UWorld Review 1 Flashcards
Describe the clinical presentation of salicylate toxicity. What would the ABG show?
- the hallmark is tinnitus accompanied by fever, tachypnea, nausea, and GI upset
- it leads to a respiratory alkalosis by stimulating tachypnea and an anion gap metabolic acidosis by uncoupling oxidative phosphorylation, which promotes anaerobic metabolism
- this mixed respiratory alkalosis and metabolic acidosis leads to a near-normal pH
What is winter’s formula?
- PaCO2 = 1.5(serum bicarb) + 8 +/- 2
- it predicts the appropriate respiratory compensation for a metabolic acidosis; a PaCO2 below this range suggests a respiratory alkalosis also exists
How does paranoid personality disorder differ from delusional disorder, paranoid type?
time course and intensity: those with a paranoid personality disorder have a pattern of distrust and suspicion of others throughout their entire lives and their beliefs do not have the same intensity as those with delusional disorder
What is the most common etiology for small bowel obstruction?
adhesions, which may be post-operative, post-inflammation, or congenital (known as Ladd’s bands)
Describe the presentation, diagnosis, and management of small-bowel obstruction.
- presents with colicky abdominal pain, vomiting, an inability to pass flatus or stool, hyperactive and later absent bowel sounds, and a distended or tympanic abdomen
- diagnosis is supported by the presence of dilated bowel or air-fluid levels on plain film or CT
- it should be initially managed with bed rest, NPO status, placement of an NG, and IV fluids
- if patients show signs of a complicated SBO (fever, hemodynamic instability, peritoneal signs, leukocytosis, or metabolic acidosis), surgical exploration is needed
Describe the pathogenesis of exercise-induced hypothalamic amenorrhea.
- prolonged caloric deficiency leads to diminished GnRH
- low GnRH leads to low FSH/LH levels
- this results in low estrogen levels and thus amenorrhea
Describe the pathogenesis, presentation, diagnosis, and management of Ashermann syndrome.
- suction and sharp curettage may inadvertently remove the basalts layer of the endometrium, promoting the formation of intrauterine adhesions and endometrial cavity obliteration
- presents with abnormal uterine bleeding or amenorrhea, infertility, cyclic pelvic pain, and recurrent pregnancy loss
- hysteroscopy with lysis of adhesions confirms the diagnosis and serves as treatment
How is familial adenomatous polyposis managed?
- screen with annual signoidoscopies and then colonoscopies beginning at age 10-12
- urgent proctocolectomy is indicated for patients who initially present with CRC or adenomas with high-grade dysplasia or have a significant increase in polyp number during the screening interval
- otherwise, proctocolectomy can be delayed until patients are in their 20s
Describe the presentation of HELLP syndrome. How is it treated?
- hypertension, elevated liver enzymes, and low platelet count are the hallmark features
- usually this is accompanied by RUQ pain from stretch of the hepatic capsule, microangiopathic hemolytic anemia, nausea, and vomiting
- pulmonary edema may complicate the course due to generalized arterial vasospasm, diminished albumin, poor renal function, and an increase in vascular permeability
- treat with magnesium for seizure prophylaxis, antihypertensive medications, and delivery of the baby
Describe magnesium toxicity?
patients typically have neuromuscular depression including decreased respiratory effort, muscle paralysis, somnolence, visual disturbance, and diminished reflexes
Describe the presentation and treatment of bacterial vaginosis.
- patients report thin, off-white discharge with a fishy odor and no vulvovaginal inflammation (no erythema or prutitis)
- the diagnosis is supported by a vaginal pH greater than 4.5, a positive whiff test, and the presence of clue cells on wet mount
- treat with metronidazole
Describe the presentation, labs, potential complications, and management of cholesasis of pregnancy.
- develops in the third trimester as generalized pruritus with RUQ pain and without rash
- labs show elevated bile acids, transaminases, and bilirubin
- may lead to intrauterine fetal demise, preterm delivery, meconium-stained amniotic fluid, or neonatal respiratory distress
- treat with ursodeoxycholic acid, antihistamines, and delivery at 37 weeks
Describe the presentation and management of ITP.
- it presents as petechiae, ecchymosis, and mucosal bleeding with isolated thrombocytopenia
- treatment is a progression of steroids, IVIG, and splenectomy
Describe the management of pediatric constipation.
- begin with dietary modifications including increased fiber, increased water intake, and decreased milk
- add laxatives and stool softeners
- use suppositories and enemas if oral laxatives are unsuccessful
- plain films are only necessary for severe constipation with abdominal pain and vomiting
Describe the pathogenesis, presentation, and management of methemoglobinemia.
- it is a complication of exposure to oxidizing substances, namely dapsone, nitrites, and local anesthetics
- this exposure causes a transition from ferrous (2+) to ferric (3+) iron which increase oxygen affinity and reduces release to peripheral tissues
- presents with cyanosis, chocolate-colored blood, respiratory depression, and lethargy
- pulse ox is always approximately 85% because the methemoglobin absorbs different frequencies of light, ABG shows a normal PaO2 since it measures only unbound oxygen, and patients don’t respond to oxygen therapy
- treat with methylene blue, a reducing agent
What are the diagnostic criteria for schizophrenia?
more than 2 of the following (with 1 being the first three) for at least six months, causing functional decline
- hallucinations
- delusions
- disorganized speech
- disorganized or catatonic behavior
- negative symptoms
Name six circumstances or health issues that allow minors to provide their own consent.
- emergency care
- mental health and substance abuse treatment
- management of STIs, contraceptive care, and pregnancy care
What is the triad of symptoms seen in those with heat stroke?
- temperature greater than 104F
- CNS dysfunction
- additional organ or tissue damage
How does the management of exertional and nonexertional heat stroke differ?
- for exertion, ice water immersion for rapid cooling is preferred
- for non-exertional, which is more common in the elderly, evaporative cooling is preferred because it has lower mortality
How do cardiac index, systemic vascular resistance, and left-ventricular end-diastolic volume change in those with HFrEF?
- cardiac index declines
- systemic vascular resistance increases to maintain blood pressure and organ perfusion
- LVEDV increases due to increased blood volume and chronically reduced EF
Describe the typical presentation for TMJ dysfunction.
pain which localizes to the ear and is exacerbated by chewing, often in patients with a history of nocturnal teeth grinding
Describe the presentation and treatment of bronchial mucus plugs.
- they most often form in post-op patients and smokers
- they cause distal air trapping and eventual atelectasis, presenting with dyspnea, hypoxemia, and absent breath sounds on the affected side
- CXR reveals opacification of the affected lung with ipsilateral mediastinal shift
- physiotherapy is first-line treatment but bronchoscopy may be required
Define the following types of bias:
- ascertainment bias
- Berkson bias
- Neyman bias
- ascertainment: also known as sampling bias, it is when the study population differs from the target population due to non-random selection methods
- Berkson: studies using only hospital-based patients may lead to results not applicable to the target population
- Neyman: also known as prevalence bias, exposures that happen long before disease assessment can miss diseased patients that die early or recover
Describe the pathogenesis, presentation, diagnosis, and treatment of porphyria cutanea tarda.
- it is due to uroporphyrinogen decarboxylase deficiency
- as a cutaneous porphyria, it presents with painless blisters that heal with scarring and hyperpigmentation of sun exposed skin
- diagnosis is based on elevated plasma and urinary porphyrin levels as well as labs consistent with iron overload
- treat with phlebotomy for iron overload
What are the first two tests that should be ordered in those with suspected adrenal insufficiency?
- begin with an 8AM morning cortisol level and plasma ACTH level
- in most cases an ACTH stimulation test is run initially as well because the ACTH level takes days to come back
Describe the presentation and management of diverticulitis.
- presents with LLQ pain, fever, nausea, vomiting, and leukocytosis
- get an abdominal CT with oral or IV contrast for diagnosis
- then begin bowel rest as well as ciprofloxacin and metronidazole
Describe the work up of a palpable breast mass.
imaging is the next step, but biopsy confirms the diagnosis
> for those under 30 start with an ultrasound
- simple cysts can undergo needle aspiration
- complex cysts or solid masses undergo core biopsy
> for those over 30 start with a mammogram
- when the mass is suspicious for malignancy, perform a core biopsy
When should GBS screening occur during pregnancy and how is it managed?
- it is typically performed at week 36
- indications for prophylactic treatment include GBS-positive rectovaginal culture, GBS bacteriuria or UTI during current pregnancy, and prior infant with early-onset GBS infection
- for those with unknown GBS status, prophylaxis is indicated if the individual is less than 37 weeks gestation, has an intrapartum fever, or rupture of membranes greater than 18 hours
- treat with IV penicillin; use cefazolin for patients allergic to penicillin who develop rash; for patients who have anaphylaxis with penicillin, use clindamycin if sensitive to clinda and erythromycin and vancomycin if resistant to either
H. pylori is a risk factor for what kinds of cancer? How does this affect management?
- it is a risk factor for both MALTomas and adenocarcinomas
- however, eradication will only induce remission of some MALTomas, thus treatment plays no role in the management of adenocarcinoma
When should you suspect ectopic pregnancy and what is the proper workup/management?
consider for patients with positive B-hCG, lower abdominal pain, and/or vaginal bleeding
> if hemodynamically unstable, get immediate surgical consultation
> if hemodynamically stable, begin with a transvaginal ultrasound to identify an adnexal mass or intrauterine preganancy
- if neither is identified, draw a B-hCG (pregnancy should be visible if >1500)
- if B-hCG is more than 1500, repeat in two days with another transvaginal ultrasound
- for B-hCG less than 1500, repeat every two days until greater than 1500 then get repeat transvaginal US
How should suspected endometriosis be managed?
- most should receive conservative management with NSAIDs and OCPs
- for those with contraindications to medical therapy, failure of medical therapy, a history of infertility, presence of an adnexal mass, or concern for malignancy, laparoscopy is indicated
What is the drug of choice for stabilizing bony metastatic lesions and prevent hypercalcemia of malignancy?
bisphosphonates
How does the immunization schedule for a child change after he or she has had a post-vaccination seizure?
personal history of uncomplicated, post-vaccination seizures is not a contraindication to immunization and should not alter the schedule
What are the criteria for diagnosing Kawasaki disease? How is it managed?
> fever lasting five or more days plus four or more of the following:
- conjunctivitis
- mucositis consisting of erythematous, fissured lips or strawberry tongue
- rash
- extremity changes like erythema, edema, and desquamation of the hands and feet
- cervical lymphadenopathy
manage with echocardiogram looking for coronary artery aneurysms at the time of diagnosis and 6-8 weeks later
give aspirin and IVIG within 10 days of fever onset to reduce the risk of aneurysm
Which drug in the RIPE cocktail for TB can be hepatotoxic? How is this managed?
- isoniazid is the offending agent
- in most cases, it causes a mild transaminitis, so the drug can be continued with close follow up
- however, if signs and symptoms of severe hepatitis are observed, the drug should be discontinued
Describe the presentation, diagnosis, and treatment of acute cholangitis.
- presents with Charcot’s triad of fever, jaundice and RUQ pain; hypotension and altered mental status complete Reynolds pentad
- diagnosis can be confirmed with labs and US which shows dilation of intrahepatic and common bile ducts
- treat with antibiotic coverage of enteric bacteria and biliary drainage by ERCP
Describe colic.
- it is a pattern of excessive crying for more than three hours a day, typically at the same time and in the evenings, more than three days a week for more than three weeks in an otherwise healthy infant
- treatment is review of soothing and feeding techniques
Describe the pathogenesis, presentation, and treatment of aspirin-exacerbate respiratory disease.
- it is a non-IgE-mediate reaction to aspirin, which occurs due to inhibition of COX-½
- this inhibition prevents production of anti-inflammatory prostaglandins and shunts arachidonic acid metabolism towards inflammatory leukotrienes
- this buildup produces bronchospasm, nasal congestion, ocular symptoms, and facial flushing, particularly in patients with a history of asthma or chronic rhinosinusitis
- treatment is with avoidance of NSAIDs and the use of leukotriene receptor antagonists like montelukast
What follow up is indicated if benign-appearing endometrial cells are found on pap smear?
- for premenopausal women this is more common, so endometrial biopsy is only required if the patient has abnormal uterine bleeding or risk for endometrial hyperplasia
- for postmenopausal women, this finding is always an indication for biopsy
Among the SSRIs, which are preferred in cardiac populations?
escitalopram and sertraline have the fewest interactions with cardiac medications and cause the fewest cardiac adverse effects
What sleep and hormonal changes are associated with depression?
- sleep changes include decreased REM sleep latency and slow-wave sleep
- associated with hypercortisolemia, which is neurocytotoxic and thought to play a role in pathogenesis
What is a Marjolin ulcer?
a squamous cell carcinoma that arises in a chronic wound, burn, or scar
When is urine culture performed during pregnancy?
at the initial prenatal visit and then again only if patients develop symptoms of cystitis
Describe the timeline of routine prenatal labs.
- at the initial visit patients should have a CBC, blood typing, HIV, VDRL/RPR, HBsAg, Rubella, varicella, pap test, GC, urine culture, and urine protein
- at 24-28 weeks, repeat a H&H, get an antibody screen if RhD, and perform a glucose challenge test
- at 36 weeks, perform a GBS screening
How should impetigo be treated?
- use topical antibiotics like mupirocin for localized infections
- for more widespread infections where topical agents are impractical, use oral antibiotics like cephalexin, dicloxacillin, or clindamycin
How does the management of RV infarction differ from that for a LV infarction?
- patients with RV infarcts are often preload dependent due to impaired RV filling
- avoid nitrates and push fluids as long as the JVP is less than 3 cm above the sternal angle
What is genu varum and how should it be managed?
- it is a bowing of the legs with the knees more lateral
- because it can be physiologic from birth to age 2, it should be managed with observation as long as the bowing is symmetric, stature is normal, no leg length discrepancy exists, and there is no lateral thrust when walking
- if any of these features are present, it is suggestive of Blount disease and these patients should undergo surgical correction
What is the most significant complication of endometriosis?
infertility
What are the two primary indications for oxytocin and what are three potential adverse effects?
- indicated for induction or augmentation of labor and for management of postpartum hemorrhage
- because it shares structure with ADH, it may contribute to hyponatremia and seizures; other side effects include hypotension and tachycardia
Describe the presentation and treatment of Henoch-Schonlein purpora.
- presents with palpable purpura on the lower extremities, abnormal pain or intussusception, arthralgia, and nephritis
- treat with supportive care and monitor for intussusception; add steroids for severe cases
Describe the presentation of congenital, childhood, and adult-onset rubella.
- congenital: cataracts, sensorineural hearing loss, PDA, growth restriction, hepatosplenomegaly, and a purpuric rash
- childhood: fever and cephalocaudal spread of a maculopapular rash
- adult-onset: fever, cephalocaudal spread of a maculopapular rash, and arthralgias
Describe the pathogenesis, presentation, diagnosis, and treatment of urethral diverticulum.
- they are most common in those with a history of recurrent infections, which leads to an out pouching of urethral tissue
- presents with dysuria, postvoid dribbling of urine, dyspareunia, and a tender anterior vaginal wall mass
- diagnosis is with an MRI and treatment is surgical
What is sialadenosis and what are the typical causes?
- it is a benign, non-inflammatory, non-painful swelling of the salivary glands
- it is caused by abnormal autonomic innervation of the glands and is seen in those with liver disease and altered dietary patterns or malnutrition such as bulimia and DM
Describe the presentation, diagnosis, and treatment of Langerhans cell histiocytosis.
- presents with lytic bone lesions, skin lesions, hepatosplenomegaly, pulmonary nodules, and central diabetes insidious
- diagnosis is made by skin or bone biopsy
- treatment consists of chemotherapy and desmopressin for diabetes insipidous
What is the key finding suggestive of ischemic hepatopathy?
a rapid and significant increase in liver transaminases with only a modest elevation of total bilirubin and alkaline phosphatase
What is the classic triad of disseminated gonococcal infection?
polyarthralgia, tenosynovitis, and painless vesiculopustular skin lesions
Describe the clinical course of HSV retinitis.
- typically seen in immunocompromised individuals
- it presents with initial symptoms of keratitis and conjunctivitis with eye pain
- this is followed by rapidly progressive visual loss
- fundoscopy reveals widespread, pale, peripheral lesions and central necrosis
Which group of medications have an association with tendonopathy?
fluoroquinolones
What is first-line treatment for adjustment disorder?
psychotherapy
What happens to the FEV1/FVC in patients with obstructive and restrictive lung disease?
- obstructive disease causes the ratio to drop
- restrictive disease causes the ratio to rise
How can asthma and COPD be differentiated?
using spirometry which will show a bronchodilator response (>12% increase in FEV1) for asthma and a diminished DLCO for COPD
What are the criteria for diagnosing PCOS?
2 of the following 3:
- clinical or laboratory evidence of hyperandrogenism
- irregular menses
- polycystic ovaries on ultrasound
What is active phase arrest during delivery and how is it managed?
- it is failure of labor to progress when the cervix is dilated 6-10 cm
- this is defined by unchanged cervix with four hours of adequate contractions (>200 MVU q10 minutes) or no cervical change after six hours regardless of contractions
- the best next step is cesarean delivery
Most puncture wounds become infected by what two bacterial agents?
S. aureus or Pseudomonas
What are the four major risk factors for placenta previa and how is it managed?
- risk factors include prior c-section, prior placenta previa, multiple gestations, and advanced maternal age
- in most cases is resolves, and requires only that patients refrain from activities that manipulate the cervix as this may cause abruption
- for cases that persist, cesarean delivery is planned for 36-37 weeks gestation
Describe the workup for suspected acromegaly.
- begin with an IGF-1 level
- if elevated, move on to an oral glucose suppression test
- if there is not GH suppression, perform a brain MRI looking for a pituitary mass
For which populations are statins recommended?
- for all those with clinically evident cardiovascular disease, including ACS, angina, stroke, PVD, etc.
- for those with LDL greater than 190
- for those 40-75 with diabetes
- for those with an ASCVD risk greater than 7.5%
Which skin cancer is known for causing sensory symptoms?
squamous cell carcinoma as it is known to display early perineurial invasion causing numbness and paresthesias
Retropharyngeal abscesses are most likely to spread where?
to the posterior mediastinum
Describe the management of bilious emesis in neonates.
> start with NPO, NG tube placement, and IV fluids
get an abdominal x-ray
- may see double bubble sign indicative of duodenal atresia
- may see free air indicative of perf and the need for surgery
if dilated loops of bowel are seen, perform a contrast enema
- microcolon is indicative of meconium ileus
- rectosigmoid transition zone is indicative of Hirschsprung disease
How should intrauterine fetal demise be managed?
- from 20-23 weeks, patients can elect for dilation and evacuation or vaginal delivery
- at 24 weeks and beyond, vaginal delivery is preferred
- in either case, induction can be delayed until the mother is ready but a long delay can lead to coagulopathy
How does an AV fistulae affect SVR and CO?
it lowers SVR and increases preload which both serve to increase cardiac output
What are the three major risk factors for AAA expansion and rupture?
- diameter
- current rate of expansion
- current smoking status
What are indications for surgical repair of a AAA?
- size greater than 5.5 centimeters
- expansion at a rate greater than 0.5 cm per 6 months
- presence of symptoms regardless of size
How is PPROM managed?
> should give GBS prophylaxis and steroids and then deliver if greater than 34 weeks gestation
if less than 34 weeks and there is infection of maternal/fetal compromise, give antibiotics, steroids, and magnesium (if less than 32 weeks), and then deliver
if less than 34 weeks but stable, give latency antibiotics, corticosteroids, and continue, expectant management
Which antibiotics are used for latency prophylaxis in PPROM and which are used for intra-amniotic infection?
- latency: ampicillin and azithromycin
- IAI: ampicillin and gentamicin
When is magnesium given in preterm labor?
for babies less than 32 weeks of age
What diagnosis is suggested by a discrete, firm, hyperpigemented nodule that dimples when the area is pinched?
dermatofibroma
What is the preferred treatment for BPH and why?
alpha adrenergic antagonists are preferred because they have more immediate onset than 5-alpha-reductase inhibitors, which can be added if symptoms persist
Oral contraceptive use reduces the risk of what form of cancer?
it decreases the risk of ovarian cancer
What are the following types of spontaneous abortion:
- missed
- threatened
- inevitable
- incomplete
- complete
- threatened: vaginal bleeding, closed os, cardiac activity
- inevitable: vaginal bleeding, open os, products of conception at or above the os
- incomplete: vaginal bleeding, open os, some products of conception expelled and some remaining
- complete: vaginal bleeding, closed os, products of conception completely expelled
- missed: no bleeding, closed os, and no cardiac activity
What are the characteristic features of PVCs? How are they treated?
- wide QRS, T wave opposite the QRS axis, and a compensatory pause after each
- most often treatment is not indicated, but for patients with frequent symptomatic PVCs, beta blockers and CCBs are the preferred treatment
When can an external cephalic version be performed for breech presentation?
only after 37 weeks because there is a risk of PPROM, abruption, and preterm labor which may all necessitate delivery
What is internal podalic version?
it is a method of delivering the second baby in a set of twins via breech extraction
When intravenous access cannot be obtained in emergency cases, what is the best next step?
obtain intraosseous access
Describe the presentation and appearance of a CXR for those with newborn respiratory distress syndrome and persistent pulmonary hypertension.
NRDS
- presents with severe respiratory distress and cyanosis
- cxr shows diffuse, reticulogranular appearance, air bronchograms, and low lung volumes
Persistent Pulmonary Hypertension
- presents with tachypnea and severe cyanosis
- cxr shows clear lungs with decreased pulmonary vasculature
The only solutions appropriate for initial fluid resuscitation are what?
isotonic saline and LR
Describe the management of DKA.
- start with high-flow normal saline, add 5% dextrose when serum glucose is less than 200
- start an insulin drip
- add IV potassium for K less than 5.2
How should spontaneous pneumothorax be managed?
- for small ones less than 2 cm, observation and supplemental oxygen are sufficienct
- if larger, perform a needle thoracotomy
- if patient is unstable, perform tube thoracostomy
Continued use of hydroxychloroquine requires periodic evaluation for what adverse effect?
it has the potential for retinal toxicity and so ophthalmologic evaluation should be performed annually after 5 years of therapy
What is referred otalgia and what is it commonly an indication of?
- it is otalgia in the setting of a normal ear exam
- the most common causes are dental disease and TMJ dysfunction
- however, it is also a presenting symptom of mucosal head and neck squamous cell carcinoma, thus warranting flexible laryngopharyngoscopy
Describe the management of acute COPD exacerbation.
- initial management is with inhaled short-acting bronchodilators, glucocorticoids, and antibiotics
- if patients continue to have symptoms, noninvasive positive-pressure ventilation (CPAP or BiPAP) should be added
- for patients with poor mental status, hemodynamic instability, profound academia (pH<7.1), or who fail a two-hour trial of NPPV, move on to intubation
What role does noninvasive positive-pressure ventilation play in the treatment of COPD exacerbation?
- it is used when medical management with short-acting bronchodilators, glucocorticoids, and antibiotics are insufficient
- it is a worthwhile option prior to attempting intubation and mechanical ventilation as long as patients aren’t hemodynamically unstable, profoundly academic, or have poor mental status
- a two hour trial should be given before moving on to invasive intubation
- this strategy decreases mortality, intubation rates, treatment failure, and incidence of nosocomial infection
Describe the presentation, diagnosis, and treatment of aortic dissection.
- presents with a severe, sharp, tearing chest or back pain and a more than 20 mmHg difference in SBP between arms
- an ECG will be normal or have nonspecific ST- and T-wave changes, mediastinal widening is present on CXR, and the definitive diagnosis is made with CTA or TEE
- treat with pain control and beta-blockers; add sodium nitroprusside if SBP is still greater than 120 and move to surgery for dissections involving the ascending aorta
Why are beta-blockers the preferred medical therapy for aortic dissection?
because they reduce systolic blood pressure while also reducing heart rate
Describe the management of ureteral stones.
- for uncomplicated stones less than 1 cm, use medical management: hydration, pain control, alpha antagonists, and urine straining
- lithotripsy should be used for stones less than 1 cm that fail to pass in 4-6 weeks or have uncontrolled pain, stones greater than 1 cm, and cases complicated by urosepsis, renal failure, or complete obstruction
What are the typical characteristics of osteoid osteoma?
these tend to cause nocturnal pain that responds well to NSAIDs and appear on plain films as a small, round lucency
What are the only two therapies proven to prolong survival in patients with COPD?
smoking cessation and supplemental oxygen
The mainstay of COPD treatment is what class of medications?
inhaled muscarinic antagonists like ipratropium and tiotropium are the mainstay but may be combined with albuterol, ICS, and LABAs
What causes low back pain in pregnancy?
it is contributed by postural changes, weakened abdominal muscles, and joint/ligament laxity
When should anti-D immune globulin be given during the course of pregnancy?
it should be given at 28 week gestation and within 72 hours of delivery
What is a standard dose of anti-D immune globulin and how should it be calculated?
- the stand is 300 ug at 28 weeks
- however, after delivery, procedures, or abruption, the KB test should be used to determine how much should be given
How are late-term and post-term gestations managed?
- patients should undergo a non-stess test and along with amniotic fluid volume evaluation to look for utter-placental insufficiency
- oligohydramnios (deepest pocket <2 cm) or late decels are indications for immediate delivery
Describe the pathophysiology, clinical features, and management of TTP.
- antibodies against ADAMTS13 leads to preservation of ultra large vWF and platelet activation, producing small vessel platelet thrombi
- it presents with hemolytic anemia, thrombocytopenia, renal failure, neurologic manifestations, and fever
- treatment is with plasma exchange, glucocorticoids, and rituximab
What is primary amenorrhea and how should it be evaluated?
> it is defined as the absence of menarche by age 13 in girls with no secondary sexual characteristics or by age 15 in those with secondary sex characteristics
begin with a pelvic ultrasound looking for the uterus
- if a uterus is present, get an FSH level
* a decreased FSH level is an indication for cranial MRI
* an elevated FSH level is an indication for karyotyping looking for Klienfelters
- if a uterus is absent, get a karyotype and serum testosterone level
* XX with normal female testosterone levels is suggestive of an abnormal Mullerian development
* XY with normal male testosterone levels is suggestive of androgen insensitivity syndrome
The first step in evaluating primary amenorrhea is what?
pelvic ultrasound
What are the features associated with Turner syndrome?
- webbed neck, broad chest with widely spaced nipples, short stature, and cubitus valgus
- coarctation of the aorta and bicuspid aortic valve
- horseshoe kidney
- streak ovaries, amenorrhea, and infertility
What anticoagulant is best suited for patients with GFR less than 30?
unfractionated heparin
Review management of pap results.
when is contesting enough, when should colposcopy be performed
Describe the etiologies, diagnosis, and treatment of bacterial rhino sinusitis.
- most commonly caused by H. influenzae or Strep pneumo
- diagnosis is based on persistent symptoms of rhino sinusitis for more than 10 days without improvement, severe onset of at least three days, or worsening symptoms after an initial period of improvement
- in these cases, amoxicillin plus clavulanate is appropriate
How is hypernatremia managed?
start by assessing the patients volume status
> if euvolemic, use free water supplementation
> if hypovolemic and asymptomatic use 5% dextrose
> if hypovolemic and symptomatic use normal saline
Describe the presentation and treatment of the Jarisch-Herxheimer reaction.
- it follows initiation of syphilis treatment and occasionally the treatment of other spirochetes
- symptoms include fever, chills, myalgia, and rash progression in secondary syphilis
- treatment is supportive with IV fluids and the disease is self-limiting
What are the most common complications of pre-eclampsia?
- fetal growth restriction secondary to uteroplacental insufficiency
- maternal seizures, DIC, and placental abruption
Describe the symptoms of digoxin toxicity.
- arrhythmias
- GI upset
- fatigue, weakness, and confusion
- visual disturbance including color vision alterations
How is nursemaid’s elbow corrected?
with hyperpronation of the forearm or supination of the forearm with flexion of the elbow
What drives breast development during puberty? What drives axillary and pubic hair growth during puberty?
- breast development is driven by estrogen
- hair growth is driven by testosterone
Why do XY individuals with androgen insensitivity develop the phenotype they do?
- without testosterone, there is no virilization of external genitalia during birth, given the appearance of a female
- however, no ovaries are present and AMH still prevents development of the uterus and fallopian tubes
- during puberty, hair growth is limited because it is driven by testosterone, but the build up of testosterone is aromatized to estrogen which drives breast development
Describe H. ducreyi infection.
- larger, deep ulcers with a gray/yellow exudate, well-demarcated borders, and friable base
- severe lymphadenopathy that may suppurate
Which therapies have been shown to improve mortality in the post-ACS setting?
- dual anti platelet therapy
- beta blockers
- ACEi or ARBs
- statins
- aldosterone antagonists
What is senile purpura?
a noninflammatory disorder in which the loss of elastic fibers in perivascular connective tissue leads to the formation of ecchymoses in response to minor trauma, particularly on the dorsum of the hands and forearms
Describe the pathophysiology, presentation, diagnosis, and treatment of chronic granulomatous disease.
- a deficiency of NADPH oxidase leads to the inability to form hydrogen peroxide, which impairs intracellular killing in phagocytes
- presents with recurrent pulmonary and cutaneous infections with catalase-positive organisms
- diagnosis is made with oxidative burst testing in the form of nitro blue tetrazolium or diydrorhodaamine testing and confirmed with genetics
- patients need bactrim and itraconazole prophylaxis
What is congenital dermal melanocytosis?
also known as Mongolian spots, these are benign, flat, blue-gray patches found in infants over the lower back and buttocks due to melanocytes in the dermis
What signs are consistent with prerenal AKI?
- increased serum creatinine
- decreased urine output
- BUN/Cr > 20
- FENa < 1%
Why does the BUN/Cr ratio risk in those with prerenal AKI?
because poor renal perfusion activates the renin-angiotensin-aldosterone system, leading to increased absorption of sodium; urea follows this reabsorption of sodium and water while creatinine has no mechanism for reabsorption
Give the following for papillary muscle rupture in the post-MI setting:
- which coronary artery is typically involved
- when and how does it present
- it typically results secondary to infarction of the RCA
- most often 3-5 days post-MI
- presenting with severe pulmonary edema and a new holosystolic murmur consistent with acute mitral regurgitation
Give the following for free wall rupture in the post-MI setting:
- which coronary artery is typically involved
- when and how does it present
- typically results secondary to LAD infarction
- most often 5 days to 2 weeks post-MI
- presents with chest pain, biventricular failure, and shock
Which thyroid cancer produces calcitonin?
medullary thyroid cancer because it arises from parafollicular C cells
What is hidradenitis suppurativa and how does it present?
- it is a chronic inflammatory occlusion of folliculopilosebaceous units, which prevents keratinocytes from properly shedding from the follicular epithelium
- it presents initially as solitary, painful, inflamed nodules that can progress to multiple draining abscesses
What is the most accurate method for determining gestational age?
first trimester ultrasound with crown-rump length
What are the most common etiologies for vulvar cancer and how does it typically present?
- most cases are secondary to persistent HPV infection but chronic inflammation is also a potential etiology
- it presents with vulvar pruritus and a single vulvar plaque/ulcer with or without abnormal bleeding
Describe the presentation, diagnosis, and management of hereditary angioedema.
- it presents with recurrent edema in the absence of pruritus or urticaria
- this often occurs in the face, limbs, and genitals, but bowel wall edema is seen and presents as pain, vomiting, and diarrhea
- the diagnosis is based on low C4 levels and low C1 inhibitor protein levels or functiong
- treat with C1 inhibitor concentrate, bradykinin antagonists, and kvllikrein inhibitors
What is the difference between a strong, positive, and statistically significant correlation?
- strength is based on the correlation coefficient (r) and is said to be strong when r > 0.5
- positive is based only on the sign of r and whether it is positive or negative
- statistically significant is based on the p value less than 0.05
Describe the presentation of pubic symphysis diastasis and how it is managed.
- presents as difficulty ambulating, radiating suprpubic and pain pubic symphysis point tenderness
- it usually follows birth of a macrosomic infant or operative vaginal delivery
- it is managed conservatively with NSAIDs and physical therapy
What is the treatment for PID?
- the outpatient regimen is intramuscular ceftriaxone plus oral doxycycline
- however, indications for in patient treatment are high fever, inability to take PO meds, and adolescence due to the risk of non-adherence
- for inpatient treatment, use IV cefoxitin plus doxycycline or clindamycin plus gentamicin
What are three mechanisms that contribute to physiologic jaundice of the newborn?
- elevated hematocrit with shorter RBC half-life resulting in high hemoglobin turnover
- diminished uridine diphosphogluconurate glucuronosyltransferase activity
- sterile gut cannot break down bilirubin to urobilinogen for fecal excretion so more is resorbed for enterohepatic circulation
What are the core features of nephrotic syndrome? What are possible complications?
- it is a syndrome of proteinuria (>3g/day), hypoalbuminemia, edema, and hyperlipidemia
- potential complications include iron resistant microcytic anemia due to the loss of transferring, susceptibility to infection due to the loss of immunoglobulins, hyper coagulability due to the loss of antithrombin, protein S, and protein C, etc.
What do each of the following serologic markers for hepatitis B indicate:
- HBsAg
- anti-HBs
- HBcAg
- anti-HBc
- HBeAg
- anti-HBe
- HBsAg: first serologic marker detected after inoculation and remains elevated during active infection
- anti-HBs: indicates immunity but may take time after the disappearance of HBsAg to arise (“window period”)
- anti-HBc: helps differentiate immunity from vaccination from that secondary to infection
- HBeAg: indicates active viral replication and infectivity similar to HBV DNA
Describe the etiology, presentation, and diagnosis of nasopharyngeal carcinoma.
- they are associated with EBV reactivation and thus endemic to southern China
- they present with nasopharynx obstruction, nasal congestion, epistaxis, headache, CN palsies, serous otitis media from eustachian tube obstruction, and nontender cervical adenopathy
- patients should undergo flexible scope for visualization and biopsy
Describe the etiology and presentation of analgesic nephropathy.
- it is a nephropathy associated with the habitual use of combined analgesics
- it typically takes the form of papillary necrosis or chronic tubulointerstitial nephritis
- as such, polyuria and sterile pyuria are early manifestations
- other symptoms are microscopic hematuria and renal colic following sloughing of renal papilla, hypertension, mild proteinuria, and impaired urinary concentration
Describe the proper evaluation for hyperthyroidism.
begin with measurement of TSH and free T3/T4
> if TSH is absolutely or relatively high, it suggests secondary hyperthyroidism and an MRI should be perform
> if TSH is appropriately low, look for signs of Graves disease, which can be diagnosed without further workup
> if not, perform a radioactive iodine uptake study
- low uptake should be followed by measurement of serum thyroglobulin: low indicates exogenous hormone while high indicates thyroiditis or iodide exposure
- high uptake in a diffuse pattern is also suggestive of Grave’s disease despite symptoms and high uptake in a nodular pattern is suggestive of a toxic adenoma or multinodular goiter
How do we define poly and oligohydramnios?
- polyhydramnios is an AFI greater than 24
- oligohydramnios is an AFI less than 5
Ulcerative colitis is associated with which biliary disease?
primary sclerosing cholangitis
When can CVS and amniocentesis be performed?
CVS from 10-13 weeks and amniocentesis from 15-20
Describe the presentation of a Morton neuroma.
- numbness or pain between the 3rd and 4th toes which is worse by walking on hard surfaces or wearing tight or high-heeled shoes
- clicking sensation when palpating the space between those toes while squeezing the metatarsal joints
How can plantar fasciitis be differentiated from stress fracture?
- plantar fasciitis produces pain that is worsen when initiation running or with the first steps of the day and typically localizes to the plantar surface of the heel
- stress fractures have focal pain on a metatarsal and patients typically have risk factors
Describe the management of a hydatidiform mole.
- perform dilation and curettage to evacuate the uterus
- obtain weekly B-hCG levels monitoring for plateau or increase, which are diagnostic for gestational trophoblastic neoplasia
- once undetectable continuing monitoring B-hCG monthly for six months while using contraception
The most common cause of isolated alkaline phosphatase is what?
paget disease of bone
What is primary amenorrhea?
cramps, bilateral, lower abdominal pain that begins 1-2 days prior to menses and resolves a few days after the onset caused by excessive endometrial prostaglandin release
Which colonic polyps are at greatest risk for malignant transformation?
- adenomatous polyps with villous features
- size greater than 1 cm
- multiple, with 3 or more concurrently
What features are suggestive of secondary rather than primary dysmenorrhea?
- symptom onset after 25
- unilateral pelvic pain
- absence of systemic symptoms
- abnormal uterine bleeding
What is the recommendation for AAA screening?
men age 65-75 with any smoking history should have a one time screening US
How can secretory and osmotic diarrhea’s be differentiated?
- both are characterized as watery diarrhea
- the best way to differentiate them is with the stool osmotic gap, which equals plasma osmolality - 2 x (stool sodium + stool potassium)
- the SOG will be low for secretory diarrhea but high for an osmotic diarrhea because those osmolites aren’t part of the equation
Most cases of Paget disease of the breast are secondary to whaat sort of malignancy?
adenocarcinoma
Describe the presentation, diagnosis, and treatment of heparin-induced thrombocytopenia.
- presents following more than 5 days of heparin therapy with decreased platelet count, arterial and venous thrombosis, and necrotic skin lesions at heparin injection sites
- gold standard for for diagonsis is a serotonin release assay
- treat by discontinuing all heparin products and starting a direct thrombin inhibitor or fondaparinux
Describe the presentation and treatment of food protein-induced allergic proctocolitis.
- it presents in young infants with painless, bloody stools, typically in those with a family history of atopy
- treat by eliminating milk and soy from the maternal diet or using hydrolyzed formula
How should the diagnosis of aortic dissection be confirmed?
- a CTA is the initial study of choice in hemodynamically stable patients
- TEE is preferred for patients with hemodynamic instability or renal insufficiency
How are the ACL and PCL named?
for their relationship to one another at their insertion on the tibial plate
What features of nipple discharge suggest that it is pathological? What tests should be performed if it isn’t?
- unilateral, bloody discharge or discharge associated with a palpable lump or skin changes deserves a pathological workup with US or mammography
- if these aren’t occurring, start with pregnancy test, guaiac test, serum prolactin, TSH, and consider an MRI of the pituitary
Post-menopausal women should have an endometrial thickness less than what?
a thickness of 4cm or less is acceptable
Which lung cancer is associated with hypercalcemia?
squamous cell carcinoma (sCa++mous) due to the paraneoplastic condition PTHrP
What are two treatments for hyperkalemia that drive potassium into the intracellular space?
beta2-agonists and insulin
