UWorld Pt 1 Flashcards
Dose of epi for ACLS algorithm
Epinephrine for asystole and PEA arrest: 1g q3-5 minutes to increase tissue perfusion
3 indications for sodium bicarb during ACLS
3 indications for sodium bicarb during ACLS
- metabolic acidosis (lactate…sepsis)
- hyperkalemia
- TCA overdose
Cough variant asthma
(a) symptoms
(b) physical exam
Cough variant asthma
(a) Cough usually worse w/ exercise, induced by forced exhalation, commonly occurs at night
- triggered by exercise, forced expiration, allergens (work exposure etc)
(b) No wheezing, no SOB, unremarkable physical exam
2 factors that determine severity of asthma for pts not on ICS
- frequency of SABA use
daily = moderate persistent - nighttime awakenings
once a week but not nightly = moderate persistent
Escalation steps 1 through 6 of asthma treatment
- SABA
- SABA + ICS
- SABA + ICS + LABA
4-5. SABA + escalating dose of ICS + LABA - SABA + high dose ICS + LABA + oral corticosteroid
Tracheomalacia
(a) Physiology
(b) Clinical finding
Tracheomalacia
(a) Weakness of tracheal wall causing collapse w/ expiration
(b) Expiratory stridor
5 Hs
5 H’s of reversible causes of cardiac arrest
- hypovolemia
- hypothermia
- hypo/hyper-kalemia
- H+ ions (acidosis)
- hypoxia
5 Ts
5 T’s of reversible causes of cardiac arrest
- Toxins (narcotics, benzos)
- Trauma
- Thrombosis (coronary or pulmonary)
- Tamponade (cardiac)
- Tension pneumothorax
Lung cancer associated w/ 2 different paraneoplastic syndromes
- Small cell carcinoma and SIADH due to ectopic ADH secretion
- Squamous cell carcinoma and hypercalcemia due to parathyroid-related hormone production
2 Drugs sometimes used in refractory chronic SIADH
Demeclocycline (tetracycline abx, first line b/c less nephrotoxic than lithium) and lithium both blunt the tubule’s response to ADH
(hence why lithium can cause nephrogenic diabetes insipidus)
G6PD deficiency
(a) Pathophysiology of disease
(b) Presentation
(c) Triggers
G6PD deficiency
(a) Enzyme used by RBCs to make NADPH and handle oxidative stress. When deficiency RBCs hemolyze under stress
(b) Either first few days of life w/ jaundice or later w/ acute hemolytic anemia
(c) Triggers = oxidative stress: infection, fava beans, sulfa drugs
Peripheral smear findings of G6PD deficiency
G6PD deficiency on peripheral smear
- ‘bite’ cells where RBCs literally look like a bite has been taken out
- Heinz bodies which is deposits/accumulation of denatured hemoglobin in the RBC
Tx for supraventricular tachycardia to 170s
SVT
Pt stable? If unstable => synchronized cardioversion
If stable- vagal maneuvers, adenosine
Buzzword: intracranial calcifications in a newborn
Congenital toxoplasmosis
From undercooked meat, cat poop, contaminated soil
Name 3 EKG findings of Wolff-Parkinson-White
WPW EKG findings:
recall accessory pathway
- prolonged PR (b/c not going through the pause gate of the AV note)
- delta wave- upsloping due to ventricular preexcitation
- Widened QRS b/c not going thru native conduction system
What are the following used for
(a) Dialectical behavioral therapy
(b) Exposure and response prevention therapy
(a) DBT for borderline personality disorder
(b) Exposure and response prevention therapy is a type of CBT used for OCD
What are you testing for w/ the following in the workup of HTN
(a) Plasma renin
(b) Urine metanephrines
(a) Plasma renin- testing for primary hyperaldosteronism, b/c in primary hyperaldo plasma renin is low to almost undetectable (since it’s suppressed by the volume expansion due to high aldo)
(b) Urine metanephrines testing for pheochromocytoma (catecholamine secreting tumor- MC presents w/ paroxysmal HTN)
Autosomal dominant Polycystic kidney disease
(a) Clinical features
(b) Key thing for treatment/management
(c) What to do for family members?
AD PCKD
(a) B/l flank pain (stones, large cysts etc), HTN HTN HTN, then LVH on EKG from the HTN
(b) ACEi for tight BP control and to try to prevent progression of kidney disease
- don’t need to screen for RCC, they’re not at increased risk
- don’t need genetic testing, b/l renal ultrasound w/ enlarged kidneys w/ multiple cysts is diagnostic enough
(c) Screen family members w/ renal ultrasound
Window period where false negative on HIV test
Up to 4 weeks, b/c takes 1-4 weeks for antibody titers against the virus to develop
So wait 4 weeks then repeat testing
Proposed mechanism of gestational diabetes
(a) Risk to mother gDM
(b) Risk to baby of gDM
Human placental lactogen secreted by placenta promotes maternal insulin resistance
(a) To mother- preeclampsia
(b) To baby- hyperglycemia and hyperinsulinemia => macrosomia => shoulder dystocia
When are pregnant F screened for gestational diabetes?
(a) Screening test
At 24-28 weeks, give 50g glucose and check in one hour, if 140 or over then do glucose tolerance test
(b) Glucose tolerance test Give 100g of glucose and check q1hr for 3 hours
Treatment for gestational diabetes
Insulin, metformin, glyburide all safe
Besides the three mainstay drugs w/ mortality benefit in HF, what else improves mortality?
Beta-blocker, ACEi, and spironolactone have mortality benefit
But then in African Americans w/ EF < 40% and NYHA class III-IV HF (markedly limited activity 2/2 HF): combination of hydralazine and nitrates (isosorbide dinitrate) has a mortality and symptomatic benefit
Clinical presentation of cerebral palsy
(a) Risk factors
Spasticity. Child w/ delayed motor milestones, hyperreflexia, scissoring and clonus, associated w/ seizures
(a) Prematurity, low birth weight
CNS oxygen deficit => progressive damage
BMP abnormality expected in early compartment syndrome (before loss of pulses/sensation)
Acute renal failure 2/2 rhabdo- myoglobin is toxin to renal tubules from muscle breakdown
Papillary muscle vs. chordae tendinae
Papillary muscles = muscles that connect to the trebeculae carne of the LV
Then the chordae tendinae are the connective tissue (‘parachute’) that holds the valve to the muscle
Typical cause of
(a) Papillary muscle rupture
(b) Chordae tendinae rupture
(a) 3-5 days post-MI watch out for papillary muscle rupture
(b) Connective tissue disorders (Ehrlos-Danlos, Marfans) associated with chordae tendinae rupture
Marfans vs. Ehler-Danlos- major clinical difference
Both joint hypermobility, pectus excavatum, scoliosis
Ehler-Danlos: derm manifestations: velvety, transparent and hyperextensible skin
More prominent skin findings and atrophic scarring
1st line agent to manage HR and BP in acute aortic dissection
(b) Why not hydral
Beta-blockers: reduce HR and BP
(b) Hydral- prominently arterial vasodilator, but reflex sympathetic surge can cause tachycardia and hypotension
Define torsades de points
Gradual prolonging of QT causing form of polymorphic VT- cyclic alteration in QRS axis and morphology 2/2 acquired vs. congenital QT prolongation
Explain mechanism of Torsades
(a) PVC
(b) Bradycardia
(a) PVC w/ compensatory pause short-long RR phenomenon) can progress to VT
(b) Bradycardia (sinus brady or pause) can cause prolonged QTc
Immediate treatment of torsades
1st line- IV mag sulfate, regardless of serum mag levels
When inadequate response to IV mag- temporary transvenous pacing
When is CRT indicated in HFrEF in sinus rhythm?
LVEF under 35%
LBBB causing QRS over 150 msec
NYHA class II or above (essentially any heart failure symptoms)
Indications for ICD placement in heart failure
- Prior MI with LVEF under 30
2. NYHA class II-III (aka HF symptoms) w/ LVEF under 35
PAILS mneumonic
ST elevations in posterior leads, expect reciprocal depressions in anterior leads
Posterior (V7-V9) Anterior (V1-V3) Inferior (II, III, aVF) Lateral (V5, V6) Septal (V3,V4)
65 y/oM p/w substernal CP and SOB x2 hours, got ASA and SLN by EMS w/ big improvement in pain
EKG on arrival w/ ST depressions in II, aVF, V3-V6
Best next step in management?
NSTEMI- not straight to cath!! (no STE)
ASA/plavix load
Anticoagulation (heparin gtt)
Statin
Nitrate/beta-blocker
Pt p/w acute decompensated HF requiring BiPap
Still SOB despite IV lasix
Next step?
Add IV vasodilator (IV nitroglycerin = nitro gtt) = venous vasodilator- rapid decrease in cardiac preload = reduced intracardiac filling pressures to improve/reduce pulmonary edema
Why is nitroglycerin used over nitroprusside in flash pulmonary edema?
Both are venous vasodilators to reduce cardiac preload => reduce amount of fluid poured into lungs
But nitroprusside can cause cyanide toxicity and severe hypotension => use nitro(glycerin) gtt
Escalation of treatment for claudication 2/2 PAD
- Start w/ modification of risk factors
- smoking cessation
- BP and dit control
- ASA and statin
- supervised exercise therapy
Only once that fails ^ do cilostazol (PDE3 inhibitor)
Then can consider revascularization
Point is to try statin and exercise before cilostazol and stent
12 y/o boy, very tall, increased arm span to height ratio
(a) Possible diagnosis
(b) Further eval required prior to starting strenuous sports at school
(a) Marfanoid habitus
(b) TTE to evaluate aortic root for aneurysmal dilation, Aortic regurg, aortic dissection
MC cause sudden cardiac death in 20 y/oM w/ normal EKG and normal TTE
Normal EKG => not Brugada or WPW
Normal TTE => not HOCM
Actually pretty common is anomalous aortic origin of the coronary artery
-artery takes a sharp curve (doesn’t tolerate high flow well) or sometimes goes btwn aorta and pulmonary atery (externally compressed)
57 y/oF p/w syncope 2/2 severe AS
Gets aortic bileaflet mechanical valve
Indicated ppx
ASA?
Warfarin with what INR goal?
Yes ASA, always ASA for mechanical valve (mitral or aortic)
Warfarin goal
2.0-3.0 given aortic valve w/o risk factors
If had AFib, HFrEF, prior VTE, or cancer: higher INR goal (2.5-3.5)
Indications for INR goal 2.5-3.5 (instead of typical 2-3)
- mitral valve replacement
- aortic valve replacement WITH risk factors: AFIb, HFrEF, hypercoag state (cancer), prior VTE
27 y/oF p/w chest pain after cocaine ingestion, BP 208/102
First line management?
First line- benzos (IV lorazepam)! reduce sympathetic drive
Beta-blockade contraindicated- unopposed alpha can vasodilate peripherally and drop pressures
68 y/oF getting breast implants after mastectomy for CA coming for pre=op clearance
H/o CAD s/p stent, LVEF 40%
Trouble walking up stairs to appt
Preop mgmt?
Proceed to surgery w/o further testing
B/c such low risk procedure
Need to take into account risk of procedure, METS4 really for bigger procedures
WHO classes of pulmonary HTN
Pulmonary HTN
Class I- idiopathic
Class II- 2/2 left heart failure
Class III- 2/2 chronic lung disease: COPD, ILD
Class IV- 2/2 chronic thromboembolic disease
Class V- other (sarcoid)
29 y/oM used cocaine 2 hrs ago, p/w chest pain, STE
STE persist after ASA, diazepam, nitro gtt
Next step?
Cocaine- increases coronary vasospasm (so give CCB), increases platelet activity (so give ASA)
If STE persist => cath!
Initial mgmt of cardiac chest pain after cocaine ingestion
(b) For persistent CP
(c) For persistent HTN
(d) Anti-platelet?
Cocaine-induced cardiac chest pain- benzos to control HR and BP
(b) Persistent chest pain- CCB
(c) Persistent HTN- phentolamine = alpha-2 agonist
(d) Yes ASA! b/c cocaine increases platelet activity
67 yoM 2 days s/p cath p/w persistent R groin pain
Mild swelling and bruising, accentuated pulsation
Next step?
Ultrasound of groin
Could just be hematoma but need to r/o pseudoaneurysm or AV fistula
Local vascular complications of cath when done femorally
- Hematoma
- Pseudoaneurysm: systolic thrill
- AV fistula from femoral artery to vein: continuous thrill
Calculate CHADS-VASC
1 point for each
CHF HTN Age: 2 pts for over 75 DM Stroke, TIA, thromboembolism
Vascular disease: 2 pts for prior MI, PAD
Age: 1 pt 65-74
Sex: 1 pt for female
How many CHADS-VASc points indicate anticoagulation
CHF, HTN, Age, DM, Stroke, Vascular (MI, PAD), Age, Sex
0 = low risk 1 = intermediate risk 2 = high risk for stroke in AFib, def anticoagulate
HOCM
(a) beta-blocker use
(b) ACEi use
HOCM
(a) Beta-blockers good- want to decrease HR decrease LVOT
(b) ACEi bad- decreasing preload increases the LVOT gradient
Indications for ICD in HOCM
ICD in HOCM
- recurrent or exertional syncope
- prior arrest
- spontaneous VT
- family history of sudden death
- extreme LDH
62 y/o African American M w/ HFrEF 30%, on metop/lisinopril/lasix/spironolactone
What med is best to add?
Isosorbide dinitrate and hydral have mortality benefit for HF in African Americans
72 y/oF p/w chest pain, STE in II, III, aVF
Shortly after becomes cold, hypotensive
First line management while waiting for cath lab?
(b) What to avoid
Inferior wall MI => cardiogenic shock
While waiting for cath, if lungs not crackly give IV fluids to increase preload
If not responding to fluids can give dobutamine
(b) Avoid nitrates or diuresis which would drop preload
Marfan syndrome
(a) Mode of inheritance
(b) Ocular symptom
(c) Cardiac involvement
(a) Autosomal dominant of connective tissue glycoprotein fibrillin-1
(b) Ectopic lentis = lens subluxation or dislocation- acute unilateral vision loss
(c) Aortic dissection, aortic regurg
50 y/oM p/w chest pain, cold extremities
BP 84/52, HR 34
Crackles at lung bases b/l
ECG: sinus brady w/ 3mm STE II, III, aVF
Mgmt prior to cath? (first line, second line)
Cardiogenic shock after inferior MI, fluid overload with sinus brady
-complication of ischemia to SA node
Give atropine to reverse sinus brady, if unresponsive start temporary transcutaneous pacing
Downs syndrome associations
(a) Neurologic
(b) Oncologic
(a) Alzheimer’s dementia
(b) Acute leukemia
2 Conduction abnormalities seen in inferior wall MI
SA node ischemia => sinus bradycardia
AV node ischemia => AV block
Patellar tendonitis vs. patellofemoral syndrome
Patellar tendonitis = jumpers knee, episodic inferior patellar pain
Patellofemoral syndrome- young F athelets w/ subacute to chronic pain
Patellofemoral compression test- pain on extension of knee w/ anterior patellar compression
Typical causes of reactive arthritis
Reactive arthritis = spondyloarthropaty p/w peripheral asymmetric oligoarthritis
Typically after GU (chlamydia) or GI (salmonella, shigella, yersinia, campylobacter) infection
ex: 35 y/oM p/w R knee and ankle pain x2 weeks, also eye pain/blurry vision, dysuria. Reports diarrhea after eating 1 month ago
Extra-articular symptoms of reactive arthritis
Reactive arthritis- typically asymmetric oligoarthritis w/ h/o GU or GI infection
Enthesitis (pain at ligament/tendon insertion)
Dactylitis
Extra-articular: uveitis, urethritis
HLA-B27 pt w/ diarrhea, at risk for?
Reactive arthritis- sacroilitis, peripheral asymmetric oligoarthritis (knee and ankle pain), enthesitis, dactylitis, uveitis (b/l conjunctival erythema), uretheritis (dysuria)
What would joint aspiration show for reactive arthritis?
Sterile- no growth but w/ elevated WBC count
Diagnostic joint aspiration features for septic joint
Over 2000 WBCs
75% PMNs (polymorphonuclear leukocytes)
Scoliosis vs. kyphosis
Scoliosis = S-shaped curvature of thoracic and lumbar spine
Kyphosis = exaggeration of posterior thoracic curvature (hunchback)
3 month old girl p/w fussiness, decreased PO intake, L leg flexed and externally rotated
Afebrile
WBC 16k, CRP 8.5
Effusion on joint ultrasound
Dx?
Septic arthritis- despite afebrile, elevated inflammatory markers/WBC w/ hip pain and effusion = septic arthritis
Not hip dysplasia b/c wouldn’t have effusion
Not Legg-Calve-perthes b/c wouldn’t be
MC cause of septic arthritis
Staph aureus
Presentation of Legg-Calves-Perthes disease
= idiopathic avascular necrosis of the hip
Child age 3-12 who presents w/ insidious-onset hip pain and limp
Normal inflammatory markers
Deformity of femoral head on Xray
Top risk factors for osteonecrosis (avascular necrosis)
- corticosteroid use
- ex: lupus pt on chronic prednisone 20mg p/w hip pain - excessive EtOH
22 y/o F p/w knee pain
while running felt a popping sensation in R knee, then pain and rapid swelling
Aspiration yields gross bloody fluid
Dx?
popping sensation, rapid swelling/hemathrosis (bloody fluid) = anterior cruciate ligament tear
hemathrosis not seen in PCL or meniscal injury
Classic features of Scarlet Fever
Scarlet fever = kids after strep pharyngitis p/w sand-paper rash (little papules), strawberry tongue, circumoral pallor
Feared complications of Kawasaki disease
Kawasaki disease = febrile vasculitis of unknown etiology
Coronary artery aneurysm
Myocardial ischemia/infarction
Tx of Kawasaki disease
ASA and IVIG- by unclear mechanism reduces risk of cardiac sequelae
Typical arthralgia seen in
(a) Parvovirus B12
(b) Acute rheumatic fever
(c) Lyme arthritis
(a) Parvovirus B19- acute symmetric joint pain, typically small joints (of the hand)
(b) RF- migratory polyarthritis of large joints (knee, elbow)
(c) Lyme- monoarticular
16 y/o girl p/w hand and knee stiffness upon waking 1 week after URI
Dx?
Viral arthritis- typically symmetric and involves small joints of hands
Specifically MC parvovirus B19
Buzzwords
(a) Sandpaper rash
(b) Slapped cheek rash
(a) Sandpaper rash = scarlet fever = post-strep pharyngitis
(b) Slapped cheek rash = parvovirus B19
anti-cyclic citrullinated peptide antibodies
Over 90% specific for rheumatoid arthritis
So yes order RF, but anti-CCP also for RA
52 y/oM p/w difficulty using L hand
Progressive stiffness at palm and 3rd/4th digis
Decreased extension of 3/4th MCP joints
Dx?
Risk factors?
Dupuytren’s contracture
RF: diabetesssssss, males over 50, tobacco and EtOH
53 y/oF p/w 6 months pain/tightness in neck, posterior shoulders, buttocks
+fatigue, insomnia
Widespread symmetric tenderness to firm palpation over muscles and bony prominences
Normal CBC, normal ESR
Dx?
Polymyalgia rheumatica widespread MSK pain, associated cognitive/psychiatric disturbances (depression, impaired concentration, impaired sleep), disordered sleep, fatigue, impaired cognition
Over 3 months
Typical features of fibromyalgia
Middle aged F w/ widespread MSK pain (ex: tightness/pain in neck/shoulders/buttocks), disordered sleep (ex: insomnia), impaired cognition, fatigue
Normal inflammatory markers (ESR, CRP)
52 y/oF p/w left groin pain x1 week
Is on 20mg/day prednisone for SLE
+limp, limited ROM
(a) Dx?
(b) Scan most sensitive for diagnosis
(a) Osteonecrosis = avascular necrosis of hip
- high dose prednisone (over 15-20 daily for over 3 weeks, high risk AVN)
(b) MRI most specific
Why do women w/ hemochromatosis typically present later than men
Menstrual iron loss
Hereditary Hemochromatosis manifestations
(a) Dermatologic
(b) MSK
(c) Cardiac
HH
(a) Dermatologic- hyperpigmentation (‘bronze diabetes’)
(b) MSK- arthritis, pseudogout, chondrocalcinosis
(c) Restrcitve cardiomyopathy, conduction abnormality
46 y/oF p/w knee pain x3 weeks after initial insult
Initial insult- no deformity/edema, able to walk normally
2 weeks later- intense pain, unable to weight bear, swollen, hot
L leg: mottled, bluish discoloration, sweating more tan R
Dx?
Chronic regional pain syndrome = pain, swelling, skin changes (mottled), vasomotor changes (sweating), not immediately after but following injury
Features of complex regional pain syndrome
Complex regional pain syndrome = pain, excess sweating, mottled/blueish skin (vasomotor, skin changes) following an injury
due to over-active sympathetic activation after an injury
27 y/oM w/ knee pain after hitting knee on dashboard during MVA
Mild swelling and stiffness
Which ligament is injured?
PCL injury- typical after dashboard (anterior) force application
Not huge effusion seen in ACL tear
2 knee injuries that typically have large effusion
(b) How to distinguish
ACL tear
(b) Rapid onset hemathrosis
Meniscal tear
(b) Onset w/in 24 hrs, not bloody
Risk factors that would indicate Xray in pt w/ back pain
Nighttime pain
Age over 50
Unexplained weight loss (?inflammatory condition)
H/o malignancy (?mets)
Pt w/ Sjogrens p/w neck mass
Most likely diagnosis?
Sjogrens assocaited w/ proliferation of monoclonal B-cells that infiltrate salivary glands=> increased risk B-cell lymphoma
Mechanism of methotrexate
Purine antimetabolite
Main adverse effect of hydroxychloroquine
Retinopathy
Mechanism of hydroxychloroquine
Hydroxychloroquine = DMART, TNF and IL-1 suppression (same as sulfasalazine)
Main adverse effects of methotrexate
- hepatotoxicity
- stomatisis
- cytopenias
Inhibits division of rapidly-dividing cells
36 y/o AA F p/w HA, acute onset blurry vision
PMH: Raynauds, GERD
BP 200/110, no abd bruit, +b/l papilledema
Cr 2.0
Dx?
Systemic sclerosis = scleroderma, specifically scleroderma renal crisis
Get narrowing of renal arterioles => RAAS activation => HTN
Triad of HUS
HUS = hemolytic uremic syndrome
- AIHA
- uremia = acute renal failure
- thrombocytopenia
Tx of scleroderma renal crisis
Scleroderma renal crisis- ACEi, the one time in acute renal failure that ACEi would be indicated
B/c directly inactivates the RAAS system (which is the problem)
Mechanism of disease in scleroderma
Scleroderma = systemic sclerosis = abnormal collagen deposition in organs
Tx algorithm for acute gouty attack
(b) How this changes in ESRD
Acute gout attack: tx w/ indomethacin (NSAIDs) and colchicine
Not allopurinol, which reduces urate production, and can actually worsen symptoms in acute attack
(b) Both NSAIDs and colchicine contraindicated in renal failure, so
if monoarticular- do steroid injection
if polyarticular- consider PO systemic steroids
45 y/oM p/w L shoulder pain/stiffness x3 months
Constant day/night
No focal tenderness but global restriction in both passive/active motion
Xray normal
Dx?
Frozen shoulder = adhesive capsulitis
- both passive and active motion restricted
- no bony stuff on Xray
- features: stiffness more prominent than pain
Tx of adhesive capsulitis
Adhesive capsulitis = frozen shoulder
Tx = rest and gentle ROM exercises
12 y/oM p/w worsening hip pain x3 weeks
No recent URI symptoms
95th percentile weight, 50th for height
R hip externally rotated in pain
Dx?
Obese kid w/ gradually progressive hip pain = SCFE = slipped capital femoral epiphysis (ice cream slipping off cone)
= displacement of femoral head along the plane of the physis
SCFE
(a) Xray findings
(b) Tx
SCFE
(a) Ice-cream slipping off cone due to displacement of femoral head along plane of the physis
(b) Tx = immediate surgical pinning to reduce risk of avascular necrosis and nerve impingement
When to attempt manual reduction by flexion and supination
For nursemaid’s elbow = radial head subluxation = displacement of annular ligament btwn radius and humerus
From elbow subluxation (ex: swinging child by hands)
Fracture expected after FOOSH in
(a) Adults
(b) Kids
FOOSH = fall on outstretched hand
(a) Adults- distal radius fracture (near wrist) = Colle’s fracture
(b) Kids- distal humerus fracture = supracondylar fracture of distal humerus
After FOOSH in kids- how to check the following are intact
(a) Blood vessels
(b) Nerves
FOOSH => supracondylar fracture of distal humerus at elbow- dangerous b/c exposed arteries and nerves in the area
(a) Ensure brachial artery is ok- feel pulses, test cap refill
(b) Ensure median nerve ok- would cause weakness in hand/wrist flexion
2 y/o girl p/w sudden refusal to move R arm after being grabbed by wrist by mother to prevent from falling
Dx?
Radial head subluxation = nursemaid’s elbow, annular ligament gets displaced btwn humerus and radius due to traction on forearm w/ elbow extended
7 y/o boy p/w red round lesions that merged on legs and butt, abdominal pain, nausea, 1 week after URI
Pos stool guaiac
Dx?
Henoch-Schonlein purpura = IgA-deposition mediated vasculitis
rash = palpable purpura, abd pain due to small bowel intussusception, hemturia, joint and kidney involvement later
50% antecedent UTI
Features of Henoch-Schonlein purpura
IgA-deposition mediated vasculitis
Starts w/ palpable purpura and abdominal pain (from intussusception)
Then later get joint pains and kidney involvement (nephritic syndrome)
What common blood pressure drug has an association with drug-induced lupus?
(b) Expected antibody
Hydralazine
(b) ANA and anti-histone antibody
Why is CKD associated w/ high PTH?
Reduction in phosphate filtration, Ca binds to phos so reduced circulating phos => elevated PTH
74 y/oF p/w cough x4 weeks, DOE
Meds: ASA, metop, lasix, synthroid, amio, MVI
Afebrile, nonproductive cough, fine end inspiratory crackles at bases
Diffuse interstitial opacites at b/l LL fields
Dx?
Amiodarone induced pulmonary toxicity- chronic interstitial PNA
Why even biopsy someone w/ lupus who comes in w/ LE edema, renal dysfunction, proteinura, UA w/ active sediment?
So you know they have lupus nephritis…butttt need biopsy to determine class which determines treatment
basically some classes warrant immunosuppressives while others dont
Size cut-off for removal vs. medical management of ureteral stone
10mm
Under 10mm: hydration, pain control, alpha blockers
Over 10mm: urology consult
2 other causes of hyponatremia aside from SIADH that cause low urine osms w/ low urine sodium
Adrenal insufficiency
Hypothyroidism
Explain two mechanisms by which familial hypocalciuric hypercalcemia causes hypercalcemia
Autosomal dominant inheritance of inactivating mutation in calcium sensing receptor
- Need higher levels of serum Ca to suppress PTH
so serum 11-12 suppresses PTH, instead of 8-9 (normal) - Increased resorption of Ca by kidneys
Classic clinical presentation of analgesic (NSAID)-induced neprhopathy
Rapid onset gross proteinuria- due to reversible decline in GFR from inhibition of vasodilatory prostaglandin production
42 y/oM p/w nausea, weakness, oliguria, and purpura x4 days
- also tingling in hands/feed and arthralgias
- hepatomegaly, pitting edema, absent b/l ankle reflexes
Dx?
Lab test for diagnosis
Mixed cryoglobulinemia- dx w/ serum cryoglobulin levels
= vasculitis from immune complex (IgM and IgG RF) into small and medium vessel walls
Clinical triad: palpable purpura, weakness, arthralgias
2 stages of treatment for mixed cryoglobulinemia syndrome
- initial immunosuppressives (prednisone, rituxan) to stabilize end-organ damage (glomerulonephritis)
- Treatment of underlying disease
Some underlying inflammatory condition that generated the immune complexes that caused the vasculitis
Ex: antivirals for tx of underlying hep C
Typical murmur of VSD
VSD murmur = harsh holosystolic murmur with thrill
best heard at 3rd/4th L intercostal space
Smaller the VSD = harshes the murmur
Explain why a soft, single second heart sound (S2) is heard during inspiration in severe aortic stenosis
During inspiration (increased RV volume) pulmonic valve typically closes just later than AV
W/ severe AS there is delayed closure of the aortic valve => simultaneous closure of aortic and pulmonic valves during inspiration
42 y/oF presents w/ amitriptyline toxicity
EKG shows sinus tachy w/ wide QRS
How to prevent ventricular arrhythmia?
TCas inhibit fast Na channels => decreased conduction speed = prolonged QRS
Sodium bicarbonate!!! best agent to manage cardiotoxic effect of TCAs- goal is to increase serum pH to neutralize TCAs so TCA is less available to bind to rapid sodium channels
Syndromes causes by fibrillin vs. myosin gene mutation
Fibrillin mutation = Marfan’s
Myosin mutation => HOCM
Name 3 contraindications to OCPs
b/c of association w/ ischemic stroke and CV events, contraindicated if have additional risk factors:
- Migraine w/ aura
- BP > 160/100
- Over age 35, smoke > 15 cigs/day (not just any smokers)
62 y/oF w/ HTN presents w/ LE edema
What med is she most likely taking?
Amlodipine or nifedipine- CCBs (not ACEi) are assocaited w/ peripheral edema due to preferential dilation of precapillary vessels => increased capillary hydrostatic pressure
Describe the murmur of mitral valve prolapse
MVP murmur = non-ejection click and systolic murmur
Click is snapping of the mitral chordae as the valve cusps extend into the LA during systole
What is the unique similarity between MVP and HOCM murmurs?
Both decrease w/ increased venous return/LVEDP (squatting, suping leg raise)
While other murmurs all increase w/ those maneuvers
What is the unique similarity between MVP and HOCM murmurs?
Both decrease w/ increased venous return/LVEDP (squatting, suping leg raise)
While other murmurs all increase w/ those maneuvers
Why would progestin-containing IUD be better than copper-IUD for PCOS?
PCOS = oligo or anovulation => unopposed estrogen which causes endometrial hyperplasia and potentially cancer
So need progestin (either in combined OCPs or in progestin-containing IUD) to help protect the endometrium
Top most effective emergency contraception option
(b) Contraindication
Most effective is placement of a copper IUD (99%)
- marginally more effective than ulipristal (98%)
- more effective than Plan B = levonogesterol (50-90%)
(b) Acute cervicitis
What STIs do the following treat
(a) Azithro
(b) CTX
(a) Azithro treats chlamydia
(b) CTX treats chlamydia
Age for HPV screening
HPV screening q5 years once age 30
46 y/oF G2P2 p/w increasingly heavy menses: heavy bleeding w/ clots and severe abd cramping
-uniformly enlarged, mobile uterus
Dx?
Adenomyosis = abnormal endometrial tissue in the uterine myometrium
dysmenorrhea, heavy bleeding, diffuse uterine enlargement
22 y/oF w/ RLQ pain x3 weeks exacerbated w/ BMs
small, nontender uterus
R adnexa enlarged and tender
nodularity and tenderness on rectovaginal exam
Dx?
Dyschezia = pelvic pain exacerbated by BMs
-nodularity
dx = endometriosis
chronic pelvic pain, dysmenorrhea
Why does endometriosis carry increased risk of infertility?
causes pelvic adhesions and inflammation => infertility and chronic pelvic pain
Adenomyosis vs. endometriosis
(a) Physiology
(b) Exam
Adenomyosis
(a) abnormal endometrial tissue in uterine myometrium
(b) diffuse uterine enlargement
Endometriosis
(a) fixed, immobile uterus, rectovaginal nodularity, tender adnexa
Adenomyosis vs. endometriosis
(a) Physiology
(b) Exam
Adenomyosis
(a) abnormal endometrial tissue in uterine myometrium
(b) diffuse uterine enlargement
Endometriosis
(a) fixed, immobile uterus, rectovaginal nodularity, tender adnexa
Coast of Maine cafe-au-lait spots
Buzzword for Mccune-Albright Syndrome
Coast of Maine cafe-au-lait
Precocious puberty
Bone dysplasia
Management of familial hypocalciuric hypercalcemia
Benign- no treatment needed
Contraindication to metformin
GFR under 30
T3 vs. T4
T4 = hormone made by they thyroid gland, then it’s deiodinated peripherally to make T3
78 y/oM p/w hyperthyroidism, 2.8cm thyroid nodule with RAI of 55% (ULN 30%) with rest of gland showing reduced uptake
Mgmt?
Mgmt = methimazole and that’s it
Hot nodule (high uptake on RAI w/ rest of gland suppressed) low suspicion for cancer => doesn’t need to be resected
3 types of cancer that can cause hypercalcemia
- Squamous cell carcinoma (lung, renal, breast, bladder, ovarian) b/c PTHrP
- Bony mets
- Lymphoma- secretes 1-25OHD that increases Ca resorption from bone
Clinical features of 21-hydroxylase deficiency in infancy?
MC form of congenital adrenal hyperplasia
No cortisol => hypoglycemia
No aldo => hyperkalemia, hyponatremia (salt wasting) => nausea/vomiting
Classic congenital adrenal hyperplasia
(a) Mode of inheritance
(b) Enzyme deficiency
(c) Confirmed by elevation in what hormone
CAH
(a) autosomal recessive
(b) 21-hydroxylase
(c) Elevation of 17-OH progesterone
Medication helpful in glyburide overdose
Glyburdie = sulfonylurea (like metformin) that increases insulin release
So overdose => recurrent hypoglycemia episodes refractory to D50
Tx w/ octreotide = somatostatin analog that inhibits insulin secretion
27 y/oF on synthroid, wants to start OCPs
How to adjust synthroid dose?
Increase dose b/c estrogens stimulate production of thyroid-binding globulin that binds serum thyroid hormone
Management of familial hypocalciuric hypercalcemia
Benign- no treatment needed
Contraindication to metformin
GFR under 30
Treatment for hyperthyroidism during pregnancy
PTU in first trimester
Then back to methimazole in 2nd/3rd trimester given high risk of hepatotoxicity w/ PTU
Explain how pregnancy can induce diabetes
Placenta releases human placental lactogen that promotes insulin resistant (to ensure baby gets enough glucose)
hence gestational diabetes
Calcitonin
(a) Action
(b) Site of production
(c) Elevated in what cancer
Calcitonin
(a) Works to oppose PTH, reduces serum Ca
(b) Produces in C-cells (parafollicular cells) of the thyroid
(c) Medullary thyroid cancer
Antithyroid peroxidase antibody
Elevated in Hashimoto’s thyroiditis
How does Hashimoto’s thyroiditis increase risk of future cancer?
Hashmoto’s thyroiditis = autoimmune chronic leukocytic infiltration of thyroid gland => increases risk of lymphoma
