uworld stuff! Flashcards
infant of mother with pregestationa diabetes, presents with cyanosis and structural abnormality on second trimester ultrasound
hypoplastic left ventricle syndrome
infant with weak femoral pulses and decresed postductal oxygen saturation
coarctation of aorta
diaphoresis, cool extremities, JVD, pulmonary crackles, hyperdynamic impulse, apical decrescendo murmur, rapid onset pulmonary edema, heart failure
acute mitral valve prolapse from chordae tendinae rupture
easy bruising, velvety skin with atrophy and scarring, MVP, scoliosis
ehlers-danlos syndrome
biggest give away is the velvet skin and atrophy
mid systolic murmur at the left upper sternal boarder with right atrial and ventricular dilation
atrial septal defect , secundum type
wide fixed splitting of second heart sound
heart failure patients with EF <40 should get what
ACE inhibitor
trastuzumab cardiotoxicity is reversible or irreversible
irreversible
nonejection click and murmur that vary in timing depending on body position
Mitral valve prolapse
worse with decreased venous return
ejection crescendo-decresendo systolic murmur
aortic or pulmonic valve stenosis
harsh holosystolic murmur with maximal intensity over the left thrid and fourth intercostal space with a palpable thrill
VSD
SOB, fatigue, palpitations, cough while laying down, anxious, fatigue, loud fst heart sound with short apical low pitched diastolic rumble. broad notched P wave in lead II with right axis deviation
CXR showing pulmonary edema, elevaton of the left mainstem bronchus, left atrial enlargement with flattening of the left heart boarder
what is this and what can cause this 10 - 20 years after the initial event
mitral stenosis
rheumatic heart disease
progressive dyspnea, fatigue, JVD, lower extremity edema
poor sign is early right ventricular collapse
pericardial tamponade
person has ASCVD risk factors, ACS, angina, arterial revascularization (CABG), stroke, TIA, PAD. what do they need
statin
young person, chest pain and palpitation, lightheadedness that pass out after overexertion, prolonged QT, dies of sudden cardiac death
anomalous aortic origin of coronary arteries
how does bicarb work to treat TCA overdose
what about salicilate overdose
inhibition of fast sodium channels to decrease QRS duration and prevent arrhythmia
alkalynize urine to promote excretion
what medication do you give to people with Afib with RVR (variable R-R) interval
metoprolol, do not give adenosine
PAD disease treatment course
smoking cessation, comorbidity control, statin
exercise program
cilostazol
angioplasty
treatment of cocaine overdose
benzodiazepine, do not give b-blockers previous studies where conducted poorly and are unreliable. can lead to unopposed alpha vasocontriction
suspect this in cocaine overdose in patient with controlled vitals but has persistent chest pain, and new development of neurologic symptoms
aortic dissection
give this medication to acute heart failure patients that are hypertensive and fluid overload
nitroglycerin
what complication is the most common with compartment syndrome
AKI due to myoglobin release
what pressure indicates compartment syndrome
30 or greater
ekg showing narrow complex tachycardia, regular r-r interval and retrograde p waves
psvt
s3 is highly specific for what
heart failure
loud harsh, holosystolic murmur in 4th left intercostal space with palpable thirll
VSD
polymorphic VT such as torsades is usually precipitated by what
bradycardia
what is contraindicated in acute decompensated heartfailure (CP, nausea, weakness, lightheadedness) due to causing decreased contractility of the heart causing worsening of pulmonary edema
b-blockers
edema, ascities, hepatic congestions, elevated JVP with prominent “y” decent, pericardial knock, with CXR showing pericardial thickening or calcification typically after cardiac surgery
constrictive pericarditis
fix this arrhythmia with treatment of underlying lung pathology
multifocal atrial tachycardia,
s4 with systolic murmur along left sternal boarder that increases with valsalva
HOCM
treatment for heart failure with LVOT obstruction
b-blocker or ccb
difference between acute pericarditis and dressler syndrome
dressler occurs several weeks after MI
treatment of peri-infarction pericarditis
aspirin
digoxin toxicity is caused by what four medications
verapimil, amiodarone, quinadine , spironolactone
aortic jet velocity, transvalvular gradient, and valve area that indicated aortic stenosis
> 4 sec, >40mmHg, and <1cm
if they have shortness of breath, angina, syncope, CABG, or EF <50 then replace
HOCM patients die from what and need what to prevent it
sudden cardiac death and ICD
what indicates severe AS as far as the sound of the murmur
loud and late peaking single sound on inspiration
biggest modifiable risk factor for AAA
smoking cessation
INR goal of mitral valve
INR goal of aortic valve
m - 2.5 to 3.5
a - 2 to 3
lower leg claudication, upper extremity HTN
murmur can be interscapular and persistent, left sternal border with brachio-femoral delay
coarctation , associated with turners syndrome
syncope with no prodrome is likely related to what
cardiogenic
syncope triggered by prolonged standing, acute stress, or pain typically with nausea, flushing, warmth, pallor, and sweating that resolves in minutes
vasovagal syncope
holosystolic murmur at the apex with a click
mitral regurgitation
low pitch diastolic murmur over cardiac apex with emboli
atrial myxoma
treatment of cocaine overdose
benzos
bp control from acute ischemic stroke
with TPA
without TPA
<185/105 but greater >140/90
<220/120
vertigo, dizziness, unable to walk, dysarthria, numbness, and visual disturbance
vertebrobasilar insufficieny
cognition waxes and wanes, parkinsonism like symptoms, and hallucinations in older person with frequent falls can also have delusions, depression, and autonomic dysfunction
dementia with lewy bodies, antipsychotics but this can cause things to get worse
bilateral polyspike and slow wave discharges, absoncse, morning myoclonus
juvinile myoclonic epilepsy, valproic acid which can cause thrombocytopenia, hepatotoxicity, and panceatitis
medication that causes gingival hyperplasia
phenytoin
dopamine agonist used for parkinsons treatment
pramipexol or bromocriptine
wet, wobbly, wacky
normal pressure hydrocephalus, LP then VP shunt if LP resolves symptoms
progressive weakness, sensory loss, urinary retention after URI
transverse myelitis
headache under stress, bandlike or bilateral lasting 30 minutes to 7 days
tension headache
patient wakes up during sleep, pain behind one eye, lacrimation, flushing, pupillary changes, and nasal congestion
cluster headache, verapamil for prevention
unilateral, aura, pulitile, phonophobia, photophobia, nausea
migraine headache
vertigo, diplopia, horizonta and vertical nystagmus, sensory loss, dysphagia, hoarsness, ipsilateral horners syndrome
wallenberg syndrome usually caused by occluded intracranial vertebral artery
these brain lesions affect the sensory loss in the contralateral face and body
thalamus or cortex
lesion associated with aphasia, neglect, and agrapesthesia
cortical lesion
lesions that affect the ipsilateral face and contralateral body
brainstem
these two drugs are disease modifying agents for relapsing and remitting MS
beta interferon, glatiramer acetate
pt with seizures that develops horizontal nystagmus, blurred vision, diplopia, ataxia, slurred speech, lethargy
phenytoin toxicity
severe, sudden onset headache with nausea, ptosis, mild anisocoria, and nuchal rigidity
SAH due to posterior communicating artery aneurysm
used in treatment of opioid withdrawal in hospital setting vs rehab
clonidine
methadone
three acetylcholinesterase inhibitor meds and one NMDA receoptor antagonist used for dementia related cognitive impairment
ace - donepezil, rivastigimine, galantamine
nmda - memantine
constant tremor in arms that is worse with movement
benign essential tremor, propranolol
hypertonia, hyperreflexia, clonus, delayed motor milestones, MRI shows periventricualr leukomalacia, basal ganglia lesions
cerebral palsy
progressively worsening severe back pain, mid-thoracic level and wraps around upper abdomen in band like fashion, with weakness, numbness, and tingling in both lower extremities. can also have bowel and bladder incontinence
epidural spinal cord compression, high dose steroids
staring spells, preserved muscle tone, short in duration, 3Hz spike and wave discharges. associated with ADHD, anxiety, and depression
childhood absence epilepsy, ethosuximide
gradually progessive symptoms that impact memory and language first, while behavioral symptoms become more prominent late in disease course
Alzheimer disease, cholinesterase inhibitors slow disease
headache that is different form the past, often with nausea, vomiting, LOC, focal deficits, meningial signs, usually from berry anurysm
SAH, LP definitively excludes SAD if CT is negative
loss of pupillary light reaction, vertical gaze paralysis, loss of optokinetic nystamus, and ataxia. often cause headache due to obstructive hydrocephalus
Parinauds syndrome from pineal tumor
frequent headaches, rhythmic pulsating sound in ears when he bends over, when standing up his vision dims in both eyes, opthalamic exam shoes peripapillary flame hemorrhages, venous engorgement, and hard exudates
pseudotumor cerebri
autosomal dominant disorder with hypopigmented skin lesions “ash leaf spots”, shagreen patches, CNS lesions, epilepsy, intellectual disability
tuberous sclerosis complex
initially presents as asymmetric weakness in one limb, cramping, then progresses over time to atrophy and fasciculations and bulbar involvement causing fasciculation of face
ALS, riluzole which is a glutamate inhibitor
pneumonic for OSA
snoring tired observed apnea pressure (htn) bmi >35 age >50 neck >17 gender male 2 - low 5 - high
what do you measure to assess muscle weakness in the lungs as it relates to neurological disease that cause difficulty breathing
vital capacity at bedside
fever, severe focal back pain, and neurologic deficits
spinal epidural abscess
stroke in the non dominant parietal lobe is called what and what cant the patient do?
construction apraxia, copy line drawings, or will get dressed on half the body
stroke to the dominant parietal lobe is called what and what cant the person do?
gerstmann syndrome, presents with acalculia, finger apraxia, and left vs right confusion
lesions of nondominant temporal lobe cause what
homonymous upper quadrantanopia
lesions of the dominant temporal lobe causes what
homonymous upper quadrantanopia and wernickies aphasia
carbamazepine causes what
bone marrow suppression
think about this in pts with atherosclerotic disease, present with hematochezia, diarrhea, leukocytosis, lactic acidosis. ct shows fat stranding, endoscopy shows edematous and friable mucosa. acute crampy abdominal pain with fecal urgency thats followed by bloody diarrhea
colonic ischemia, bowel rest and abx
acute pancreatitis patients that get worse or develop sepsis do what?
CT scan for necrotizing pancreaitis
decreased tone or excessive transient relaxations of LES
GERD
diffuse abdominal pain in ascities or pt with peritoneal dialysis cath
SBP
rocephin for tx
prophylaxsis give fluoroquinolone
how to calculate saag
serum albumin - ascities albumin = number
>1 infectious
<1 pressure
what decreases the incidence of mortality in SBP? what if that doesnt work
IV albumin
treat hepatorenal syndrome with octreotide or midodrine
when will you see HBV core antibody
window period, (subclinical hepatitis), years after HBV recovery
people who dont improve after 2-3 days after acute diverticulitis should get what
CT scan to evaluate for abscess because this would need surgical intervention
suboptimal breasstfeeding with signs of dehydration
breastfeeding failure jaundice
adequate breastfeeding with normal examination with unconjugated hyperbilirubinemia
breast milk jaundice
diabetic patients with recurrent hypoglycemia episodes with sweating during meals, postural dizziness, postprandial fullness, early satiety and constipation
gastroparesis, erythromycin or metoclopramide
person with gastric ulcer perforation should get what after a chest xray confirms the diagnosis
IV antibiotics, broad spectrum
nonbloody, nonbilious , projectile vomiitng immediately after feeding with the infant that is hungry following the episode of emesis, weight loss and signs of dehydration,?
what is a major risk factor for developing this
infantile hypertrophic pyloric stenosis
macrolides like azithromycin and erythromycin
what metabolic derangement do you see with severe pyloric stenosis
hypokalemic, hypochloremic metabolic alkalosis
patient has discomfort after eating typically 30-40 minutes after meals, coffee makes it worse, complains of back pain, dry cough, and constipation
GERD, consider screening EGD for barrett esophagus
intermittent abdominal pain for 6 months, sharp and located across his mid-abdomen, relieved with sitting upright. post prandial bloating and discomfort. pain gets worse recently. lasts minutes and then resolves. frequent large loose stools that are fatty in nature. multiple hospitalizations in the past. 15lb weight loss over the last 6 months, drinks 4-5 beers daily with some liqour occassionaly. Alk phos is elevated
chronic pancreatitis , pain may be relieved by sitting up or leaning forward.
test of choice is MRCP, alternative would be CT scan
five small frequent meals plus pancreatic enzyme supplementation
the presence of air in the distal colon makes the diagnosis of what less likely
complete bowel obstruction
what is associated with increased risk of death in a patient that presents with acute pancreatitis
BUN greater that 20
pt has bloody bm, urge to defecate followed by blood loss in stool but then self resolves. pts have painless hematochezia that is self liitied
diverticular bleeding,
pt tired, bilateral xanthelasmata, elevated alk phos, transamonitis. can also have pruritus, arthritis, hyperpigmented skin, RUQ pain?
what test confirms this
imaging shows fibrosis and obliteration of intrahepatic bile ducts
primary biliary cholangitis, ursodeoxycholic acid
anti-mitochondrial antibody
PBC has what issues with bones
osteopenia and osteoporosis
diarrhea, mucus discharge, tenesmus after radiation. can be associated with stricture, fistula formation, and rectal bleeding. sigmoidoscopy shows
pale rectal mucosa, serpinginous telangiectasisa, and small area of mucosal hemorrhage
high saag is related to what?
what about low saag?
high pressure aka portal hypertension
cancer or infection
if the patient has sensations of food getting stuck on the esophagus or lower chest what is the best test to order
this is esaophageal dysphagia , thest is nasopharyngeal laryngoscopy due to visualization of obstruction/mass
angiodysplasia is associated with this
ESRD
untreated celiac disease can lead to what in the jejunum
enteropathy associated t-cell lymphoma
watery diarrhea and emesis, abdomen is otherwise benign, dehydration
viral gastroenteritis
give a regular diet and avoid fruit juice and sugar
multiple bloody bowel movmeents and severe abdominal pain, what is the diagnosis and what do you have to evaluate for with a KUB
ulcerative colitis, toxic megacolon
UC patient with multiple air fluid levels on KUB
toxic megacolon, give glucocorticoids and consult surgery
triple and quad therapy for h.pylori
clarithromycin, pantoprazole, amoxicillin
quad - pantoprazole, bismuth, metro, tetracycline
pts with GERD over the age of 60 should get what
EDG looking for cancer because they are high risk
if a patient has gall stones on imaging and symptoms how are they managed
elective lap choley
seen with short bowel syndrome and post choley with daily diarrhea that is water
bile salt induced diarrhea, cholestyramine
pleural protein/ serum protgein is >0.5 or pleural LDH/serum LDH >0.6 or pleural LDH >2/3 upper limit of normal of serum LDH
exudative pleural effusion, inflammation due to infection malignancy, connective tissue disease, pulmonary embolism, pancreatitis, post cabg
transudative causes of pleural effusion
restrictive pericarditis, nephrotic syndrome, HF, and cirrohsis
treatment for decompensated cirrhosis
sodium restriction, lasix, and spironolactone
abdominal pain, diarrhea, nausea, vomiting, dizziness, sweating, and dyspnea after gastric sleeve or other gastic surgery
dumping syndrome, start high protein diet
pt with progressively increasing lower leg pain over shins, weight loss, with a normal diet and family history of hypothyroidism. pt has hypochromic and microcytic rbc. has iron deficiency and vitamin d deficiency. what is diagnosis and what is the antibody testing
celiacs disease, anti endomysia antibody and anti tissue transglutaminase
pt with intermittent dysphagia for months with sensation of food and water getting stuck on chest several seconds after swallowing with chest pain. also has iron deficiency anemia, . manometry shows premature and simultaneous contractions of the distal esophagus
diffuse esophageal spasm, esophageal shows corkscrew pattern treat with CCB or nitrates
pt with gastrointestinal hemorrhage and isolated gastric varicies, anemia, thormbocytopenia in the setting of pancreatitis likely has what
splenic vein thrombosis
well demarcated lesion of the liver that has peripheral enhancement likely made worse by OCP
hepatic adenoma
>5 surgery
<5 stop OCP
epigastric fullness and nausea with no other findings or meds, or history
dyspepsia, get h.pylori testing
full term infant with failure to pass meconiu, abdominal distension, poor feeding, bilious emesis, xray shows absense of rectal air and contrast enema shows transition zone
hirschsprung disease, dx with rectal mucosal suction biopsy
prevention of esophageal varicies
propranolol
enlarged liver, elevated alkaline phasphatase and ggt with hypercalcemia, and hilar adenopathy
hepatic sarcoidosis, steroids
pts admitted for variceal bleeding are at increased risk of what and should recieve what to treat it in order to decrease mortality
infection like spontaneous bacterial peritonitis, ceftriaxone 7 days
when is one of the few times to get stools studies,
chronic diarrhea
inguinal hernia in kids are at increased risk of what
bowel ischemia
acute diarrhea with visible blood or mucous
dysentery, rehydration until EHEC is suspected
prior to definitive treatment of a toxic thyroid nodule a patient needs what
pretreatment with antithyroid drugs like methimazole to achieve chemical euthryoidism
reduced 21 hydroxylase activity causing excess androgen production causing advanced bone age, acne, pubic hair development in young boys with precocious puberty.
girls with have hirsutisim and menstrual irregulaties with elevated 17 hydroxyprogesteron levels on acth stim test
nonclassic congenital adrenal hyperplasia, hydrocortisone
all adrenal tumors >4cm or that are functional require this
surgery
pt has hypercalcemia and after repeat testing you get PTH
3 things if it is high normal or elevated
if it is suppressed then measure PTHrP and vitamin d. major causes here are
primary or tertiary hyperparathyroidism, family hypercalcemia, lithim
malignancy, granulmatous diseases, thiazides, milk alkali syndrome, thyrotoxicosis, immobilization
hypercalcemia of malignancy
decreased PTH with increase PTHrP
decreased everything
decreased PTH and increased vitamin D
SCC, renal/blader, breast
breast, multiple myeloma,
lymphoma
weight loss, abdominal pain, amenorrhea, fatigue, weakness, poor appetite, muscle tenderness, decreased axillary and pubic hair, hyperpigmentation, hyponatremia, hyperkalemia, hyperchloreic metabolic acidosis
addisons disease or chronic adrenal insufficiency
NPH causes what more so than basal bolus insulin
hypoglycemia
first step in evaluating thyroid nodule is what?
when is the only time to do iodine scintigraphy?
TSH level and US
when TSH is low, all the other times do a FNA
hot vs cold nodule treatment
hot - treat hyperthyroidism
cold - FNA
goiter, HTN, tremor, hyperreflexia, proximal muscle weakness, lig lag, atrial fibrilation
long term complications, 3 in total
hyperthyroidism
arrhythmia, cardiomyopathy, osteoporosis
first line drugs for diabetic neuropathy
duloxetine, pregabalin, tricyclic antidepressantsw
what does amiodarone do to thyroid function
everything and anything if there is undetectable RAIU then give glucocorticoids because its causes destructive thyroiditis
bitemporal hemianopsia and hyperpigmentation following abdominal operation (bilateral adrenalectomy for cushings syndrome)
nelsons syndrome, prevention is with radiation to the pituitary but this causes hypopituitarism
episodic headaches, diaphoresis, tachycardia, palpitations, pallor, resistant hypertension, orthostatic hypotension, blurry vision, and weight loss
if suspicition is high what is the next step
pheochromocytoma, do preoperative alpha blockade
abdominal MRI/CT if negative do MIBG scan and if >5cm likely have extra adrenal disease
newborn with lethargy, poor feeding, constipation, and hypotonia, born at home with no prenatal screening. these have been progressive and werent present when born
congenital hypothyroidism
increased urinary cortisol level, nonsuppressible hight dose dexamethasone suppression test, and undetectable ACTH levels.
weight gain, tired, weak, difficulty climbing the stairs and in combing her hair, HTN, DM, fat distributed in the trunk, face round and plethoric, buffalo hump
cushings syndrome secondary to an adrenal etiology
diffuse goiter, afib rvr, bone loss with mild hypercalcemia, vasospasm, and hight output heart failure
thyrotoxicosis, bblocker first then thyroid hormone synthesis
young female started developing breasts, no mensturation, growth spurt, fatigue, with no pubic and axillary hair most likely diagnosis
androgen insensitivity syndrome, 46 xy
difference between androgen insensitivity syndrome and abnormal mullerian development
androgen insensitivity syndrome looks like a woman and is 46,xy but has no pubic hair development
abnormal mullerian development is female looking 46 xx but has pubic hair development
new born girl with dehydration, hypotension, and ambiguous genitalia, hyponatremia, hyperkalemia
what else will be elevated
what is the treatment
congenital adrenal hyperplasia specifically 21 hydraxylase deficiency aka salt wasting syndrome
17 hydroxyprogesterone
tx is hydrocortisone
hypertension with hypokalemia and ambiguous genitalia in girls
11b-hydroxylase
hypertension, hypokalemia, ambiguous genitalia in boys, absent puberty
17a-hydroxylase
mutations of calcium sensing receptor with CCCR > 0.02
familial hypocalciuric hypercalcemia
amenorrhea, hypogonadism, decreased LH and FSH but increased alpha subunits in someone with blurry vision
nonfunctioning pituitary adenoma, do surgery
increased alpha subunit is the give away
elevated calcium with suppressed PTH, in a person that is quad
parathyroid hormone independent hypercalcemia, due to immobilization give bisphosphonates
oral glucose control that has a risk of hypoglycemia
sulfonylureas (glyburide, glipizide, glimepirde)
meglitinides (nateglinide, repaglinide)
major risk factor for untreated acromegaly
cardiovascular disease
elevated TSH with normal free thyroxine, irregular menses, depression, lethargy, poor sleep
when to treat?
in women can cause what
subclinical hypothyroidism, Hashimoto
goiter, high TPO antibody
recurrent spontaneous miscarrage
with increased levels of estrogen, what do you have to do to levothyroxine?
increase the dose because estrogen increases thyroxine binding globulin
is lithium induced hypothyroidism an indication to stop lithium
no, increase levothyroxine
delayed puberty in boys due FSH, LH, and testosterone levels
elevated FSH and LH
if they are low to normal
primary hypogonadism likely klinefelter syndrome
secondary hypogonadism any other cause essential, constituational delay, illness, hypothyroidism, kallmann syndrome, craniopharyngioma
lethargy, weight loss, nausea, vomiting, constipation, prolonged relaxation time to ankle reflexes, hyponatremia, hypoglycemia, low TSH, low T4, low am cortisol
if cortisol information wasnt available what would this be?
adrenal insufficiency
central hypothyroidism, if you give leveothyroxine during uncorrected adrenal insufficiency you could trigger adrenal crisis
amennorrhea can lead to what if untreated
osteoporosis
after starting antithyroid medication what do you need to follow to assess how well meds are working
t3 and t4
pt has early secondary sexual development
advanced bone age with high LH and then with low LH
normal bone age with isolated breast development and then with isolated pubic hair
precocious puberty
central precocious puberty then peripheral precocious puberty
premature thelarche, premature adrenarche
after thyroid cancer treatment how low should you titrate TSH to with meds
low normal to super low depending on the aggresiveness of cancer
low T3
euthyroid sick syndrome
loss of proprioception, brisk reflexes, loss of ankle jerk, tingling and numbness in distal lower extremities, fatigue, babinski present, romberg in someone who has hashimoto
thyroiditis
pernicious anemia, further autoimmune destruction of parietal cells
treating b12 deficiency can cause what
hypokalemia
hyperthyroidism with fever, neck pain, tender goiter, ESR elevation often after upper respiratory infection
subacute thyroiditis (de quervain) will have low radioiodine uptake on thyroid scintigraphy, give nsaids and beta blocker
sexual dysfuntion, no notournal erections, hx DM, dark complexion with sparse body hair, liver enlarged 1 cm below right costal margin, decreased testicular volume, alk phos elevated, transaminitis, decreased FSH and LH and low testosterone
hereditatary hemochromotosis,
therapeutic phlebotomy
recurrent hypoglycemia or has symptomatic hypoglycemia, low blood glucose, resolution after glucose administration (whipple triad)
low c-peptide
positive hypoglycemic drug assay
everything elevated to normal
exogenous insulin
oral hypoglycemic agent
insulinoma
elevated parathyroid hormone, abdominal pain, neuro symptoms, kidney stones, elevated urinary calcium exretion
what if urine calcium was <200
primary hyperparathyroidism, parathyroidectomy
familial hypocalciuric hypercalcemia
thyroid symptoms with low RAIU and low thyroglobulin but has hyperthyroidism
exogenous thyrotoxicosis from supplements
untreated prolactinoma causes what i women long term
osteoporosis
oral diabetes medication that will causes orthopnea, hypoxia, pulmonary edema
pioglitazone
uncontrolled hypertension, DM, mood swings, hypokalemia, metabolic alkalosis with evidence of osteopenia
cushings syndrome
causes of hypocalcemia pt will have bilateral cataracts and basal ganglia calcifications, tetany, seizures, muscle cramping hyperreflexia,
phos low PTH high
phos High PTH low
phos and PTH high
what if they have all of the above and have dysmorphic features like short stature, round faces, short 4-5 metacarpals
vitamin d deficiency
hypoparathyroidism
seudohypoparathyroidism or hyerphosphatemia
albright hereditary osteodystrophy
pt has exertional dyspnea, orthopnea, PND, hemoptysis, pulomonary edema, right sided heart failure and a new murmur opening snap with middiastolic rumble at the apex
mitral stenosis , commonly seen in people with rheumatic heart disease
biggest difference between febrile seizures and meningitis
meningitis will have headache, vomiting, bulging fontanelle (increased ICP), nuchal rigidity, petechial rash but most importantly the post ictal state is >10 minutes
pt is hypocalcemic after vitamin d therapy what do you add to the treatment regimen
thiazide diuretic
if concerned about thyroid cancer when is the only time not to do a FNA
if you see a hyperfunctional hot nodule (TSH will be low)
what do you give in sulfonylurea overdose when dextrose doesnt work
octreotide
amenorrhea at age <40, hot flashes, increased FSH and decreased estrogen
primary ovarian insufficiency, estrogen therapy (conjugated equine estrogen with medroxyprogesterone acetate
back pain, low phos, high alk phos, bariatric surgery, osteomalacia, fractures
vitamin d deficiency, cholecalciferol D3
polyuria, polydipsia, hypertensive, hypokalemia
hyperaldosteronism
pt has hashimoto’s thyroiditis and has acute enlargement of thyroid gland
thyroid lymphoma
new cases that develop in a population over a certain period of time
10,000 cases
1000 already have it
two years of follow up 200 people die and 200 people get the disease
whats the early incidence
incidence
100/9000
when calculating incidence do not take into account the number of cases that already existed in the populaton before the counting period.
then in the denominator only include the people at risk of developing disease. so in this part people that have the disease are excluded
total number of cases (new and old) measured at a particular point in time
prevalence
chronic disease treatments that prolong patient survival do what to prevalence
increase due to accumulation of cases over time, this is usually due to improved quality of care
improved diagnostic accuracy does what to incidence and prevalence
increased
how do you decreased incidence and prevalence
primary prevention
What do second generation antipsychotics cause
Metabolic syndrome and hyperglycemia
scaling of the webs of the fingers, wrists, and upper arms
scabies, permethrin
colitis with diarrhea, bloody stool, abdominal pain, RUQ pain, fever, liver abscess that is well defined hypoechoic mass in the right hepatic lobe.
entamoeba histolytica, diagnose with stool ova and parasites
tx metronidazole
man with UTI symptoms plus perineal discomfort or bladder obstruction
acute bacterial prostatitis
difference between coin and button battery on xray
button battery will have double ring
when to remove a coin that is swallowed
unknown time of ingestion, or symptomatic or >24 ingestion and lodged
when to do parathyroidectomy
pt <50 or has symptomatic hypercalcemia
circular discoid plaques, that combine together in places in spots and others as they get bigger will start to clear. typically with flu like prodrome
what is this associated with
erythema multiforme
HSV infection, mycoplasma pneumonia, abx, allopurinol
first step with a palpable breast mast if malignancy hasnt been excluded
ultrasound
pt has HCC
is AFP high or low or normal
what cells are mutated
high
liver parenchyma
brief transiety euphora, lethargy, poor coordination, LOC lasting 15-45 minutes typically seen in children and adolescents with rash around nostrils and mount
inhalant abuse
treatment of a cough that has inspiratory whoop, postussive emesis lasting weeks to months
pertussis, azithromycin which is also used as prophylaxsis despite vaccine status
when to fix inguinal hernia in children when asymptomatic
1-2 weeks elective surgery
pt started on new medication and now has muscle pain and elevated CK what is most likely cause
statin
normal PT and prolonged PTT is a sign of what
these are rare in women so if see in them think
hemophilia a (8) and b (9)
aqcuired coagulation inhibior
pt has exertional shortness of breath, decrease stamina, small joint pain, HTN, GERD, tachycardia, telangiectasias, heave along lower sternum
what antibody is associated
scleroderma, anti centromere
common infection in people with saphenous venectomy
tineas pedia causing cellulitis
HTN management in gout
losartan or ccb
what electrolyte causes confusion and shortened QT interval, can also lead to nephrogenic SIADH
hyperglycemia
how long does it take troponin to raise after STEMI chest pain
2-3 hours
aching pain and stiffness that involves shoulders, neck, and or hip girdle that is worse in the morning, pts have difficulty getting dressed, malaise, fatigue, weight loss. muscle strength is intact but range of motion is reduced. inflammatory markers are elevated
plymyalgia rheumatica, steroids which provides symptomatic relief
normocytic anemia, hypercalcemia, renal insufficiency, chronic back pain
how do you diagnosis this and what does it show
multiple myeloma
24 hour urine protein electrophoresis shows monoclonal protein
soft scrotal mass that decreases while supine and increased with standing or valsalva
what can this cause if not treated
varicocele, gonadal vein ligation or scrotal support in older men
infertility and testicular atrophy
infant with noisy breathing and cyanosis during feeding, mouth breather
how do you diagnosis this
choanal atresia (narrowing or obstruction of the posterior nasal passages), needs surgical repain
pass a samll catheter via each nostril, confirm with CT
coloboma, heart defects, atresia choanae, growth retardation, genital and ear abnormalities
charge syndrome
levels of lead toxicity
> 70 severe –> dimercaprol and EDTA
<44 mild - observe and move people from home
between is moderate - DMSA (succimer)
indolent onset of fever, dry cough, dyspnea, weight loss in HIV pt
first line diagnostic modality
PCP pneumonia, typically requires blood gas analysis
induced sputum
hodgkin lymphoma places you at risk for was
secondary malignancies
people with prior MI and LVEF <30% or that have new york heart association class II or III heart failure and LVEF <35% should get what
implantable cardioverter-defibrillator
pts with moderate to severe heart failure, LVEF <35% and wide QRS complex should get what
biventricular pacer and cardiac resynchronization
most common inherited thrombophilia that is due to resistance of anithrombic effects of protein C
factor V leiden, look for coagulopathy in health person with no risk factors
normal RDW is an indication of what
what about increased
thalassemia
iron deficiency
nephritis in renal transplant recipient that is immunosuppressed with renal tubular damage and basophilic intranuclear insclusions
BK - virus indueced nephropathy (polyomavirus)
muscle pain and weakness associated with elevated CK, AST, ALT, pins and needles sensation, normocytic anemia, mild hyponatremia, HLD, creatinine elvation
hypothyroid myopathy
looks like healed grease burn, pruritic, planar, polygonal and purple located on flexor surfaces, lesions can have wickham stiae
lichen planus
pts with severe nephrotic syndrome are predisposed to what
thrombotic events typically chronic renal vein thrombi and DVT
pt has fever but had joint pain for several days and is now starting to notice a faint, diffuse rash (lace-like) after having son that had the same type of thing earlier in the week. can have red cell aplasia or aplastic crisis
what does this cause to a fetus
parvovirus b19
fetal demise, anemia, hydrops fetalis do ultrasound which will show fluid accumulation, can also do middle cerebral arteyr doppler
if severe do intrauterine blood transfusion
most dangerous complication of granulomatosis with polyangitis
diffuse alveolar hemorrhage
what medications causes hyperglycemia and metabolic syndrome
clozapine and olanzapine (second generation anti psychotics)
neonate with mild cyanosis at birth followed by rapid clinical deterioration on day of life 1 is due to what disease and process.
marked by severe cyanosis, respiratory distress, and cardiogenic shock
hypoplastic left heart syndrome which is a ductal dependent congenital heart defect PFO and PDA, give prostaglandin E1
pt has dyspnea, fatigue/weakness, exertional angina, syncope, abdominal pain found to have left parasternal lift and right ventricular heave, tricuspid regurgitation, JVD, ascites, right heart failure
pulmonary hypertension, get transthoracic echocardiography
most important factor in OSA
neck circumference
growing pains, pathologic fracture, splenomegaly, anemia, thrombocytopenia, FTT, delayed puberty
gaucher disease AR lysosomal storage disorder due to glucocerebrosidase deficiency
decompensation after protein feeding
maple syrup urine disease, PKU
early childhood with hypoglycemia and hepatomegaly, muscle pain and weakness with no bone pain
Von Gierke Disease, glycogen storage disorder
self mutilation, arthritis, immunodeficiency
nucleotide metabolism disorders, Lesch-Nyhan disease, gout, ada deficiency
oliogmenorrhea, hyperandrogenism, ultrasound showing enlarged ovaries
PCOS, get glucose tolerance test
indications for mitral valve repair
chronic primary valve issue (issue with valve itself)
LVEF 30-60%
purulent monoarthritis, tenosynovitis, dermatitis, mifratory polyarthralgia
disseminated gonococcal infection, ceftriaxone
periarticular osteopenia, joint effusions, and symmetric joint space narrowing
RA, cytotoxic medications like methotrexate and hydroxychloroquine
eosinophilia and eosinophiluria
atherosclerotic embolism to kidney
muddy brown casts
contrast induced nephropathy
young female athlete with poorly localized knee pain that is worse with standing from and sitting position after extended periods of time. squatting reproduces the pain
patellofemoral pain syndrome, exercise to strengthen hip and knee muscles
effect of the main exposure is mixed with the effect of extraneous factors
confounding bias
results from inaccurate estimation of exposure and/or outcome
measurement bias
subjects selected for the study are not representative of the study population
selection bias
selecting control subjects for a case control study from hospitalized patients
Berkson fallacy
patients are sampled from specialized medical centers
referral bias
in cohort studies when people are lost to follow up
selection bias
incidence of disease is estimated based on prevalence and date becomes skewed by selective survival
prevalence bias or neyman bias
bias seen in case control studies
recall bias
investigators decision is adversely affected by knowledge of the exposure status
observer bias
how do you limit confounding bias
randomization, matching, and stratified analysis
this treats confounding and susceptibility bias
randomization
how to minimize placebo effect
single blinding
how to treat observer bias
double blind
how to deal with selective non-compliance
intention to treat approach
what to do if patients change treatment groups
use as treated rule
wrongfully concluding that there is an association between exposure and disease when there is non
type 1 error, described as alpha and p value (they are the same thing)
wrongfully concluding that there is no association between exposure and outcome when there is one
type II error
alpha level and beta level (power of the study) are inverse or converse
converse
how do you increase B or the power of the study
meta analysis
probablity of commiting type II error
1 - B which is probability of detecting an association if it exists in reality
error explained by chance and is unpredictable
random error
the reliability and reproducibility of measurements is called
precision
caused by flows in study design and/or analysis and is not a product of chance
systematic error which compromises the validity of the study
cancer patient with hodgkin lymphoma that has progressive shortness of breath with chest pain, recieved chemotherapy and radiation therapy. 2/4 diastolic murmur at left sternal border, large left atrium, EF >60%, diastolic dysfunction, mitral and aortic valves are sclerotic and calcified, aortic regurgitation, ostial narrowing of the right and left main coronaries
what causes dose dependent decline in ejection fration leading to dilated cardiomyopathy
radiation cardiotoxicity
anthracycline chemo
pt with frequent RBC transfusions but blood grouping and cross matching cant find a suitable blood match. what is the cause
alloantibodies typically seen in patients with sickle cell anemia or myelodysplasia
first step for evaluation of normocytic/normochromic anemia
reticulocyte count which is also the first thing that responds to treatment of anemia resulting in increase in reticulocyte count
child with pallor, microcytic anemia, elevated RDW with HbS and HbA in blood, associated with prematurity, lead exposure, exclusive breast feeding after 6 months >24 oz of cows milk per day
iron deficiency anemia although HbS with HbA is also consistent with sickle cell trait which doesnt cause anemia
side effect of IVC filters
recurrent DVT
when is the only time Rh incompatibility is possible
Rh negative mother and Rh positive father
presents with target cells, and appears like iron deficiency anemia but has normal RDW
how do you tell them apart
thalassemia minor, hemoglobin electrophoresis with have incrase HgA2 in b-thalassemia, alpha thalassemia will be normal
pt has bleeding, everything is normal except bleeding time is prolonged, what is the next best step. this is typically seen in renal failure
IV desmopressin, release of VIII:von willebrand factor multimers from endothelium.
autoimmune destruction of parietal cells and detected by measurement of auto-antibodies against intrinsic factor in someone with macrocytic anemia and normal serum folate but suppresed cobalamin
what would endoscopy show
pernicious anemia - b12 deficiency.
absent rugae in the fundus
pt with rash over her ankles that started 2 weeks ago and spread up her knees , exam shows fine petechiae and purpur around her ankles and lower legs, blood smear shows thrombocytopenia, after platelets her thrombocytopenia doesnt improve
antiplatelet antibodies caused by immune thrombocytopenia.
kids only if bleeding give steroids, IVIG, or anti D
adults >30k platelets observe or <30k same as kids
isolated thrombocytopenia <100,000
ITP which is platelet destruction by antiplatelet autoantibodies against membrane proteins GPiib/IIIa
thrombocytopenia and microangiopathic hemolytic anemia with schistocytes on peripheral smear and ELEVATED LACTATE DEHYDROGENASE, can also have renal failure, fever, and neurological abnormalities
thrombotic thrombocytopenic purpura
pt has elevated hemoglobin and you get EPO level
high means what
low means what
chronic hypoxia or cancer like RCC
polycythemia vera, confirmed with Jak2 mutation,
osteomylitis treatment in sickle cell child
clindamycin and ceftriaxone
acute chest in sickle cell child
azithromycin and ceftriaxone
rapid reversal of warfarin
PCC
young child, abdominal mass, constipation, facial flushing, perspiration, weight loss, nontender, fixed mass in right mid abdomen. can cave periorbital ecchymosis (orbital metastases), spinal cord compression (dumbbell tumor), opsoclonus myoclonus syndrome, small round blue cells on cytology with N-myc gene amplification
neuroblastoma
unilateral painful abdominal mass with hypertension and hematuria in young children
wilms tumor
nasal or oral bleeding, blurry vision, confusion, headache, heart failure, other neurologic problems seen in cancers and vasculitis
hyperviscosity syndrome seen in multiple myeloma and waldenstroms macroglobulinemia (elevated IgM)
fatigue, poor exercise tolerance, weight loss, abdominal discomfort, leukocytosis elevated incidentally on CBC
what chromosome abnormality
CML, tyroisine kinase inhibitor
phyladelphia chromosome 9:22 bcl/abl fusion protein
most common cause of inherited or hereditary thrombophilia
factor V leiden
difference in g6pd and abo incompatibility for timing of onset in newborn
g6pd is 2-3 days negative direct combs test
abo is 24 hours with positive direct combs test
highest risk for colorectal cancer
alcohol
keratosis pilaris tx
salicylic acid or urea cream
what group causes tinea versicolor
malassezia species
post viral rash with herald patch followed by smaller pink/tan lesions
pityriasis rosea
painless blisters, increased skin fragility typically doral hand, facial hypertrichosis and hyperpigmentation
porphyria cutanea tarda
first line for onychomycosis
terbinafine, itraxonazole
facial flushing in response to hor or cold temps, emotion, spicy food. reddening of face, erythematous papulses on nose, telangiectasias
papulopustular rosacea, topical metronidazole, clindamycin, or peroxide
pea sized nodule in eyelid associated with rosacea
chalazion, optho consult
mild to mod plaque psoriasis tx
severe tx
facial tx
topical steroids
methotrexate
tacrolimus
treatment for atopic dermatitis
topical glucocorticoids like triamcinolone
tinea capitis tx
oral griseofulvin or terbinafine
shiny, discrete, intensely pruritc, polygonal shaped violaceous plaques and papules that are most frequent on flexural surfaces
lichen planus, needs biopsy for diagnosis
also associated with hep c
treatment for fine wrinkles, hyperpigmentation, reducing AKs, improving brown spots
tretinoin, all trans retinoic acid
beefy red papules and plaques with satellite lesions
what if it involves skin folds
contact dermatitis from diaper rash, barrier cream
candida dermatitis, clotrimazle or nystatin cream
what antihypertensive can cause sun burns to be worse
HCTZ
random areas of hair loss on the scalp that resolve and then return
alopecia areata, corticosteroids intralesional
dysuria, postvoid dribbling, dysparenunia, anterior vaginal mass, hematuria, recurrent UTI, stress incontinence . manipulation of urethra will express bloody purulent fluid
urethral diverticulum, dx with MRI or transvaginal US
sudden, overwhelming, or frequent need to urinate
urge incontinence, bladder training and antimuscarinic medications
constant dribbling of urine, incomplete bladder emptying
overflow incontinence, intermittent cath correct underlying issue
bilateral flank pain with gross hematuria following flu like illness 3 days ago, also has CVA tenderness bilaterally
why is this not poststrep glomerulonephritis
igA nephropathy
poststrep glomerulonephritis happens more than 10 days after
nighttime urinarly incontinence after age 5
primary nocturanl enuresis, enuresis alarm, desmopressing
vasculitis due to immune complex deposition in small and medium size vessels, typically associated with hep C. presents with palpable purpura, weakness, arthralgias, glomerulonephritis, and hypocomplementemia
mixed cryoglobulinemia, treat with viral infection therapy
abdominal pain, skin rashes, and joint inflammation in children with no neurologic changes
HSP
fever, lymphadenopathy, sore throat, headache, fatigue, myalgia, painful mucocutaneous ulcers, maculopapular rash, leukopenia, thombocytopenia
acute HIV infection
babys born to mothers with active Hep b should get vaccine when
at birth
flu-like febrile illness with marked myalgias and joint pain (bone break fever) retro-orbital pain, rash, thrombocytopenia, spontaneous bleeding with a positive tourniquet test (causes petechiae)
what bug causes this
dengue fever, supportive care
aedes mosquito
pt has palpitations and lightheadedness, has ventricular tachycardia, apical aneurysm. can also have biventricular heart failure, mural thrombosis, fibrosis leading ot conduction abnormalities, toxic megacolon or esophagus
what cases this
chagas disease, trypanosoma cruzi (protazoa)
involvement with salt water cuts, pt develops rapidly progressive ceellulitis with hemorrhagic bullae, also associated with raw oysters. can ultimately lead to septic shock quickly
vibrio vulnificus, ceftriaxone and doxycycline
three main causes of nec fas
group A strep (pyogenes), staph aureus, clostridium perfringens
fever, hypotension, swelling, erythema after a puncture wound. Notably the wound site is more painful to palpation that would be expected
what if there was crepitus on exam
nec fasciitis, broad spectrum
zosyn or carbapenem for group A strep and anaerobes
vancomycin - MRSA
clindamycin to inhibit toxin formation
clostridum perfingens
fever,petechiae, IV drug use, holysytolic murmur at apex
what about if they have headache, lethargy, neckstiffness
infective endocarditis
subarachnoid hemorrhage secondary to mycotic aneurysm rupture
acute otitis media treatment
first amoxicillin
second - augmentin
pcn allergic - clindamycin or azithromycin
initially pt will have erythema migrans, fatigue, headache, myalgia, arthralgia
next with have multiple erythema migrans areas, CN 7 palsy, meningitis, AV block
late can have arthritis, encephalitis, or peripheral neuropathy
lyme disease caused by borrelia burgdorferi
ixodes scapularis, deer tick
fever, headache, myalgia, arthralgia, macular and petechial rash, encephalitis, pulmonary edema, bleeding, shock, decreased platelets, sodium, transammonitis
rocky mountain spotted fever, doxycycline
abx treatment for young kids pna
amoxicillin
fever, sore throat, pseudomembraine and grey patches in throat with cervical lymphadenopathy, myocarditis, kidney disease
diphtheria, corynebacterium, tx is erythromycin or Pen G
most common cause of gastroenteritis
norovirus
meningitis with very high opening pressures
cryptococcal meningoencephalitis typically seen in HIV, do repeated lumbar munctures until symptoms abate
abx treatment is amphotericin B and flucytosine for >2 weeks until symptoms abate and CSF is sterilized
then high dose oral fluconazole 8 weeks
then low dose fluconazole for 1 year
spinal tap looks normal but might have elevated protein
guillain barre syndrome
tap has >500 wbc
bacterial meningitis
tab has low glucose
tuberculous meningitis
tap is just a little of normal in all catergories
viral meningitis
sudden sore throat, fever, abdominal pain, headache, with no cough or rhinorrhea or congestion
tonsillar erythema, anterior cervical lymphadenopathy, and palatal petechiase
strep pharyngitis, PCN or amoxicillin
pcn allergy, cephalosporin, azithromycin, or clindamycin
10 day course to prevent rheumatic fever only, others arent prevented by treatment
in fetus this causes sensorineural hearing loss, cataracts, and PDA
rubella aka german measles
child has cephalocaudal spread of maculopapular rash and a fever, adults get this as well but have arthralgia as well
rubella aka german measles
hepatosplenomeagly, purpuric leasions and sensorineural hearing loss in new boorn with periventricular calcifications
what about the same but with intracerebral calcifications
congenital cytomegalovirus, gangciclovir
congenital toxoplasmosis, pyrimethamine, sulfadiazine, spiramycin
newborn with skin, eye, mouth vesicles, severe CNS infection
HSV congenital
maculopapular skin rash on palsm and soles of newborn with lymphadenopathy, osteitis
syphilis, PCN
repeated episodes of jaundice with stressors
gilbert syndrome
persistent hyperbilirubinemia despite plasmapheresis and bili-light
cringar-nijar syndrome
cough, coryza, conjunctivities and loplic sports, srash starts on the face and spreads down 2 days after symptoms start
measles - rubeola
high spiking fevers for 3-5 days and then rash shows up on chest
roseola HHV 6 or 7
fever, malaise, headache, anorexia, parotid swelling and orchitis
mumps
fever, malaise, followed by vesicles on mouth, palms, and soles
HFM disease - coxsackievirus
symptoms begin after 6 months with repeated encapsulated organisms like pseudomonas, s pneumoniae, haemophilus, can have absent tonsils
will have absent b cells
bruton agammaglobulinemia, ivig and abx
all ig levels are low, decreased plasma cells, pyogenin upper and lower respiratory infections, increased risk of lymphom
common variable immunodeficieny, ivig
recurrent respiratory and gi infections, anaphylactic reaction to ivig infusion
igA deficiency
absence of CD 40 ligand, high levels of IgM, recurrent sinopulmonary infections
hyper IgM syndrome, abx and ivig
infected with everything, xray shows absent thymic shadow
thymic aplasia (digeorge syndroem) needs bone marrow transplantation and ivig
increase risk of malignancies of the blood and stomach, preogressive cerebellar ataxia, oculocutaneous telangiectasia
ataxia-telangiectasia, ivig
lack of b and t cells, frequent bacterial infections, chronic candidiasis
severe combined immunodeficiency aka bubble boy disease, bone marrow transplantation and IVIG
increase in IgE and A, decrease IgM, thrombocytopenia, bleeding, eczema, purpura
wiskott aldrich syndrome, bone marrow transplant
clenched overlapping hands, cardiac defects, rocker-bottom feet
trisomy 18 - edwards
cns malformations, polydactlyly, deafness, sloping forehead,
trisomy 13 pitau syndrome
congenital heart disease, thymic hypoplasia, absent parathyroid glands, hypocalcemia
digeorge syndrome
short female with shield chest, wide nipples, webbe neck, horseshow kidney, coarctation, hearing loss, infertility
turner syndrome, 45 XO
macroorchidism, tall stature ro girls with learning disability form cgg repeat in fmr1 gene
fragile x syndrome
hypogonadism, testicular atrophy, tall with long extremities
klinefelter 47 xxy, increase risk of breast cancer
cafe au lait macules, freckling inguinal and axillary folds, lisch nodules, optic glimoa, acoliosis and arthosis
NF 1
sensorineural hearing loss for bilateral acoustic schwannomas
NF2, peripheral nerve sheath cell
inhibits bacterial cell wall synthesis
pcn cephalosporin carbapenems monobactam/aztremonam vancyomycin
inhibits dna synthesis
fluoroquinalones, metronidazole, bactrim
inhibit bacterial protein syntesis
macrolides/azitho aminoglycocides/gent or tobramycin clindamycin linezolid tetracyclines most of these end with mycin
