UWorld Step3 Flashcards
What is subclinical Hypothyroidism?
Mild elevation in TSH levels (5-10) w/normal free T4 levels.
When are considered “convincing hypothyroid sxs” hypothyroidism?
When there is presence of: 1- Antithyroid antibodies 2- Abnormal lipid profile 3- Sxs of hypothyroidism 4- Ovulatory and menstrual dysfunction
should obtain anti-TPO abs in all pts. before treating
Common signs of hypothyroidism overtreatment:
Bone Loss
aFib
Features of cough-variant asthma:
Chronic non-productive cough is predominant sx instead of wheezing and SoB.
Allergens are common triggers as well as exercise and forced expiration.
Commonly occurs at night.
Features of Radiation Proctitis:
Often presents w/diarrhea, mucus discharge and tenesmus during or w/in 6wks of pelvic radiation.
Chronic cases occur >9wks to yrs after radiation.
Chronic radiation proctitis commonly a/w strictures, fistula formation and rectal bleeding.
Colonoscopy findings: continuous lesions w/pallor, friability, telangiectasias, and mucosal hemorrhage
Tx of chronic radiation proctitis:
Sucralfate or Glucocorticoid enemas
Acute cases often tx’d w/supportive measures
Characteristics of tracheomalacia:
Weakness of tracheal walls leading to expiratory airway collapse.
Sxs: coughing, SoB and stridor on PE
Features of Upper Airway Cough Syndrome (UACS):
Aka Post-Nasal Drip
Chronic non-productive cough, rhinorrhea, and often oropharyngeal cobblestoning on PE
Tx of Generalized convulsive status epilepticus:
- Stabilize circulation, airway/breathing; Evaluate for cause; Give IV BENZOS (lorazepam, diazepam or Midazolam)
- Give adjunctive IV agent: fosphenytoin, phenytoin, valproate
- If seizure still not terminated: EEG + continuous infusion of barbituate, midazolam or propofol
When should a skeletal survey be done in a patient with multiple myeloma?
At time of diagnosis – can assess extent of skeletal involvement and identify impending pathologic fractures.
Typically reveal punched-out lytic lesions and diffuse osteopenia
What kind of lesions do Technetium-99m bone scans primarily detect?
Blastic bony lesions
Much less sensitive than conventional xray for lytic lesions
Features of Hyperviscosity Syndrome:
Nasal or oral bleeding (d/t impaired platelet fxn)
Blurry vision
Neurologic sxs (confusion, HA)
Heart Failure
should obtain plsamapheresis for symptomatic pts
Cxs of Multiple Myeloma (6):
Hypercalcemia Renal Insufficiency Infections (pneumonia, UTIs) Skeletal lesions Hyperviscosity syndrome Thrombosis (arterial and venous)
Common signs/sxs of renal failure:
Dyspnea Nausea Peripheral edema Mental status changes Eventual anemia
Common sxs of hypercalcemia:
Anorexia Nausea Polyuria Constipation Weakness Confusion Pleuritis
Uterine effects of Tamoxifen in pre- v. post- menopausal women:
Post-menopausal: have increased risk of endometrial hyperplasia/cancer and uterine sarcoma
Pre-menopausal: increased risk of endometrial polyp development
Tamoxifen will increase endometrial thickness in both groups
When should pts taking Tamoxifen be screened for adverse effects on the uterus?
Only if they develop sxs: AUB, postmenopausal bleeding, etc.
What is a meta-analysis?
biostats
When data is pooled from several studies
It is used to increase the power of a study (ability to detect difference in outcomes if one exists) by increasing the sample size.
What is stratified analysis?
biostats
Analyzing pts based on the presence or absence of a certain variable.
Used to control confounding factors and distinguish b/w confounding and effect modification.
What is quarternary prevention?
biostats
Set of health activities that mitigate and/or limit the consequences of unnecessary or excessive intervention by the health system.
Ex: use of shared EMR to limit unnecessary, repeat procedures in a pt who has already had a specific procedure done
What is the preferred choice of meningococcal post-exposure prophylaxis?
Rifampin – prescribed 2x/d for 2 days.
Ciprofloxacin (single 500mg oral dose) and Ceftriaxone (250mg single dose) are acceptable alternatives for those who cannot take Rifampin
When should Rifampin not be prescribed as meningococcal pphx?
In women taking oral contraceptives or anyone taking a CYP450 metabolized drug
(it’s a CYP450 inducer and increases hepatic clearance)
What type of HS is caused by the scabies mite?
Delayed type IV HS rxn to the mite and its feces and ova
How is Scabies diagnosed?
Clinically plus confirmation by skin scrapings from lesions that reveal mites, ova and feces under LM.
CYP 450 Inducers (7):
*These will decrease drug effects* Carbamezapine, phenytoin Ginseng, St. John’s Wort Oral Contraceptives Phenobarbital Rifampin
CYP450 Inhibitors (11):
*These will increase drug effects* Acetaminophen, NSAIDs Abx/Antifungals (metronidazole) Amiodarone Cimetidine Omeprazole/PPIs Cranberry Juice, Ginko, Vit.E Thyroid hormone SSRIs (fluoxetine)
Laboratory abnormalities in hypothermic patients (9):
anion-gap Metabolic acidosis Respiratory acidosis Azotemia Hyperkalemia Hypergylcemia Elevated lipase Elevated Hct/Hemoconcentration Coagulopathy w/increased coagulation markers (INR and aPTT) Leukopenia/Thrombocytopenia
Medical contraindications to pregnancy (6):
LVEF <40% NYHA class III-IV heart failure Prior peripartum cardiomyopathy Severe obstructive cardiac lesions Severe pHTN (Eisenmenger syndrome) Unstable aortic dilation >40mm
First line contraceptive option for pts w/Eisenmenger syndrome:
Hysteroscopic sterilization or subdermal progestin implant
Estrogen-containing methods are contraindicated d/t increased risk of thromboembolism
Risk factors for spontaneous abortion:
Previous spontaneous abortion
Advanced maternal age
Substance abuse
Extremes in BMI
What is the Wells criteria?
Calculates pretest probability for PE
+3 points for: Clinical signs of DVT; Alternate dx less likely than PE
+1.5 points for: previous PE or DVT; Heart rate >100; Recent surgery or immobilization
+1 point for: Hemoptysis; Cancer
Total Score = 4 is low pretest probability (PE unlikely); >4 is high pretest probability (PE likely)
What are the 2 distinctive features of acute HIV/retroviral syndrome?
Painful mucocutaneous ulcer (shallow, discrete, white base)
Generalized maculopapular rash that may include the palms and soles
What is a Type II error?
A false negative
The failure to detect a difference bw groups when one exists.
The smaller a study the less power and higher likelihood of type II error
When should balloon valvuloplasty be performed in pts w/bicuspid aortic valves?
Done in symptomatic or asx (pts who plan to become pregnant or participate in competitive sports) young adults if the following criteria are met:
Aortic Stenosis
No significant AV calcification or AR
Peak gradient >50mmHg
Contraindications to fibrinolysis w/tPA (6):
Presence of active internal bleeding
Bleeding diathesis (platelets <100k)
Hypodensity in >33% of an arterial territory on CT
Presence of intracranial hemorrhage on CT
Intracranial surgery in last 3mos
BP > 185/110mmHg
What must be present to diagnose ankylosing spondylitis?
Evidence of sacroiliitis
What are the extraarticular manifestations of ankylosing spondylitis?
Apical pulmonary fibrosis/Restrictive lung disease
Ocular: acute anterior uveitis, cataracts, cystoid macular edema
Cardiac: aortic regurg, MVP
Varicocele
GI: ileal and colonic mucosal ulcerations
Atlanto-axial subluxation –> spinal cord compression
Cauda equina syndrome
Nephrotic syndrome caused by IgA nephropathy and secondary amyloidosis
What are risk factors for disability/poor px in ankylosing spondylitits?
Smoking is a/w very bad px
Prolonged standing and exposure to cold conditions increase risk of disability
1st line therapy for prevention of cluster headaches:
Verapamil – usually initiated at 240mg
Should not be taken repeatedly, and should only be used as a preventive treatment started at the onset of a cluster period.
Occasionally topiramate may be added to verapamil therapy.
Sumatriptan may be used in the acute setting but is not preventative
What is onychomycosis and how is it tx’d?
Fungal infection of finger or toenails most commonly caused by dermatophyte Trichophyton rubrum
1st line: Terbinafine, Itraconazole
2nd line: Griseofulvin, Fluconazole, Ciclopirox
How to distinguish a-thalassemia from B-thal minor:
Both will have same lab values (decreased MCV, normal RDW, norm/high RBCs, norm/high Iron and ferritin) and same peripheral smear (target cells).
Must distinguish w/Hb electrophoresis – will show increased HbA2 for B-minor and normal for a-thal
What is the major threat to internal validity?
biostats
Confounding
What is hungry bone syndrome?
A complication that can be seen following parathyroidectomy
Caused by sudden withdrawal of PTH in pts w/severe hyperparathyroidism, causing an increased influx of Ca2+ from the circulation into the bone.
Typically see signs/sxs of hungry bone syndrome 2-4 days post-op
Pre-op risk factors: severe hyperparathyroidism, severe bone disease and VitD def.
(all these conditions have v high bone turnover)
What are the likely causes of hypocalcemia following a parathyroidectomy?
Relative hypoparathyroidism – suppression of normal parathyroid glands by high Ca2+ levels pre-op fail to respond to low Ca2+ levels post-op
Hungry bone syndrome – when PTH levels fall post-op the dynamics of bone turnover shift from net efflux of Ca2+ from bone to net influx of Ca2+ into bone.
What is the diagnostic criteria of Acute Chest Syndrome?
New pulmonary infiltrate on CXR plus one or more of the following:
Increased work of breathing, cough, tachypnea, wheezing
Temp >38.5C/101.3F
Hypoxemia
Chest pain
What is the initial tx of Acute Chest Syndrome?
Ceftriaxone/Cefotaxime + Azithromycin
IVF
Pain control
When should a blood transfusion be given in acute chest syndrome?
If O2 sat is <92%
Significant anemia
Worsening sxs despite initial tx
How does VitB12 def cause hyperbilirubinemia?
Ineffective erythropoiesis causes hemolytic anemia and indirect hyperbilirubinemia
What is the classic pattern of pain seen in pts w/rotator cuff injuries?
Lateral shoulder or deltoid pain aggravated by reaching or lifting the arms up.
Seen in rotator tears and tendonitis, impingement syndrome and frozen shoulder
What are the 5 steps of a root cause analysis in order?
biostats
- Collect Data
- Create causal factor flow chart
- Identify root causes
- Generate recommendations and implement changes
- Measure success of changes
What medications can cause digoxin toxicity?
Verapamil
Quinidine
Amiodarone
Spironolactone
How is spontaneous bacterial peritonitis diagnosed?
Diagnostic paracentesis w/either positive cultures or 250+ neutrophils in the ascitic fluid
How is a patient’s 90-day survival calculated in the setting of End-Stage liver disease?
With the MELD score
Values used to calculate are serum BR, INR, and serum Creatinine.
Na+ is sometimes added to the calculation
How to tell between an obstructive stone v. sloughed renal papilla:
If there is no evidence of stone on CT then check BUN/Cr
Only renal papillary injury will cause increases in BUN/Cr
Stones will only lead to kidney injury if it is a solitary kidney or they are bilaterally obstructing.
What are some of the side effects of licorice?
May cause HTN and hypokalemia
Will likely see as a result a suppression of the RAAS system with low renin and aldosterone
What is a side effect of black cohosh?
Hepatic injury
When is Indomethacin indicated for tocolysis?
When <32 weeks gestation
32+ weeks it is contraindicated d/t risk of oligohydramnios and premature closure of ductus arteriosus.
When should tocolytics be given?
To pts <34 weeks gestation Give CCBs (Nifedipine) when 32-34 weeks Indomethacin when <32 weeks
What is the tx for V. vulnificus infection?
Doxycycline + Ceftriaxone
What should be done in pts w/cryptococcal meningitis w/recurrent sxs of elevated ICP?
These pts need serial lumbar punctures until the sxs stop – often the yeast and capsular polysaccharides can clog the arachnoid vili and lead to markedly increased ICP which if not managed can cause herniation/death.
In rare cases VP shunts need to be placed
What are the 3 tx-stages for HIV pts w/cryptococcal meningitis?
- Induction – amphotericin B + flucytosine for 2+ weeks (until sxs stop and CSF is sterile)
- Consolidation – high dose oral fluconazole for 8wks
- Maintenance – low dose oral fluconazole for 1+yr to prevent recurrence
This is the same tx strategy for disseminated/cutaneous cryptococcus
What is the definition of a non-preventable adverse event?
biostats
Harm/injury caused by medical management, not by disease/condition
What lab testing should be ordered in a patient found to have an adrenal mass?
ALL adrenal masses should be worked up. Serum electrolytes Dexamethasone suppression testing 24-hr urine catecholamine Metanephrine VMA 17-ketosteroid measurement
When should surgical excision be recommended for an adrenal tumor?
All functional tumors (hormone secreting, etc.) All malignancies (which demonstrate characteristic heterogenous appearance on imaging) All tumors >4cm
Features of lateral Medullary Syndrome:
aka Wallenberg syndrome – most sxs ipsilateral
Vertigo, falling to side of lesion, diplopia, nystagmus, difficult sitting upright, limb ataxia
Abnormal facial sensation or pain
Dysphagia, aspiration, hoarseness
Horner’s syndrome, hiccups, lack of autonomic respiration
Where would a lesion be expected to cause sensory loss in the contralateral face and body?
The thalamus or cortex – loss in face and body on the same side, contralateral to the lesion
Contrast to lesions in the brainstem (medulla) involving the CNs, these will cause losses in ipsilateral face and contralateral body
What type of contraception is ideal for pts w/PCOS?
1st line are combined OCPs, but they should all receive progestins – these confer endometrial protection and help thin and reverse the hyperplasia thereby reducing the risk of cancer
What exam findings are consistent w/severe aortic stenosis?
- Soft, single second heart sound (S2) – d/t delayed closure of the aortic valve
- Pulsus parvus et tardus – delayed and diminished carotid pulse
- Loud and late-peaking systolic murmur
What is most likely to cause multi-nutrient malabsorption in a young patient?
Celiac disease
What are some of the extraintestinal manifestations of celiac disease?
General: fatigue, weight loss Skin: dermatitis herpetiformis, vitiligo MSK: osteopenia/porosis, osteomalacia – high alk phos levels, low Ca2+, low PO4-, low Vit. D Heme: anemia (esp. Fe-deficient) Neuro: peripheral neuropathy, HAs Endocrine: AI thyroiditis, Type I DM Psych: depression, psychosis
What are the characteristics and causes of subclinical hyperthyroidism?
Characteristics: Suppressed TSH, normal thyroid hormone levels, +/- hyperthyroid sxs
Causes: Exogenous thyroid hormone, graves disease, nodular thyroid disease, inflammatory thyroiditis
When is tx indicated in the setting of subclinical hyperthyroidism?
If TSH is persistently <0.1 If TSH is 0.1-0.5 PLUS additional risk factor: Age 65+ Heart disease Osteoporosis Nodular thyroid disease
What is the tx of symptomatic bacterial vaginosis?
Oral or vaginal Metronidazole or Clindamycin
during pregnancy only symptomatic pts are tx’d; tx does not decrease cxs in asx pts
When should a carotid endarterectomy be performed?
In patients w/symptomatic carotid artery disease who have high grade stenosis (70-99%) and a life expectancy of 5+ years
Risks outweigh benefits in pts who are poor surgical candidates or have shorter life expectancies.
What are the 3 CHD risk equivalents/most significant predictors of adverse cardiovascular outcomes?
- Noncoronary atherosclerotic disease (carotid, PAD, AAA)
- Diabetes
- CKD
How is Juvenile myoclonic epilepsy diagnosed?
EEG showing bilateral polyspike and slow wave activity/discharges
What are the characteristics and tx of infantile spasms?
Epileptic disorder of infancy characterized by symmetric spasms, developmental delay and hypsarrhythmia on EEG.
Gold-standard tx: Corticotropin (ACTH) and Vigabatrin
What are common secondary causes of restless leg syndrome?
Fe-deficiency anemia Uremia/ESRD/CKD DM MS or Parkinson Pregnancy Drugs – antidepressants, metoclopramide
How would cholecystitis and cholangitis be differentiated on US?
Cholecystitis will show gallbladder wall thickening and edema/pericholecystic fluid (no obstruction, just inflammation)
Cholangitis will show dilation of the intrahepatic ducts and common bile duct (obstruction leading to infection)
What is a common complication of gallstone pancreatitis?
Acute cholangitis – should be suspected in anyone w/gallstone pancreatitis who has fevers, RUQ pain, jaundice, AMS, and HoTN.
Must do ERCP stat to relieve obstruction to prevent development of sepsis and death
What Rxs are contraindicated or should be avoided in pts w/RVMI?
Nitrates – decrease RV preload and cause profound HoTN and cardiogenic shock
Diuretics – volume depletion and HoTN
Opiates – venous dilation and decreased RV preload
BBs – sometimes appropriate, but contraindicated in pts w/bradycardia or cardiogenic shock
How can a large PE be differentiated from RV MI?
PE is more likely to cause tachycardia, dyspnea, and syncope
RVMI is more likely to cause bradycardia and arrhythmias
Both can cause RV dysfxn, increased CVP and decreased LV preload and CO
What are signs of RV MI?
Often in patients w/acute inferior wall MI d/t occlusion of the RCA proximal to the RV brs.
Signs/Sxs: chest pain, HoTN, autonomic signs (diaphoresis, V), and EKG findings of ST elevation in leads II, III, and aVF.
May also have JVD, +Kussmaul’s sign, and clear lung fields suggestive of RVF
Possible bradycardia or AV block bc enhanced AV tone.
EKG leads involved in RV MI:
Blocked RCA
ST elevation in V4-V6
Occurs in 1/2 of Inferior MIs
EKG leads involves in lateral MI:
LCX, diagonal vessel blocked
ST elevation in I, aVL, V5 and V6
ST depression in II, III, and aVF
EKG leads involved in posterior MI:
LCX or RCA blocked
ST depression in V1-V3
ST elevation in I and aVL (LCX)
ST depression in I and aVL (RCA)
EKG leads involved in inferior MI:
RCA or LCX blocked
ST elevation in leads II, III, and aVF
Inferior MIs are a/w HoTN, bradycardia and AV block.
EKG leads involved in anterior MI:
LAD blocked
Some or all of V1-V6
Anticholinergic effects of TCAs:
Dry mouth Blurred vision Dilated pupils Flushing Hyperthermia Urinary retention
How is Dementia w/Lewy bodies treated?
Cholinesterase inhibitors (donepezil) for cognitive impairment Carbidopa-levodopa for parkinsonism Melatonin for REM sleep behavior disorder
antipsychotics may be used to tx functionally impairing visual hallucinations/delusions, but pts w/DLB are vv sensitive to antipsychotics and they can cause significant worsening of confusion, parkinsonism and autonomic dysfunction
If antipsychotics need to be prescribed in DLB which should be used?
Low-potency 2nd gens like Quetiapine
High-potency 2nd gens (Risperidone) and 1st gens are a/w significant exacerbations of sxs
What is the MoA of Organophosphates?
They inhibit acetylcholinesterase at the NMJ – causes CHOLINERGIC toxicity
What is the MoA of Atropine?
Competitive inhibition of acetylcholine at muscarinic receptors – causes anticholinergic toxicity.
What are the signs/sxs of Cholinergic toxicity?
Muscarinic effects: “DUMBELS” Defecation/diarrhea Urination Miosis Bronchospasm/bradycardia Emesis Lacrimation Salivation Nicotinic effects: mm. weakness, paralysis, fasciculation CNS: respiratory failure, seizure, coma
often caused by organophosphate poisoning
Mgmt of organophosphate poisoning:
Emergent resuscitation – O2, IVF, intubation Atropine & Pralidoxime Activated charcoal (if w/in 1hr of exposure)
Common sxs seen in anticholinergic toxicity:
Dry mucous membranes Flushing Mydriasis Urinary retention Decreased bowel motility
1 risk factor for PID:
Multiple sexual partners
Common signs/sxs of salicylate toxicity:
Brain: Tinnitus, dizziness, AMS, cerebral edema, seizures
Lungs: tachypnea, pulmonary edema
Heart: arrhythmia
Liver: hepatitis
Stomach: nausea, vomiting
Systemic: fever/hyperthermia, metabolic acidosis/lactic acidosis
Tx of salicylate toxicity:
Alkalinization of serum and urine w/sodium bicarb
Other options: supplemental glucose (dextrose 5% H2O), activated charcoal (if w/in 2hrs of ingestion), dialysis (if pt has pulm edema, fluid overload, AMS, renal failure, cerebral edema, severe acidosis or v high salicylate levels)
What are the typical lab findings in RMSF?
Thrombocytopenia
Hyponatremia
Increased AST and ALT
What is the tx of RMSF?
Doxycycline – even for children and pregnant women
What is the tx of Lyme disease?
Doxycycline for all late stages and early stage in everyone >8yo
Amoxicillin for early lyme in children <8
When should inotropic agents be used in pts w/RVMI?
When a pt. has persistent HoTN despite aggressive fluid resuscitation.
Dopamine is the initial Rx of choice
Dobutamine should be avoided as it can decrease PVR and worsen HoTN.
When would hypertrophic osteoarthropathy be seen?
It is a paraneoplastic syndrome a/w intrathoracic malignancy + other pulm diseases (CF)
Polyarthropathy a/w digital clubbing and periostosis (xs bone formation)
Dx of Polymyositis:
Elevated m. enzymes – CK, aldolase, AST
Auto-Abs – ANA, anti-Jo-1
Bx – Endomysial infiltrate and patchy necrosis
DTR in polymyositis:
NORMAL! Differentiates it between other causes of muscle weakness – Hypothyroidism (delayed), and Lambert Eaton (absent)
What is mixed connective tissue disease and what are the lab findings?
AI disorder w/variable features of: SLE, Systemic Sclerosis and Polymyositis
Lab findings: Anti-U1 ribonucleoprotein, ANA, RF, anti-CCP, elevated CK, anemia/cytpoenias
What is the difference b/w PMR and Polymyositis?
PMR has pain and stiffness in muscles, but NO weakness. Have increased ESR and CRP, but CK, aldolase, etc are all normal
Polymyositis has severe weakness, but pain is mild/absent and no stiffness. Will have increased CK, aldolase, AST and ANA/Anti-Jo-1 Abs. Need muscle bx to dx this but not PMR
What are the side effects of SGLT2 inhibitors?
Sodium-glucose cotransporter-2 inhibitors (canagliflozin) can cause:
Genitourinary infections – vulvovaginal candidiasis, UTIs
Fluid loss – symptomatic HoTN, AKI
Metabolic abnormalities: Hyperkalemia, hyperglycemia, euglycemic ketoacidosis
Misc – low trauma fractures, amputation
What is the approximate chance of a patient with acute HBV infection progressing to chronic HBV infection?
The chance decreases with age:
Perinatally acquired infections have 90% chance of progressing to chronic HBV
Children age 1-5 have a 20-50% progression rate
Adults have <5% progression rate
In contrast, HAV has an almost 0% progression rate, and HCV has a 75-85% progression rate
What should be suspected in an alcoholic who develops weakness after feeding/fluids are started?
Rhabdomyolysis 2/2 hypophosphatemia that is exacerbated/unmasked by refeeding
What electrolyte disturbances are seen in refeeding syndrome?
Increased insulin occurs d/t carbohydrate ingestion (IV or enteral)
This causes increased cellular uptake and decreased serum levels of: K+, PO4, Mg2+, and Thiamine
Phosphate is the primary deficient electrolyte bc its needed to make ATP
Deficiencies in Mg2+ and K+ cause cardiac arrhythmias
Thiamine deficiency causes Wernicke
Aggressive nutrition w/o adequate electrolyte replacement – cardiopulmonary failure
DoC for folate-def anemia induced by MTX therapy:
Folinic acid (Leucovorin) – more potent than folic acid, and can rescue RBCs by bypassing the block on DHFR
What are the features of Tuberous sclerosis complex?
Neurocutaneous disorder w/benign tumors in multiple organs – intracardiac rhabdomyomas, renal angiomyolipomas
Angiofibromas, ash-leaf spots and shagreen patches (thick leathery skin, dimpled like an orange peel)
What are the features of Sturge-Weber syndrome?
Triad of port-wine stain on the face, ocular disease (visual deficits or glaucoma), and leptomeningeal capillary-venous malformations.
Often have seizures from the malformations
When does renal biopsy need to be performed in the pediatric population?
Kids >10 w/nephrotic syndrome
Kids of all age w/nephritic syndrome
Patients <10 w/minimal change that don’t respond to steroids
What imaging should be part of the initial evaluation in a pt. suspected to have Tuberous Sclerosis Complex?
Brain MRI/EEG – determine if there are any tumors or baseline seizure activity
Abdominal US or MRI – evaluate for renal involvement (obstructive renal angiomyolipomas)
Neurologic impairment/epilepsy is the #1 cause of death in TSC and renal involvement is the 2nd
How is Cerebral palsy diagnosed?
Clinically (usually by 1-2yrs) + Brain MRI (shows periventricular leukomalacia, brain malformation, ischemia, BG lesions, etc.)
EEG should only be done in pts who have seizure-like activity
Sxs of Scombroid poisoning:
Flushing, throbbing HA, palpitations, abdominal cramps, diarrhea, oral burning, skin erythema, wheezing, tachycardia, and HoTN
Occurs when fish is stored improperly and histidine undergoes decarboxylation to form histamine
Sxs of pufferfish poisoning:
Primarily neurologic: perioral tingling, incoordination, weakness, etc.
What are the common features of subphrenic abscess and how is it diagnosed?
Commonly seen 14-21 days after abdominal surgery
Often have hx of abdominal surgery, swinging fever, leukocytosis, and cough and shoulder-tip pain may be the presenting sxs.
Abdominal US is best diagnostic test
What is the role of Lamotrigine in bipolar patients?
An anticonvulsant, it is used in the depressed phase and for maintenance therapy
It is not effective for treating mania.
Quetiapine and Lurasidone are alternatives for bipolar depression
When should antibiotics be added to the mgmt. of a pt. w/COPD exacerbation?
If they have any 2 of the following: Increased sputum purulence Increased sputum volume Increased dyspnea Or if they require any type of mechanical ventilation (invasive or non)
What is the definition of macrocephaly and when should neuroimaging be sought?
Macrocephaly is head circumference >97th percentile for age
Neuroimaging should be done to evaluate for pathologic processes when:
Rapidly expanding HC (>2cm/mo in an infant <6mo)
Neuro abnormalities (seizures etc)
Developmental delay
Head US is best study in infants w/open anterior fontanelle
What measure of association should be used in case control studies, and how is it calculated?
biostats
Odds ratio should be used. It is the odds of an event occurring in exposed patients divided by the odds of an event in unexposed pts. (null value is 1)
OR = (a/c) / (b/d) = (ad)/(bc)
What measure of association should be used in cohort studies and how is it calculated?
biostats
Relative risk (null value is 1.0)
RR = (a (a+b)) / (c (c+d))
= (risk of developing disease in the exposed group) / (risk in the unexposed)
What does the kappa statistic measure?
biostats
Inter-rater reliability
What is the null value when assessing OR?
biostats
1.0
Ho = 1.0 for RR and HR as well.
What is the most specific finding to suggest cardiac tamponade?
Early diastolic collapse of the RV and RA – seen on echo
Electrical alternans on EKG is also fairly specific for tamponade
In contrast, low-voltage QRS on EKG, kussmaul sign, and pulsus paradoxus are all non-specific and can be seen in multiple other disease states.
What are the signs/sxs of Ethylene glycol (antifreeze) toxicity?
Early signs: nausea, vomiting, slurred speech, ataxia, nystagmus, lethargy, kussmaul’s breathing/rapid and deep (d/t severe anion-gap metab acidosis)
Later signs/further toxicity: tachypnea, agitation, confusion, flank pain, renal failure, pulmonary edema, AMS, eventual coma
When do oral glucocorticoids need tapering?
If they have been taken for 3+ weeks, especially if they were taken at high doses or at night. Need a roughly 3 week tapering period
What antibiotic has increased risk for tendon ruptures/tears?
FLUOROQUINOLONES
Hydroxychloroquine also increases risk
What medication is approved for photoaged skin?
Tretinoins
What is the main complication of anal abscesses?
Fistula formation – up to 50% of pts w/anal abscesses develop chronic fistula
What diseases are WSW at higher risk for?
HPV infection and therefore cervical cancer
Ovarian and breast cancers – d/t higher rates of smoking and obesity, less freq screening, lower parity and less OCP use
Bacterial vaginosis
DM-II
CVD
What is net clinical benefit?
biostats
The clinical usefulness of a medication – it’s a measure of its possible benefit minus its harm
What is the primary purpose of using an “intention-to-treat” approach?
biostats
To preserve randomization
Causes of acute, painless vision loss:
- Central retinal a. occlusion – have pale fundus w/”cherry red spot”
- Central retinal v. occlusion – fundus w/retinal hemorrhages and optic disc edema
- Retinal detachment – fundus w/vitreous hemorrhages and marked elevation of retina
- Vitreous hemorrhage – decreased red reflex, visible hemorrhage on fundoscopy
What is length-time bias?
biostats
When pts w/rapidly progressive form of a disease are less likely to be detected by screening when compared to those w/slowly progressive disease
Slowly progressive pts remain asx for longer and increase their chances of being diagnosed by screening measures.
What are the calculations for Sensitivity and Specificity?
biostats
Sensitivity = True Positives / (TP + FN) or A / (A + C) Specificity = True Negatives / (TN + FP) or D / (B + D)
What are the calculations for PPV and NPV?
biostats
PPV = TP/ all(+) or A/(A + B) NPV= TN/ all(–) or D/(D + C)
What is the only azole that should not be used in Aspergillus infection?
Fluconazole – has limited activity against aspergillus and shouldn’t be used
What is the treatment of Allergic Bronchopulmonary Aspergillosis?
Systemic glucocorticoids
Antifungal therapy – itraconazole or voriconazole are DoCs
Omalizumab may occasionally be used
What findings should raise suspicion for TB meningitis?
Brain imaging showing basilar meningeal enhancement
CSF showing: increased protein, low glucose, lymphocytic pleocytosis, elevated adenosine deaminase
May also see choroidal tubercles (yellow-white nodules near optic disc) on fundoscopy
When should colchicine NOT be used in an acute gouty attack?
In patients taking other medications that cause leukopenia as that is also a risk of colchicine, and in patients w/renal failure
When do hepatic adenomas require treatment?
If they are symptomatic or >5cm – surgical resection
If asx and <5 then stop offending meds (OCPs)
What are some of the common features to suggest Cervical Myelopathy?
LMN signs at the level of the lesion – weakness and atrophy in the arms
UMN signs below the lesion – gait dysfxn, and hyperreflexia in the legs
How would paraneoplastic myelopathy present?
It is lesion against the spinal cord and will present w/flaccid or spastic paraplegia or quadriplegia, sensory deficits +/- urinary or fecal retention/incontinence
Common findings in invasive aspergillosis:
Triad of fever, chest pain and hemoptysis
Pulmonary nodules (yes plural) with halo sign (surrounding ground-glass opacities)
Positive cell wall biomarkers (galactomannan, beta-D-glucan)
Tx of Invasive Aspergillosis:
1-2wks of IV Voriconazole + an Echinocandin (Capsofungin)
Then can be transitioned to prolonged oral tx of Voriconazole alone
Tx of ITP:
glucocorticoids
What should all patients with presumed ITP be tested for?
HIV and HCV
What kind of infection is ringworm?
It is a Dermatophyte infection – Tinea Corporis
Aka this is a fungal, NOT parasitic infection and needs to be tx’d 1st line w/topical anti-fungals (Clotrimazole, terbinafine)
Dermatophyte infection involving the scalp (tinea capitis), diffuse or refractory cases are tx’d w/oral anti-fungals (griseofulvin, terbinafine)
What are the main organisms that cause central line-associated bloodstream infections?
#1: Coagulase negative staph. Others: S. aureus, gram negs. (Klebsiella, pseudomonas), and Candida
When should Cefepime be part of the tx regimen for meningitis?
If the person is IMCP’d or it occurs after neurosurgery/penetrating skull trauma
It’s a 4th gen-ceph and covers: S. pneumo, N. meningitidis, GBS, H. influenzae, MSSA and Pseudomonas
Common causes of adrenal hemorrhage:
Pts on anticoagulants w/acute stress (sepsis)
Hemorrhagic necrosis w/systemic infections: meningococcemia or pseudomonas sepsis
What characteristic of CF bronchiectasis helps differentiate it from other causes?
Upper lung lobe involvement – CF is the main cause of bronchiectasis involving the upper lobes
Infection w/Pseudomonas is also characteristic
Febrile Neutropenia common causes and treatment:
G-negs (P. aeruginosa especially) are most common infection in febrile neutropenia.
Once blood cultures are taken monotherapy w/an anti-pseudomonal B-lactam should be started – cefepime, meropenem, pip-tazo.
Presentation of Langerhans cell histiocytosis:
Lytic bone lesions (skull, jaw, femur) seen in diaphysis of long bones
Skin lesions (purplish papules, eczematous rash)
Lymphadenopathy, hepatosplenomegaly
Pulmonary cysts/nodules
Central DI
What is the most common cause of Pneumonia in CF children v. adults?
In children, S. aureus is the most common and Pseudomonas is in adults.
S. aureus starts to decline around age 20 whereas pseudomonas begins to peak.
Both pathogens should be covered in tx of pneumonia in CF children.
What renal disease are HBV+ people most at risk of getting?
Membranous nephropathy.
Normally uncommon in children, but can occur in those w/HBV
What cyanotic heart diseases of the newborn present with a single S2?
Transposition – Single S2 +/- VSD murmur
Tricuspid atresia – Single S2 + VSD murmur
Truncus arteriosus – Single S2 + systolic ejection murmur
Most common congenital cyanotic heart disease in the neonatal period:
Transposition of the great vessels.
What kind of bacteria is Bartonella henselae and what is the tx?
Fastidious gram neg bacilli
Tx: Azithromycin; However, many cases are self-limiting and don’t require tx
*may also add clindamycin if lymphadenopathy is present but dx is unclear
Tx of Sporotrichosis:
3-6mo of oral Itraconazole
Most common cause of secondary amenorrhea:
Pregnancy
What is the single-item screening question used for alcohol abuse?
How many times in the past year have you had 5 (4 for women) or more drinks in a day?
When is metformin contraindicated?
In pts w an estimated GFR <30
Should be used w caution in those w/eGFR 30-45
Mgmt of pancreatogenic diabetes:
Occurs d/t chronic pancreatitis destroying islet cells (alpha and beta)
Tx: Metformin for mild hyperglycemia, Insulin for more severe or symptomatic hyperglycemia
these pts are prone to developing hypoglycemia d/t loss of glucagon-producing a-cells, but ketoacidosis is rare bc of this glucagon loss
What is the typical difference in differentiating Upper GI Bleed (UGIB) v. LGIB?
UGIB mostly presents as hematemesis or melena
LGIB is more commonly hematochezia or bright red blood from the rectum
How does CHF cause hyponatremia?
Low CO and decreased perfusion P at baroreceptors and renal afferent aa. –> increased release of renin and NE + secretion of ADH.
ADH binds to V2 receptors in collecting ducts and increases H2O reabsorption
Renin and NE increase proximal Na+ and H2O reabsorption and limit water delivery to distal tubules
This all leads to water retention and dilutional hyponatremia
Hyponatremia in CHF parallels the severity of HF and is a predictor of adverse outcomes
When should hyponatremia be corrected in the setting of CHF?
If the patient develops sxs of hyponatremia or if they are asx in severe hyponatremia (Na+ <120)
Initial tx is water intake restriction
Correction of hyponatremia doesn’t improve clinical outcomes a/w HF
What abx pose increased risk of infantile hypertrophic pyloric stenosis?
Macrolides: Azithromycin and Erythromycin
- often given as post-exposure pphx for pertussis to infants w/a sick contact
What is the main cause of otitis-conjunctivitis syndrome?
Nontypeable H. Influenzae
Causes concurrent otitis media and purulent conjunctivitis
Tx of acute otitis media:
Initial: Amoxicillin
2nd Line: Amoxicillin-clavulanate (given for recurrent AOM if pt already received amoxicillin w/in the same month)
Penicillin-allergic: clindamycin or azithromycin
When is a cerclage typically placed?
at 12-14 weeks gestation
What is the tx of scleroderma renal crisis?
ACEIs are the DoC (captopril esp.) bc they reverse the angiotensin-induced vasoconstriction
If the pt. has malignant HTN w/CNS manifestations a 2nd agent may be added, like IV nitroprusside
What tests should be ordered when adrenal insufficiency is suspected and how are they interpreted?
Need morning plasma cortisol w/concurrent ACTH
- Low cortisol + high ACTH – diagnostic for primary adrenal insufficiency
- Low cortisol + low ACTH – secondary or tertiary adrenal insufficiency
- If testing is indeterminate get further tests to assess pituitary fxn
How will hypoaldosteronsim present?
Often asx w/hyperkalemia and mild metabolic acidosis
How will Chronic adrenal insufficiency present?
Fatigue, weight loss, myalgias, increased pigmentation, decreased axillary and pubic hair
Labs: hyponatremia, hyperkalemia, hyperchloremic metabolic acidosis
How long can lymphadenopathy be observed for following a viral illness?
Lymphadenopathy is common in mono especially and can be observed for 3-4 weeks or less if the pt. presents w/ signs of malignancy.
After this time period they should be referred for biopsy
What are the key differences b/w Aplastic crisis and splenic sequestration crisis in sickle cell pts?
Aplastic crisis – reticulocytes go down (<1%); transient arrest of erythropoiesis, secondary to infection
Splenic sequestration – reticulocytes increase; vaso-occlusion causes rapidly enlarging spleen, only occurs prior to autosplenectomy
When should a long-term tunneled catheter be removed in the setting of suspected catheter-related bloodstream infection?
If any of the following are present:
1. Severe sepsis
2. Hemodynamic instability
3. Evidence of metastatic infection (endocarditis)
4. Pus at the exit site of the catheter
5. Continued sxs >72 hrs after abx
6. Blood culture confirmation of: S. aureus, P. aeruginosa, or fungi (candida)
All other pts should just have catheter changed over a guidewire once afebrile and stable
1st line treatment of HTN in Gout pts:
ARBs and ACEIs
*Especially Losartan: has a mild uricosuric effect
Most diuretics (thiazides, furosemide) decrease urate excretion and should be avoided
When is a CT urogram safe during pregnancy?
Only in the 2nd and 3rd trimesters
It should never be the 1st imaging test ordered in pregnancy – start w/renal and pelvic US, if negative do transvaginal US, if negative either treat empirically for stone or can do MRU or low-dose CTU
What abx have activity against Pseudomonas?
Cefepime and Ceftazidime (cephalosporins)
Amikacin and tobramycin (aminoglycosides)
Carbapenems
Levofloxacin, gemofloxacin (respiratory fluoroquinolones)
Aztreonam
Colistin (aka polymyxin E)
Pip-tazo
Ticarcillin-clavulanate
What is the leading cause of death in patients with parkinson’s disease?
Aspiration pneumonia
How should all patients w/unexplained new-onset HF be evaluated?
Echo, EKG, and Stress testing or coronary angiography to assess for CAD
What adjunctive therapy can be used to tx PCP?
In addition to TMP-SMX corticosteroids may be used and have been shown to reduce mortality in severe cases.
Indications: PaO2 <70 or A-a gradient >35 on room air.
Difference b/w diagnostic tests of choice for Diverticulitis v. Diverticulosis:
Diverticulosis – barium enema is test of choice, may do colonoscopy
Diverticulitis – Contrast CT is test of choice (barium enema and colonoscopy are contraindicated until rupture is r/o)
Scleroderma renal crisis:
Sudden onset of renal failure (w/o previous kidney disease), malignant HTN (HA, blurry vision, N).
UA may show mild proteinuria
PBS may show microangiopathic hemolytic anemia or DIC w/schistocytes and thrombocytopenia.
Auto-Abs in Scleroderma:
Antinuclear-Ab (most sensitive, but not specific)
Anti-topoisomerase I (anti-Scl-70) Ab & anti-RNA pol III (most specific)
Anticentromere-Ab (mostly in limited disease/CREST)
What kind of shock can be seen in mineralocorticoid deficiency?
Distributive shock – norm from primary adrenal insufficiency.
Will have HoTN from low aldosterone levels and low SVR a/w hyperkalemia and hyponatremia.
How to differentiate between primary and secondary adrenal insufficiency:
Primary – d/t AI destruction of adrenal gland will see hyperpigmentation and mineralocorticoid deficiency, HoTN etc. Eosinophilia and hyperplasia of lymphoid tissues (tonsils) are also common findings.
Secondary – d/t destruction of the pituitary gland will not have these effects and will only present w/signs of glucocorticoid and androgen deficiency.
What anesthetic can lead to adrenal insufficiency?
Etomidate – it inhibits 11B-hydroxylase
Tx of tinea versicolor:
Topical anti-fungals (azoles are DoC)
If topical tx is ineffective or there is extensive disease, switch to oral azole
What is a 24-hr holter monitoring used for?
To diagnose suspected paroxysmal cardiac arrhythmias
What are the 5 diagnostic criteria for Kawasaki disease?
- Rash – inguinal folds, perineum, trunk
- Nonexudative conjunctivitis
- Swelling +/- erythema of palms/soles
- Mucositis – erythema of lips, tongue, oral mucosa
- Cervical lymph node >1.5cm
All these must be present w/fever for 5+ days
How should a child w/suspected Kawasaki disease be managed when they don’t meet all 5 diagnostic criteria?
If 3 or less criteria are met in a child w/5+ days of fever then CRP, or ESR should be measured, ibuprofen should be given and daily follow up should occur to monitor for more sxs
If 4 criteria are met then you can diagnose KD and give aspirin + IVIG (only given until response is seen)
What challenge does the mgmt. of Kawasaki pose in children?
It is tx’d w/IVIG which interferes w/the body’s normal immune response to live vaccines and therefore live vaccines should be deferred for 11 months after receiving IVIG
What type of dysphagia is seen in Barrett’s esophagus?
None – it doesn’t cause dysphagia
If it transitions into malignancy the associated malignancy can cause obstructive dysphagia
What are the antipsychotic induced extrapyramidal effects and how are they treated?
Acute Dystonia – benztropine, diphenhydramine
Akathisia – BB (propranolol), benzodiazepine (lorazepam), benztropine
Parkinsonism – Benztropine, amantadine
Tardive dyskinesia – valbenazine, deutetrabenazine
How is spontaneous splenic rupture managed?
Initially non-operatively w/volume resuscitation and gaining hemodynamic stability
If pts remain hemodynamically unstable despite adequate resuscitation cut em open
Analgesics a/w Rx-induced pancreatitis:
Acetaminophen
NSAIDs
Mesalamine, Sulfasalazine
Opiates
Antibiotics a/w Rx-induced pancreatitis:
Isoniazid
Tetracyclines
Metronidazole
TMP-SMX
Antiepileptics a/w Rx-induced pancreatitis:
Valproate
Carbamazepine
Anti-hypertensives a/w Rx-induced pancreatitis:
Thiazides, furosemide
Enalapril, losartan
Antivirals a/w Rx-induced pancreatitis:
Lamivudine
Didanosine
Immunosuppressants a/w Rx-induced pancreatitis:
Azathioprine, mercaptopurine
Corticosteroids
What is the most likely outcome of chronic urticaria?
Spontaneous resolution w/in 2-5 years
What EKG findings are the diagnostic criteria of STEMI?
New ST elevation at the J-point in 2+ anatomically contiguous leads w/the following threshold:
- >1mm in all leads except V2 and V3
- 1.5+ mm in women, 2+mm in men 40+, and 2.5+mm in men <40 in leads V2 and V3
New LBBB w/clinical presentation consistent w/ACS
When are cleft lip/palate reconstruction surgeries typically performed?
By 3mos/10wks of age
Rule of 10s: 10lbs of weight, 10wks of age, 10g of hemoglobin
What are the 2main causes of acute mitral regurgitation?
Papillary muscle rupture – occurs d/t MI or trauma
Chordae tendineae rupture – can be 2/2 MVP, Infective endocarditis, Rheumatic heart disease, trauma
Main differences b/w bacterial otitis externa and bacterial otitis media:
Both caused by bacteria and typically have purulent ear drainage (if tympanic membrane is ruptured in AOM)
- Otitis externa almost always has pain on manipulation of the ear, and fever is generally absent
- Otitis media almost always has fever, but pain is often absent once the tympanic membrane is ruptured
Characteristics of late decels on FHR tracing:
Onset w/contraction and 30+ seconds to the nadir
Often seen in setting of fetal hypoxia
Characteristics of variable decels on FHR tracing:
<30 sec to nadir with variable depths, can have more than one between contractions
Often caused by umbilical cord compression
What cancers cause primarily osteoblastic lesions when they have bone mets?
Prostate
Small cell lung
Hodgkin lymphoma
evaluate w/radionuclide bone scan
What cancers primarily have osteolytic lesions when they have bone mets?
Myeloma
Non-small cell lung
Non-hodgkin lymphoma
evaluate w/XR, PET or PET/CT
What abx can be used to treat UTI in pregnancy?
Nitrofurantoin is DoC (5-7d) Amoxicillin (3-7d) Amoxicillin-clavulanate (3-7d) Fosfomycin (single dose) Cephalexin (3-7d) **Tetracyclines, flouroquinolones and TMP-SMX are contraindicated**
When should chelation therapy be used to tx lead poisoning?
When venous lead levels are >45 ug/dL
Dimercaptosuccinic acid (succimer) is used when levels are 45-69
Dimercaprol (British anti-Lewisite) + EDTA is used in emergency when levels are >70 or there are signs of acute encephalopathy.
What are some of the features unique to Ehlers-Danlos syndrome?
Skin manifestations – transparent/hyperextensible skin, easy bruising, poor healing, velvety w/atrophy and scarring
Abdominal and inguinal hernias
Uterine prolapse
High arched palate
What are some of the features unique to Marfan syndrome?
Tall w/long extremities Pectus carinatum Progressive aortic root dilation Lens and retinal detachment Spontaneous pneumothorax
Genetics a/w Ehlers-Danlos and Marfan syndromes:
Both AD inheritance
ED – COL5A1 and COL5A2 mutations
Marfan – FBN1 mutation
Calculation for NNT:
biostats
NNT = 1/ARR
ARR = (% affected in control group) – (% affected in treatment group)
= (c/(c+d)) – (a/(a+b))
How is PPV influenced by other factors?
biostats
PPV increases with increasing prevalence and increases with increased specificity
NPV increases with increasing sensitivity
What is attributable risk and how is it calculated?
biostats
AR is the difference in risk b/w exposed and unexposed
AR = (a/(a+b)) - (c/(c+d))
Risk factors of cerebral palsy:
Prematurity
Low birth weight
Smoking and EtOH use are NOT risk factors
Why does prematurity increase the risk of Cerebral Palsy?
Premature infants are more likely to have periventricular leukomalacia (white matter necrosis from ischemia/infarction) and intraventricular hemorrhage
Both of these are a/w CP
Diagnostic study for suspected aortic dissection:
TEE or CTA – but can’t use CTA in renal disease.
TTE should not be used
What complications can be prevented by lowering HbA1c/achieving glycemic control in DM?
The microvascular complications – nephropathy and retinopathy – will be reduced.
It will have no change on the macrovascular complications – MI, stroke.
Most common AE w/in 1-6hrs of transfusion:
Febrile nonhemolytic transfusion rxn. – can be prevented with leukoreduction.
When should cells be washed prior to transfusion?
If the pt. has IgA deficiency or had a prior allergic transfusion rxn.
Difference in lung region affected by Silicosis v. Asbestosis:
Asbestosis is one of the only pneumoconiosis that affects the LOWER lobes of the lungs
Pneumoconioses that affect the upper lobes:
Silicosis (a/w sandblasting and foundries, increases risk of TB)
Berylliosis (a/w aerospace engineering, vv. high risk of lung ca.)
Coal worker’s pneumoconiosis (aka black lung disease)
Evaluation of hypergastrinemia in patients on a PPI:
Nearly all pts on long-term PPIs will have hypergastrinemia (typically <400)
1st step to evaluate is withdrawal PPI and repeat gastrin levels; most pts will have normal gastrin levels after withdrawal
If gastrin levels are still high after PPI d/c then evaluate for other causes: H. pylori, ZES, gastrinoma, etc.
What are cannon waves and when are they seen?
Cannon waves are large a-waves seen on JVP tracings – d/t the RA contracting against a closed tricuspid valve
Seen in heart block and ventricular tachycardia/AV dissociation
What Rxs are used for rate control in aFIb?
CCBs – diltiazem, verapamil
BBs – metoprolol, propranolol, esmolol, atenolol, timolol, carvedilol
What supplement can cause a false-negative occult blood stool test?
Vitamin C
What should be given as long-term tx in anxiety attacks/panic attacks?
SSRI is 1st line
In children with viral GE what can exacerbate sxs and should be avoided?
Fruit juice – juice high in fructose or sorbitol increases the osmotic load and causes fructose malabsorption in the SI. Juices should be avoided until sxs of GE resolve.
What diagnostic tests should be done at the time of diagnosis of Scleroderma?
PFT +/- TTE
Should evaluate for pulmonary involvement as it is common in systemic sclerosis
ILD is common in diffuse cutaneous systemic disease, and pHTN is common in CREST syndrome
How long is the washout period from discontinuing one serotonergic Rx before beginning another?
Most antidepressants require a 14-day washout period before beginning another serotonergic med, but Fluoxetine has a long t1/2 and requires at least 5 weeks.
Mgmt of acute colonic ischemia:
IVF and bowel rest
Abx w/enteric coverage
Colonic resection if necrosis develops
Drugs that decrease levothyroxine absorption:
Bile acid-binding agents (cholestyramine)
Iron
Calcium
Aluminum hydroxide
PPIs
Sucralfate
can try taking these at a different time of day than levothyroxine to avoid malabsorption
Drugs that increase TBG concentration:
Estrogen (oral not IUDs) Pregnancy Tamoxifen, raloxifene, HRT Heroin, methadone Acute hepatitis
Drugs that decrease TBG concentration:
Androgens Glucocoticoids/hypercortisolism Anabolic steroids Slow-release nicotinic acid Chronic liver disease Hypoproteinemia: nephrotic syndrome, starvation
Drugs that increase thyroid hormone metabolism:
Rifampin
Phenytoin
Carbamazepine
What imaging should be done to assess for suspected osteonecrosis of the femoral head?
MRI – much more sensitive than XR
What are the indications for parathyroidectomy?
Age <50
Symptomatic hypercalcemia
Cxs: Osteoporosis, nephrolithiasis/calcinosis, CKD (GFR <60)
Elevated risk of cxs: Ca2+ 1+ above normal, urinary Ca2+ excretion >400mg/day
What complications of lead toxicity occur at the lowest levels?
Cognitive impairment and behavioral problems can occur at levels as low as 10-20
Encephalopathy and hemolytic anemia only occur with severe toxicity (70+)
Decreases in nerve conduction can also occur at low lead levels but peripheral neuropathy is uncommon.
Contraindications to breastfeeding:
Active, untreated TB HIV infection Herpetic breast lesions Active varicella infection Chemo or radiation therapy Active substance use disorder Galactosemia in the infant
When should external cephalic version be performed?
37+ weeks gestation
What is the definitive mgmt. of a tension pneumothorax?
Chest tube placement – needle decompression is appropriate in the emergency setting where tension physiology is present and they are at risk of cardiac arrest, but then should always be replaced with a chest tube.
Needle decompression should not be done in a patient who is stable and has not yet developed tension physiology (tachycardia, JVD, tachypnea, hypoxemia, decreased/absent breath sounds)
Tx of urinary schistosomiasis:
Praziquantel
Tx of Keloid scars:
Intralesional glucocorticoids
Surgical excision can be considered if steroids fail
Tx of Cyanide toxicity
Sodium thiosulfate
What are common causes of SIADH?
CNS disturbance – stroke, hemorrhage, trauma Drugs – carbamazepine, SSRIs, NSAIDs Lung disease – pneumonia Ectopic ADH secretion – SCLC Pain and nausea
How to differentiate SIADH v. XS water ingestion:
SIADH will have serum hypotonicity (<275 mOsm), inappropriately high urine osmolality (>100mOsm), high urine sodium (>40), and clinical euvolemia
Excessive water ingestion will have low urine osmolality (<100mOsm) and euvolemic hyponatremia
Tx of Tourette syndrome:
2nd generation antipsychotics: Risperidone, aripiprazole, are preferred tx
1st generation antipsychotics: fluphenazine, pimozide, haloperidol, can also be used
Other 2nd line options: a2-agonists (clonidine, guanfacine), and tetrabenazine (DA depleter)
What is the most likely outcome of Sarcoidosis?
Resolution of sxs without recurrence (~75%)
Many need no tx, but those who do typically are treated for 1-2 years with steroids and then they are discontinued
Mgmt of Heparin-induced thrombocytopenia:
1st stop all heparin products
2nd start a direct thrombin inhibitor (argatroban) or fondaparinux (these are not oral)
3rd transition to warfarin (bc it is oral) after platelet count has recovered to >150k
Preferred tx of hyperthyroidism:
Methimazole is preferred over PTU bc of the severe hepatotoxicity a/w PTU
PTU is only preferred for women in the first trimester of pregnancy
What is raloxifene?
A SERM – used for breast ca prevention and tx of osteoporosis
What is sensitivity analysis?
biostats
Repeating a primary analysis calculations after modifying certain criteria or variable ranges
Used to determine if such modifications significantly affect the results initially obtained
What are the main complications of HOCM?
Sudden cardiac death
Arrhythmias – Vtach, aFib, etc.
Strong a/w WPW which increases risks of SCD
Drugs that are contraindicated in pts. w/WPW:
BBs CCBs Digoxin Adenosine **AVN conduction should NOT be slowed in these pts. which all these Rxs do**
Diseases associated with HOCM:
Wolf-Parkinson White
Friedreich ataxia
What is saw palmetto often used to tx and what are its side effects?
BPH
Side effects include mild GI sxs and increased bleeding risk
What are Likelihood ratios and how are they calculated?
biostats
LR is the probability of a given test result occurring in a pt. w/a disorder compared to the probability of the same result occurring in a pt. w/o the disorder.
Provides clinically useful information for individual patients and is not effected by prevalence
+LR = sensitivity / (1- specificity) ; -LR = (1-sensitivity)/specificity
LR>2 rules in the disease; LR<0.5 rules out the disease; LR 0.5-2 is equivocal
What does aFib w/rapid ventricular response look like on EKG and what is used to tx?
Narrow QRS-complex tachycardia
Absence of organized P waves
Irregularly irregular rhythm w/varying R-R intervals
Tx w/an AVN blocking agent like a BB or CCB (diltiazem, verapamil); unstable pts need cardioversion
Although adenosine is used to tx narrow-complex tachycardia it has no role in tx of aFib
What should be the initial test in determining the cause of polycythemia?
Serum EPO level
Rxs that increase lithium levels:
Thiazides ACEIs/ARBs NSAIDs (but not aspirin) Abx: tetracycline and Metronidazole Also, volume depletion (often d/t the above stated Rxs)
acetaminophen does not
When should pts w/Lithium toxicity be treated w/hemodialysis?
If levels are >4mEq/L
>2.5 w/sxs or renal failure
Increasing level despite tx w/IVF
What are common signs/sxs of Cushing’s syndrome?
HTN Hyperglycemia – newly diagnosed DM Osteoporosis Mood Swings Hypokalemia Metabolic Alkalosis
Evaluate with overnight dexamethasone suppression test or 24hr urinary free cortisol
Common causes of constrictive pericarditis:
Idiopathic or viral
Cardiac surgery
Radiation therapy
TB pericarditis in endemic areas
What is cardiac cirrhosis?
Hepatic congestion that occurs 2/2 RHF that eventually leads to cirrhosis
Often seen as a result of constrictive pericarditis
Treatment of alopecia areata:
Topical or intralesional corticosteroids
side note: fingernail pitting is commonly a/w this condition
What is the initial mgmt. of DKA?
IV insulin + aggressive IVF (NS) + Potassium supplementation if <5.2
Once serum glucose falls <200 the rate of insulin infusion should be halved and dextrose should be added to IVF to prevent hypoglycemia
When should IV insulin be switched to subQ in DKA?
SubQ insulin can be started for the following: pt is able to eat, glucose is <200, anion gap <12 and serum HCO3 is 15+
IV insulin and SubQ insulin should be overlapped by 1-2hrs
When should mammography begin?
Between 40-50; 50 is recommended for general population but can start as early as 40 depending on individual and patient’s preferences
When should genetic testing for inherited breast cancer disorders be recommended?
2 1st-degree relatives w/breast ca (1 before age 50)
3 first or second degree relatives w/breast ca (at any age)
1st or 2nd degree relative w/breast and ovarian ca
1st degree relative w/ bilateral breast ca
Breast ca in a male relative
Ashkenazi jews w/any 1st or 2nd degree relative w/breast or ovarian ca
Tx for shingles:
7d of oral valacyclovir if they present <72hrs after rash onset
If >72hrs after rash onset typically just get analgesia and topical rash care (zinc oxide cream)
If IMCP’d or widespread disease – get IV acyclovir for 7+ days
How does splenic vein thrombosis often present?
May be asx, but can present w/variceal bleeding d/t isolated gastric varices – this is the hallmark of the disease
May also see portal HTN, ascites and congestive splenomegaly
Often a/w pancreatitis
How should infants of +HBV mothers be managed?
At birth HBV vaccine and HBV-Ig should be administered
Then HBV vax series should be completed at 2 and 6 months
Serology should be taken at 9months – if no HBsAg at that time, infant is uninfected
liver function tests are not used in detection of infantile HBV
Causes of central retinal a. occlusion:
Carotid a. atherosclerosis (most common) Cardiogenic embolism Sm. a. disease d/t DM +/- HTN Carotid a. dissection Hematologic disease (SCD, hypercoagulability) Vasculitis (giant cell arteritis)
central retinal v. occlusion in contrast is usually not d/t embolic disease
What skin manifestation is highly concerning for Neurofibromatosis1?
Axillary and inguinal freckling
They also have numerous, widespread café-au-lait macules (more numerous than the gen population)
What should take precedence in evaluation of a patient suspected to have NF1?
Ophthalmologic evaluation – asses for bilateral optic pathway gliomas
These are pathognomonic for NF1, but often initially asx
When is egg allergy a contraindication to vaccine?
It’s not – personal or FHx is not a contraindication bc anaphylaxis is so rare
Can be given in an inpatient setting though if they want
What do overlapping confidence intervals imply?
biostats
Overlapping areas may or may not imply a statistically significant difference
Non-overlapping areas do imply a statistically significant difference.
What are the features of Pemphigoid gestationis?
Aka herpes gestationis
It’s an autoimmune disease typically presenting in the 2nd or 3rd trimester w/pruritis that precedes a truncal rash
Characteristic rash: begins periumbilical as urticarial papules and plaques – develop into vesicles and bullae
Rash spreads over entire body but spares mucous membranes
Tx of Pemphigoid gestationis:
High-potency topical steroids (triamcinolone)
Antihistamines
Typically resolves after delivery
When should IV-potassium be given in Diuretic-induced hypokalemia?
If the patient has dysfunctional bowel/paralytic ileus, cardiac or neurologic complications
What is penetrance?
The probability of a gene or trait being expressed
Aka will someone with a gene show any presence at all that they have the gene or will they be a silent carrier with no phenotypic expression
What is expressivity?
The variation in phenotypic expression
How to differentiate Sm Bowel Obstruction v. Ileus:
Causes, PE findings and Imaging findings
Small Bowel Obstruction:
Causes – prior surgery (wks to years)
PE – distended abdomen, increased bowel sounds
Imaging – small bowel dilation present; Large bowel distention ABSENT; air-fluid levels
Ileus:
Causes – recent surgery (hrs to days), metabolic (hypokalemia), medication induced
PE – possible distention, reduced/absent bowel sounds
Imaging – small bowel AND large bowel dilation; gas in colon and rectum, no air-fluid levels
Risk factors for testicular cancer:
Cryptorchidism – #1 risk
FHx
HIV infection
Workup in suspected testicular cancer:
Scrotal US
PE – firm ovoid mass or unilateral swelling, absence of transillumination
Tumor markers – AFP, B-hCG
Staging imaging – CT scan, Chest XR
Locations with highest prevalence of tick paralysis:
Australia
Western North America
most cases caused by Rocky Mtn. Wood tick and American Dog Tick
Features of tick paralysis:
Neurotoxins in tick saliva are transmitted over 4-7days and then sxs start:
Brief prodrome of fatigue and paresthesias
Gait ataxia and ascending paralysis develop over hrs
Absent DTRs
Fever and sensation abnormalities are usually absent and Lab and imaging are typically normal
Tx of Tick paralysis:
Meticulous skin examination to find and remove offending agent (tick)
Most patients recover completely after this and have dramatic improvement in sxs w/in few hrs after removal of tick
What features on head CT in an infant would suggest abuse over accident?
A mixed-density pattern showing both acute (hyperdense) subdural bleeds on chronic (hypodense) subdural bleeds
Accidental trauma is more likely to only show acute, hyperdense, bleeding
Mgmt of Shoulder Dystocia:
BE CALM: should be performed in this order
B – breathe, do not push
E – Elevate legs/flex hips (McRoberts)
C – call for help
A – apply suprapubic pressure
L – enlarge vaginal opening w/episiotomy
M – Maneuvers: deliver post. arm; rotate post. shoulder; adduct post. fetal shoulder; mother on hands and knees; all else fails replace fetal head and go for cesarean
When should endoscopic screening be performed to evaluate for Barrett esophagus?
Hx of chronic GERD (>5yrs) or frequent reflux sxs and 2+ of the following risk factors:
Age >50
Male sex
White
Hiatal hernia
Obesity/increased waist circumference (>102cm)
Current or former tobacco use
1st-degree relative w/Barrett esophagus or esophageal adenocarcinoma
What is the standard caloric intake recommended for enteral feeding?
30 kcal/kg/d with 1g/kg of protein
lower amounts are used for pts w/severe malnutrition to prevent refeeding syndrome
What are the tx options and durations of tx for Strep pharyngitis?
Penicillin is preffered tx – should be given orally for 10d minimum
Single dose IM Penicillin can be given to those who can’t tolerate oral abx
Azithromycin or Clindamycin may be given for 5d to those w/anaphylactic Pen allergies
Cefazolin is given for mild pen allergies
abx are continued for this length of time to reduce risk of ARF and suppurative cxs
What is the tx of papulopustular rosacea?
Topical metronidazole – most commonly prescribed
Others:
Azelaic acid
Topical clindamycin
Benzoyl peroxide
Common manifestations of ocular rosacea:
Burning or foreign body sensation Blepharitis Keratitis Conjunctivitis Corneal ulcers Recurrent chalazion
What patients have a higher association of angiodysplasia?
Those with advanced renal disease, Von Willebrand, and Aortic stenosis (d/t acquired vWF deficiency).
What is likely to cause jejunal atresia and how will it present?
Jejunal and ileal atresia likely d/t vascular insults in utero that cause necrosis and resorption of fetal intestine
Common causes: maternal vasoconstrictive meds, tobacco or cocaine abuse
Presents w/bilious emesis, abdominal distension and “triple bubble” sign on xray and gasless colon typically w/in first 24hrs
What is the mgmt. and contraindications for chest pain in cocaine use?
Managed with benzos for BP and anxiety
Aspirin, Nitroglycerin, and CCBs for pain
BBs are contraindicated and Fibrinolytics should be avoided d/t risk of ICH.
Cardiac catheterization w/reperfusion done when indicated aka if there are signs of STEMI on EKG.
What kind of arrhythmia is Carotid massage used for?
Helps to terminate PSVT – a regular, narrow-complex tachycardia. It increases PSNS activity which helps directly slow AVN conductivity
Not used in the tx of aFib
Contraindications: recent TIA/stroke, carotid bruit
What is a desmoid tumor?
Locally aggressive benign tm arising from fibroplastic elements w/in the muscle or fascial planes
It has v. low potential for mets or differentiation
Thought to be d/t abnormal wound healing or clonal chromosomal abnormalities causing neoplastic behavior
Increased risk in patients w/familial adenomatosis polyposis (Gardner syndrome)
How do desmoid tms often present?
As deep seated painless, sometimes painful, masses in the trunk/extremity, intraabdominal bowel and mesentery, and abdominal wall.
They have high rate of recurrence even after aggressive surgery removal
What does exertional lightheadedness/exertional syncope raise suspicion for?
Cardiogenic syncope – d/t an underlying structural heart defect
What sided heart failure causes pulmonary edema?
LEFT – back up in the pulmonary a. leading into the LA will cause pulm edema
What findings on PFT suggest an obstructive lung disease?
Reduced FEV1
Reduced FEV1/FVC ratio – bc FVC is typically normal
TLC, and DLCO are typically normal but may be slightly elevated in asthma and DLCO is decreased in COPD.
What findings of PFT suggest a restrictive lung disease?
FEV1 and FVC both decreased
FEV1/FVC ratio normal or increased
TLC and DLCO are also decreased
What size lesions should be considered suspicious for melanoma?
6+ mm in diameter – these need excisional/punch biopsies with 1-3mm margins
Rxs that can either cause increase or decrease in Lithium levels:
Loop diuretics – furosemide
CCBs – verapamil; but these Rxs are usually considered safe and Amlodipine is routinely used
Rxs that decrease Lithium levels:
K+ sparing diuretics (Spironolactone)
Theophylline
What conditions has Bullous Pemphigoid often been a/w?
Many neurologic conditions such as dementia, Bipolar and MS
What is one of the major complications seen in Sjogren’s Syndrome?
polycloncal B-cell activation and infiltration of the salivary glands leading to B-cell NH lymphoma
Often detected as a submandibular mass
What range of proteinuria is seen in Nephrotic Syndromes?
> 3-3.5 g/d
What is hypoglycemia defined as?
<60mg/dL
What are common EKG findings for Brugada syndrome and long QT syndrome?
Brugada – right bundle branch block and ST elevation in V1-V3
Long QT syndrome – QTc >450 msec in men and >470 in women
What are features of anomalous aortic origin of a coronary artery?
Common cause of SCD in young athletes
May have premonitory sxs of exertional angina, lightheadedness or syncope; SCD may also occur without any prior sxs
EKG and TTE are often nondiagnostic and appear normal
CTA or coronary MRA are diagnostic tests of choice
What is the problem created by anomalous aortic origins of a coronary artery?
By having both L and R coronary artery originate from only one aortic sinus the defect creates a sharp curvature for the anomalous artery and makes it less amenable to high-volume flow.
The anomalous artery also passes between the aorta and pulmonary a. and makes it susceptible to external compression during exercise
Differences b/w Pseudoaneurysm and AV fistula:
Pseudoaneurysm – bulging, pulsatile mass with audible systolic bruit
AVF – no mass, continuous bruit
Both may present with localized pain to the area and can typically be diagnosed w/US
What is the standardized incidence ratio?
biostats
A measure used to determine if the occurrence of a disease in a small population is high or low relative to an expected value derived from a larger comparison population
It is calculated by dividing the observed cases in that population by the expected number of cases
Preferred tx for Guillain-Barre:
Pooled human immune globulin (IVIG) or therapeutic plasma exchange
What is the mgmt. of severe malnutrition (marasmus/kwashiorkor)?
Rewarming for hypothermia
Abx for presumed systemic infection
Rehydration – oral fluids preferred; IVF if in shock
Refeed cautiously
What should pts w/alcohol use disorder and progressive cognitive decline be tested for?
Folate deficiency
What is used to assess the respiratory mm. weakness and monitor respiratory status in pts w/GBS?
Frequent measurement of Vital Capacity and negative inspiratory force
What is a/w broad-notched P-waves on EKG?
Mitral stenosis
EKG shows “P mitrale” (broad, notched P waves), atrial tachyarrhythmias, RVH (tall R waves in V1 and V2)
When is skeletal maturity typically reached?
By the end of puberty with Tanner stage 5
What is the main cause of spreading for viral conjunctivitis?
Eye discharge – pts. are infective and should stay home from school/limit contacts until eye discharge has resolved.
Eye redness and morning crusting may occur after discharge has stopped but these are not considered signs of contagiousness
What is a factorial design?
A study that involves the randomization to different interventions w/additional study of 2+ variables.
Therapy for hyperkalemia and when it should be instituted:
Acute tx: Calcium gluconate or chloride, insulin w/glucose
Should be given to pts. w/ ECG changes, K+ > 7 w/out ECG changes, or rapid K+ d/t tissue breakdown.
Manifestations of hyperkalemia:
Chronic may be asx until K+ > 7mEq/L
Acute causes sxs at lower levels –> ascending m. weakness, flaccid paralysis, ECG changes (peaked Twaves, short QT interval, loss of P wave, QRS widening, sine wave w/vFIb).
What pediatric patients are at risk for Wilm’s tm. and hepatoblastoma?
Patients with Beckwith-Wiedemann syndrome, as well as those with isolated Hemi-hyperplasia
(WAGR complex and Denys-Drash are also at risk for Wilm’s tm.)
Both need to undergo frequent screening w/US and AFP measurements
Features of Neuroblastoma:
Neural crest origin, involves adrenal medulla and sympathetic chain.
Often presents <2yrs, w/abdominal mass. Can get Horner syndrome if in SNS chain
Other features: periorbital ecchymoses (orbital mets), spinal cord compression from epidural invasion, opsoclonus-myoclonus syndrome (rapid vertical and horizontal nystagmus w/myoclonus), HTN, flushing and diaphoresis
Dx: elevated CAs (VMA, HVA), n-myc amplification, small round blue cells on histo.
What is the attributable risk percent (ARP)?
biostats
It’s a measure of excess risk
Estimates the proportion of the disease in the exposed subjects that is attributable to exposure status
ARP = (risk in exposed – risk in unexposed) / (risk in exposed)
= (RR-1)/RR
What is Population attributable risk percent (PARP)?
biostats
It is a measure of excess risk in the total population, not only in exposed subjects
PARP = (Risk in total population – Risk in unexposed) / (Risk in total population)
= [(Prevalence)(RR-1)] / [(Prevalence)(RR-1) +1]
Risk in total population = (risk in exposed)(proportion of exposed) + (risk in unexposed)(proportion of unexposed)
What is the best PE maneuver to assess for complete rupture of the Achilles tendon?
The Thompson test – squeeze the calf to see if there is plantar flexion; no plantar flexion is basically pathognomonic of complete rupture of Achilles tendon.
What signs/sxs would be seen if there were a tibial nerve defect?
Loss of gastrocnemius-soleus motor function
Loss of plantar sensory function
What makes S. pneumoniae more invasive in pts. w/HIV infection?
Its encapsulated and they have deficits in opsonization, humoral immunity and macrophage/neutrophil fxn
When is UDS needed to evaluate incontinence?
If the patient has mixed incontinence or complicated incontinence.
How to differentiate constitutional delay of growth and puberty from familial short stature:
Familial short stature – short stature will be seen with normal growth velocity and a normal bone age
Constitutional delay of puberty – delayed bone age on xray with height and pubertal development correlated more closely with the bone age rather than chronological age
At what age is puberty considered delayed?
If no secondary sexual characteristics (testicular enlargement/breast development) are present by age 14 in boys and 12 in girls
What diet should be recommended in pts w/viral GE?
A normal age-appropriate diet
A bland diet is no longer recommended and diets high in sugar and fats should be avoided until sxs resolve
When should steroids be used in the setting of Infectious Mononucleosis?
If airway obstruction appears imminent – tonsillar enlargement is so large it will cut off the airway
Or if pts are IMCP’d/experiencing other serious cxs: aplastic anemia, overwhelming infection, thrombocytopenia
What is the mgmt. of pediatric patients w/Meningoencephalitis?
Most common causes are viral; enteroviruses (coxsackie) are #1 and HSV is #2
However, empiric tx should be started
Get LP right away and then start IV Acyclovir and abx (Vancomycin + 3rd gen Cephalosporin)
Once HSV and bacterial infections are excluded can stop abx and acyclovir and tx supportively
Steroids are NOT useful in viral meningoencaphalitis
What is Metolazone?
A thiazide diuretic
What are the Kocher Criteria to differentiate septic arthritis v post-viral inflammatory arthritis?
- Non-weight bearing
- Fever >101.3
- ESR >40 or CRP >2
- Leukocytosis
If peds patients have 3 or more than its most likely septic and joint aspiration needs to be done ASAP
What are the most common organisms in pediatric septic arthritis?
S. aureus > S. pneumoniae > S. pyogenes
These should be covered w/IV Vancomycin
Can add a 3rd gen cephalosporin when there is suspicion for unusual pathogens (Kingella in a kid<3 w/oral ulcers; H influenzae in unimmunized kids; Neisseria in sexually active adolescents)
What are common signs of Acute Decompensated HF?
Pulmonary edema
JVD
Presence of an S3
When are BBs contraindicated in the mgmt. of NSTEMI and unstable angina?
If the patient has bradycardia or heart failure (may worsen pulmonary edema in ADHF)
What medications can be used for bipolar mania during pregnancy?
Haloperidol
Lithium – should be continued if already started and can be initiated for severe mania
What is late-life depression a significant risk factor for?
Major neurocognitive disorder (dementia) both vascular and Alzheimer types
It is not a/w development of comorbid anxiety as is earlier development of depression
What DM medications pose the biggest risk for hypoglycemic events?
Insulin
Oral agents that increase insulin secretion even when blood glucose levels are normal:
Sulfonylureas – glyburide, glipizide, glimepride
Meglitinides – nateglinide, repaglinide
What is idiopathic premature pubarche?
Isolated pubic hair development
Patients will have normal bone age and no additional signs of adrenarche (acne, etc.)
What causes central v. peripheral precocious puberty?
Central is d/t early maturation of the hypothalamic-pituitary-gonadal axis
Peripheral is d/t excess sex hormone production from the gonads, adrenal glands, or an exogenous source
What is the tx of nonclassical Congenital Adrenal Hyperplasia?
Hydrocortisone
What is the pathophysiology seen in nonclassic congenital adrenal hyperplasia?
It is AR inheritance
Decreased 21-hydroxlase activity leads to increased 17-hydroxyprogesterone levels and increased androgens
Patients will have normal glucocorticoids and mineralocorticoids (aka no salt wasting like seen in classic CAH)
Clinical features of nonclassic Congenital Adrenal Hyperplasia:
Early pubic/axillary hair growth
Severe acne
Hirsutism and oligomenorrhea in girls
Increased growth velocity and bone age (makes tall children, but short adults)
Typically no evidence of precocious pubertal testicular or breast development
What is the mgmt. and EKG findings of Mobitz Type II AV Block?
On EKG will see intermittent non-conducted P waves (dropped beats not preceded by a change in the length of the PR interval) and regular PR intervals
Often have significant bradycardia
Need placement of permanent pacemaker as this commonly progresses to complete block
