: (not necessary) will show small cells resembling basal cells with variable pigmentation, hyperkeratosis, and keratin-containing cysts
What are the indications for endometrial biopsy based on age?
age >/=45 = abnormal uterine bleeding, postmenopausal bleeding
age <45 = abnormal uterine bleeding PLUS:
- unopposed estrogen (obesity, an ovulation)
- failed medical management
- Lynch syndrome (hereditary nonpolyposis colorectal cancer)
Age >/=35 =
Atypical glandular cells on Pap test
Risk factors, Pt, Imaging, and management of sigmoid volvulus
Risk factors: sigmoid colon redundancy (dilation/elongation from chronic constipation), colonic dysmotility (underlying neurologic disorder)
Pt: slowly progressive abdominal discomfort/distension +/- obstructive symptoms (nausea, emesis, obstipation), abdomen distended + tympanic to percussion
Imaging: X-ray: dilated, inverted, U-shaped loop of colon (coffee bean sign)
CT scan: dilated sigmoid colon, mesenteric twisting (whirl sign)
Management: endoscopic detorsion (flexible sigmoidoscopy) + elective sigmoid colectomy; emergency sigmoid colectomy if perforation/peritonitis present
What is the first step in management of a neonate with bilious emesis?
stop feeds
NG tube decompression
IV fluids
X-ray
If the abdominal X-ray of a neonate with bilious emesis shows free are, hematemesis, or unstable vital signs, what is the next step?
surgery
If the abdominal X-ray of a neonate with bilious emesis shows dilated loops of bowel, what is the next step? What are the possible outcomes of the next step?
contrast enema
microcolon -> meconium ileus
rectosigmoid transition zone -> Hirschsprung disease
If the abdominal X-ray of a neonate with bilious emesis shows the NG tube misplaced int he duodenum, what is the next step? What is the possible outcome of this next step?
Upper GI series -> ligament of Treitz on the right side of the abdomen -> malrotation
If the abdominal X-ray of a neonate with bilious emesis shows double bubble sign, what is the dx?
duodenal atresia
What is the effect on PPV and NPV as prevalence of a particular disease increases in a population?
PPV increases, NPV decreases
What is the effect on PPV and NPV as prevalence of a particular disease increases in a population?
PPV decreases
NPV increases
Path, Pt, Dx, and Tx of lung abscess
Path: aspiration of oropharyngeal/gingival anaerobes
- risk factors: dysphagia, substance abuse, seizures
- Pneumonitis -> pneumonia -> abscess/empyema
Pt: subacute fever, night sweats, weight loss; cough with putrid sputum
Dx: cavitary infiltrates with air-fluid levels, cultures rarely useful
Tx: amicillin-sulbactam, imipenem, meropenem
Alternate: clindamycin
What are the likely causative organisms of deep infections following puncture wounds? What is the treatment?
Stap aureus and Pseudomonas (pseudomonas especially after puncture wounds through the sole of a shoe); Tx = IV Abx (ciprofloxacin, pipperacilin-tazobactam) and surgical debridement
What does diffuse uptake of radioactive iodine indicate?
Graves disease
What does a nodular pattern of radioactive iodine indicate?
toxic adenoma, multinodular goiter
What is the next step in workup with low radioactive iodine uptake? What are the possible outcomes?
measure serum thyroglobulin; high -> thyroiditis or iodine exposure
low -> exogenous hormone
What factors make a pancreatic cyst concerning for malignancy?
large size (>/=3cm)
solid components or calcifications
main pancreatic duct involvement (ductal dilation)
thickened or irregular cyst wall
How does cryptococcus neoformans cause increased ICP? What symptoms are associated?
replicates in the CNS and clogs the arachnoid villi with yeast components, leading to CSF outflow obstruction and increased ICP -> progressive HA, N/V, confusion, 6th cranial nerve invovlement with lateral gaze palsy and diplopia
(patients also frequently have fever, malaise, and umbilicate skin lesions that resemble molluscum contagiosum)
What are the AIDS-defining malignancies and their cause?
Kaposi sarcoma (HHV8)
Invasive cervical carcinoma (HPV)
Non-Hodgkin lymphoma (EBV)
Primary CNS lymphoma (EBV)
Elevated PT and/or PTT, 1:1 inhibitor mixing study results in normal PT and/or PTT -> etiologies??
factor deficiency, evaluate for individual factor assays
Elevated PT and/or PTT, 1:1 inhibitor mixing study does not correct PT and/or PTT -> etiologies??
inhibitor likely present; test for coagulation factor inhibitors
Pt and management of keratoacanthoma
Pt: rapidly growing nodule with ulceration + keratin plug; often shows spontaneous regression/resolution
Management: excisional biopsy with complete removal of lesion
**may resemble or progress to squamous cell carcinoma
Risk factors, path, and Pt of struvite stones
Risk factors: recurrent upper URI; urease-producting organisms (Klebsiella, Proteus); stones made of magnesium ammonium phosphate)
Path: hydrolysis of urea to yield ammonia, increased urine pH, precipitation of magnesium ammonium phosphate salts
Pt: large staghorn calculi; fever, mild flank pain due to infection; obstruction of collecting system and atrophy of renal parenchyma
Mechanism and causes of normal anion gap metabolic acidosis
Mechanism: loss of bicarb
Causes: severe diarrhea, renal tubular acidosis, excess saline infusion, intestinal or pancreatic fistula, carbonic anhydrase inhibitor + mineralocorticoid receptor antagonist diuretic
Renal tubular acidosis type 1
(distal)
Path: impaired H+ excretion by alpha-intercalated cells in the distal tubule
Pt: hypokalemia due to reduced K+ reabsorption, urine pH >5.5
Renal tubular acidosis type 2
(proximal)
Path: impaired HCO3- reabsorption in the proximal tubule
Pt: hypokalemia, variable urine pH usually <5.5
Renal tubular acidosis type 4
Path: reduced aldosterone activity leading to impaired H+ and K+ excretion in the collecting duct
Pt: hyperkalemia, urine PH <5.5
What two tests are required for dx of ectopic pregnancy?
pregnancy test and transvaginal u/s
What medications should be avoided with G6PD deficiency?
dapsone, isobutylene nitrite, nitrofurantoin, primaquine, rasburicase
Drug names, MOA, indications, and adverse effects of selective estrogen receptors modulators (SERMs)
Drug names: tamoxifen, raloxifene
MOA: competitive inhibitor of estrogen binding; mixed agonist/antagonist action
Indications:
1. prevention of breast cancer in high-risk patients
2. Tamoxifen: adjuvant treatment of breast cancer
3. Raloxifene: postmenopausal osteoporosis
Adverse effects: hot flashes, venous thromboembolism, endometrial hyperplasia + carcinoma (tamoxifen only)
What are the symptoms and cause of refeeding syndrome?
Pt: arrhythmia, CHF (pulmonary edema, peripheral edema), seizures, Wernicke encephalopathy
Cause: increased insulin
What nerve can be injured in a Colles fracture, and what effect does that have?
colles fracture (dorsal displacement of the radius) can result in compression of the median nerve, which provides sensation to the lateral 3 1/2 digits and motor innervation tot he thenar muscles
What is the first step in management of a fetus with recurrent variable decelerations? What is the next step?
intrauterine resuscitation with maternal repositioning (left lateral, all fours), which may reduce cord compression and improve fetal-placental blood flow; if this does not improve the variable decelerations, an amnioinfusion can be administered
What is the normal findings of the amniotic fluid volume component of the biophysical profile?
single fluid pocket >/= 2 x 1 cm or amniotic fluid index > 5
What is the normal findings of the fetal movements component of the biophysical profile?
> = 3 general body movements
What is the normal findings of the fetal tone component of the biophysical profile?
> /= 1 episodes of flexion/extension of fetal limbs or spine
What is the normal findings of the fetal breathing movements component of the biophysical profile?
> /= 1 breathing episode for >/= 30 seconds
Path, Pt, Labs, and Prevention of infantile vitamin K-deficient bleeding
Path: low vitamin K stores (poor placental transfer, sterile gut, low content in breast milk), inefficient vitamin K use by immature liver
Pt: classically presents on day 2-7 of life with easy bruising, umbilical, mucosal + GI bleeding, intracranial hemorrhage
Labs: increased PT, increased PTT (if severe), normal platelet count
Prevention: intramuscular vitamin K at birth
Path, pt, and tx of lymphangitis
Path: cutaneous injury -> pathogen invasion of lymphatics in deep dermis; strep progenies + MSSA
Pt: tender, erythematous streaks proximal to wound; regional tender LAD; systemic symptoms (fever, tachycardia)
Tx: cephalexin
Risk factors, Pt, and management of biosphosphonate-related osteonecrosis of the jaw
Risk factors: high-dose, parenteral bisphosphonates; dental procedures (extractions, implants), concurrent glucocorticoid use, concurrent or previous malignancy
Pt: chronic, indolent symptoms; mild pain, swelling; exposed bone, loosening of teeth, pathologic fractures
Management: oral hygiene, antibacterial rinses, Abx and debridement as needed
Path, Pt, and management of primary varicocele
Path: compression of left renal vein between SMA and aorta; incompetent venous valves
Pt: “bag of worms” mass, pubertal onset, left-sided, decompresses when supine
Management: reassurance and observation
Path, Pt, and management of secondary varicocele
Path: extrinsic compression (renal or retroperitoneal mass) of IVC; venous thrombus
Pt: “bag of worms” mass, prepubertal onset, right-sided, persists when supine
Management: abdominal u/s
What are structural causes of recurrent pregnancy loss?
uterine: fibroids, adhesions, polyps
cervical insufficiency
What are the chromosomal causes of recurrent pregnancy loss?
aneuploidy, translocations/rearrangements, mosaicism
What are the immunologic/hematologic causes of recurrent pregnancy loss?
hypercoagulable disorders (antiphospholipid syndrome), alloimmune intolerance
What are the endocrine causes of recurrent pregnancy loss?
thyroid disease, PCOS, DM, hyperprolactinemia
What is the pt of renal parenchymal disease as a cause of HTN
elevated serum Cr abnormal urinalysis (proteinuria, RBC casts)
What is the pt of renovascular disease as a cause of HTN
severe HTN with onset after age 55
recurrent flash pulmonary edema
rise in serum Cr
abdominal bruit
What is the pt of primary aldosteronism as a cause of HTN
spontaneous or easily provoked hypokalemia
What is the pt of pheochromocytoma as a cause of HTN
paroxysmal HTN with tachycardia
pounding HA, palpitations, diaphoresis
What is the pt of Cushing syndrome as a cause of HTN
cushingoid body habitus
proximal muscle weakness
hyperglycemia
What is the pt of primary hyperparathyroidism as a cause of HTN
hypercalcemia, kidney stones, neuropsych sx
What is the pt of coarctation of the aorta as a case of HTN
lateralizing HTN, brachial-femoral pulse delay
Path, Pt, Labs, Imaging, and Tx of Paget disease of the bone
Path: osteoclast dysfunction, increased bone turnover
Pt: most asymptomatic; bone pain and deformity:
skull: HA, hearing loss
spine: spinal stenosis, radiculoapthy
long bones: bowing, fracture, arthritis of adjacent joints
giant cell tumor, osteosarcoma
Labs: elevated alkaline phosphatase, elevated bone turnover markers (PINP, urine hydroxyproline), calcium + phosphorus are usually normal
Imaging: X-ray: osteolytic or mixed lytic/sclerotic lesions
bone scan: focal increase in uptake
Tx: bisphosphonates
Whipple disease path, pt, and biopsy
Path: tropheryma whippelii; MC in men in the fourth-to-sixth decades of life
Pt: WL, abdominal pain, diarrhea, and malabsorption with distension, flatulence, and steatorrhea; migratory polyarthropathy, chronic cough, myocardial or valvular involvement leading to CHF or valvular regurgitation
Later stages characterized by dementia, supranuclear ophthalmoplegia, and myoclonus; intermittent low grade fever, pigmentation, and LAD
Biopsy: PAS-positive material in the lamina propria of the small intestine
What neurologic findings would you expect in a patient with major depressive disorder?
increased cortisol, decreased hippocampal and frontal lobe volumes, decreased REM sleep latency and decreased slow-wave sleep
Triggers, Pt, Dx, and management of complex regional pain syndrome
Triggers: trauma: fracture, sprain; surgery
Pt:
pain: severe, regional (not dermatomal), burning/stinging
edema, abnormal sweating
vasomotor changes, altered skin temp
trophic skin, hair + nail changes
Dx: primarily based on clinical features; X-ray: patchy demineralization; bone scintigraphy: increased uptake in affected limb
Management: physical + occupational therapy, exercise
Meds: NSAIDs, antineuropathic medications (pregabalin, TCAs)
What do you expect to find on PE of aortic regurgitation?
- early diastolic mumur
- bounding pulse/”water hammer” pulse (because AR is associated with an increased stroke volume, which produces an abrupt rise in the SBP and rapid distension of the peripheral arteries)
What is pulsus paradoxus and what condition do you expect to see it in?
refers to a fall in the systemic arterial pressure by more than 10 mmHg during inspiration, and is often associated with cardiac tamponade
What are the causes of pleuritic chest pain?
costochondritis, pericarditis, malignancy, infection (pneumonia), PE
dyspnea, tachycardia, tachypnea, U/L LE edema, pleural effusion, low-grade fever, and troponin elevations - Dx?
PE
Pt and Tx of nonallergic rhinitis
Pt:
- nasal congestion, rhinorrhea, sneezing, postnasal drainage
- later onset common (age >20)
- no obvious allergic trigger
- perennial symptoms (may worsen with season changes)
- erythematous nasal mucosa
Tx: mild: intranasal antihistamine or glucocorticoids
moderate or severe: combination therapy
Pt and Tx of allergic rhinitis
Pt:
- watery rhinorrhea, sneezing, eye symptoms
- earlier age of onset
- identifiable allergen or seasonal pattern
- pale/bluish nasal mucosa
- associated with other allergic disorders (eczema, asthma, eustachian dysfunction)
Tx: intranasal glucocorticoids, antihistamines
Definition, Pt, and Tx of nonalcoholic fatty liver disease
Definitino: hepatic steatosis on imaging or biopsy, exclusion of significant alcohol use, exclusion of other causes of fatty liver
Pt: mostly asymptomatic, metabolic syndrome, +/- steatohepatitis (AST/ALT ratio <1), hyper echoic texture on u/s
Tx: diet + exercise, consider bariatric surgery if BMI >/= 35
cholesterol emboli presentation
skin: livedo reticular (reticulated, mottled, discolored skin), blue toe syndrome
kidney: acute kidney injjry
GI: pancreatitis, mesenteric ischemia
Pt, Tx, and complications of nasal foreign body
Pt: inorganic substance: asymptomatic, mild pain/discomfort
organic substance: unilateral, foul-smelling, purulent discharge
button battery: epistaxis, purulent discharge
Tx: positive pressure (patient exhalation with unaffected nares occluded), mechanical extraction
Complications: infection (sinusitis), local irritation, aspiration into airway, nasal septal perforation (with button battery or multiple magnet insertion)
Pt and Tx of preseptal cellulitis
Pt: eyelid erythema + swelling, chemoses
Tx: oral Abx
Pt and Tx of orbital cellulitis
Pt: symptoms of preseptal cellulitis PLUS pain with EOM, proptosis +/or ophthalmoplegia with diplopia
Tx: IV Abx +/- surgery
week of headaches, dizziness, blurry vision with a large gamma gap and “sausage-link” retinal changes - Dx?
Waldenstrom macroglobulinemia; gamma gap = difference between total protein and albumin
Pt and X-ray findings of SBO
Pt: N/V, obstipation, acute abdomen, hyperactive or absent bowel sounds
X-ray: air fluid levels, dilated proximal bowel, collapsed distal bowel, little/no air in colon/rectum
Pt and X-ray findings of ileus
Pt: N +/- vomiting, no flatus, abdominal distension, decreased or absent bowel sounds
X-ray: no transition point, dilated loops of bowel, air in colon/rectum
What is the effect of vagal maneuvers on the heart?
Vagal maneuvers (carotid sinus massage, cold-water immersion or diving reflex, Valsalva maneuver, eyeball pressure) increase parasympathetic tone in the heart and result in temporary slowing of the AV node and an increase in the AV node refractory period, leading to termination of AVNRT
autonomic dysreflexia path, pt
path: potentially life-threatening complication of spinal cord injury
Pt; severe HTN, HA, diaphoresis, flushing, and bradycardia in the setting of urinary retention
In which scenarios is a trial of labor contraindicated?
hx of classical cesarean delivery (vertical incision) and hx of abdominal myomectomy with uterine cavity entry
Path, Pt, Labs, and Tx of folate deficiency anemia
Path: chronic hemolysis (sickle cell dz), poor dietary intake, malabsorption (gastric bypass), medications (methotrexate, phenytoin)
Pt: dyspnea, fatigue, pallor, weakness
Labs: microcytic anemia, poor reticulocyte response (low to normal), hyperhsegmented neutrophils, low serum folate
Tx: folic acid supplementation
Screening for, serologic tests, Tx, pregnancy effects, and fetal effects of syphilis infection in pregnancy
Screening: universal at first prenatal visit; third trimester + delivery if high risk
Serologic tests: nontreponemal (RPR, VDRL), treponemal (FTA-ABS)
Tx: intramuscular penicillin G benzathine
Pregnancy effects: intrauterine fetal Demis, preterm labor
Fetal effects: hepatic (hepatomegaly, jaundice), hematologic (hemolytic anemia, decreased platelets), MSK (long bone abnormalities), failure to thrive
hyponatremia with serum osmolality >290 is caused by what?
makred hyperglycemia or advanced renal failure
hyponatremia with serum osmolality <290 and urine osmolality < 100 is caused by what?
primary polydipsia or malnutrition (beer drinker’s potomania)
hyponatremia with serum osmolality >290, urine osmolality >100, and urine sodium >25 is caused by what?
SIADH, adrenal insufficiency, hypothyroidism
hyponatremia with serum osmolality >290, urine osmolality >100, and urine sodium <25 is caused by what?
volume depleition, CHF, cirrhosis
Pt, Dx, and Tx of crohn’s disease
Pt:
GI: abdominal pain, non bloody diarrhea, oral ulcers, malabsorption, weight loss, fistula/abscess formation
Extraintestinal: MSK (arthritis), eye (uveitis, scleritis, episcleritis), skin (erythema nodosum, pyoderma gangrenosum)
Dx: increased WBC, IDA, increased inflammatory markers
Endoscopy: focal ulcerations adjacent to normal mucosa (cobblestoning), skip areas of disease
Radiography: strictures, bowel wall thickening
Tx: 5-ASA drugs, corticosteroids, Abx; azathioprine; anti-TNF therapies
fever, RUQ pain, leukocytosis, elevated liver enzymes with a rounded, hypoattenuating lesion in the liver - Dx? Tx?
pyogenic liver abscess; percuatneous aspiration and drainage = Dx and Tx
episodic pounding sensation, chronic diarrhea, WL, valvular heart disease with tricuspid regurgitation - Dx?
carcinoid syndrome
gross motor, fine motor, language, and social/cognitive developmental milestones at 2 months old
gross motor: lifts head/chest in prone position
fine motor: hands unlisted 50% of the time; tracks past midline
Language: alerts to voice/sound, coos
Social/cognitive: social smile, recognizes parents
gross motor, fine motor, language, and social/cognitive developmental milestones at 4 months old
Gross motor: sits with trunk support, begins rolling
Fine motor: hands mostly open, reaches midline
Language: laughs, turns to voice
Social/cognitive: enjoys looking around
gross motor, fine motor, language, and social/cognitive developmental milestones at 6 months old
Gross motor: sits momentarily propped on hands (unsupported by 7 months)
Fine motor: transfers objects hand to hand, raking grasp
Language: responds to name, babbles
Social/cognitive: stranger anxiety
gross motor, fine motor, language, and social/cognitive developmental milestones at 9 months old
Gross motor: pulls to stand, cruises
Fine motor: 3-finger pincer grasp; holds bottle or cup
Language: says “dada” “mama”
Social/cognitive: waves “bye,” plays “pat-a-cake”
gross motor, fine motor, language, and social/cognitive developmental milestones at 12 months old
Gross motor: stands well, walks first steps independently, throws ball
Fine motor: 2-finger pincer grasp
Language: says first word other than “dada” and “mama”
Social/cognitive: separation anxiety, comes when called
Timing, path, and Pt of breastfeeding jaundice
Timing: first week of life
Path: insufficient intake of breast milk resulting in: decreased bilirubin elimination, increased enterohepatic circulation
Pt: suboptimal breastfeeding, signs of dehydration
Timing, path, and pt of breast milk jaundice
Timing: starts at age 3-5 days; peaks at 2 weeks
Path: high levels of beta-glucuronidase in breast milk deconjugate intestinal bilirubin + increase enterohepatic circulation
Pt: adequate breastfeeding, normal examination
What do you expect to see on x-ray of a retropharyngeal abscess?
widening of the prevertebral soft-tissue space
MOA, indication, and adverse effect of succinylcholine
MOA - binds postsynaptic ACh receptors to trigger influx of sodium ions and efflux of potassium ions through ligand-gated channels -> temporary paralysis
Indications: used during rapid-sequence intubation
Adverse effects: life-threatening arrhythmia due to severe hyperkalemia
What is the diagnostic criteria for antiphopholipid Ab syndrome?
(1 clinical and 1 laboratory criteria must be met)
Clinical:
1. vascular thrombosis (arterial or venous)
2. pregnancy morbidity
- >/=3 consecutive, unexplained fetal losses before 10th week
- >/= 1 unexplained fetal loss after 10th week
- >/= 1 premature birth of normal neonate befrore 34th week due to preeclampsia, eclampsia, placental insufficiency
Laboratory:
- lupus anticoagulant
- anticardiolipid Ab
- Anti-beta-2 glycoprotein Ab
Path, pt, and management of acute limb ischemia
Path: cardiac/arterial embolus (AF, LV thrombus, IE), arterial thrombosis (PAD), iatrogenic/blunt trauma
Pt: 6 P’s of acute limb ischemia: pain, pallor, paresthesia, pulselessness, poikilothermic (cool extremity), paralysis (late)
Management: anticoagulation (heparin), thrombolysis vs surgery
Path, pt, dx, and management of guillan-barre syndrome
Path: immune-mediated demyelinating polyneuropathy; preceding GI (Campylobacter) or respiratory infection
pt: paresthesia, neuropathic pain; symmetric, ascending weakness, decreased/absent DTR, autonomic dysfunction (arrhythmia, ileus), respiratory compromise
Dx: clinical, supportive findings: CSF fluid: increased protein, normal leukocytes; abnormal electromyography + nerve conduction
Management: monitoring of autonomic + respiratory function; IV immunoglobulin or plasmapheresis
What are the risk factors of acute urinary retention? How is the dx confirmed?
- male sex
- advanced age
- history of BPH
- history of neurologic disease
- surgery
Dx confirmed by bladder u/s that shows >/= 300 mL of urine
sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity with pelvic free fluid - Dx?
ruptured ovarian cyst
vesicovaginal fistula pt, dx, and tx
Pt: continuous vaginal discharge with abnormally elevated pH (>4.5) due to urine; pelvic exam shows vaginal pooling of urine, a visible defect, or an area of raised, red granulation tissue on the anterior vaginal wall
Dx: bladder dye testing
Tx: surgical repair
What is the mechanism of anemia in chronic lymphocytic leukemia?
IgG autoantibodies against the erythrocyte membrane (warm agglutinins) -> immune-mediated hemolysis (autoimmune hemolytic anemia)
What is the lung cancer screening recommendation?
annual low-dose chest CT in patients age 55-80 with a >/=30 pack year smoking history (who are currently smoking or quit within the last 15 years)
Pt, Dx, and prognosis of IgA nephropathy
Pt: usually within 5 days of URI, more common in men age 20-30, recurrent gross hematuria
Dx: normal serum complements, mesangial IgA deposits seen in kidney biopsy
Prognosis: usually benign, possible radially progressive glomerulonephritis or nephrotic syndrome with worse prognosis
Pt, Dx, and prognosis of postinfectious glomerulonephritis
Pt: usually 10-21 days after URI, more common in children age 6-10 but can occur in adults, gross hematuria, adults can be asymptomatic or develop acute nephritic syndrome
Dx: low C3 complement, elevated antistreprtolysin O and/or anti-DNase B, kidney biopsy with sub epithelial humps consisting of C3 complement
Prognosis: good prognosis in children, possible chronic kidney disease in adults
Risk factors, Pt, Dx, and Tx of entamoeba histolytica
Risk factors; developing nations (travel/residence), contaminated food/water, fecal-oral, STI
Pt: 90% asymptomatic, colitis (diarrhea, bloody stool with mucus, abdominal pain), liver abscess (RUQ pain, fever) (complications: rupture to pleura/peritoneum)
Dx: stool ova + parasites, stool Ag testing (colitis); e histolytica serology (liver abscess)
Tx: metronidazole + intraluminoal Abx (paromomycin)
What does CXR of histoplasmosis capsulatum usually show?
lobar pulmonary infiltrate and hilar/mediastinal LAD; cavitation rarely occurs
Tx of comedonal acne
topical retinoids, salicylic, azelaic, or glycolic acid
Tx of inflammatory acne
mild: topical retinoids + benzoyl peroxide
moderate: add topical Abx (erythromycin, clindamycin)
severe: add oral Abx
Tx of nodular (cystic) acne
moderate: topical retinoid + benzoyl peroxide + topical Abx
Severe: add oral Abx
Unresponsive severe: oral isotretinoin
graft-versus-host disease pt
pt: maculopapular rash involving palms, soles, and face, blood-positive diarrhea, abnormal liver function tests and jaundice
ear pain, facial weakness, vesicular rash in the external auditory canal - dx?
herpes zoster optics (Ramsay Hunt syndrome)
What drugs decrease levothyroxine absorption?
- bile acid binding agents (cholestyramine)
- iron, calcium, aluminum hydroxide
- proton pump inhibitors, sucralfate
What drugs increase TBG concentration?
- estrogen (oral), tamoxifen, raloxifene
2. heroin, methadone
What drugs decreased TBG concentration?
- androgens, glucocrtoicoids
- anabolic steroids
- slow-release nicotinic acid
What drugs increase thyroid hormone metabolism?
- rifampin
- phenytoin
- carbamazepine
path and pt of granuloma inguinale (donovanosis)
Path: klebsiella granulomatis
Pt: extensive and progressive ulcerative lesions without LAD; base may have granulation-like tissue; deeply staining gram-negative intracytoplasmic cysts (Donovan bodies)
not painful initial lesions
path and pt of lymphogranuloma venereum
path: chlamydia trachomatis
pt: small + shallow ulcers; large, painful, coalesced inguinal lymph nodes intracytoplasmic chlamydial inclusion bodies in epithelial cells + leukocytes
not painful initial lesions
Pt, Labs, and management of acute fatty liver of pregnancy
Pt: N/V, RUQ/epigastric pain, fulminant liver failure
Labs: profound hypoglycemia, increased aminotransferases (2-3x normal), increased bilirubin, thrombocytopenia, DIC
management: immediate delivery
postoperative endophthalmitis path, pt, tx
Path: usually occurs within 6 weeks of surgery; bacterial or fungal infection within the eye
Pt: pain and decreased visual acuity, swollen eyelids and conjunctiva, hypopyon, corneal edema and infection
tx: based on severity, intravitreal Abx injection or vitrectomy is done
Corneal ulceration pt
foreign body sensation, blurred vision, photophobia, and pain, erythematous eye, ciliary injection; purulent exudates are seen in the conjunctival sac and on the ulcer surface
What are the etiologies of exudative effusions?
- empyema (purulent fluid, neutrophil-predominant, + gram stain/culture)
- chylothorax (milky white fluid, increased triglycerides)
- malignancy
- TB (+ acid fast bacterium stain/culture)
neonatal lupus path, pt, ECG, and complications
path: passive placental transfer of maternal anti-SSA (Ro) and anti-SSB (La) Abs
Pt: cardiac and cutaneous (scalp or periorbital rash); most serious complication is fetal AV block (18-24 weeks gestation due to irreversible injury to the AV node)
Fetal heart tracing: persistent fetal bradycardia (<110/min)
Complications: with prolonged complete heart block, cardiomyopathy and hydrops fetalis may develop
Path, Pt, and Dx of acute epididymitis
Path: age <35: sexually transmitted (chlamydia, gonorrhea)
Age >35: bladder outlet obstruction (coliform bacteria; E. coli)
Pt: unilateral, posterior testicular pain, epididymal edema, pain improved with testiclular elevation, dysuria, frequency (with coliform infection)
Dx NAAT for chlamydia + gonorrhea; UA/culture
What complication are patients with Turner’s syndrome at risk of during pregnancy (if they can get pregnancy via IVF)?
aortic dissection
Tick removal, prophylaxis criteria, and prophylaxis for Lyme disease prevention
Tick removal: grasp with small forceps as close to skin as possible; pull firmly upwards without twists
Prophylaxis criteria: must meet all 5
1. Ixodes scapularis (deer tick) identified
2. Tick attached for >/=36 hours or engorged
3. prophylaxis started within 72 hours of tick removal
4. local Borrelia burgdorferi infection rate >/=20% (New England)
5. No contraindications to doxycycline (pregnancy)
Antimicrobial prophylaxis: single-dose doxycycline
polyarteritis nodosa
lesions resemnling erythema nodosum, but it is usually associated with systemic (fever, arthralgias, weight loss) and extradermal (renal insufficiency, abdominal pain, mono neuritis multiplex) manifestations
Pt and Tx of acute decompensated heart failure
Pt:
1. acute dyspnea, orthopnea, paroxysmal nocturnal dyspnea
2. HTN common; hypotension suggests severe disease
3. Accessory muscle use, tachycardia, tachypnea
4. diffuse crackles with possible wheezes (cardiac asthma)
5. possible S3, JVD, peripheral edema
Treatment:
Normal or elevated BP with adequate end-organ perfusion: supplemental O2, IV loop diuretic, consider IV vasodilator (nitroglycerin)
Hypotension or signs of shock:
supplemental O2, IV loop diuretic as appropriate, IV vasopressor (norepinephrine)
Risk factor, micro, Pt, and Tx of necrotizing (malignant) otitis externa
Risk factors: age >60, DM, aural irrigation (cerumen removal)
Micro: Pseudomonas aeruginosa
Pt:
1. severe, unremitting ear pain (worse at night + with chewing)
2. deficits of lower cranial nerves (facial, vagus, accessory)
3. granulation tissue in the external auditory canal
4. elevated ESR
Tx: IV antipseudomonal Abx (cipro) +/- surgical debridement
how do you calculate attributable risk percent and what is it?
ARP represents the excess risk in a population that can be explained by exposure to a particular risk factor
ARP = (risk in exposed - risk in unexposed)/risk in exposed OR ARP = (RR-1)/RR
When should immediate endoscopic removal be performed with foreign body inhalation?
- sharp object (needle, safety pin) in the esophagus, stomach, or proximal duodenum
- Symptoms of esophageal obstruction (drooling, inability to swallow secretions)
- Symptoms of respiratory compromise
- button battery in the esophagus (due to the risk of electrical and chemical injury)
- Magnets in the esophagus or stomach (due to the potential for bowel entrapments as a result of magnetic attraction across intestinal segments
primary defect, urine pH, serum K+, and causes of distal type 1 RTA?
Primary defect: poor hydrogen secretion into urine
Urine pH >/= 5.5
serum potassium = low-normal
Causes: genetic disorders, medication toxicity, autoimmune disorders (Sjogren syndrome, RA)
primary defect, urine pH, serum K+, and causes of proximal type 2 RTA?
Primary defect: poor bicarb resorption
Urine pH <5.5
Serum potassium: low-normal
Causes: fanconi syndrome (glucosuria, phophaturia, aminoaciduria)
primary defect, urine pH, serum K+, and causes of type 4 RTA?
primary defect: aldosterone resistance
urine pH: <5.5
serum potassium: high
causes: obstructive uropathy, congenital adrenal hyperplasia
Path, Pt, Labs, and Tx of polycythemia vera
Path: clonal myeloproliferative disorder due to JAK2 mutation that makes RBC production independent of EPO
Pt: increased blood viscosity: HTN, erythromelalgia (burning cyanosis in hands/feet), transient visual disturbances
increased RBC turnover (court arthritis), aquagenic pruritus, bleeding
facial plethora (ruddy cyanosis), splenomegaly
Labs: elevated Hgb, leukocytosis + thrombocytosis, low erythropoietin level, JAK 2 mutation positive
Complications: thrombosis, myelofibrosis + acute leukemia
Tx: phlebotomy; hydroxyurea (if increased risk of thrombus)
duodenal ulcer pt and tx
path: either H. pylori infection or NSAIDs
pt: epigastric pain and intermittent melena; pain worse on empty stomach and improves with food
Dx: endoscopic biopsy or urea breath test (for H. pylori)
Tx: (for H. pylori): antisecretory therapy (PPI) and Abx eradication (amoxicillin plus clarithromycin)
SCC arising within a burn wound - Dx?
Marjolin ulcer
Renal + urinary changes in normal pregnancy (physiologic and lab findings)
Physiologic changes: increased renal blood flow, increased GFR, increased renal basement membrane permeability
Labs: decreased BUN, decreased serum Cr, increased renal protein excretion
spontaneous speech, comprehension, repetition, and associated features of Broca aphasia
spontaneous speech: sparse + nonfluent
comprehension: relatively preserved
repetition: impaired
associated features: right hemiparesis (face + upper limb)
spontaneous speech, comprehension, repetition, and associated features of Wernicke aphasia
spontaneous speech: fluent + voluminous but lacks meaning
comprehension: greatly diminished
repetition: impaired
associated features: right superior visual field defect
spontaneous speech, comprehension, repetition, and associated features of conduction aphasia
spontaneous speech: fluent with phonemic errors
comprehension: relatively preserved
repetition: very poor
associated features: none
ecthyma gangrenosum path/pt
path: pseudomonas
pt: g=prgress very rapidly from a small erythematous macule to larger, nontender nodules with necrosis
subacute bacterial endocarditis
path: occurs in patients with a preexisting valvular defect
pt: fevers, new or worsening heart murmur, splinter hemorrhages, Osler nodes, Janeway lesions
HSV encephalitis
pt: fever, HA, seizures, confusion and stupor, anosmia, gustatory hallucinations, and bizarre/psychotic behavior
Imaging: CT, MR imaging, and EEG demonstrate abnormalities in the frontotemporal region of the brain
CSF: nonspecific; classic findings are lymphocytic pleocytosis, elevated protein, elevated RBC count, and normal glucose
What type of anticoagulation should those with atrial fibrillation be on?
warfarin or non vitamin K antagonist oral anticoagulants (NOACs)
NOACs = rivaroxaban, dabigatran, apixaban, and edoxaban
TB effusion characteristics
exudative effusions with high protein levels (always >4), lymphocytic leukocytosis, and low glucose levels (<60)
headaches that are worse hwen leaning forward, JVD, facial and UE swelling - Dx?
SVC syndrome
Pt and Dx of fibromyalgia
Pt: young to middle-aged women, chronic widespread pain, fatigue, impaired concentration; tenderness at trigger points (mid trapezius, costochondral junction)
Dx: >/= 3 months of symptoms with widespread pain index or symptom severity score; normal lab studies
Pt and Dx of polymyositis
Pt: proximal muscle weakness (increasing difficulty climbing up stairs); pain mild/absent
Dx: elevated muscle enzymes (creatine kinase, aldolase, AST), autoantibodies (ANA, anti-Jo-1); biopsy: endomysial infiltrate, patchy necrosis
Pt and dx of polymyalgia rheumatica
Pt: age >50, systemic signs and symptoms, stiffness > pain in shoulders, hip girdle, neck; associated with giant cell (temporal) arteritis
Dx: elevated ESR, CRP; rapid improvement with glucocorticoids
tx for stable ventricular tachycardia?
amiodarone
What is adneosine used to treat?
supraventricular tachycardia
precipitating factors, Pt, and Tx of hepatic encephalopathy
precipitating factors: drugs (sedatives, narcotics), hypovolemia (diarrhea), electrolyte changes (hypokalemia), increased nitrogen load (GI bleeding), infection (pneumonia, UTI, SBP), portosystemic shunting (TIPS)
Pt: sleep pattern changes, AMS, ataxia, asterixis
Tx: correct precipitating causes (fluids, Abx), decreased blood ammonia concentration (lactulose, rifaximin)
Acute iron poisoning Pt, Dx, and Tx
Pt: abdominal pain, hematemesis, diarrhea, shock, liver necrosis
Dx: anion gap metabolic acidosis, elevated serum iron, radiopaque pills on abdominal x-ray
Tx: deferoxamine, whole bowel irrigation
What is the difference between CML and CLL?
CML - presents with a marked leukocytosis of predominantly neutrophil (not lymphocyte) lineage; BCR-ABL gene; imatinib for tx
CLL - marked leukocytosis of predominantly lymphocyte lineage; smudge cells on flow cytometry; rituximab (monoclonal Abx against CD20) for tx
What are the typical causative organisms for sickle cell patients with pneumonia, osteomyelitis/sepctic arthritis, bacteremia/sepsis, and meningitis?
pneumonia: strep pneumoniae
osteomyelitis/septic arthritis: staph aureus, salmonella
bacteremia/sepsis: strep pneumonia, Hib
meningitis: strep pneumoniae
What cardiac conditions require bacterial endocarditis prophylaxis?
- prosthetic heart valve
- previous infective endocarditis
- structural valve abnormality in transplanted heart
- Unrepaired cyanotic congenital heart disease
- Repaired congenital heart disease with residual defect
What procedures are indicated and what is the appropriate coverage for bacterial endocarditis prophylaxis?
- gingival manipulation or respiratory tract incision -> Viridans group strep coverage (amoxicillin)
- GU or GI tract procedure in setting of active infection -> Enterococcus coverage (ampicillin)
- Surgery on infected skin or muscle -> Staph coverage (vancomycin)
- Surgical placement of prosthetic cardiac material -> Staph coverage (vancomycin)
What 3 findings are characteristic of an ASD?
- wide and fixed splitting of the second heart sound (S2) - due to delayed closure of the pulmonic valve due to the enlarged right ventricle’s prolonged emptying
- mid systolic or ejection murmur over the left upper sternal border - resulting from increased flow across the pulmonic valve
- mid-diastolic rumble - resulting from increased flow across the tricuspid valve
Path, Pt, Dx, Tx, and complications of hypertrophic cardiomyopathy
Path: mutations in sarcomere protein genes (MC), autosomal dominant, variable expressivity/penetrance
Pt: asymptomatic or identified by family screening; fatigue, chest pain, palpitations, syncope; systolic ejection murmur exacerbated by dehydration/impaired LV filling
Dx: ECG: LVH, repolarization abnormalities
TEE: LVH, increased LV outflow tract gradient, systolic anterior motion of mitral valve; exercise testing, family screening
Tx: avoidance of volume depletion, BBs/CCBs, surgery if symptoms persist
Complications: sudden cardiac death, heart failure, stroke
What are the clinical associations of focal segmental glomerulosclerosis?
african american + hispanic ethnicity; obesity; HIV + heroin use
What are the clinical associations of membranous nephropathy?
adenocarcinoma (breast, lung); NSAIDs, hepB, SLE
What are the clinical associations of membranoproliferative glomerulonephritis?
Hep B + C, lipdystrophy
What are the clinical associations of minimal change disease?
NSAIDS, lymphoma
What are the clinical associations of IgA nephropathy?
URI
What are methods used to prevent future gout attacks?
- weight loss to achieve BMI <25
- low-fat diet
- decreased seafood + red meat intake
- protein intake preferably from vegetable + low-fat dairy products
- avoidance of organ-rash foods (liver)
- avoidance of beer + distilled spirits
- avoidance of diuretics when possible
What are common manifestations of superior pulmonary sulcus tumor?
- shoulder pain
- horror syndrome (invasion of paravertebral sympathetic chain/stellate ganglion)
- neurologic symptoms in the arm (invasion of C8-T2 nerves) -> weakness/atrophy of intrinsic hand muscles; pain/paresthesia of 4th/5th digits + medial arm/forearm
- supraclavicular LAD
- weight loss
Pt, Dx, and Tx of granulomatosis with polyangiitis
Pt:
upper respiratory: sinusitis/otitis, saddle-nose deformity
lower respiratory: lung nodules/cavitation
renal: rapidly progressive GN
skin: livedo reticularis, nonhealing ulcers
Dx: ANCA:PR3 (~70%), MPO (~20%)
Biopsy: skin (leukocytoclastic vasculitis), kidney (pauci-immune GN), lung (granulomatous vasculitis)
Tx: corticosteroids + immunomodulators (MTX, cyclophosphamide)
Path, Pt, Dx, and Tx of myelodysplastic syndrome
Path: hematopoietic stem cell neoplasm, increased risk with older age and previous chemo/radiation; may transform to acute leukemia
Pt:
cytopenias:
- anemia: weakness, fatigue
- leukopenia: infections
- thrombocytopenia: bruising/bleeding
HSM/LAD are rare
Dx: dysplastic red + WBCs on peripheral smear; bone marrow biopsy (hypercellular marrow)
Tx: transfusion for symptomatic cytopenias, chemo, hematopoietic stem cell transplantation
In which portion of the adrenal gland are catecholamines made?
adrenal medulla
Micro, Pt, Tx, and complications of nonbullous impetigo?
Micro: staph aureus, group A beta-hemolytic strep (S progenes)
Pt: painful, non-itchy pustules + honey-crusted lesions
Tx: topical Abx (mupirocin)
Complciations: poststreptococcal glomerulonephritis
What are the side effects of efavirenz? What drug class is this?
drug class: non-nucleoside reverse transcriptase inhibitor
Side effects: dizziness, insomnia with vivid or bizarre dreams, depression, anxiety, confused thinking, and aggression
What drug class are abacavir and lamivudine? What side effects do they have?
drug class: nucleoside reverse transcriptase inhibitors
Side effects: insomnia + depression rarely; more commonly, they can result in lactic acidosis and hepatotoxicity; abacavir is also associated with a potentially fatal hypersensitivity reaction
What are the abortive and preventative migraine therapies?
Abortives: triptans NSAIDs, acetaminophen, antiemetics (metoclopramide, prochlorperazine), ergotamine (dihydroergotamine)
Preventatives: topiramate, divalproex sodium, TCAs, beta blockers (propranolol)
recurrent kidney stones since childhood, family history of nephrolithiasis, hexagonal crystals on u/a - Dx? What test helps dx this?
cystinuria
path: impaired transport of cystine and the dibasic amino acids ornithine, lysine, and arginine by the brush borders of renal tubular and intestinal epithelial cells
dx: cyanide-nitroprusside test, which detects elevated cystine levels and can help confirm the dx
Risk factors, Pt, PE of age-related cataracts
Risk factors: age >60, chronic sunlight exposure, DM, glucocorticoid use, smoking, HIV infection
Pt: gradual loss of visual acuity, excessive glare, hallows around bright lights, myopic shift
PE: opacification of lens, loss of red reflex
platelets >600,000, thrombosis, and hemorrhage - Dx?
essential thrombocythemia
MOA, indication, and side effects of indomethacin for tocolytics
MOA: cyclooxygenase inhibition
Indication: first-line tocolytic: < 32 weeks
Side effects:
maternal: gastritis, platelet dysfunction
fetal:
oligohydramnios, closure of ductus arteriosus
MOA, indication, and side effects of nifedipine for tocolytics
MOA: calcium channel blocker
Indication: first-line tocolytic: 32-34 weeks
Side effects:
Maternal: tachycardia/palpitations, nausea, flushing, HA
MOA, indication, and side effects of terbutaline for tocolytics
MOA: beta agonist
Indication: short-term tocolytic: inpatient use
Side effects:
maternal: tachycardia/arrhythmias , hypotension, hyperglycemia, pulmonary edema
Micro, path, Pt, and Tx of roseola infantum
Micro: HHV-6 is MC
Path: age < 2 years
PT: 3-5 days of high fever followed by blanching maculopapular rash
Tx: supportive care
When is screening for hemoglobinopathies indicated for pregnant patients? How do you screen?
indicated for patients with anemia (Hgb <11 during preganncy) and an MCV <80; screen with hemoglobin electrophoresis
Pt and PE of complete atrioventricular septal defect (CAVSD)
MC congenital heart defect in patients with Down syndrome due to failure of endocardial cushions to merge
Pt: diaphoresis and dyspnea with feeds and crackles typically manifest around age 6 weeks as pulmonary vascular resistance falls
PE:
- fixed split S2 due to delayed pulmonary valve closure from flow across the ASD
- Systolic ejection murmur from increased flow across the pulmonary valve due to L->R shunt across ASD
- Holosytolic murmur of VSD that may be soft or absent if large
- Holosystolic apical murmur depending on the degree of AV valve regurgitation
Pt and Tx of magnesium toxicity
Pt: mild: nausea, flushing, HA, hyporeflexia
moderate: areflexia, hypocalcemia, somnolence
severe: respiratory paralysis, cardiac arrest
Tx: stop magnesium therapy; give IV calcium gluconate bolus
What is the criteria for initiating long term O2 therapy in those with chronic hypoxemia?
- resting arterial O2 tension (PaO2) = 55 mmHg or pulse ox saturation = 88% room air
- PaO2 = 59 mmHg or SaO2 = 89% in patient s with cor pulmonale, evidence of right hareat failure, or Hct > 55%
What is the pathology of sialadenosis?
path: benign noninflammatory swelling of the salivary glands; can result from overaccumulation of secretory granules in acing cells in patients with chronic alcohol use, bulimia, or malnutrition; can also result from fatty infiltration of the glands in patients with DM or liver disease
Risk factors, Pt, PE, Tx, and complications of pelvic inflammatory disease
Risk factors: multiple sex partners, age 15-25, previous PID, inconsistent barrier contraception use, partner with STI
Pt: lower abdominal pain, abnormal bleeding
PE: fever >100.9, cervical motion tenderness, mucopurulent cervical discharge
Tx: outpatient: ceftriaxone + doxycycline
Inpatient: cefoxitin + doxycycline
Complication: tuboovarian abscess, infertility, ectopic preganncy, perihepatitis
When do patients with sickle cell disease usually undergo autoinfarction of the spleen? What would you expect on peripheral smear?
autoinfarction and functional asplenia by age 5; Howell-jolly bodies on PS (appear as small purple dots within the RBC)
What conditions cause basophilic stippling on peripheral smear?
thalassemias and lead or heavy metal poisoning
What conditions cause helmet cells or schistocytes on peripheral smear?
traumatic microangiopathic hemolytic conditions such as DIC, HUS, and TTP
Path, Pt, and management of staphylococcal scalded skin syndrome
Path: staphylococcus aureus exfoliative toxin
Pt: fever, irritability; generalized erythema, blisters; epidermal shedding
Managment: antistaphylococcal Abx (nafcillin, vancomycin), wound care
Pt of toxic shock syndrome
- fever usually > 102
- hypotension with SBP = 90
- diffuse macular erythroderma
- skin desquamation, includign palsm + soles, 1-2 weeks after illness onset
- mulitsystem involvement (3 or more systems):
- GI (vomiting +/or diarrhea)
- muscular (severe myalgias or elevated CK)
- mucous membrane hyperemia
- renal (BUN or serum Cr >1-2x upper limit of normal)
- hematologic (platelets < 100,000)
- liver (ALT, AST + total bilirubin >2x upper limit of normal)
- CNS (AMS without focal neuro signs)
What labs should you expect with toxic shock syndrome?
luekocytosis may not be present
immature neutrophils elevated
thrombocytopenia common
Path, Pt, Complications of vertebral compression fracture
Path: trauma, osteoporosis, osteomalacia, bone mets, metabolic (hyperparathyroidism), Paget disease
Pt:
acute: low back pain + decreased spinal mobility, pain increasing with standing, walking, lying on back, tenderness at affected level
chronic: painless, progressive kyphosis, loss of stature
Complications: increased risk for future fractures; hyperkyphosis, possibly leading to protuberant abdomen, early satiety, weight loss, decreased respiratory capacity
Pt, Dx, and Tx of pseudogout (acute calcium pyrophosphate crystal arthritis)
Pt: acute mono- or oligoarticular arthritis, peripheral joints (knee most common)
Dx: inflammatory effusion (15,000-30,000 cells), CCPD crystals (rhomboid shape, positive birefringence), chondrocalcinosis on imaging
Tx: intra-articular glucocorticoids, NSAIDs, colchicine
Path, sources, Pt, Dx, and Tx of foodborne botulism
Path: clostridium botulinum toxin inhibits presynaptic ACh release at neuromuscular junction
Sources: improperly canned foods (fruits, veggies), aged seafood (cured fish)
Pt: acute onset within 36 hours of ingestion:
- B/L cranial neuropathies (blurred vision, diplopia) (facial weakness, dysarthria, dysphagia)
- symmetric descending muscle weakness
- diaphragmatic weakness with respiratory failure
Dx: serum analysis for toxin
Tx: equine serum heptavalent botulinum antitoxin
What are the indications for noninvasive positive-pressure ventilation?
COPD (severe exacerbation, prevent extubation failure), cardiogenic pulmonary edema, acute respiratory failure (post-op hypoxemia respiratory failure, immunosuppressed patients), facilitate early extubation
What is expected on Labs of acute tubular necrosis?
- BUN-to-Cr ratio of 10-15
- urine osmolality of 300-350 mOsm/L (but never <300)
- Urine Na of >20
- FENa >2%
Path, onset, findings, tx of anaphylactic transfusion reactions
Path: anti-IgA Abs (IgG or IgE) in IgA-deficient patient against donor blood IgA
onset: seconds to minutes
Findings: respiratory distress/wheeze, angioedema, hypotension, hives
Tx: immediate cessation of transfusion, epinephrine, antihistamines, O2, fluids, and vasopressors
Path, onset, findings, tx of urticarial transfusion reactions
Path: preformed recipient IgE Abs against soluble allergen in donated plasma
onset: hours
findings: hives, itching
Tx: immediate cessation of transfusion, antihistamines, resume transfusion if patient is otherwise asymptomatic
How can you tell the difference between Parkinson’s disease with dementia and dementia with Lewy bodies?
cognitive impairment develops before or at the same time as Parkinsonism in Lewy body dementia whereas Parkinson’s disease has Parkinson sx before dementia
Type I hypersensitivity reaction immunology and examples
(immediate)
IgE mediated
Ex: anaphylaxis, urticaria
Type II hypersensitivity reaction immunology and examples
(cytotoxic)
IgG + IgM auto-Ab mediated
Ex: autoimmune hemolytic anemia, Goodpasture syndrome
Type III hypersensitivity reaction immunology and examples
(immune complex)
Antibody-antigen complex deposition
Ex: serum sickness, poststreptococcal glomerulonephritis, lupus nephritis
Type IV hypersensitivity reaction immunology and examples
(delayed type)
T-cell and macrophage-mediated
Ex: contact dermatitis, TB skin test
Pt, Path, causes, and Dx of bronchiectasis
Pt: cough with daily mucopurulent sputum production; rhino sinusitis, dyspnea, hemoptysis; crackles, wheezing
Path: infectious insult with impaired clearance
Causes: airway obstruction (cancer), rheumatic disease (RA, Sjogren), toxic inhlation, chronic or prior infection (aspergillosis, mycobacteria), immunodeficiency (hypogammaglobulinemia), congenital (CF, alpha-1-antitrypsin deficiency)
Dx: HRCT scan of the chest (needed for initial Dx), immunoglobulin quantification, CF testing, sputum culture (bacteria, fungi + mycobacteria), pulmonary function testing
What will high-resolution CT (HRCT) scan of the chest show with bronchiectasis?
characteristic bronchial dilation, lack of airway tapering, and bronchial wall thickening
Definition, risk factor, complications, and management of late and post-term pregnancy?
definition: late-term: >/= 41 weeks gestation; post-term: >/= 42 weeks gestation Risk factors: prior post-term pregnancy, nulliparity, obesity, age >/= 35, fetal anomalies (anencephaly) Complications: fetal/neonatal: - macrosomia -dysmaturity syndrome - oligohydramnios - demise Maternal: - severe obstetric laceration - C-section - postpartum hemorrhage Management; frequent fetal monitoring )nonstress test), delivery prior to 43 weeks gestation
Path, pt, dx, and tx of mediastinitis
Path: complication of dehiscence due to contiguous spread of superficial infection or intraoperative deep tissue contamination
Pt: fever, tachycardia, chest pain, chest wall edema/crepitus, and purulent wound discharge
Dx: CT scan showing mediastinal fluid collections or pneumomediastinum
Tx: emergency surgical debridement, tissue cultures, and empiric IV Abx
thromboangiitis obliterans
men 40-45 yo; get ANA and other blood tests prior to arteriogram (bc systemic diseases should be ruled out first)
Ascaris lumbricoides path, pt, dx, and tx
Path: parasitic roundworm spread via fecal-oral transmission; endemic to Asia, Africa, and South America
Pt: pulmonary manifestations (cough, eosinophilic pneumonitis) are rare but can occur within the first few weeks of infection
GI Sx much more common and occur 1-2 months later: abdominal pain, N/V, anorexia, diarrhea
Complication: adult worms can obstruct the lumen of the small bowel or hepatobiliary tree, resulting in SBO, biliary colic, cholangitis, or acute pancreatitis
Dx: peripheral eosinophilia and signs of malnutrition (vitamind eficiency, anemia); dx confirmed with visualized ascaris eggs or worms in the stool or respiratory secretion
Tx: conservative and includes nasogastric suction and fluid/electrolyte repletion; albendazole or mebendazole
HIV associated nephropathy Pt, complications, Dx
Pt: untreated HIV infection, edema, acute kidney injury, and proteinuria
Complications: can progress quickly to heavy proteinuria and rapidly progressive renal failure
Dx: renal biopsy that shows collapsing focal segmental glomerulosclerosis with tubuloreticular inclusions on electron microscopy
persistent ST-segment elevation after a recent MI, deep Q waves in the same leads as the MI - Dx? Complications?
ventricular aneurysm -> can progress to LV enlargement, causing heart failure, refractory angina, ventricular arrhythmias, mural thrombus with systemic arterial embolization, or mitral annular dilation with MR
What does subarachnoid hemorrhage show on lumbar puncture?
elevated opening pressure and xanthochromia
Path and Pt of trichinellosis
Path: ingestion of undercooked meat (usually pork); endemic in Mexico, China, Thailand, parts of central Europe + Argentina
Pt:
Intestinal stage (within 1 week of ingestion): can be asymptomatic or include abdominal pain, nausea, vomiting + diarrhea
Muscle stage (up to 4 weeks after ingestion): myositis, fever, subungual splinter hemorrhages, periorbital edema, eosinophilia (usually >20%) with possible elevated CK and leukocytosis
pancreatic fistula
Path: Ldisruption of the pancreatic ducts results in leakage of pancreatic digestive enzymes, most commonly due to acute or chronic pancreatitis
Dx: amylase-rich exudative pleural fluid on Light criteria
Pt: cough, dyspnea, dysphagia, and chest pain, but can be asymptomatic
Tx: bowel rest, but ERCP with sphincterotomy and/or stent placement could be required
Pt and complications of infectious mononucleosis
Pt: fever, tonsillitis/pharyngitis +/- exudates, posterior or diffuse cervical LAD< significant fatigue, +/- HSM, +/- rash after amoxicillin
Complications: acute airway obstruction, autoimmune hemolytic anemia + thrombocytopenia, splenic rupture
Risk factors, Pt, and Tx of Genito-pelvic pain/penetration disorder
Risk factors: sexual trauma, lack of sexual knowledge, history of abuse
Pt: pain with vaginal penetration, distress/anxiety over Sx, no other medical cause
Tx: desensitization therapy, Kegel exercises
CD40L deficiency (hyper IgM syndrome) B cell count, IgG, IgA, IgM, and IgE
B cell count: normal IgG: decreased IgA: decreased IgM: increased IgE: decreased
CVID B cell count, IgG, IgA, IgM, and IgE
B cell count: normal IgG: decreased IgA: decreased IgM: decreased IgE: decreased
Job syndrome (hyper-IgE syndrome) B cell count, IgG, IgA, IgM, and IgE
B cell count: normal IgG: normal IgA: normal IgM: normal IgE: increased
Selective IgA deficiency B cell count, IgG, IgA, IgM, and IgE
B cell count: normal IgG: normal IgA: decreased IgM: normal IgE: normal
X-linked agammaglobulinemia B cell count, IgG, IgA, IgM, and IgE
B cell count: decreased IgG: decreased IgA: decreased IgM: decreased IgE: decreased
What is the treatment for torsades de pointes for unstable vs stable patients?
unstable: immediate defibrillation
stable: IV magnesium
Pt, hormone levels, long-term consequences, and tx of exercise-induced hypothalamic amenorrhea
Pt: strenuous exercise, relative caloric deficiency, stress fractures, amenorrhea, infertility
Hormones: decreased GnRH, decreased LH/FSH, decreased estrogen
Long term consequences: decreased bone mineral density, increased total cholesterol, increased triglycerides
Tx: increased caloric intake, estrogen, calcium + vitamin D
idiopathic intracranial HTN (pseudotumor cerebri)
Path: impaired absorption of CSF by the arachnoid villi
Pt: young woman with obesity, HA suggestive of a brain tumor but with normal neuroimaging and elevated CSF pressure, papilledema, visual field defects and sometimes sixth nerve palsy; may be a history of exposure to provoking agents such as glucocorticoids or vitamin A
Management: weight reduction and acetazolamide (if weight reduction fails); when medical measures fail or visual field defects are progressive, shunting or optic nerve sheath fenestration is done to prevent blindness
What will CXR of primary TB show?
hilar LAD, effusion, consolidation, cavitation
tracheoesophageal fistula with esophageal atresia path, pt, dx, and management
Path: defective division of foregut into esophagus + trachea; most commonly results in proximal esophageal pouch + fistula between distal trachea + esophagus
Pt: coughing, choking, vomiting with feeding, excessive secretions; commonly part of VACTERL association (vertebral, anal, cardiac, tracheoesophageal, renal, limb defects)
Dx: inability oto pass enteric tube into stomach; X-ray: enteric tube coiled in proximal esophagus
Management: surgical correction; VACTERL screening: echo, renal u/s
acute renal allograft rejection path, pt, labs, dx, and tx
Path: T-cell mediated response to antigens within donor kidney. MC occurs within the first 6 months following transplant
Pt: usually asymptomatic; fever, decreased urine output, or graft tenderness possible
Labs: increased serum Cr, proteinuria
Dx: renal Bx required -> shows lymphocytic infiltration of the intima with inflammatory tubular disruption; intimal arteritis is often present as well
Tx: IV glucocorticoids + increased immunosuppression
BK virus reactivation path, pt, and dx
Path: excessive immunosuppression in renal allograft recipients -> tubulointerstitial nephritis
Pt: asymptomatic increase in serum Cr
Dx: renal bx shows intranuclear inclusions and a mixed lymphocytic and neutrophilic infiltrate
WAGR syndrome path, pt
Path: gene deletion on chromosome 11p13
Pt: Wilms tumor, Aniridia, Genitourinary abnormalities, Intellectual disability (previously mental Retardation)
Risk factors, Pt, Dx, and Tx of greater trochanteric pain syndrome (trochanteric bursitis)
Risk factors: age >/= 50, women > men, obesity, low back + LE disorders (scoliosis, osteoarthritis, plantar fasciitis)
Pt: chronic lateral hip pain, pain worse with hip flexion or lying on affected side
Dx: focal tenderness over trochanter, X-ray to rule out hip joint pathology; u/s: degeneration of tendons, tendinosis
Tx: exercise, PT< activity modification; NSAIDs, corticosteroid injection
What is the usual cause of a non traumatic spontaneous pneumothorax in a tall, thin young man?
primary spontaneous pneumothorax from rupture of a sub pleural bleb; can cause dyspnea and subcutaneous emphysema with decreased breath sounds on the affected side
Path, pt, Dx, and Tx of bacillary angiomatosis
Path: bartonella henselae/quintana; cat exposure or homelessness (lice), severe immunocompromise (advanced HIV with CD4 <100)
Pt: vascular cutaneous lesions (papular, nodular, peduncular); systemic symptoms (fever, night sweats, fatigue); organ involvement rarely (liver, bone, CNS)
Dx: lesional biopsy with microscopy/histopathology
Tx: doxycycline or erythromycin, antiretroviral therapy
What would you expect on labs of infective endocarditis?
normocytic anemia, elevated ESR, elevated rheumatoid factor, u/a positive for blood and protein (immune complex-mediated glomerulonephritis with hematuria and red cell casts)
Adult Still disease
uncommon inflammatory disorder characterized by recurrent high fevers. arthritis/arthralgias, and a salmon-colored macular or maculopapular rash
ESR may be markedly elevated
What is the treatment of primary adrenal insufficiency?
glucocorticoids (hydrocortisone, prednisone) + mineralocorticoids (fludrocortisone)
Path, Pt, Dx, and Tx of Legionella pneumonia
Path: contaminated water in hospital or travel (cruise, hotel)
Pt: fever > 101.8, relative bradycardia, GI (diarrhea, vomiting, cramps), pulmonary symptoms delayed
Dx: hyponatremia
CXR - patchy unilobar or interstitial infiltrates
sputum gram stain - PMNs, few/no organisms
urine legionella Ag
Tx: respiratory fluoroquinolone or newer macrolide
When does a pap smear with benign-appearing endometrial cells require endometrial evaluation?
premenopausal women with: abnormal uterine bleeding OR risk for endometrial hyperplasia
postmenopausal women
When does a pap smear with atypical glandular cells require endometrial evaluation?
women age >/= 35 OR at risk for endometrial hyperplasia
FSH, LH, prolactin, and TSH of ovarian failure
FSH: elevated
LH: elevated
Prolactin: normal
TSH: normal
FSH, LH, prolactin, and TSH of functional hypothalamic amenorrhea
FSH: decreased
LH: decreased
Prolactin: normal
TSH: normal
FSH, LH, prolactin, and TSH of asherman syndrome?
FSH: normal
LH: normal
Prolactin: normal
TSH: normal
FSH, LH, prolactin, and TSH of prolactinoma?
FSH: decreased
LH: decreased
Prolactin: increased
TSH: normal
FSH, LH, prolactin, and TSH of hypothyroidism
FSH: decreased
LH: decreased
Prolactin: increased
TSH: increased
When is duloxetine considered first line for depression?
when the patient has depression and diabetic neuropathy (it is an SNRI)
Pt, Dx, and Tx of enterobius vermicularis (pinworm)
Pt: perianal pruritus, especially at night
Dx: eggs on tape test
Tx: pyrantel pamoate OR albendazole for pt + all household contacts
Path, Pt, Dx, and Tx of common variable immunodeficiency
Path: abnormal differentiation of B cells into plasma cells -> decreased immunoglobulin production
Pt: symptom onset classically age 20-40, as early as puberty, recurrent respiratory infections (pneumonia, sinusitis, otitis), recurrent GI infectinos (Salmonella, campylobacter, giardia); chronic disease: autoimmune (RA, thyroid disease), pulmonary (bronchiectasis), GI (chronic diarrhea, IBD-like conditions)
Dx: very low IgG, low IgA/IgM; no response to vaccination
Tx: immunoglobulin replacement therapy
management of preterm labor from 34 0/7 to 36 6/7
+/- betamethasone, penicillin if GBS positive or unknown
management of preterm labor 32 0/7 to 33 6/7
betamethasone, tocolytics, penicillin if GBS positive or unknown
management of preterm labor <32 weeks
betamethasone, tocolytics, magnesium sulfate, penicillin if GBS positive or unknown
What are alarm features concerning constipation?
onset at older age (>/= 50), accompanied by early satiety or pain unrelated to bowel movement, weight loss, hematochezia, family history of malignancy, hx of inflammatory bowel disease
Rule out colon cancer and ovarian cancer in females
Pt, Dx, and Tx of psoas abscess
Pt: subacute fever + abdominal/flank pain that may radiate to the groin or hip; anorexia, weight loss, abdominal pain with hip extension (psoas sign)
Dx: CT scan of the abdomen + pelvis; leukocytosis, elevated inflammatory markers, blood and abscess cultures
Tx: drainage, broad-spectrum Abx
chronic alcohol abuse, epigastric pain that worsens postprandially, ascites with high amylase and total protein - Dx?
pancreatic ascites
rare complication fo chronic pancreatitis that results from damage to the pancreatic duct, leading to leakage of pancreatic juice into the peritoneal space -> abdominal distension, weight gain, dyspnea, and early satiety; PE = shifting dullness and fluid wave
physiologic effect, LV blood volume, and murmur intensity of valsalva, abrupt standing, and nitroglycerin administration on hypertrophic cardiomyopathy
Physiologic effect: decreased preload
LV blood volume: decreased
Murmur intensity: increased
physiologic effect, LV blood volume, and murmur intensity of sustained hand grip on hypertrophic cardiomyopathy
Physiologic effect: increased afterload
LV blood volume: increased
Murmur intensity: decreased
physiologic effect, LV blood volume, and murmur intensity of squatting on hypertrophic cardiomyopathy
Physiologic effect: increased afterload + preload
LV blood volume: increased
Murmur intensity: decreased
physiologic effect, LV blood volume, and murmur intensity of passive leg raise on hypertrophic cardiomyopathy
Phsyiologic effect: increased preload
LV blood volume: increased
Murmur intensity: decreased
Path, Pt, and Dx of Behcet disease
Path: young adults; Turkish, Middle EAstern, or Asian descent
Pt: recurrent, painful oral aphthous ulcers, genital ulcers, eye lesions (uvieitis), skin lesions (erythema nodosum, acneiform lesions), thrombosis
Dx: pathergy - exaggerated skin ulceration with mnior truama (needlestick); Bx - nonspecific vasculitis of different-sized vessels
Causes, Pt, and Dx of osteomalacia
Causes: malabsorption, intestinal bypass surgery, celiac sprue, chronic liver disease, chronic kidney disease
Pt: may be asymptomatic, bone pain + muscle weakness, muscle cramps, difficulty walking, waddling gait
Dx: increased alkaline phosphatase, increased PTH, decreased serum calcium and phosphorus, decreased urinary calcium; decreased 25-OH-D levels, X-rays may show thinning of cortex with reduced bone density; B/L and symmetric pseudofractures are characteristic radiologic findings
Path, pt, and Tx of thrombotic thrombocytopenic purpura
Path: decreased ADAMTS13 level -> uncleared vWF multimers -> platelet trapping + activation; acquired (autoantibody) or hereditary
Pt: hemolytic anemia (increased LDH, decreased haptoglobin) with schistocytes; thrombocytopenia (increased bleeding time, normal PT/PTT); sometimes with: renal failure, neurologic manifestations, fever
Tx: plasma exchange, glucocorticoids, rituximab
