UWORLD Practice Flashcards
Itching worse at night and is mildly relived with OTC antihistamines. Did chagne her soap recently and does not use any hand cream.
Her husband had a similar a while ago.
Diagnosis and Treatment?
Usually made based on hx and distribution of the lesions alone, although confirmation can be made with skin scraping of the lesions.
Topical permethrin
Treatment of Benign Paroxysmal Positional Vertigo
Head positioning exercsies, such as the Epley manuever
Why does BPPV occur?
displaced otoliths within the posterior semicircular canal.
Since the normal function of the semicircular canal is to detect angular acceleration, an abnormal triggering of the canal can lead to the sensation of vertigo.
What is considered normal grief?
tearfulness, insomnia poor appetite, weight loss, hallcucination of her recently decresed husband, and wish that she had died instead is normal grief.
If persvasive sadness, low self-esteem or suicdial ideation, then that would make more characterisitc of major depression.
Gold standard for diagnosis of Hirsprung disease?
What will it reveal?
Rectal suction biopsy.
Can be performed at bedside without the need for general anesthesia
absence of ganglion cells and nerve fiber hypertrophy
Diagnosis of BPPV
Treatment of BPPV
Provacation of vertigo with the Dix-Hallpike mnaeuver is diagnostic.
Treatment of BPPV consists of primarly of positioning exerices (such as Epley manuever) to reposition the otoliths
Pharmaconkinetic profiles of common insulin preparation
(Short, regular and long acting)
Insulin Lispro - short acting analog that has a very rapid onset and a short half-life.
Often given in multiple daily doses, usually with long acting basal insluin formulation (ex: insulin glargine)
Bugs and RBC
Hydatid disease versus protozoal infection of the liver
Entamoeba histolytica - RUQ pain, fever and hypoechogenic hepatic cyst after 8-20 weeks after inoculation. Diagnosis is made with serology or antigen testing; aspiration is rarely needed.
From water
Hydatid cysts - due to tapeworm echinococus granulosus. Cysts tend to grow slowly over the years and remain asymptomatic until the size is >10 cm. Fever is rare without cyst rupture;
From dog feces
Hydatid cysts in liver, causing anaphylaxis if antigens released (surgeons preinject with ethanol to kill cysts before removal)
Treatment of Entamoeba histolytica
Metrondiazole & intraluminal antibotic (ex: paromyomycin)
Main with fever, dysuria, frequency, pyuria and bacteriuria.
What is the differential diagnosis?
Next step in management?
cystitis or acute bacterial prostatitis
DRE (gives definitive diagnosis)
THe presence of prostatic warmth, edema and tenderness indicates acute bacterial prostatitis, whereas a normal exmination more likely sugggests UTI with cysitits.
Management of esophagel coin ingestion
How do you tell the difference between a coin versus a button battery in a child?
Do a 2-view (posterior anterior PA and later) neck xray and chest xray.
It confirms the location of the foreign body and distinguishes btwn a coin and battery (the latter can cause performation in just a few hours).
Coin is seen a homogenous object with a sharp, crisp edge; the bilaminar structure of a button battery causes a “double-ring” sign)
Child aspiration- battery versus coin?
Coin - homogenous with sharp crisp edge
Child aspiration (coin or battery)?
button battery
“double-ring” sign
WHen do you use emergency bronchoscopy versus endoscopy?
Emergency bronchoscopy would be appropriate for an airway foreign body causing respiratory distress.
This patient has no stridor, wheezing or respiratory distress and the lateral radiograph indicates the foreign body is in the esophagus rather than the airway.
In addition, an esophagel coin appears linear on lateral x-ray, a tracheal coin appears linear (project on end in the PA view) in the PA view.
Coin in esophagus versus trachea
an esphagel coin appears linear on lateral x-ray, a tracheal coin appears linear (project on end in the PA view) in the PA view.
Second most common cause of small bowel obstruction?
Hernias
The presence of a tender, non-reducible mass in the hernia sac is consistent with an incarcerated hernia
In an incarierated hernia, a portion of the small bowel becomes trapped.
The associated edema can compromise blood flow, leading to ischemia and infraction (aka strangulation). this this is an condition requiring urgent surgical management.
How does small bowel obstruction present?
What are the commmon causes of SBO?
abdominal cramps, vomiting, high pitched bowel sounds and abdominal distention.
Post operative adhesions, hernias and tumors.
Indications for parathyroidectomy
T-score
-1 and above
Between -1 and -2.5
-2.5 and below
Those with primary hyperparathyroidism who do not require parathyroidectomy require what?
regular follow up and serum calcium, creatinine and DXA testing
A femur fracture in a nonambulating child
A femur fracture in a nonambulating child, particularly a spiral fracture, is suspicious for a twisting force on the thigh.
WARNING SIGNS OF CHILD ABUSE
Red flags for child abuse include?
Posterior rib fractures,
metaphyseal corner fracture (“bucket-handle”) and
fractures at various stages of healing.
All patients with < or = 75 with established cardiovacular disease should be treated with what?
high intensity statins regardless of baseline LDL cholesterol levels.
High intensity statin is provided by daily use of atorvastin 40-80 mg or rosuvastatin 20-40mg.
Lower doses of these 2 drugs and all doses of statin agents consitute low-moderate-intensity statin therapy.
Identify
Erythema multforme presents as a mutitude of symmetric targetoid skin lesions on the extensor surfaces of the extremities, palms and soles.
HSV is the most common cause, with medication being the next most common cuase..
Classic findings of acute rheumatic fever
What is this?
Strep pyogenes can lead to development of rheumatic fever.
Erythema marginatum is a manifestation of rheumatic fever and using has lesions with clearing in the center, but the lesions are usually larger and not as numerous (unlike eryhtema multiforme).
Erythema migrans
Erythema marginatum
Erythema nodosum
Erythema multorme
Neisseria meningitidis can cuase what type of rash?
petechial rash
Management of palpable breast mass
In women age > or = 30, inital evaluation is with diagnostic mammography. If mammographic results are indeterminate or normal, an ultrasound is prefered to further characterize the lesion.
Management of uncomplicated low back pain?
In patients with low back pain, what are the red flags that make you consider a serious underlying diagnosis
NSAIDS and close observation.
Imaging studies are indicated only if the patin persists after a period of several weeks despite conservative therapy.
hx of cancer, unexplained weight loss, pain predominately at night, urinary symptoms, fever
*symmetric decreased ankle reflexes (is a nonspecific findings)
Plain xray in a 45 year old shows narrowing of L4-L5 and L5-S1 disc spaces, traction osteophytes and end plate scerlosis
degenerative disc disease
If uncompicated, management should include NSAIDS for pain and follow up evaluation in 4-6 weeks.
Postpartum hemorrhage is considered?
the loss of > or = 500 mL of blood after vaginal delivery or > or = 1,000 mL after cesarean delivery is an obsteric emergency and a leading cuase of maternal mortality.
What are the four differential diagnosis of postparum hemorrage?
What do you see on examination and what is the management?
Hx of HIV and sexual encounters with men has a verrucous, ulcerated anal lesion, indicates likely?
These patients have a history of?
anal carcinoma
Anal carcinoma is a rare GIT malgnancy typically liked to infection with HPV (>=90%).
As such, patients often have a hx of:
-Receptive anal intercourse
-Genital warts
-Men who have sex with men
Bacterial pneumonia versus Pulmonary infarction
Bacterial pneumonia typically presents with SOB, fever, and productive cough; lack of sputum production in this patient makes the diagnosis less likely.
In addtion, pneumonic consolidation are typically more centrally, rather than peripherally, located (in bacterial infarction)
Pulmonary infarction
potential complication of?
How does it appear on CT?
is a potiental complication of acute PE and typically appears on CT scan as a periperhally located hemispherical consolidation abutting the pleura.
Bleomycin can cause?
What would be seen on CT scan?
pulmonary fibrosis in some patients who have received chemotherapy with the drug; however a diffuse pattern of reticular septal thickening and honeycombing would be expected on CT scan.
A liver mass in a patient with Hepatitis B and evidence of chronic liver disease is highly concerning for?
Hepatocellular carcinoma (HCC), a tumor that orginates from hepatocytes.
Allthough serum AFP levels are often elevated in patietns with HCC, up to 40% of patients with small tumors have normal AFP levels (so don’t exclude diagnosis).
Cholangiocarcinoma versus HCC
Cholangiocarcinoma (bile duct cancer) is assocaited with obstructive jaundice, abdominal pain and weight loss.
A mass lesion may be seen on ultrasonography, but dilation of the bile ducts is typically seen as well.
Patients with prostate cancer are generally stratifed as very low-risk when the following features are present?
Mangaement of these patients?
Gleason score < or = 6 with <3 cores affected (<50% involvement in each affected core)
Normal DRE
PSA<10
Active surveillance needed only - monitor serum PSA levels every 3-6 months, having a DRE yearly and a repeat biopsy at the end of year 1 to ensure high greade deiase was not missed on the original biopsy.
High risk Prostate cancer treatement
Radiotherapy or radical prostatecomy
Inhalants can produce what symptoms?
beief transient euphoria, lethargy, poor coordination and loss of consciouness.
The effects can be immediate and typically last 15-45 minutes.
most signifcant finding ont he above ECG is peaked T waves, which are commonly associate dwith Hyperkalemia.
Can occur from worsening renal failure, and can be precipated by certain medications including ACEI, ARBS or potassium sparing diuretics.
Severe pulmonary disease results on a EKG
Right ventricular hypertrophy, which would cause tall R waves in V1 and V2 as well as deep S waves in V5 and V6.
Congestive Heart failure versus Chronic Renal disease on an EKG
CHF may results in worsening renal function, but would not cause hyperkalemia.
This patient’s fluid overload is secondary to renal failure, not CHF
Pertusus
Clinical phases
Diagnosis
Treatment
PRevention
Gram negative bacillus that is transmitted by respitatory droplets.
The patietn and all clsoe contacts should receive a macrolide antibiottic (regardless of their vaccination status)
Inguinal hernias in children
inguinal hernias commly present with asymptomatic reducible groin mass that is more pronouced with maneuvers that increase the intraddmonial pressure.
Prompt surgical conrrection is required in all children to avoid potentally serious complications like incaration and strangulation.
Differential diagnosis of urinary incontinence
Effects of combined estrogen/progesterone menopasual homrone therapy
What is recommended for immunocompetent adults > or = 60?
Who should it not be given to?
Herpes zoster vaccination
it is a live-attenutated vaccine, it should be not be given to patietns with impaired immunity.
When can an oral directive be honored?
if a patient is diagnosed with a terminal or irreversiable condition and the patient’s wishes are declided to the attending physician in the presence of TWO witnesses.
Diagnosis of kawaki disease
Fever > or = 5 days PLUS > = 4 of the following findings:
- conjuctivitis - bilateral, nonexudative
- Mucositits: Injected/fissured lips or pharynx, strawberry tongue
-Cervical lympahdenopahty: > or =1 lymph node > 1.5 cm in diameter
- rash: Erythematous, polymourovus, genralized; perineal erythemia & desquamoation; morbiliform (trunk, extremities)
-Ereythemia of the hand & Feet
Incomplete (atypical) kawasaki disease
< or = 3 criteria but have elevated inflammatory markers (C-Reactive protein and ESR) and other supporting laboratory criteria (leukocytosis, thrombocytosis, anemia, hypoalbuminia, elevated transaminases and bilirubin, sterile pyuria) reflecting multisystem inflammation.
These patients should receive the same management as those with classic KD.
Menieres disease
PT and PTT values in hemophilia A and B
Normal PT and prolonged aPTT
These x-linked recessive disorders result from deficiency of factor VIII or IX respectively.
What happens to the PTT, PT and platelet count in DIC?
Elevated aPTT, prolonged PT and low platelet count
TTP
FATRN = TTP = Plasma Exchange.
(TTP-adults = HUS children).
DIC
HIT
discontinue heparin products, start direct thrombin inhibitor (lepirudin).
HIT antibodies will be sent out; once stabilizd, he can be transitioned to Coumadin for 6 months.
Dabigatran is used for nonvalvulatr aFIB thromboprophylaxis
ITP
ITP is “not anything else but low platelets.”
Leukocytoclastic vasculitis
is the most common cutaneous vasculitis and is characterized by a neutrophil-predominant inflammation of dermal vessels.
It produces isolated purpura, often on the legs and may be painful.
Statin-induced myopathy
when does it occur?
patients who are concurrently taking what medication are more suspectible to muscular damage?
myositits typically occur within the first few months of initating statin therapy, it can be precipitated by the use of certain CYP34A4-inhibiting medications, such as cyclosporine and macrolide antibotics.
First time patient is experiencing this for the past several weeks.
Management?
The rsik of systemic thromboembolism in A.flutter is the same to that of AFIB.
In patietns with new atrial flutter (or fibrillation) of unknown duration or >48 hours, > or = 3 weeks of anticoagulation is required prior to cardioversion or cardiac ablation.
Tx with warfarin, an oral factor Xa inhibitor (ex: apixaban or rivaroxaban) , or an oral direct thrombin inhibitor (ex: digatran) is appropriate.
What are common abnormalities seen in patients with scleroderma?
Skin involvement and scleroderma
Intersitital pulmonary fibrosis and esophagel hypomotility
Heart failure in scleroderma can occur either as a primary abnormality or secondary to the lung disease.
Patietns with scleroderma may have limited skin involvement (ex: telangiectasia around lips) without the classic skin sclerosis; these patietnts are said to have limited cuntaeous scleroderma and are frequently positive for anti-centromere.
Antibodies specific for which disease
Anti-double stranded DNA
Anti-smith
Anti-mitochondrial
antibodies to thyroid periodiase
Anti-DS DNA & Anti-smith - SLE
Anti-mitochondrial antibodies - PBC
Antibodies to thyroid peroxidase - Hashimoto’s thyroditis
Inflammatory breast cancer presentation?
May be confused with?
Diagnosis?
rapidly develop breast pain, erythema and edema, often with peau d’orange appearance.
These findings may be confused with mastitis, but patients with IBC do not respond to antibiotics.
Diagnosis requires a core biopsy with histopathologic demostration of tumor infasion of the dermal lymphatics.
Mgmt of hematochezia
Need to give bowel preparation (ex: laxatives) followed by colonoscopy
Patient has this and also yellowed thicken nail - what is this evidence of?
What is typically associated with this and treatment?
Dermatophyte infection with tinea pedis (scaling, fissuring between toes) and tinea unguium (yellow, thickened nail)
Recurrent cellultiis (acute lower extremity erythema, edema and pain the setting of leukocytosis and negative doppler studies)
Treatment with topical antifungals (ex.topical terbafine cream) is likely to reduce risk of recurrent cellulitis episodes.
Tratement of acne vulgaris
Severe oral antibiotics are for widespread acne: tetracyclines (tetracycline, doxycycline, minocycline), macrolides (erythromycin, azithromycin) and trimethroprim-sulfamethoxazole.
Patietns with intussception should first be managed with
first stablize with IV isotonic fluids followed by attempted enema reduction (air or saline contrast under sonographic or fluorscopic guidance)
Most likely cause of this patient’s syncope
cardiac tamponade
Electrical alternans, which descriibes alternativing amplitude of the QRS complexes on ECG likely due to changes in the ventricular axis as the heart moves within the excess fluid of the pericardial space, is a poorly senstive but specific finding for cardiac tamponade.
What is varicocele?
tortous dilation of veins in tthe pampiform plexus surrounding the spermatic cord and testis.
It presents as a soft, irregular mass (bag of worms) that increase in size with standing and valsalva.
Varioceles can cause elevated scrotal tempteratures, increasing the risk for infertility and testicular atrophy.
How doe you diagnosis varicocele?
confirmed by ultrasound which can show retrocgrade venous flow and dilation of the pampinform plexus.
Varicocele versus Hydrocele
Hdyroceles are caused by the collection of peritoneal fluid between the layers of tunica vaginalis and typically present as cystic scrotal masses.
The irregular character of this patietns mass and changes with valsalva and position are more consistent with varicocele.
Why are varicoceles more common on the left side?
A right sided varocele is a sign of and warrants what?
The left spermatic vein drains in the left renal vein, which then passes between the superior mesenteric artery and aorta.
Compression between the SMA (nutcracker effect) can lead to increased pressure in the spermatic vein and venous dilation.
For this reason, varioceles are more common on the left side.
In contrast the right spermatic vein drains directly in the IVC and right sided varicoceles are relatively rare.
A right sided varcicele can be a sign of malignant compression (ex: RCC) and therefore warrants CT imaging.
CT Scan is not recommeneded for workup of an isolated, left sided varicele.
Choanal atresia versus Tacheoesophageal fistula?
Infants with TEF can have increased secretions of coughing, choking and respiratory distress after feeding, symptoms are not prsent in this infant.
When TEF is suspected, atttempted insertion of a gastric catheeter followed by CXR is the first step in determining whether the esophagus is patient, a catheter terminating in the esophageal pouch suggests esophagel atreasia as indicated by the white arrow on the x-ray. Red arrow indicates mild ateletctasis and green arrow indicates umbilical venous cather in its expected location.
How do you diagnosis H type TEF
An upper GI series can be used to diagnosis H-type TEF, in which the esophagus and trachea are both fully patent but have a distal connection.
The other types can be confirmed with a CT scan.
What is this patients syncope due to?
Long QT >450 msec in male patients and >470msec in females
What is the single greatest risk factor for developing pancreatic cancer?
cigarette smoking which increases relative risk >2 fold.
Indications for implantable cardioverter-defibrillator placement
Prior MI & LVEF < or = 30%
NYHA Class II or III with LVEF < or = 35%
Cardiac resynchronization therapy
used in patietns with moderate to severe heart failure, and LVEF < or = 35 and a widened QRS (>120msec)
Infant of diabetic mother - complications
Differential diagnosis of Myopathy
What is this?
Lichen planus
pruritic, planar, polygonal and purple
wickham’s straie are white, lacelike patterns that are sometimes seen on the surface of these papules.
Management of acute exacerbation of COPD
Treatment
Furuncles (one hair follicle) and carbuncles (multiple) are types of subcutaneous involving hair follicles.
The majority are caused by S.Aureus, with many isolates being methicllin resistant.
Oral antibotics against MRSA include clindamycin, TMP and doxycyline
conjunctivitis types
Infertility is defined as
Disseminated gonoccocal infection can present as
purulent monoarthris or as a triad of tenosynovitis, dermatitis or polyarthralgias.
Patients with possible disseminated gonococcus should be evaluated with blood cultuers, NAAT of urine and supsected primary sites, and synovail fluid analysis
Chronic managemetn of gout
Urate lowering therapy (ex: allopurinol) is indicated for patietns with current gouty attacks.
However, changes in uric acid levels during initation can trigger an acute flare of gout.
Therefore patients should also receive colchiine or a NSAID to prevent acute gout durnig the initation and titration of treatment
What is most likely responsible for this person’s hypotension?
tension pneumothorax
cardiovascular collpase can occur due to compression of the vena cava and marked derease in venous return.
Thyroiditis
Three types
Clinical features
Diagnostic Testing
Postpartum thyroiditis is similar to silent thyrodiitis but by definition occurs within one year of pregnancy
