UWORLD Step 3 QBANK Flashcards
irritability, poor feeding, aversion to being held and a hip joint which is flexed, abducted, and externally rotated
pediatric septic arthritis
MC organisms in pediatric septic arthritis
[] <3 months old
[] >= 3 months old
[] < 3 months old:
- Staphylococcus aureus
- GBS
- GN bacilli
[] >=3 months old:
- Staphylococcus aureus
- GAS
end-of-life care is focused on minimizing discomfort, anxiety, and distress for the patient and family once efforts to cure or modify disease become futile
[] what is the stepwise approach toward family disagreements with palliative care
- Family meetings, where treatment and prognosis are discussed and joint-decision making is performed
- Palliative care consultation or referral to Ethics Committee
this research principle answers the question, “how generalizable are the results of the study to other populations?”
external validity
aka “fully crossed design”
a type of experimental study design that utilizes >=2 interventions and all combinations of these interventions
Factorial
a type of experimental study design in which subjects are exposed to different treatment or exposures sequentially
a crossover study
a form of retrospective observational study in which subsets of controls are matched to cases and analyzed for the variables of interest
nested study
this type of study seeks to determine whether an intervention works in real-life conditions
pragmatic study
how should patients with acute decompensated heart failure be initially managed and what is the physiologic idea?
diuretics (and/or IV vasodilators)
to reduce cardiac preload
the prevalence of clinically apparent DVT in acute stroke patients is 2-10% with the highest risk being 2-7 days following a stroke and is particularly high in those with hemiparesis (75%)
[] what should be given?
Low dose heparin or LMWH for prophylaxis in most patients with acute ischemic stroke
Most morbidity from silicone breast implants is associated with what?
[] should a pregnant woman worry about the fetus and/or breastfeeding?
[] how does mammography screening recommendations change for breast implants?
local complications such as capsular contracture, implant deflation, and rupture
silicone implants do not cause disease or defects in the developing fetus; additionally, breast milk is safe and the best source of nutrition for infants with no evidence of any harmful effects in babies who are breastfed by mothers with silicone implants
women with implants should continue to have screening mammography at regular intervals
older adults with new-onset cognitive impairment should be assessed for what disease?
[] this is a risk factor for development of what disease?
depression
late life depression frequently presents with reversible cognitive impairment (aka pseudodementia)
patients with late-life depression (MDD >=65) are at a high risk of developing Alzheimer’s dementia and vascular dementia
this is the MC fracture of the carpal bones caused by falling onto an outstretched hand with a dorsiflexed wrist, leading to decrease grip strength, decreased ROM in wrist, and tenderness to palpation of the wrist within the anatomic snuffbox
[] how would you confirm?
[] what if the test is negative?
[] how do you treat?
[] complication
Scaphoid fracture
confirm with XR of the wrist in full pronation and ulnar deviation to better expose the schapoid
n.b., initial XR can be negative if the fracture is compressed or minimally displaced, therefore, either MRI/CT of the wrist, repeat XR in 7-14 days or radioscintigraphy in 3-5 days should be performed
wrist splinting should be done
complicated by non-union or avascular necrosis; if not treated with casting for 12 weeks
this medication is a potent vasodilator that works on both arterial and venous circulation and is used for HTN emergency management because of its rapid onset and offset; however, it must be avoided in chronic renal failure
[] what are some clinical features of its toxicity
Cyanide toxicity from Nitroprusside
Nitroprusside > CN, which may accumulate and be toxic in patients with CKD or those on high dose or prolonged infusion
Always suspect toxicity in unexplained metabolic acidosis and AMS with patients who have “cherry red” flushing, tachypnea, arrhythmias, ABD pain, nausea/vomiting
new sexual behaviors with recent onset of irritability, argumentativeness, risky sexual behavior and impaired concentration in a child/teen should raise suspicion for what?
child abuse
results from a critical elevation in intra-cardiac filling pressures most often due to coronary ischemia, prolonged HTN, valvular disease, or excessive volume overload/resuscitation
[] early goals of therapy
[] what are important parts of therapy?
[] if initial therapy fails, what should be next?
acute decompensated heart failure
early goals: hemodynamic stabilization, improved oxygenation, and optimization of volume status
IV-diuretics (furosemide)
IV-vasodilators (e.g., Nitroglycerin) reduce intra-cardiac filling pressures and are recommended in patients with ADHF who have inadequate response to initial diuretics or as initial therapy in “flash” pulmonary edema
once a patient in ADHF of uncertain etiology is stabilized, what should be done?
Transthoracic ECHO (TTE)
look for LV dysfunction and valvular abnormalities
this ubiquitous organism is a common cause of pulmonary disease in patients who are immunocompromised, particularly those with prolonged neutropenia or on chronic corticosteroids
[] CT findings
[] how to confirm diagnosis
[] treatment
[] mortality rate
Invasive pulmonary Aspergillosis
CT shows nodules with surrounding ground-glass opacities (“Halo sign”) or cavitation with air-fluid levels (“air crescent sign”)
confirm diagnosis with serum fungal biomarkers (galactomannan and beta-d-glucan assay) with sputum sample for fungal staining and culture
IV-voriconazole and a reduction of immunosuppressive meds
MR >80%
the MC cause of a palpable breast mass in adolescents or women <30 YO, it is often a single, rubbery, mobile, well-circumscribed mass in the UOQ
[] how does the pain change
[] management
Fibroadenoma
due to hormonal fluctuations, many patients have tenderness a few days prior to menstruation, with tenderness and size often improving after menses
after observing for 1-2 menstrual cycles, reassurance can be given for spontaneous regression
persistent lesions should have an US, which would likely reveal a solid, well-circumscribed, avascular mass
(4) Broad Causes of prolonged QT
BOMM the QT
Bradyarrhythmias
Other (4)
Metabolic disorders
Medications (8)
these 8 types of medications can cause QT prolongation
BOMM
Brady, other, meds, metabolic
Meds: Antibiotics Cardiac (angina, arrhythmia) Depression (TCA, antipsych, SSRIs) Electrolytes Emetics
diuretics (electrolytes)
antiemetics (zofran)
antipsychotics (Haldol, Seroquel, Risperdal)
TCAs
SSRIs
Anti-arrythmics (amiodarone, sotalol, flecainide)
Anti-Anginas drugs (ranolazine)
Anti-infectives (e.g., macrolides, fluroquinolones, antifungals)
what are the (4) other causes of QT prolongation?
BOMM
Brady, other, metabolic, meds
Other:
- Hypothermia
- MI
- Intracranial disease
- HIV
a brief arrhythmia that terminates spontaneously, but can evolve into recurrent episodes in rapid succession, with a risk of degenerating into VFIB and death
[] if the patient is conscious and hemodynamically stable, what treatment should be given?
[] if the patient does not respond to this treatment, what is next?
Mag sulfate (even in patients with normal serum Mag)
temporary transvenous pacing should be used in patients who do not respond to IV-Mag sulfate
what are the (3) parameters of the GCS?
(E) = eye 4 (V) = verbal 5 (M) = motor 6
the MC cause of ascites in the USA
hepatic cirrhosis
this gradient is useful in identifying the presence or absence of portal HTN and has replaced the old transudative-exudative model of classification
[] how do you calculate
[] how do you interpret
[] what clinical conditions have a high or low SAAG?
Serum Ascites Albumin Gradient (SAAG)
serum albumin minus the ascitic fluid albumin
SAAG >=1.1 g/dl indicates a high gradient and likely portal HTN
High: CHF, cirrhosis, ETOH hepatitis
Low: peritoneal carcinomatosis, peritoneal TB, nephrotic syndrome, pancreatitis, and serositis
these injuries commonly occur when a force is applied to the knee from the lateral to medial direction during skiing or contact sports with PE showing values laxity
[] treatment
Medical collateral ligament tear
uncomplicated MCL tears can be managed non-operatively with rest, ice, compression, and elevated (RICE), as well as analgesics
may parents consent for sterilization of intellectually disabled children?
forced sterilization is considered unethical and involuntary sterilization violates a woman’s right to privacy, her reproductive rights, and her body integrity
these two findings are strongly suggestive of NF-2
[] inheritance pattern
bilateral acoustic neuroma
hypo-pigmented skin lesions
Autosomal Dominant
recent onset of asymmetric oligoarthritis that is inflammatory, yet sterile (culture negative) in a patient with a recent history of chlamydia
[] MC preceding infection
[] classic triad of symptoms
[] an extraarticular manifestation that is painless, resolves in several months, and not a/w LAD
[] what is the treatment
Reactive Arthritis
GI:
- Campylobacter
- Shigella
- Salmonella
- Yersinia
- C diff
GU: Chlamydia
“Cant see, can’t pee, can’t climb a tree”
Uveitis, conjunctivitis
Urethritis, cervicitis, prostatitis
Arthritis
Circinate balanitis is extra-articular manifestation
active infections should be treated (i.e., chlamydia) with antibiotics, and symptoms treated with NSAIDs
a life-threatening disorder of thiamine deficiency seen MC in patients with heavy ETOH use and/or severe malnutrition
[] classic triad
[] treatment
[] complication
[] what are the signs of the complications and MRI finds?
Wernicke’s Encephalopathy
- Encephalopathy
- ams, disoriented - oculomotor dysfunction
- lateral rectus palsy - gait ataxia
- wide based or complete impairment
tx: IV-thiamine
cx: Korsakoff Syndrome
up to 80% show retrograde or anterograde amnesia, often with confabulation; usually not reversible
n.b., cognition, attention, social behavior, and long-term memory are preserved
MRI shows mammillary body atrophy
a generalized maculopapular rash in a patient with recent amoxicillin use probably actually had what infection?
[] pathophys
[] management
Infectious mononucleosis
(amoxicillin or ampicillin)
pathophys: unknown, but likely antibodies against PCN derivatives
not a true allergy to ABX, it will resolve spontaneously over time with observation and supportive care
patients with mononucleosis generally have rash, fever, fatigue, and throat pain
[] what patients have increased risk for prolonged fatigue
supportive care is the mainstay of treatment for individuals with IM, and most symptoms (including a rash) will resolved spontaneously within 1-2 weeks. Fatigue may persist for months, and women or individuals with pre-existing mood disorders may be at increased risk for prolonged fatigue
pooling the data from several studies to increase statistical power
Meta-analysis
rapidly progressive weakness of the LE after an URI, accompanied by sensory loss and urinary retention
Transverse Myelitis
recurrent, unexpected attacks consistent with chest pain, palpitations, SOB, sweating, nausea, dizziness, derealization/depersonalization, and fear of losing control or dying
[] treatment
Panic disorder
1st line/maintenance:
SSRI/SNRI +/- CBT
acute: benzodiazepines
EKG findings in WPW?
short PR
delta wave
wide QRS
the overall incidence of sudden cardiac death in patients with WPW is very low (<1%), but the risk is increased if patient’s have what?
[] recommended therapy
tachyarrhythmias due to Afib, as impulses can conduct from the atria > ventricles at a very fast rate, potentially causing rhythmic degeneration to VFIB
catheter ablation
commonly seen in patients >50 YO with sub-acute/chronic pain in the shoulder and hip girdle with morning stiffness >1h, constitutional symptoms, elevated ESR, and no other apparent explanation
[] treatment
Polymyalgia rheumatica (PMR)
Low-dose prednisone
a common inflammatory skin disorder characterized by erythematous, well-defined plaques covered by thick, silverly scales
[] what are the (3) classifications
[] treatment by class
Psoriasis
Mild-moderate psoriasis
Severe plaque psoriasis
Facial/intertriginous psoriasis
guttate psoriasis
Mild-Moderate:
- topical high potency CS
- topical Vitamin D
Severe:
- Phototherapy
- MTX, biologics
Facial/Intertriginous
- Topical tacrolimus
- Low potency CS
Guttate
-Observation or phototherapy
Moms with O type blood who give birth to A or B infants are at risk of this disease
[] when is bilirubin considered severe?
[] treatment by type
Neonatal hyperbilirubinemia
Bilirubin >20-25 mg/dl is severe
Mild (physiologic)
-breast feed q2-3 hours
Moderate
- phototherapy
- formula, IV hydration
Severe
-exchange transfusion
a procedure in which bilirubin and circulating antibodies are removed and the infant’s RBCs are replaced with donor RBCs
[] in which bilirubin level is this indicated
[] feared cx
Exchange transfusion
Bili >20-25 mg/dl
Failed phototherapy
Worsening hyperbilirubinemia
prevent Kernicterus (bilirubin crossing BBB)
(5) Causes of Recurrent Pneumonia
- Aspiration
- COPD/asthma
- Immunodeficiency
- Post-obstructive
- TB
a common cause of recurrent pneumonia in Parkinson’s disease duet o mental status and dysphagia/dysarthria
[] MC organisms
[] MC location in lung
[] best way to diagnose
[] treatment
Aspiration PNA
Anaerobes
Polymicrobial
MC in RML/RLL
dx: videofluoroscopic swallow study
Tx: Clindamycin
a common cause of recurrent pneumonia in smokers or those with prolonged SOB/cough
[] MC organisms
COPD/asthma/bronchiectasis
S pneumo HiB Moraxella Pseudomonas (esp in bronchiectasis) Viral
MC cause of recurrent pneumonia in recent immigrants, institutionalized patients, or homeless/low SES
Mycobacterium TB
(3) phase/classifications of acne
- Comedonal
- Inflammatory
- Nodular (cystic)
closed or open comedones on the forehead, nose, and chin which may progress to inflammatory pustules or nodules
[] treatment
Comedonal acne
- topical retinoids
- salicylic acid
- glycolic acid
inflamed papules (<5 mm)and pustules with erythema on the face
[] treatment
inflammatory acne
- topical retinoids + benzoyl peroxide
- topical abx (e.g., erythromycin, clindamycin)
- oral abx
large (>5 mm) nodules that can appear cystic on the face, forehead, chin, and may merge to form sinus tracts with scarring
[] treatment
[] special considerations
Nodular (cystic) acne
- topical retinoids + benzoyl peroxide + topical abx
- po abx
- oral isotretinoin
tazarotene and oral retinoid isotretinoin are designated Category X in pregnancy and never used
used in survival analysis, it is similar to relative risk
Hazard ratio
significantly increased urinary cortisol levels, non suppressible high-dose dexamethasone, and undetectable ACTH levels are highly suggestive of this disease
[] diagnosis
Cushing Syndrome secondary to adrenal etiology
[] CT/MRI abdomen
transient neurologic disturbance (e.g., dizziness, disorientation, amnesia) after a mild traumatic brain injury
[] management
Concussion
after a concussion, average-risk adults should rest for >=24 hours before gradually increasing their activity level each 24-hour period they remain asymptomatic, potentially returning to full contact sports within 1-week; if you develop symptoms, you should return to the last activity level in which you were asymptomatic for 24 hours prior to progression
a screening test should have this high characteristic to prevent as many of these
high sensitivity to prevent as many false negatives and help “rule out” disease
what is the MC location of an abdominal aortic aneurysm
infrarenal
what are some RF associated with the development of an AAA?
male sex, smoking, age >60, family history, white ethnicity, and atherosclerotic disease
who do we screen for AAA?
men 65-75 YO who have ever smoked
what is the management for AAA?
it is by size
<4 cm, US q 2-3 years
4.0-5.4 cm, US q 6-12 months
Surgery is indicated for:
- Large (>=5.5 cm)
- Growth >=0.5 cm in 6 months
- associated with PAD or aneurysm
these two antibodies are associated with SLE, although one is more sensitive at 66-95%
anti-smith
anti-DS DNA
anti-DS DNA is more sensitive
which antibodies can be used to follow disease activity in SLE and are associated with lupus nephritis?
anti-DS DNA
antibodies in scleroderma
anti-centromere
antibodies in primary biliary cirrhosis (PBC)
anti-mitochondrial
antibodies associated with Sjogren’s syndrome
anti-Ro
anti-La
how do you treat SLE associated with arthralgia, serositis and cutaneous symptoms?
Hydroxychloroquine (anti-malarial)
how do you treat serious manifestations of SLE (e.g., nephritis, cerebritis, vasculitis)
Prednisone with Cyclophosphamide
in SLE, if patients with significant organ involvement have an incomplete response to prednisone alone, this can be added
Methotrexate
this drug is not used often in SLE as there are reports of progressive multifocal leukoencephalopathy (PML)
Rituximab (CD20)
ocular symptoms consistent with keratoconjunctivitis sicca and oral symptoms consistent with xerostomia should lead to the diagnosis of this syndrome
[] antibodies
[] test for ocular symptoms
[] complication
Sjogren’s Syndrome
chronic, auto-immune inflammatory condition that primarily affects the lacrimal and salivary glands
anti-Ro
anti-La
Schirmer test is used to confirm keratoconjunctivitis sicca; filter paper is placed along the lower eyelid and wetting of the paper is measured after a defined period of time
B-cell NHL is a complication of chronic B-cell activation in Sjogren’s
an acute confusional state that is very common in elderly patients and those in SNF, it manifests as a change in awareness, easy distractibility, cognitive and perceptual disturbances which include memory loss, disorientation, hallucinations, and even agitation
[] management
Delirium
physical and chemical restraints should be judiciously used in a combative and disruptive patient
always give Haldol before restraints
Do not give BDZ, as they can worsen delirium
the result of an abnormal fertilization of an empty ovum by either 2 sperm or 1 whose genome duplicates, the result is a gestation which is pre-malignant
[] can develop into
[] labs to order
[] treatment
[] further management
Hydatidiform mole
can develop into gestational trophoblastic neoplasia (GTN)
order b-hCG
management is by suction curettage, after which serial b-hcg are followed until undetectable for 6 months. Because pregnancy can confound this follow-up, contraception is required during the surveillance period
progressive, painless, proximal muscle weakness with elevated muscle enzymes and inflammatory markers, it is an inflammatory myopathy triggered by unknown, possibly viral, antigens
[] clinical signs
[] what is a similar disorder which has one distinction
[] these disorders can often be seen as sequelae of what bigger entities
[] testing / definitive diagnosis
Polymyositis
peak incidence 40-50 YO
muscle weakness can manifest as difficulty climbing stairs, getting into or out of a chair/car, or working with the arms overhead
dermatomyositis is similar, but has skin manifestations (Gottron’s papules)
may occur as a paraneoplastic syndrome
anti-Jo may be elevated
definitive: muscle biopsy
antibodies elevated in polymyositis
[] what complication can be seen if elevated
anti-Jo
interstitial lung disease, infections, drug-induced pneumonitis (e.g., MTX), and respiratory ms weakness
young to middle aged women with chronic, widespread pain associated with fatigue and impaired concentration
[] physical exam findings
[] how do you diagnose
Fibromyalgia
tenderness at trigger points (e.g., mid-trapezius, costochondral junction)
> =3 months of widespread pain or symptom severity score with normal labs
a flu-like febrile illness with marked myalgia and joint pain
[] transmission
[] dangerous progression
[] management
Dengue fever
Aedes mosquito from endemic areas (SE Asia, Pacific Islands, Caribbean, Americas)
dengue hemorrhagic fever:
- increased vascular permeability
- thrombocytopenia (<100)
- spontaneous bleed > shock
- positive tourniquet test (petechiae after cuff inflation for 5 mins)
supportive care
abrupt onset of fever, myalgia, and HA with slow reddening of the eyes without inflammation; it can also involve GI symptoms such as nausea/vomiting
Leptospirosis
conjunctival suffusion is key
a severe form of this bacterial infection, it is characterized by dysfunction of the kidneys and liver, abnormal enlargement o the liver, jaundice, and/or alterations in consciousness
Weil Syndrome
severe Leptospirosis
which is the best test to diagnose osteomyelitis?
how long does this test take to show infection
MRI
changes are present within 5 days of onset, therefore, patients with symptoms >1 week are considered “ruled out” for O.M.
after O.M. is confirmed, what test should be done next?
since DM foot infections are likely polymicrobial, bone biopsies are needed to determine the pathogenic organism
fatigue, exertion dyspnea, a systolic murmur which accentuates with Valsalva, asymmetric septal hypertrophy, systolic anterior motion of mitral leaflets, and increased LVOT gradient
[] genetics
[] symptomatic patients require what treatment
hypertrophic cardiomyopathy
Autosomal dominant genetic disorder of the cardiac sarcomere; it has heterogenous and variable clinical presentation
patients with symptoms of heart failure and LVOT gradient should be given negative inotropic agents (Beta blockers then verapamil, or disopyramide)
these (3) maneuvers decrease preload
Valsalva
Abrupt standing
Nitroglycerin
this maneuver increases afterload
hand grip
this maneuver increases preload
leg raise
this maneuver increases both preload and afterload
squatting
these two scenarios are indications for ICD placement for primary prevention
- Prior MI & LVEF <=30%
2. NYHA II or III with symptoms and LVEF <=35%
these two scenarios are indications for ICD placement for secondary prevention
- Prior VF or unstable VT without a reversible cause
2. Prior sustained VT with underlying cardiomyopathy
should we screen for cervical cancer in women who have sex with women?
WSW have an increased risk of cervical cancer from HPV infection compared with heterosexual women, likely due to the lower rates of vaccination, lower rates of screening, and higher rates of smoking and obesity
there is also a higher risk of ovarian and breast cancer due to the above, as well as low parity and less OCP use
Bacterial vaginosis (while not an STI) is transmitted through vaginal fluids and is therefore more commonly seen in WSW; screening is not recommended, but symptomatic infection should be treated
an invasive infection of the external ear canal
[] MC organism
[] MC risk factors
[] treatment and for how long
[] complication
External otitis externa
MC: Pseudomonas
Advanced age, DM, HIV
IV-fluroquinolones (Cipro), but anti-pseudomonas PCN (Piperacillin) with/without amionglycosides and 3rd gen cephalosporins (Ceftaz); treat with IV, if inflammatory markers are normal, then switch to po for 6-8 weeks
cx: untreated MOE can progress rapidly to involve the skull base, TMJ, and cranial nerves, leading to O.M. and CN palsy
first line treatment for prolactinomas, including large prolactinomas
DA receptor agonists
usually see a decrease in tumor size within a few days and visual symptoms usually improve before the tumor’s decrease in size is seen on MRI
pregnant women should not receive live vaccines, what are they?
Rotavirus
MMR
Varicella
if a parent refuses medically necessary care for a child in an emergency situation, what are the options for the provider?
In emergency situations, the inability to obtain consent or parental refusal of consent should not delay care. Parental refusal to an intervention that may prevent severe injury or death may be considered an act that is not in the best interest of the child, and medical providers should proceed with treatment. A court order should also be sought to legally overrule a parental decision; however, treatment should not be withheld while awaiting a decision
this infection may occur in patients with advanced HIV (CD4<100) and is typically a marker of disseminated disease; it most commonly includes the rapid onset of multiple papular lesions with central umbilication and central hemorrhage/necrosis
[] what other infection does this resemble?
[] how do you diagnose?
[] treatment
cutaneous cryptococcosis
it resembles molloscum contangiosum, but the central necrosis is key
diagnosed by lesion biopsy with histopathological exam
usually treated with >=2 weeks of IV Amphotericin B and po Flucytosine, followed by 1 year of po Fluconazole (higher dose for 8 weeks, then maintenance)
meningoencephalitis following the bite from a mosquito, it typically occurs in the summer and presents with fever, HA, vomiting, nuchal rigidity, and AMS
[] diagnosis
[] treatment
West Nile Virus
CSF aseptic pleocytosis
viral serologies
supportive care
acyclovir for HSV
patients with primary hypothyroidism are predisposed to get other AID. If a patient with this disorder starts to present with loss of proprioception, brisk reflexes, and loss of ankle jerks, what should be considered?
[] pathophys
[] what is the neuro-syndrome referred to as?
Vitamin B12 deficiency secondary to pernicious anemia
AI destruction of the parietal cells, leading to achlorhydria and decreased production of intrinsic factor
involvement of the posterior and lateral columns in the spinal cord is known as “subacute combined degeneration” and leads to ataxia, loss of proprioception, and vibratory sensation
treatment of moderate to severe megaloblastic anemia with vitamin B12 can lead to this
[] mechanism
hypokalemia
results following the uptake of potassium by newly forming RBCs; monitor for 48 hours, replete as needed
mutations of filaggrin and other epidermal barrier proteins lead to this disrupted skin barrier which has increased antigen exposure and hypersensitivity causing pruritus
[] associations
[] differences between infants and children/adults
[] lab findings
[] treatment
Atopic dermatitis (eczema)
infants - extensors
child/adult - flexural
associated with:
Asthma
Allergic Rhinitis
Atopic dermatitis
high serum IgE
eosinophilia
po antihistamines and regular use of emollients to maintain skin hydration
most patients will benefit from topical glucocorticoids:
hydrocortisone > TAC, betamethasone
if face or eyes > tacrolimus
if severe > UV therapy or systemic immunosuppresants
acute onset symmetric joint pain, swelling, and stiffness in the PIP and MCPs a week after a flu-like illness
[] diagnosis
[] treatment
[] prognosis
viral arthritis with ParvoB19
serum serology with IgM
supportive and NSAIDs
no long term sequelae
presents 2-4 weeks after GAS pharyngitis, causing a migratory polyarthritis in the larger joints (e.g., knee, elbow); skin findings often include erythema marginatum and SQ nodules
acute rheumatic fever
often monoarticular (e.g., knee) associated with erythema migrans following exposure
lyme arthritis
a chronic, inflammatory arthritis which often presents with morning stiffness in bilateral MCP and PIP joints, is insidious in onset and requires symptoms for at least >6 months
rheumatoid arthritis
polyarticular arthritis, often gradual in onset, but with constitutional symptoms, malar or discoid rash
SLE
what 3 things should you assess in a patient with high suspicion of self harm?
[] who needs admission
Ideation
Intent
Plan
ideation - passive vs active
intent - strength of compulsion, how close are they to completion
plan - method, time/place, lethality, likelihood of rescue
patients who have attempted or who have active SI with a specific plan and intent require hospitalization
this drug has evidence of reducing the risk of suicide in mood disorder patients
Lithium
what cardiac valvular disorder can cause dyspnea, orthopnea, PND, and hemoptysis with possible Afib and systemic thromboembolism and voice hoarseness
mitral stenosis
What are the murmur findings in mitral stenosis?
Loud S1 (loud P2 if PHTN)
Opening snap (high freq, early diastole)
Mid-diastolic rumble (apex)
what are the CXR, EKG, and TTE findings in mitral stenosis?
CXR: pulmonary blood flow redistribution to upper lobes, dilated p vessels, LAE, flat heart border
EKG: “p mitrale” (broad, notched p waves), atrial tachyarrhythmias, RVH (tall R waves in V1 and V2)
TTE: MV thickening/calcification, decreased mobility, coexisting MR
the MC cause of hemoptysis in COPD
[] if patients have increased SOB, sputum volume, or purulence in sputum, what should be given?
while ABX are generally not recommended for acute bronchitis in otherwise healthy individuals 2/2 viral etiology, patients with COPD who have any 2 of these features should receive ABX:
- increased sputum purulence
- increased sputum volume
- increased SOB
nearly 25% of C diff infection (CDI) recur after successful treatment, usually within 1-3 weeks (but up to 3 months)
[] mechanism of recurrence
[] how to confirm
[] how to treat
CDI
recur - persistent spores or reinfection with same/different strain
confirm with stool studies for C diff
First Recur:
-po vanc in prolonged/tapered course OR fidaxomicin if Vanc used in first episode
Multiple recur:
- po vanc followed by Rifaximin (or above)
- fecal transplant
fulminant (hypotension/shock/ileus, megacolon):
-flagyl IV plus high dose po vanc (or per rectum if ileus), surgical eval
how do you treat an initial episode of C diff
po Vancomycin or Fidaxomicin
what risk assessment tool is used for unstable angina/NSTEMI?
[] what are the 7 clinical variables
[] how do you interpret?
Thrombolysis in Myocardial Infarct Score (TIMI)
- Age >=65 YO
- > =3 risk factors for CAD
- Known CAD with >50% stenosis
- Use of ASA within 7 days
- > =2 anginal episodes in the past 24 hr
- elevated biomarkers (e.g., troponin)
- ST deviation >0.5 mm on EKG
0-2 pts: Low Risk
-Stress Test
3-4: Intermediate or 5-7: High risk
-early coronary angiography within 24h
Hemodynamic instability, heart failure or new MR, recurrent CP, ventricular arrhythmia
-immediate coronary angiography
symptoms which suggest ACS, but without elevated troponin
unstable angina
symptoms which suggest ACS, but without EKG changes
NSTEMI
prevents employers from requiring or requesting genetic testing results of their employees, and if they already have the information, they cannot use it to discriminate against the employee
the genetic information nondiscrimination act of 2008 prevents this employer discrimination based on genetic testing information
if a patient with SLE presents with proteinuria, active urinary sediment, or declining renal function, what should be done?
a kidney biopsy is needed prior to initiation of treatment to guide therapy, as treatment varies by class
Class I and II are mild and do not require treatment
Classes III and IV require immunosuppression with glucocorticoids (e.g., Methylprednisolone, Prednisone) and Cyclophosphamide or Mycophenolate
Class V requires immunosuppression if proliferative lesions or nephrotic syndrome is present
Class VI is advanced and immunosuppression is not recommended
use this to monitor renal disease activity in SLE nephritis
complement and anti-ds-DNA antibody
immune complexes are deposited in the mesangial, subendothelial, or subepithelial space, with resultant influx of PMNs and mononuclear cells.
immune complex deposition within the glomerulus induces complement fixation, leading to low circulating completement levels; therefore, higher disease activity is associated with lower complement levels
brief and shooting back pain provoked by bending forward and straining is typical for this nerve root irritation
[] diagnostic sign
Sciatica
straight leg raise at 60 degree angle or less should provoke the pain
flaky, itchy skin with erythematous plaques and loose, greasy-looking scales commonly on scalp, central face, ears, and chest
[] risk factors
[] pathophys
[] treatment
[] prognosis
Seborrheic dermatitis
on the scalp – its dandruff
on central face – eyebrows and nasolabial
RF: CNS disease (parkinson) and HIV
Malassezia spp
Treatment:
- topical antifungals (e.g., selenium sulfide, ketoconazole)
- topical glucocorticoids
- topical calcineurin inhibitors (e.g., pimecrolimus)
chronic, relapsing condition and initial treatment may provide improvement in symptoms, but patients often require intermittent re-treatment
most commonly seen as a rash in children, it causes annular plaques with peripheral scaling and central clearing
treatment
Tinea capitis
Griseofulvin
what is hospice care and what are the rules of entry/exit?
an interdisciplinary palliative care service for patients with life-limiting illnesses (prognosis <=6 months) who have chose to stop pursuit of disease-modifying, curative therapies
Patients are free to leave hospice at any time to pursue curative treatments and can return later
which of these is a contraindication to hospice care?
A: ischemic brain damage
B: lack of advanced directive regarding return to hospice
C: lack of patient’s consent
D: ventriculoperitoneal shunt
E: None of these
the only requirements for hospice care are a prognosis <=6 months and the patient’s or surrogate’s decision to forego life-sustaining treatment.
Physicians should educate patients and family that comorbid medical conditions and inability to give full informed consent are not contraindications
patient with RUE hypertension, LE claudication, weak delayed pulses, and heart murmur
[] MC location of defect
[] notoriously associated with this syndrome
[] CXR findings
[] how to confirm the diagnosis
Aortic coarctation
the defect is usually congenital and located distal to the L-subclavian
notoriously associated with Turner syndrome, but it can sporadically develop in males
CXR shows rib notching from collateral vessels and “figure 3 sign” at the site of aortic narrowing
EcHO confirms
define delayed puberty
puberty is considered delayed if there are no secondary sexual characteristics (testicular enlargement >4mL or breast development by age 14 in boys or 12 in girls)
delayed development of secondary sexual characteristics in conjunction with delayed bone age, short stature but normal growth velocity, and a family history of “late bloomers”
[] contrast to this other disease
[] management
[] prognosis
constitutional delay of growth and puberty
contrast to familial short stature, in which short stature and normal growth velocity are accompanied by normal bone age
management consists of watchful waiting, reassurance +/- hormonal therapy
prognosis is good with normal expected adult height and correlates with family members
ureteral stones which cause proximal ureteral obstruction resulting in hydronephrosis, superimposed infection, and hemodynamic instability
management
requires decompression of upper urinary tract with percutaneous nephrostomy or ureteral stent placement
MC manifestation of sickle cell disease
vaso-occlusive crisis
acute episode of minor to severe pain that typically affect the back, chest, abd, or extremities in patients with SCD
[] common triggers
[] management
[] complication
vaso-occlusive pain crisis
triggers include dehydration, infection, stress, weather change, menstruation
often requires hospitalization and prompt administration of po or IV pain medications with gentle rehydration
acute chest syndrome is defined by the presence of a new pulmonary infiltrate on CXR and fever, hypoxemia, chest pain, tachypnea, or increased WOB; treat them with Ceftriaxone and Azithromycin with pain meds and IVF
recurrent pneumonia in an elderly smoker should raise concern for what?
[] how do you diagnose?
bronchogenic carcinoma due to endobronchial obstruction
flexible bronchoscopy is a primary diagnostic tool to evaluate patients with persistent or nonresolving PNA or pulmonary infiltrates
are patients with active TB infectious?
patients with active TB are at risk of transmitting MTB to close contacts via aerosolized droplets for up to 3 months prior to the onset of their symptoms
to evaluate potential exposure to TB via healthcare personnel, what should be done?
ppd or IFN y assay
if initial screening is negative, repeat the test in 8-10 weeks
this ppd is positive in HCP
> =10 mm induration
is latent TB infectious?
those with no CXR abnormalities and no symptoms (e.g., wt loss, NS, chronic cough), but positive screening are considered to have latent TB
LTBI is noninfectious, and individuals may continue to work and live normal lives. However, treatment should be offered if there is a high suspicion of conversion to active TB (only 5-10% do), such as immunocompromised individuals, inmates, or those who work in high risk congregate settings (health care)
how do you treat LTBI?
3 options
- INH and rifapentine weekly for 3 months (not recommended for HIV)
- INH for 6-9 months
- Rifampin for 4 months
when are patients treated for active TB considered non-infectious?
when 3 consecutive AFB sputum smears are negative (8-24 hour intervals, and >=1 early morning)
these two herbs are used for memory enhancement and improved mental performance, but carry risk of bleeding
ginkgo biloba and ginseng
this herb is used for BPH, but carries risk of mild ABD discomfort and bleed risk
saw palmetto
this herb is used for postmenopausal symptoms (hot flashes and vaginal dryness), but can lead to hepatic injury
black cohosh
this herb is used for depression and insomnia, but can lead to serotonin syndrome if used with antidepressants, or react with OCPs, Warfarin (low INR), dignoxin, and cause HTN crises
St John’s Wort
used for anxiety and insomnia, it can lead to severe liver damage
kava kava
used for stomach ulcers and bronchitis/viral infections, it can lead to HTN and hypokalemia
licorice
used to prevent colds/flu, it can cause anaphylaxis (esp in asthmatics)
echinacea
used to treat cold/flu or as a weight loss supplement, it can lead to HTN, arrhythmias/MI, CVA, seizures
ephedra
an important natural phenomenon of disease epidemiology, it refers to both disease pathogenesis and exposure to risk modifiers to describe how an inciting event sometimes takes time before a clinical manifestation is evident
latency period
an inherited disorder marked by multiple, bilateral renal cysts; patient are often asymptomatic, but can develop HTN, hematuria, proteinuria, AKI or flank pain
[] genetics [] diagnosis [] what % require renal replacement therapy by age 60? [] extra-renal manifestations [] management
autosomal dominant polycystic kidney disease
inherited with prevalence of 1 in 500
diagnosis requires renal US
50% require RRT by age 60 YO
Extra-Renal:
- cerebral aneurysms
- hepatic/pancreatic cysts
- MVP, AR
- colonic diverticulosis
- ventral/inguinal hernia
Management:
- aggressive HTN management
- control risk factors for CVD and CKD, including statins
- ACE-in for HTN
- H.D., renal transplant
vaginal bleeding with a friable, exophytic cervical lesion
[] diagnosis
[] if patient has HIV+, what does this tell you
[] what are other risk factors for this condition?
cervical cancer
biopsy of the lesion (cervical punch)
in patients who are HIV+, cervical cancer is an AIDS-defining illness as immunocompromised patients do not clear HPV infections and have persistent infection that can progress to cervical dysplasia and cancer
Risk Factors:
- HPV 16, 18
- Hx of STD
- Early onset of sexual maturity
- Multiple or high-risk partners
- Immunosuppression
- OCPs
- low SES
- Tobacco use
this reduces the statistical power to detect an association
sample size (low)
pooling data from several studies to increase statistical power
Meta-analysis
these (3) cause increased maternal serum AFP
- open neural tube defects (e.g., anencephaly, open spina bifida)
acute retrosternal chest pain following episodes of repeated vomiting
[] where are the lesions
[] diagnostic studies
[] management
Boerhaave syndrome
full-thickness tear of the esophagus due to sudden elevation in esophageal pressure (e.g., vomiting) allowing gastric contents to enter sterile sites (e.g., mediastinum)
Most are in the distal 1/3
esophagography or CT with water soluble contrast
acid suppression, NPO, abx
emergency surgical consult
this physical exam finding in a patient with recurrent, forceful retching should be concerning for Boerhaave syndrome
crepitus, crunching sound
Hamman sign
