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