Uworld Step 2 CK Flashcards
What is the difference between projection, displacement, and sublimation?
Immature:
- Displacement: Transferring feelings to a more acceptable object
- Projection: Attributing one’s own feelings to others
Mature:
Sublimation: Channeling impulses into socially acceptable behavior
Contraindications for external cephalic version?
- C section already indicated for another reason
- Placental previa or abruption
- Oligohydramnios
- Ruptures membranes
- Multiple gestation
- Fetal/Uterine anomaly
How to diagnose metabolic syndrome?
3 of 5 criteria met:
1 - Abdominal obesity (waist >40 in men, >35 in women) 2 - Fasting glucose > 100 3 - Blood pressure > 130/80 4 - Triglycerides > 150 5 - HDL cholesterol (men
What is physiologic leukorrhea?
Normal vaginal discharge
How do you diagnose bacterial vaginosis?
3 of 4 Amsel criteria must be met: 1 - Thin, gray-white vaginal discharge 2 - Vaginal pH > 4.5 3 - A positive whiff test with KOH 4 - Clue cells on wet mount
What are the week cutoffs for when preterm labor should be managed?
- Under 37 weeks is considered preterm labor
- 34 to 37 weeks, risks are low so jsut go with it
- 23 to 34 weeks, should delay unless it’s emergent
Pregnant female at 31 weeks gestation having regular contractions, cervical dilation. She has no fluid leakage, pregnancy complications, or recent trauma. Next step?
- Tocolytics
- Corticosteroids for lung maturity
- Magnesium sulfate for neuroprotection (under 32 wks)
What are first-line tocolytics for delaying delivery for a couple days?
- Beta-adrenergic receptor agonists
- Calcium blockers
- NSAIDS
Most common viruses in viral meningitis?
Echovirus
Coxsackie Virus
Risks of combo oral contraceptives:
Bleeding Breast tenderness, nausea, bloating Amenorrhea HTN Venous thromboembolisms Increased risk of cervical cancer Decreased risk of ovarian and endometrial cancer Liver disorders (Hepatic andenoma) Increased triglycerides
Weight gain is NOT a side effect!
Red flags that may distinguish preseptal peri-orbital infections from orbtial cellulitis?
- Pain with extraocular movement
- diplopia
- opthalmoplegia
Premature infant with very low brith weight. He is getting enteral feeds and appears lethargic and has abdominal distention. What are you worried about?
Necrotizing Enterocolitis
- Looking for hallmark finding of pneumatosis intestinalis
What is the classic image finding for infant with bilious vomiting shortly after feeds. Without abdominal distention.
Double-bubble sign of duodenal atresia
36 hours after birth infant has abdominal distention, has failed to pass meconium, and mother is worried because infant is not feeding well…
Hirschsprung Disease
Patient has had intermittent episodes of N/V, hyperactive bowel sounds. Now on imaging - dilated loops of bowel and pneumobilia is seen.
Gallstone ileus
Occurs due to gallstone entering GI tract and causing “timbling obstruction” before finally causing complete obstruction. Often occurs at ileocecal valve
Describe potential manifestation of severe eclampsia:
HELLP syndrome:
1 - Hemolytic Anemia
2 - Elevated Liver enzymes
3 - Low Platelets
(Remember abdominal pain is due to liver swelling and distention of Glisson’s capsule)
Lung problems in HELLP syndrome?
Factors that contribute to this problem?
Can cause severe pulmonary edema.
4 contributing factors
1 - HTN increases afterload, which increases pulmonary capillary pressures
2 - Decreased albumin
3 - Increased vascular permeability
4 - Decreased renal function
Common manifestations of eclampsia:
New onset seizures HTN Proteinuria headache visual changes
(when seizures occur in pre-eclampsia patient, the patient now has eclampsia)
Neonate delivered at 30 weeks has had decreased spontaneous movements, decreased tone, seizures, and rapidly increasing head circumference the last few days. (normal prenatal ultrasounds)
Currently neonate is intermittently bradycardic and apneic, he is lethargic with high pitched cry, tense fontanels, and hypotonia. Most likely diagnosis?
Intraventricular hemorrhage
If you said a malformation like Arnold Chiari or Dandy-Walker, it’s true these could cause noncommunicating hydrocephalus. However, this swifter neurological decline and acute hydropcephaly is more consistent with IVH.
IVH is a big complication in prematurity
Most important interventions for septic arthritis?
Surgical drainage and IV abx to prevent permanent joint destruction
50 year old man in the STAB room with altered mental status and gait instability.
He has had two falls in the last day. He drinks 1 pint of vodka and smokes 2 packs a day. He has horizontal nystagmus and conjugate gaze palsy in both eyes. Absent ankle relfexes in both legs. Lungs CTAB.
Diagnosis?
Triad of Wernicke’s Encephalopthy:
1 - Encephalopathy
2 - Oculomotor Dysfunction
3 - Gait Ataxia
Atopic dermatitis presents as dry thickened skin often in antecubital/popliteal fossae or extensor surfaces and cheeks.
Excoriation can cause superimposed skin infections.
Name these two superimposed infections:
1 - Painful vesicular reash with punched out erosions and hemorrhagic crusting
2 - Painful non-pruritic pustules with honey-crusted adherent coating
1 - Eczema herpeticum - caused by HSV-1
2 - Impetigo - Caused by Staph Aureus or Strep Pyogenes
treatment for varicocele
Gonadal vein ligation
Episodic painless GI bleeding in a 65 year old patient. Stools have been maroon red. Recent colonoscopy did not see anything, although prep wasn’t great in ascending bowel. What do you think?
Angiodysplasia
Especially get suspicious if they have renal disease or a bleeding disorder or aortic stenosis
Genital ulcers, which are painful?
Chancroid, herpes genitalis, and primary syphillis
Genital ulcers in chancroid and herpes are painful
Best test to diagnose primary syphillis?
Dark field microscopy!
If you said RPR, this is a SCREENING serological test that actually has a very high false positive rate, so should be avoided in primary syphillis.
FTA-ABS could be used for confirming RPR and would get you the diagnosis
Woman presents with recurrent pregnancy loss and history of TIA. Likely diagnosis?
Antiphospholipid Syndrome
Tx: Chronic anticoagulation is indicated
Atypical antipsychotic most likely to cause tardive dyskinesia?
Risperidone
Best thing to do is switch to clozapine.
Mechanism by which maternal diabetes can cause RDS in infants?
Maternal hyperglycemia causes fetal hyperglycemia and in turn fetal hyperinsulinemia.
High levels of fetal insluin antagonize cortisol and block the maturation of sphingomyelin - a vital component of surfactant
Risk factors for RDS in infants?
PREMATURITY maternal diabetes male gender perinatal asphyxia C-section without labor
Infant with bulbar palsies (ptosis, sluggish pupillary light response, poor suck) with descending flaccid paralysis, constipation, and drooling.
NO history of eating honey, but recently moved to UT. Diagnosis?
Classic Infant botulism causes by Clostridium Botulinum.
- Can get spores from soil even if no honey toxin is ingested.
- Most common in soil of UT, PA, and CA
Give human-derived botulism immune-globulin as treatment even before confirmation of toxin or spore
Tx for viral menignitis?
IV acyclovir should be given empirically immediately for possible HSV encephalitis until confirmatory tests return
What kind of fluid should be used for resuscitation of an infant with severe hypovlemic hypernatremia?
Normal saline
Isotonic solutions should always be used for initial resuscitation when you want the sodium to correct more slowly
3 year old boy with cystic fibrosis. Presents with respiratory distress and likely recurrent pneumonia. What empiric antibiotics should he get right away?
Vancomycin
Why? Because Staph Aureus is the MOST common pathogenic organism in young children with CF. (he has CF so he’s in the hospital all the time so you want to assume MRSA)
Why not amikacin, caftadidime, cipro? These are great for Pseudomonas Aueruginosa, the most common pathogen in ADULTS with CF. Less common in young kids.
1st line therapy for giardia?
Metronidazole
Symptoms of giardia?
diarrhea from international travel abdominal cramps foul-smelling stools bloating benign abdomen
Patient with COPD without smoking and family history of liver disease.
Alpha-1 antitrypsin definciency
Patient presents to clinic with 2 months of low grade fever, abdominal pain, weight loss, and bloody diarrhea. Symptoms have worsened over the last 2 days. Patient with fever of 101.1, pulse of 128, WBC of 15,000 and hgb of 9.2. Abd XR shows extremely distended large bowel. Dx?
This is likely ulcerative colitis which has become toxic megacolon
Emergency: prompt IC steroids, NG decompression, IV antibiotics
43 year old man with history of SLE complains of frequent epigastric burning which he cannot relieve with antacids. Usually brought on by lifting heavy boxes at work. He is on prednisone for SLE. He has no shortness of breath, arm or neck pain. What should your first step in manging this patient?
Exercuse EKG
Concerning story for ischemic heart disease
(steroid use and SLE are risk factors for accelerated coronary atherosclerosis)
What are the 4 centor criteria for strep throat?
- Tonsilar exudates
- Fever by history
- Tender anterior cervical adenopathy
- Absence of cough
Treatment if + for strep = oral penicillin or amoxicillin
29-yr-old woman with 6 months of amenorrhea. Normal menarche at age 14. irregiular periods from 14-16, then oral contraception until getting married last year. She eat healthy with a normal BMI and does not smoke drink or use drugs.
1st and 2nd steps to evaluate amenorrhea?
1 - Check beta-hCG for pregnancy
2 - If not pregnant, check serum prolactin, TSH, and FSH
These are to check for most common causes of secondary amenorrhea (hyperprolactinemia, thyroid dysfunction, and premature ovarian failure)
Patient complains of fatigue and SOB for 2 weeks. No chest pain, no N/V, no weight loss. Recent URI. NO tobacco, EtOH, or drugs. BP 98/55, HR 105. Jugular veins distended sitting down. Lungs CTAB. CXR shows enlarged heart silhouette.
Pericardial effusion
Signs of pericardial effusion:
- enlarged water-bottle shaped cardiac silhouette
- diminished heart sounds with difficult-to-palpate maximal apical impulse
1 year old swinging from father’s arms, but now she is in pain and will not move her right arm.
Diagnosis?
Treatment?
Nursemaid elbow: AKA subluxation of radial head
2 Techniques to treat:
1 - Hyperpronation of forearm while applying pressure to radial head
2 - Supination of forearm and then flexion of elbow while held in supination with pressure on radial head
What is the pathophysiology for functional hypothalamic amenorrhea?
AKA: When strenuous exercise, anorexia, weight loss, stress, or serious illness causes amenorrhea.
The HPO (hypothalamic-pituitary-ovarian) axis can be suppressed without an anatomic cause. Factors like low body fat and leptin, Ghrelin, NPY, GABA, beta-endorphin, and others are implicated in the actual suppresion at the hypothalamic level (GnRH). THis then goes on to suppress LH and FSH secretion from the pituitary and then estrogen from the ovaries.
The low estrogen state creates amenorrhea and puts patient at risk for bone loss as well
Neonatal heart anomaly presenting in first few hours of life with cyanosis and a single loud second heart sound?
Transposition of great vessels
- Start prostaglandins to optimize intra-circulatory mixing
What is the genetic make-up of Edwards syndrome?
Trisomy 18
What are the characteristics of Edward’s syndrome?
- Micrognathia
- Microcephaly
- Rocker-bottom feet
- Overlapping fingers
- Absent palmar creases
- Holosystolic murmur @ LL sternal border
Triad of Spherocytosis?
Coombs negative hemolytic anemia
Jaundice
Splenomegaly
Eosin-5-maleimide Binding and Acidified Glycerol Lysis tests used to confirm
On CT you see a well-circumscribed dural-based mass with partial calcifications.
Management?
Likely a meningioma
- Surgical resection is tx, if causing symptoms
Patient presenting with incontinence, shuffling gait, and dementia. CT brain showed very widened ventricles.
Management?
Normal pressure hydrocephalus
Try large colume lumbar puncture, if this works then do a ventriculoperitoneal shunt
When do you treat rhinosinusitis as if it is bacterial?
Persistent: > 10 days w/o improvement OR Severe: >102F, 3+ days of face pain OR Worsening: > 5 days after initial improvement of viral URI
How do you treat uncomplicated, acute bacterial rhinosinusitis?
Amoxicillin - Clavulanate
augmentin
Disorders that can present with vitiligo?
Try to name a couple at least/
pernicious anemia, autoimmune thyroid disease, type 1 diabetes, alopecia areata, hypopituitarism
Autoimmune condition - these areas of depigmentation lack melanocytes. May have something to do with autoimmune response against melanocytes.
30 year old patient has vaginal discharge with vulvar pruritis. pH is 6.0 and wet mount shows pear-shaped motile organisms. She gets treated with first-line medication along with her partner. Don’t forget to tell her to avoid ______ during the treatment period.
Alcohol use
Metronidazole combined with alcohol will have disulfiram-like reaction
55 year old caucasian male who is having icnreasing falls the last few weeks. He has also noticed dry mouth, dry skin, and erectile dysfunction over the same period. PMH: recently developed resting tremor, diagnosed with DM II 6 months ago. Patient has orthostatic hypotension and physical exam shows rigidity and bradykinesia.
Diagnsosis?
Multiple System Atrophy (Shy-Drager Syndrome)
Degenerative Disease characterized by:
1 - Parkinsonism
2 - Autonomic Dysfunction (postural hypotnesion, impotence, abnromal salivation/lacrimation, gastroparesis, disturbance in bowel/bladder control)
3 - Widespread neurological sings (cerebellar, pyramidal, lower motor neuron)
Always consider this diagnosis when patient with parkinsonism has orthostatic hypotension, impotence, incontinence, and other autonomic signs
In HHS or DKA, K can get out of whack. Up or down? Why is that?
Can cause K deficit (even if labs look elevated or normal)
Occurs because of urinary loss in glucosuria-induced osmotic diuresis. Aggressive insuln therapy can lower K even more, so be careful
3 year old presents with 2 day hx of decreased appetite, neck swelling, and irritability. He keeps his head slightly rotated to the right and resists attempts to passively flex or rotate the neck to the left.
What is this condition called?
What do you do first?
- Acquired torticollis
- First, get a cervical spine XR (to check for fracture or dislocation)
Most commonly caused by URI, minor trauma, cervical lymphadenitis, retropharyngeal abscess
Home-birthed 5-day old without prenatal care presents with easy-bruising and periumbilical bleeding. Platelets are 270. PT and aPTT are prolonged. What do you think is the most likely cause of bleeding?
Vitamin K deficient bleeding
Often develops in the first week of life, which is why newborns are given Vit K shot. (many times are given by midwives)
Kids are deficient in Vit K because of poor placental trasnfer, absent gut flora, immature liver fxn, and inadequate levels in breast milk.
Obese 13 year old boy presents with R groin pain, R knee pain, and limping. Gotten worse over two weeks. Afebrile with normal vitals.
Exam shows normal range of motion in knee. Hip movements are restricted. External rotation of thigh is seen with flexion of hip.
Diagnosis?
Tx?
Slipped Capital Femoral Epiphysis
Treated with surgical pinning fo the slipped epiphysis where it lies in order to decrease risk of avascular necrosis of femoral head and chondrolysis
40 year old woman with PMH of SLE on chronic glucocorticoids
Pain in her hip for last 4 weeks which is worse weight-bearing. She has had no trauma and no pain like this before. She doesn’t use EtOH/tobacco/drugs. Afebrile with normal vitals. Hip XR comes back clean.
What’s going on?
Next step for management?
Avascular Necrosis (osteonecrosis) of femoral head
MRI is next step
She is at risk due to SLE and steroid use. XR often normal for first few months as well as exam. MRI is a much more sensitive test and can show the boundary between normal and ischemic bone.
What are the symptoms of an individual who tests positive on the “Quantitative pilocarpine iontophoresis” test?
Cystic Fibrosis
Patients have recurrent respiratory infections, steatorrhea, failure to thrive
25 year old pregnant woman at 32 weeks gestation precents with acute onset abdominal pain and vaginal bleeding soaking her clothing. Blood presure is 160/95 and pulse is 100/min. Exam shows firm tender uterus. Speculum exam shows 100ml clot in vaginal vault. Bleeding is observed from cervix. No decelerations are seen in fetal heart beat and contraction are ever 2 minutes.
Diagnosis?
Abruptio Placentae
Premature separation of the placenta from the uterus caused by bleeding into the decidua-placenta interface are rupture of maternal decidual blood vessels. Abruption is a common cause of antepartum hemorrhage.
Risk factors include: cocaine use, HTN, tobacco use, abdominal trauma
Patient presents withseveral months of worsening severe watery diarrhea, muscle weakness, facial flushing, and N/V. Labs show hypokalemia. No recent travel. No fever, slightly tachycardic. CT scan shows 3 cm mass in pancreatic tail. Diagnosis?
VIPoma
Confirm with VIP level greater than 75
Apart from seeing those rhomboid-shaped crystals, what is another classic finding in pseudogout?
Chondrocalcinosis
calcified articular cartilage
How do you treat pseudogout?
Intra-articualr gluticorticoids
NSAIDs
Colchicine
What is erythromycin ophthalmic ointment used to treat in neonates?
Treatment of choice for gonococcal conjunctivitis.
NOT for chlamydia, oral eythromycin would be key here
When do you normally detect placenta previa?
How do you manage once it’s detected?
Usually found on prenatal US at 18-20 weeks.
Pelvic rest indicated: no intercourse, no digital vaginal exam, schedule C-section for 36-37 weeks gestation
Describe the syndrome of Hemolytic Uremic Syndrome:
- Hemolytic anemia
- Thrombocytopenia
- Renal Failure
Main cause of HUS?
Tx?
Shiga-toxin mediated endothelial damage after infection with E Coli O157:H7 or Shigella
Tx is supportive - can require dialysis in about 50% of kids
What is uterine tachsystole?
6+ contractions in 10 minute period
What is a potential complication of oxytocin?
- tachsystole or tetanic contractions
- hyponatremia
- hypotension
33 year old evaluated in office for bilateral intermittent leakage of pale gray fluid from breasts. Exam is benign, guiac is negative for blood. Pregnancy test negative.
Next steps?
Check prolactin and TSH
Can consider MRI of pituitary if prolactin is elevated and/or other signs of pituitary mass
Boy under 5 with proximal weakness and bilateral calf enlargement.
First thing you should think of?
Duchenne muscular dystrophy
What 2 tests confirm the diagnosis of Duschenne muscular dystrophy?
absent dystrophin gene on genetic testing
AND
undetectable dystrophin protein on muscle biopsy
What is the root cause of Duchenne muscular dystrophy?
X-linked recessive deletion of dystrophin gene on chromosome X p21
What is the Gower’s sign?
Classic finding indicating proximal muscle weakness. Patient has to use own arms to “walk up” their body to standing position
(common in Duchenne muscular dystrophy)
What is the risk of Benzos in the elderly?
increased risk of:
- cognitive impairment
- falls
- paradoxical agitation
risk factors for placental insufficiency?
- advanced maternal age
- tobacco use
- HTN
- Diabetes
A biophysical profile is performed to assess fetal oxygenation through ultrasound and a nonstress test. What are the scoring components of the BPP? What is normal?
1 - Nonstress test (want to see reactive HR)
2 - Amniotic Fluid volume (Single fluid pocket >2x1cm or amniotic fluid index >5)
3 - Fetal movements (3+ movements)
4 - Fetal tone (1+ episode of flex/ext of fetal limbs or spine)
5 - Fetal breathing movements (1+ breathing episode for 30+ seconds)
Study is 30+ minutes. 2 points are given in each of these categories for a normal result, 0 for abnormal. Max score is 10.
8 or 10 is normal
17 yo black male comes into office after en episode of gross hematuria which resolved spontaneously. He has no other complaints or medical problems. Normal physical exam and UA is only significant for blood. Micro examination of urine shows RBCs that are intact with no abnormalities.
Most likely cause?
Sickle cell trait leading to Renal Papillary necrosis
Hgb AS
Renal complications can include painless hematuria, urinary tract infections, and renal medullary cancer
What is a quick differential for main causes of gross hematuria?
- Bladder (cystitis, cancer)
- Renal (glomerulonephritis)
- Ureteral (nephrolithiasis)
- Prostate (BPH)
Apart from antipscyhotics, what is another good intervention for schizophrenia?
Family counseling and psychoeducation in order to reduce conflict adn stress at home will decrease the risk of relapse.
What is HER2 and how can it be detected?
It is an oncogene and can be deteted with immunohistochemical staining or FISH
Determining positivity in breast cancer will predict positive response to trastuzumab and anthracycline chemotherapy
18 yo woman with primary amenorrhea, sexual infantilism, and clitoromegaly. Laparotomy at 2yo showed normal internal female genitalia. Estradiol and estrone are undetectable. FSH and LH are high. Testeosterone and androstenedione are high. Diagnosis?
Aromatase deficiency
Enzyme that converts androgens to estrogens
1 day old in nursery born uncomplicated at term. Physical exam shows breast hypertrophy and swollen labia with blood-tinged vaginal discharge. Next step in management?
Routine care without work-up
These are normal effects from transplacental exposure to maternal estrogen
What are early and late decelerations? Are either concerning?
Decelerations are decreases in fetal heart rate below its baseline. The gradually decrease and then increase back to baseline over a period greater than 30 seconds
Early decelerations coincide directly with the increasing and decreasing strength of the uterine contractions. They are caused by vagal stimulation when the head is compressed in the contraction.
Late decelerations are shifted so that the peak of contraction occurs at the beginning of the decrease in HR. THe delay occurs because they are caused by hypoxia which constricts blood vessels, leading to HTN and then vagal response of slowed HR. This two step process makes it take longer. Late decels are CONCERNING!!!!!
Etiology of late decelerations:
- Excessive uterine contractions
- maternal hypotension
- maternal hypoxemia
- reduced placental exchange (HTN, diabetes, IUGR, abruption)
Patient with history of poor feeding in infancy, but now at 4yo currently has binge-eating and obesity problems. Has short stature, hypogonadism, and frequent problems with temper tantrums. What genetic abnormality is causing this diagnosis?
This is Prader-Willi Syndrome
Sporadic disorder due to maternal uniparental disomy of chromosome 15q11-q13
5 mo old in for well-child. Born uncomplicated at term. Has visited both the ED and clinic previously for inspiratory stridor with little improvement after racemic epinephrine. Feeding well on formula. His inspiratory stridor improves with neck extension, but not prone positioning. No cough or fever. Patient does have 3/4 holosystolic murmur heard best over left lower sternal border.
What’s going on?
Vascular ring or sling
Why?
Improves with neck extension is classic. Improvement with positioning would be more laryngomalacia
Unlike croup or asthma, respiratory symptoms do not improve with nebulized racemic epi or brocnhodilators
Surgery is only tx
1st line antihypertensive for pregnancy?
- Methyldopa
- Labetolol
Also good:
- Hydralazine
- Nifedipine
40 year old patient arrives with a Na of 156, intense thirst, lethargy, and confusion. Turns out she is on Lithium for bipolar. You determine she likely has nephrogenic diabetes insipidus. Her blood pressure is 80/60, HR 122, RR 15. On physical exam you also note that she has very dry skin and mucous membranes. What do you want to do for fluids?
IV NS until euvolemia is achieved, then you can decide to amke the switch to D5W.
The reason is because in assessing fluid status we see that this patient is HYPOvolemic AND symptomatic (hemodynamically unstable). If they were euvolemic then we could just use free water. If they were hypovolemic and stable then we might just give D5W.
Diabetic patient with severe ear pain radiating to TM joint. On further exam you see otorrhea and granulation tissue in lower external auditory canal…
What organism is likely responsible?
Pseudomonas Aerginosa
Malignant Otitis Externa
Speaking of defense mechanisms: What is the difference between Sublimation and Reaction Formation?
Sublimation: Channeling impulses in socially acceptable behavior
Reaction Formation: Responding in a manner opposite of one’s true feelings
Both might be socially acceptable, but in sublimation the behavior matches the original thought/impulse whereas it is the opposite in reaction formation.
For example: A woman is angry and resentful for having to quit her job to take care of an ailing parent who never treated her well.
Sublimation: Woman plays paintball in her free time in order to blow off steam
Reaction Formation: Is very solicitous to all of parent’s needs smiles a big fake smile and says, “Boy it sure is great to have dad back with me again!”
Most common conditions in which you see sialadenosis? (swollen salivary glands)
- advanced liver disease
- nutritional disorder
1st line tx for Magnesium toxicity?
IV calcium gluconate
26 year old male is on anti-retroviral therapy and presents with hematuria. On further analysis urine contains needle-shaped crystals in sediment. Which category of anti-retroviral is causing this problem?
Protease inhibitor
Indinavir, a protease inhibitor, has a well-known side effect of crystal induced nephropathy.
Polycythemia in term neonates is defined as >65% hematocrit. What symptoms commonly occur?
Respiratory distress, hypoglycemia, and neurological manifestations
Also: Ruddy skin, cyanosis, abdominal distention
14 yr old boy with 3 week skin rash. Started as red spots on arms and legs which itched and burned. They then filled with clear fluid and some crusted over. Rash located on extensor surfaces of elbows and knees. Diagnosed with type 1 DM five years ago. He has been tired lately and has lost 10 lbs in 4 months. CBC is unremarkable except for some iron deficiency anemia. Fecal occult blood test is negative x2.
Next step in management?
This rash is suspicious for Dermatitis Herpeteformis and the overall presentation is suspicious for Celiac Disease.
Next step is screening with:
Anti-tissue transglutaminase antibody assay
Confirmation with:
Duodenal biopsy showing increased intraepitheial lymphocytes and flattened villi
Most common adverse effect associated with olanzapine?
Weight gain
64 year old patient recovering from URI develops mailaise and productive cough. Presents to your ED 2 days later with confusion, severe dyspnea, and coughing copious amount of yellow sputum with blood streaks. Temp is 104, BP 150/90, HR 110. CXR shows infiltrates of lung midfields bilaterally and multiple thin-walled cavities. Most likely causal organism?
Staph Aureus
Known to cause 2ndary pneumonia complicating a viral URI
AND
associated with necrotizing bronchopneumonia resulting in pneumatoceles (which is what we are seeing in this case)
Child with fever, dysphagia, inability to extend neck, muffled voice.
Lateral XR shows widended prevertebral space.
Dx?
Retropharyngeal abscess
Refeeding syndrome can occur in individuals with severe anorexia nervosa after initiating feeding. What are the main manifestations?
Arrhythmia and cardiopulmonic failure
Insulin release causes cellular uptake of phosphorous, potassium, and magnesium
Older patient with renal artery stenosis leading to HTN. How do you manage it?
ACEi’s or ARBs
Stenting or revscularization is not indicated unless resistant HTN, recurrent pulmonary edema and/or refractory HF from HTN
Long term cyclophosphamide carried risk of what primarily?
Acute hemorrhagic cystitis and bladder carcinoma
Pregnant patient has pap testing done which shows high grade squamous epithelial lesion. Colposcopy shows no abnormalities. Next step in management?
Repeat cytology and colposcopy are delivery
Raloxifene contraindications?
Venous thromboembolism history
All medicine with estrogen agonist activity will increase risk of VTE.
Raloxifene is an agonist in the bone and an antagonist in the breast and uterus
7 year old presents with bleeding in gums for 3 months. Easy fatigability, punding sensation in ears. 5th percentile for height, 25th percentile for weight. Thumbs bent with areas of hypopigmentation of the skin. Labs studies show WBC 3, Hgb 7.5, PLT 40, and MCV 115.
What’s the likely cause?
Fanconi anemia (caused by chromosomal breaks)
Labs are showing aplastic anemia and in kids this is more likely going to be congenital. Macrocytic anemia is common in Fanconi. Hypopigmentation, short stature, and abnormal thumbs are all part of syndrome as well.
44 yr old non-pregnant female with tubal ligation presents with abnormal uterine bleeding. She asks how things will go depending on the result. How do you manage results of:
Hyperplasia without atypia AND
Hyperplasia with atypia
Without Atypia: Progestin therapy to stop the effects of unopposed estrogen and reverse hyperplasia
With Atypia: Hysterectomy if they are done having kids OR if they fail progestin therapy
6 year old asian patient with high grade fever and brick-red maculopapular rash which started on his face and then spread to trunk and extremities. Parents say before reash patient had cough, tearing eyes, and runny nose. Labs show leukopenia and thrombocytopenia.
What is the dx?
Measles
32 year old F in labor, on arrival 6cm dilated, 60% effaced, head at 0 station. Fetal heart tracing normal. 2 Hours later patient suddenly appears restless, pelvic exam shows moderate vaginal bleeding, cervix is 6cm dilated, 60% effaced, -3 station. Fetal heart shows tachy w/ variable decelerations.
Likely dx?
Uterine rupture
Sudden abd pain, recession of presenting part during active labor, and fetal HR abnormalities are red flags for rupture.
Risk factors: pre-existing uterine scar (like c-section)
Woman in prolonged labor and rupture of membranes. She has a fever and the fetus tachycardic. Likely dx?
Chorioamnionitis
Osteoarthritis is most common at which joints?
- large weight bearing joints of lower extremity
- lumbar spine
- proximal and distal interphalangeal joints
(Remember RA is most frequently in MCP joints)
More people in Pawnee Indiana seem to have obesity than in Camas Washington. What type of study design should be used to determine if there really is a difference in incidence of obesity between the two towns?
Cohort study
50 yr old having diffciulty following solids but not liquids. GERD for 12 years, recently found to have barret’s. Barium study shows circumferential narrowing of distal esophagus. Best explanation?
Esophageal stricture
What diseases should all pregnant women be screened for regardless of risk factors?
Syphillus, HIV, Hep B
How should medications be managed for a pregnant patient who has hypothyroid? She has been a on a stable dose of levothyroxine for many years.
Levothyroxine requirements will increase during pregnancy, so this patient will need to increase their dose when pregnancy is detected.
Subsequent adjustments can be made accordingly based on TSH and T4 later.
What is the prophylaxis used by HIV+ patients to prevent opportunistic infections by Pneumocystis Jiroveci and Toxoplasma Gondii?
Trimethoprim/Sulfamethoxazole
bactrim
36yo nulliparous female presents with syncope at work. Patient on day 10 of menses. Periods have become longer and heavier, but continue at regular 28 day intervals. On oral contraceptives, sexually active with boyfriend only. UPT negative. Hgb is 5.5. Pelvic exam shows irregularly enlarged uterus.
Likely cause of anemia?
Uterine fibroids
Proliferation of smooth muscle cells within the myometrium
Heavy menstrual bleeding is hallmark. Anemia and irregularly enlarged uterus also occur.
Most important points in managing mastitis in breastfeeding women?
- Analgesics
- Frequent breastfeeding
- Antibiotics targeting staph aureus
Greatest risk of completing homocide?
Access to firearms
Classic presentation of Leukocyte Adhesion Deficiency?
Delated umbilical cord separation, recurrent skin and mucosal bacterial infections, and severe peridontal disease.
Usually you also see lots of leukocytosis with TONS of neutrophils
20 year old woman evaluated 8 hrs after nomral vaginal delivery. She has fatigue, perineal discomfort, and bloody vaginal discharge. Has voided twice since delivery, but finds it hard to initiate urination. 3rd degree laceration was quickly repaired. After spontaneous placental delivery patient experienced rigors and chills for 30 minutes which resolved. Temp is 100.2, BP 120/80 and pelvic exam shows intact perineal repair, but bloody discharge with small clots on perineal pad. Uterus is firm and fundus at umbilicus.
What is the next step in management of this patient?
Normal post-partum care
Normal puerperium changes include :
- Shivering
- Uterine contraction and involution
- Lochia
Most concerning complications stemming from RSV infection and bronchiolitis in neonates?
Apnea and respiratory failure
Big risk factors for abruptio placentae?
cocaine use and HTN
Elevated maternal serum alpha-fetoprotein is an indicator of what fetal abnormalities?
- open neural tube defects
- gastroschisis
- omphalocele
- (also multiple gestation)
- US should be performed if alpha fetoprotein is elevated
Dipyridamole is used during myocardial perfusion scanning to reveal areas of restricted myocardial perfusion. How does this drug work?
Coronary blood blow is redistributed to the non-diseased segments by a phenomenon called “coronary steal.”
It works because the narrowed ischemic vessels are maximally dilated all of the time. Using a vasodilator like dypridamole causes blood to shunt into the non-ischemic vessels because now they are way bigger than the ischemic ones.
Big pieces of diagnosis of congenital adrenal hyperplasia in female?
Hyperandrogenism in adolescence or adulthood
Elevated 17-hydroxyprogesterone
(usually caused by 21-hydroxylase deficiency)
Term for normal age-related sensorineural hearing loss?
presbycusis
Fetal demise is suspected and then confirmed in 28 week gestation. Coagulation abnormalities are found in lab results. Fibrinogen and platelet levels are just under normal. Next step?
Labor induction
induce without delay in these patients because these fibr/platelet abnormalities could indicate developing DIC
Most common ear pathology in a patient with HIV?
Serous otitis media
- caused by auditory tube dysfunction arising from lymphadenopathy or obstructing lymphomas
- Characterized by presence of middle ear effusion without evidence of acute infection
The vast majority of head and neck cancers are what type?
Squamous cell carcinoma
What is the other name for Wilson’s Disease?
Hepatolenticular degeneration
How do you confirm case of hepatolenticular degeneration?
One of these three:
- Low ceruloplasmin
- Increased urinary copper excretion
- Kayser Fleischer Rings
Usually unexplaiend chronic hepatitis in patients under 30
65 year old presenting with back pain in lumbar/throracic spine. Worse with activity. Takes OTC Vit D and Ca supplements. 1 year ago had normal physical and lab results. No lymphadenopathy. Cardio/Abd exams normal. NO fical tenderness in spine. Muscle strength 5/5 in all extremities.
Labs:
Hgb: 10.2, PLT: 220, WBC: 8.8
Na: 138, K: 4.2, Cl: 102, HCO3: 26
BUN: 30, Cr: 2.5, Ca: 10.9, Glu: 118
Urine Dip/Sediment: Negative and bland except a few granular casts.
Whats the dx?
Multiple Myeloma
Often presents with fatigue, weight loss, or bone pain.
Proliferation of neoplastic cells in bone marrow and excessive production of single immunoglobulin.
(see bone destruction, hypercalcemia, anemia, monoclonal protein)
Monoclonal protein can accumulate at high levels in the serum and deposit in the renal tubules resulting in renal insufficiency. Often has bland UA with granular casts.
38 year old male with PMH of DMII presents with nodular lesions under his arm. Have been there for 1 year, but much worse over last 6 months. THey have begun to smell and look like fluctuant tender nodules with subcutaneous fibrosis in the axillae. Dx?
Hydradenitis Suppurativa
Treatment for croup in mild cases vs moderate/severe cases:
Mild (no stridor at rest): Corticosteroids
(dexamethasone)
Mod/Severe (stridor at rest): Corticosteroids AND nebulized epinephrine
Corticosteroids reduced airway inflammation and nebbed epi constricts mucosal arterioles in upper airway and alteres capillary hydrostatic pressure to decrease airway edema and reduce secretions
How do you treat children with ITP, who aren’t actively bleeding?
Observation - usually will resolve in 6 months
If they start bleeding then they should get IVIG or glucocorticoids
This is different than adults who should be treated with with glucocorticoids or IVIG if they get a platelet count less than 30,000
Woman has profound blood loss after MVC. She has emergent surgery and ends up receiving about 7L of blood products and crystalloid. Her Cr is 2.2. What microscopic findings do you expect to see on UA?
Muddy brown casts. Why?
Profound hypotension often leads to ATN
Let's talk HIGH YIELD casts!!!!!!! Muddy brown granular: RBC: WBC Fatty: Broad/Waxy:
Muddy brown granular: ATN RBC: Glomerulonephritis WBC: Interstitial nephritis and Pyelo Fatty: Nephrotic syndome Broad/Waxy: Chronic renal failure
What disease can lead to Sicca syndrome?
Where everything is dry
Sjogrens
1st line medication for enuresis, when behavior modifications and alarm therapy have already failed?
Desmopressin
Test used to compare proportions of categorized outcome?
Chi square
Risperidone is a second generation antipsychotic. What is it’s mechanism of action?
- Serotonin 2A antagonist
- Dopamin D2 Antagonist
12 week old child was born outside the US and appeared normal at birth, but is brought in by mother because of changes in the last 3 weeks. Apathy, weakness, hypotonia, large tongue, sluggish movement, abdominal bloating, and an umbilical hernia. What’s going on?
Classic of congenital hypothyroid
How do you manage eclampsia?
- Administer Mag Sulfate
- Administer anti-hypertensive
- Deliver fetus
4 year old diagnosed with Pertussis. Her family members are all up to date on vaccinations and have no symptoms. How can risk to household contacts be limited?
Prescribe macrolide antibiotic for all household contacts
53 year old has localized R-sided abdominal pain. Lightly touching the skin to the right of the umbilicus causes severe pain. Abdomen is soft, nondistended, without guarding. Patient had breast cancer a year ago followed by radical mastectomy and chemo which she finished 3 weeks ago.. Lung field are clear. What’s going on?
Likely shingles from ractivated varicella zoster
Triggered by stress of cancer treatment
Give 5 features of turner syndrome:
- Loss of X chromosome
- bicuspid aortic valve or coarctation
- short webbed neck
- broad sheft
- widely spaced nipples
Explain the kind of acid base disturbance that can be cause by Tuberculosis?
Can commonly cause adrenal insufficiency (addison’s disease). This then goes on to cause a hyperkalemic hyponatemic metabolic acidosis
Lead points for intussusception:
- Meckel’s Diverticulum
- Henoch Schonlein Purpura
- Celiac disease
- Intestinal tumor
- Polyps
Describe levels of AST, ALT, GGT, and ferritin in alcoholic hepatitis:
AST/ALT: elevated but not crazy, AST about 2x as much as ALT
GGT: elevated
Ferritin: elevated
Effective treatment for bipolar depression?
2nd gen antipsychotics like Quetiapine and Lurasidone
Also Lamotrigine, Lithium, valproate or a Olanzapine/Fluoxetine combo
Remember NO antidepressant monotherapy
HIV patient has a subacute cough and a cavitary lesion on CXR. Likely dx?
Tuberculosis reactivation
Preeclampsia is defined by new onset HTN > 140/90 and proteinuria or end-organ damage after 20 weeks gestation.
What are the manifestations that would identify a patient with severe disease?
- HTN >160/110
- Thrombocytopenia
- High Cr
- High transaminases
- Pulm edema
- Visual/Neuro sx
Primigrad coman at 26 weeks gestation. Has had very uneventful course, but urine culture shows bactiuria. She is asymptomatic. What complication are you most worried about for this patient?
Progression to pyelo
Patient presents with fatigue, exudative pharyngitis, and cervical lymphadenopathy. After taking her mom’s leftover amoxicillin, she suddenly develops a full body maculopapular rash. What organism is likely responsible for this infection?
EBV
Definitive dx of vesicoureteral reflux made by:
voiding cystourethrogram
13 yo male presents with intermeittent knee pain for 3 months. Wrose after basketball, but does not remember any recent trauma. NSAIDs and rest offer relief. Has tenderness and swelling over proximal tibia at site of patellar tendon insertion. NO effusion or abnormality of joint. Pain reporduced with extension of knee against resistance. Likely cause of pain?
Traction apophysitis
(AKA Osgood-Schlatter)
Common is adolescents. Rapid growth makes quadriceps tendon put ttraction on the apophysis of the tibial tubercle where the patellar tendon inserts)
Tx: Activity restriction, stretching, NSAIDs
Contraindication of rotavirus vaccine for kids?
History of inussusception
Most effective post-coital contraceptive?
Copper IUD insertion
Remember though that contraindicated in PID
13 day old infatn presents with mild swelling of both eyelids and conjunctival injection. Scant mucopurulent discharge is noted. Rest of exam normal. After sending sample to lab, what is the next step in management?
Administer oral erythromycin
Probably neonatal chlamydial conjunctivitis
- occurs at 5-14 days of life and presents with swelling, chemosis, and watery or mucopurulent discharge
Remember that topical is best for prophylaxis of gonococcal conjunctivitis and would not be effective for chlamydial infection
You remember that amiodarone can cause pulm toxicity. What are the other big side effects to this drug?
Thyroid dysfunction
Hepatotoxicity
Cornal deposits
Skin changes (blue)
Characteristic ECG findings in wolf-parkinson-white?
- Short PR interval
- Delta wave (slurred upstroke of QRS)
- Widened QRS
60 yr old woman has fever, cough productive of foul-smelling sputum. 1 week ago had EGD for GERD sx. What are you worried about?
Anaerobic lung infection
Think clinda, metronidazole+amoxicillin, or amoxicillin/clav.
42 yearold olf with skin rash and hair loss. PMH of many years of Crohn’s disease s/p resection leading to short bowel. Currently on TPN. Complains that food no longer tastes good. Stable vitals. Exam shows alopecia and bullous, pustular lesions around perioral and periorbital areas. Nutritional deficiency in what is leadign to this presentation?
Zinc
Alopecia, abnormal taste, bullous/pustular lesion surrounding orifices, impaired wound healing
Guillain Barre is an acute or subacute ascednign flaccid paralysis often occurring after URI or diarrheal illness. What does the CSF look like?
Elevated protein level with normal cell count and normal glucose.
29 year old with severe HTN and signs of LV hypertrophy. What do you need to check for?
Coarctation of the Aorta
How do antipsychotics cause infertility?
Block Dopamine D2 receptors not only in CNS, but ALSO in the tuberoinfundibular pathway. When DA is blocked here it increases the production of Prolactin. This can lead to galactorrhea, menstrual irregularity, and infertility.
Which antipsychotics most likely to cause infertility?
high potency 1st gen (haloperidol, fluphenazine) and second gen risperidone
Man with lymphoma shows evidence of nephrotic syndrome. Dx?
Minimal change disease
African American heroine user shows signs of nephrotic syndrome. Dx?
Focal segmental glomerulosclerosis
Treatment for incidentally found endometriosis. No sx.
?
No treatment necessary without symptoms
IF symptomatic - NSAIDS, oral contraceptives, or a progesterone IUD
Best strategy to reduce transmission of HIV to infant with HIV+ mother?
Combination antiretrivral therapy for mom (HAART).
Then neonatal Zidovudine for the infant.
15 year old male presents with epistaxis and is found to have a small right-sided mass at the back of the left nostril. His septum is intact. CT scan reveal erosion of adjacent bone.
What should you think of?
Angiofibroma
12 year old sickle cell patient with 2 hr right-sided arm weakness and slurred speech. He takes hydroxyurea, oxycodone PRN, and floic acid. Vital relatively stable. CT shows no intracranial bleed. Next best step in management?
Exchange transfusion
This may not reverse changes from initial vascular event, but will help decrease % of sickle cells in the bloodstream and makes additional strokes less likely.
Type of incontinence stemming from multiparity?
Stress urinary incontinency.
Loss of urine with increased intraabdominal pressure
High parity weakens urethral support and leads to urethral hypermobility
32 year old woman is showing all the signs of CHF following a viral illness. What’s the dx? What will you see on echocardiogram?
Sounds like dilated cardiomyopathy secondary to acute viral myocarditis.
Echo is going to show dilated ventricles and diffuse hypokinesia resulting in low systolic ejection fraction.
Management basically supportive.
7 year old presents with malaise and headache after camping trip. Red ring rash is apparent on right thing. Treatment?
Lyme disease.
Treat with amoxicillin.
Normally tx is doxycycline, but that is contraindicated in children and pregnant women. Can cause enamel hypoplasia/teeth staining in kids and slow bone development in fetuses.
MOst important first step for patient who appears to be symptomatic from severe hypercalcemia?
Aggressive normal saline infusion
23 year old with infertility. Appears to be related to stress and overexercise. What would be your first line to improve her anovulation?
1st: cut down on stress/exercise.
If that doesn’t work: Pulsatile GnRH therapy
Single episode of major despressive epsisode. Treat with SSRI for how long?
Recurrent or severe MDD?
4-9 months
Recurrent/severe: 1-3 years or indefinitely
Patient with multiple liver masses. You are assuming this is cancer. Most likely primary? secondary? from where?
Most likely metastatic disease. Most commonly from GI tract, lung, and breast.
16 year old female with history of very irregular periods. Currently having abnormal uterine bleeding. SHe is hemodynamically stable. Management?
Hormone treatment is 1st-line in this case, including estrogen, combo pills, or progesterone.
Most common cause of abnormal uterine bleeds in adolescents is annovulation from immature hypothalamuc-pituitary-ovarian axis. Without ovulation, the endometrium builds up for way too long.
Tranexamic acid can be used if hormonal therapy cannot be used.
MS patient with internuclear opthalmoplegia bilaterally. This results to damage to what structure?
Medial longitudinal fasciculus
Most important side effects to monitor in Olanzapine and Clozapine?
Metabolic syndrome
Monitor fasting glucose and lipids
Labs that should be tested when a patient has suspicious symptoms for normal menopause, but you want to make sure it isn’t an overlapping disorder?
TSH and FSH levels should be tested as Hyperthyroidism can have overlapping symptoms
Potential complications of uncontrolled maternal hyperglycemia?
- congenital malformations (heart, neural tube, small L colon)
- macrosomia
- neonatal hypoglycemia
- Polycythemia
Infant has low birth weight, tachycardia, flushed skin, and irritability. Mother has hx of Grave’s disease. Diagnosis?
Tx?
Thyrotoxicosis
(Due to transplacental maternal TSH receptor antibodies)
Tx: Short-term Methimazole and a beta-blocker
17 year old male with left shoudler pain and swelling. X-ray shows sunburst periosteal reaction.
Dx?
Osteosarcoma
18 year old patient with left flank pain radiating to the groin. He says he has had these issues with stone passage many times before. It has happened since childhood and two of his uncles have the same issues. UA shows hexagonal crystals and is posistive on cyanide nitroprusside test. Likely pathogenesis of this issue?
Amino acid transport abnormality
defective transport of dibasic amino acids by the brush borders of renal tubular and intestinal epithelial cells
Patient is showing all the classic signs of Vit B-12 deficiency (macrocytic anemia, glossitis, neuro changes) and you suspect pernicious anemia. What long term complications should this patient be monitored for?
Gastric cancer
Risk increases 2-3x in this population
How does oral estrogen affect patients on oral thyroid replacement therapy?
Oral estrogen increase thyroxine-binding globulin (TBG). Patients on estrogen will thus need higher doses of thyroid replacement in order to saturate the increased number of TBG sites.
