UWORLD2 Flashcards
Pregnancy and Thyroid Hormones
What happens to the Free T3, T4 and TSH?
Mechanism & Why?
What is the best inital scening test for evaluating thyroid function during pregnancy?
What if specific laboratory reference ranges are not available?
HCG-induced thyroid stimulation -
free T3 and T4- typically high normal or borderline high TSH - appropriately low or even mildly suppresed.
HCG stimulates production of thyroid hormones by binding to the TSH receptors on thyroid follicular cells.
*Higher production of thyroid hormones is required during pregnancy to saturate higher levels of TBG and for the tranplacental transfer of thyroid hormoens to the developing fetus.
TSH - best inital screening test for evaluating thyroid function during pregnancy;
if TSH is abnormally low using hte trimester-specific table, then measurement of thyroid hormones will be necessary.
Trimester-specific normal reference ranges are not available in all laboratories, so either total T4 or T3 with their reference levels should be adjusted at 1.5 times the nonpregnant range
Gestational transient thyrotoxicosis versus Normal thyroid function during pregnancy?
Common causes of hyperthyroidism in pregnancy include Grave’s disease and gestational transietn thyrotoxicosis.
Thyroid function during pregnancy must be assessd using pregnancy specific reference ranges for patient.
Total T3 and T4 are in the normal range if the levels are adjusted 1.5 x the normal range for adults.
Gestational transient thyrotoxicosis may cocur in the first trimester of pregnancy due to hCG-mediated thyroid stimulation.
Gestational hyperthyroidism is generally associated with minimal symptoms and mild biochemical hyperthyroidism with resolution as hCG levels decline after 12 weeks pregnancy.
Mild gestational hyperthyroidism is nto assoicated iwth adverse prgancy outcome and does not require treatment.
More severe hCG hyperthyroidism may occur with hyperemesis gravidarum or molar pregancy due to very high levels of HCG in these conditions.
Dysphagia
orophyarngeal dysphagia versus esophageal dysphagia
neuromuscular disorder versus mechanical obstruction
Oropharyngeal dysphagia - difficulty initiating a swallow, often accompanied by coughing, drooloing or aspiration
Esophageal dysphagia - delayed sensation of food sticking in the upper or lower chest
Both solids & liquids = neuromuscular disorder
Solids, then later liquids - mechanical obstruction
Structural lesions that lead to dyphagia in the pharynx and upper esophagus may be visualized with
How does this differ in a patient with lower-esophagel symptoms?
Nasopharyngeal laryngoscopy
EGD - lower esophageal problem.
EGD is not recommended as inital evaluation with patients with possible upper-esophageal lesions as the upper esophagus is often not visualized well during scope insertion and peroration is possible.
What may be helpful if an esophagel motility disorder is suspected?
Manometry
Identifies upper esophagel disorders (ex: Zenker)
Esophagram
Location of Esophageal adenocardinoma versus Squamous cell carcinoma
Esophageal adenocardinoma - lower esophageal and associated with chronic gastroesophagel reflux
Squamous cell carcinoma - patients who use alcohol and tabacco chronically and is usually located in upper esophagus.
Breast discharge evaluation
Bilateral - Pregnancy test, Galactorrhea evaluation
Unilateral:
Age <30 - Ultrasound (+/- mammogram)
Age >30 - Ultrasound + Mammogram
Selection bias
sample is unrepresentative of the target population and may lead to incorrect measures of association
Berkson bias
What is it a type of?
disease studied using only hospital-basedpatients may lead ot results not applicatiable to the target population
- selection bias
Amiodarone and the Thyroid
Amiodarone decreases the peripheral conversion of T4 to T3, causing increased serum T4 and decreased serum T3 levels with normal to borderline elevated TSH
These patients are clinically euthyroid
These abnormalities then improve over the subsequent 3-6 months.
Not treatment necessary
Patients with HIV may develop what several weeks after initation of antiretroviral therapy?
due to?
Management?
transient worsening of infectious symptoms
due to immune reconstitution of inflammatory syndrome (IRIS). The renewed ability to recognize and respond to foreign antigens can result an overabundant inflammatory response to an ongoing infection, which causes a paradoxical worsening of infectious symptoms
it is self limited and requires no alteration to ongoing treatment.
Anti-inflammatory medications are sometimes added if IRIS symptoms are bothersome.
Peripheral blood smear findings for the following:
Iron deficiency
Thalasemia
Folate & B12 deficiency
Iron deficiency - microcytic hypochromic anemia
Thalasemia - target cells
Folate & B12 deficiency - macrocytic anemia and hypersegmented neutrophils
Excessive daytime sleepiness (EDS) versuss Narcolepsy
Test for each?
Narcolepsy should be considered in a young patient with EDS, especially if the patient also experiences falling asleep suddently at inappropriate times, hypnagogic hallucinations or cataplexy (conscious, brief episodes of sudden bilateral muscle tone loss precipated by emotions such as laughter or joking)
Polysomonography (Sleep study) can diagnose narcolepsy - multiple spontaneous aweakening and reduced sleep efficiency and latency of REM sleep (less than or equal to 15 mins)
EDS - sleep diary
What is also associated with Narcolepsy
Lack of Hypocretin-1
key brain chemicals that help sustain alertness and prevent REM sleep from occurring at the wrong times.
(can determine from CSF analysis)
First line pharmacotherapy for narcolepsy
First line treatment for cataplexy
Modanifil
stimulant, Good effectivness with tolerable side effect and low abuse potential.
Older stimulants such as methylphenidate may also be useful.
Behavorial interventions such as good sleep hygiene and scheduled naps are also recommended.
Cataplexy - Stimulants may mildly improve but are often inefficient. SNRI (ex: Venlafaxine) or SSRI, TCA
Recurrent Urinary Tract infections refer to what?
Management?
> or = to 2 infections in 6 months or > or = 3 infections in one year.
Management is with antibotic prophylaxis.
Renal US is only used for patients with recurent UTIs that do not respond to antibotics.
SBO obstruction versus Ileus
Etiology
Abdominal examination
small bowel dialation
large bowel dilation
Etiology
SBO - Prior surgery (weeks to years)
Ileus - recent surery (hours to days), metabolic (ex: hypokalemia), medication induced
Abdominal examination
SBO- Increased bowel sounds
Ileus - absent/reduced bowel sounds
small bowel dilation
SBO - present
Ileus - Present
large bowel dilation
SBO- Absent
Ileus - Present
What electrolyte abnormality can cause paralytic ileus?
What drug can usually cause this?
Mgmt?
Hypokalemia
Loop diuretics
Give oral potassium replacement
What is used to reverse opioid-induced constipation?
Mechanism?
How do you tell if the person is constipated versus having an ileus?
Mehtynaltrexone
selectively blocks mu opiod receptors in the gut without reveresing the analgesic effect of opiods.
constipation has stool in the colon and rectum. wherease ileus has gas (not stool).
Orbital cellulitis
What do you see in patients?
Complications?
Management?
how does this differ from preseptal cellulitis?
Proptosis, opthalmoplegaia and pain with eye movements
Dangerous complications include orbital abscess, intracranial infection and cavernous sinus venous thrombosis.
IV broad specrum antibotics
Preseptal (is just eyelid erthema, swelling and tenderness). You just treat with oral antibotics.
Primary closure of Dog bites injuries to the hand and puncture wounds anywhere on the body
What other conditions are the same?
Should not be closed primilary due to high risk of wound infection.
Should be left open to train and examined frequently for signs of infections.
Human bites, cat/dog bites should also not be closed.
The major problem that leads to difficulty finding cross-matched blooed in patients with history of multiple transfusions?
What other scenario do you see this in?
ALLOantibodies
alloimmunization develops during pregnancy or from previous blood transfusions.
Sterilization of women with intellectual disabilities
Involuntary sterilization of women with intellectual disabilities is considered unethical.
Family members nd legal guardians cannot conset to sterilization on any women’s behalf
How do you confirm the diagnosis of gastroparesis?
What is the management?
Assess motility with nuclear gastric emptying study
Dietary modification - smaller, more frequent meals with decreased fat and fiber intake
If dietary changes alone are not sufficient, promotility agents such as eryhtromycin or metoclopramide may be needed
Sickle cell disease is definitively diagnosed by
hemoglobin electrophoresis
determines which form of sickle cell diseae is present
what is an opiod antagonist used in management of alcohol and opiod dependence?
naltrexone
Major complication of Rhabdomyolysis?
Patient should receive?
Acute kidney injury due to myoglobinuria
Receive early and agressive isotonic saline infusion to improve volume status and prevent intratubular cast formation.
Diagnosis for Rhabdomyolysis is made when?
What will urinalysis often reveal?
Markedly elevated creatine kinase levels (usually >10,000)
Blood with no RBC, indicating myoglobinuria.
First line therapy in treatment of syphillus during pregnancy?
What happens when they have an allergy to this medication?
Penicillin.
Patients with penicillin allergy require pencillin desensitization prior to initating treatment
granulomatosis with polyangititis
what is it?
what is it marked by?
Systemic necrotizing vasculitis
Marked by glomerulonephritis, chronic pneumonitis and recurrent sinusitis/otitis media
Common causes of chronic sinusitis
Exposure to cigarette smoke and air pollution
damages the cilia responsible for moving mucus through the sinuses. mucus builds up and obstructs the sinuses, resulting in secondary bacterial growth.
other causes -inadequately treated acute sinusitis, structural abnormalties of the nasal septum or palate, and allergic rhinits
Most frequent complicatin of transurethral resection of the prostate?
Retrograde ejaculation
What is a common finding in infection from human bites?
Management?
What is a common finding from cat and dog bites?
HUMAN: Eikenella corrodens, a gram negative anaerobe
Local wound care & Irrigation
No primary closure (except face)
Antibotics - Oral amoxicillin/clavulanate)
consider tetanus booster
DOG/CATS: Pasteurella multocida.
Due to their pointed, sharp teeth, cats are especially capable of implanting bacteria under the periosteum causing osteomyelitis
Management of functional constipation in children
Dietary modifcation first (increase dietary fiber & water intake, limit cow’s milk intake to <24 oz)
Then ostmotic laxatives. Causes retention of fluid in the gut lumen and stool, resulting in softer bowel movements.
Acute and long-term use of osmotic laxatives is considered safe for pediatric use.
Treatment with stimulant laxatives (increases peristalsis to promote defecation)or enemas (distends the retum and stimulates colonic muscles) is generally reserved for acute relief of fecal impact
Patients with late-life depression >65 are at higher risk for developing what than those with depressive episodes earlier in life.
Alzheimer disease adn vascular dementia
Oral contraceptives effects on thyroid hormones?
How does this affect patients with hypothyriodism?
Increases the serum concentration of thyroid binding globulin (TBG)
in Normal patients, feedback loops promote increased endogenous production of thyroid hormones to compensate for the increased number of boud thyroid hormone molecules.
However, patients with hypothyroidism cannot adequately compensate and an increased dose of levothyroxine is usually necessary.
Effect of Oral contraceptives on TBG versus Androgens and glucocorticoids
Oral contraceptives increase the serum concentration of TBG by promoting its glycosylation (which slows its clearance).
Icnreased concentraitons of TBG means more bound T3 and T4 hormones.
Androgens and glucocorticoids cause the opposite problem since they decrease TBG.
Normal pressure hydrocephalus
How does it present?
What will MRI show?
Management?
Classic triad of gait disturbance followed by impaired cognition and urinary incontinence.
MRI - ventriculomegaly out of proportion to sulcal enlargement and the abscence of an obstruction.
Lumbar drainage of the CSF fluid with pre-post assessement of gait and cognition is helpful in predicting effectiveness of ventriculoperitoneal shunting.
If there is no improvement with CSF drainage, VP shunting may not be helpful.
Permission to treat a child can only be granted by?
An exception to this rule is?
Parent or legal guardian.
Adolescents are typically alllowed to give consent for their own care in regards to pregnancy, contraception. STD, substance abuse and emotional illness.
Hepatic encephalopathy is usually triggered by?
What is a common trigger?
Treatment includes?
Elevated ammonia levels due to underlying precipitating event.
A common trigger is excessive diuresis which results in:
Hypovolemia (high urea nitrogen)
hypokalemia (facitlates conversion of Ammonium to ammonia)
and metabolic alkalosis - decreases urinary loss of ammonia
Volume and electrolyte repletion first and using medications (ex: lactulose) to reduce ammonia levels.
What are common findings in patients taking SSRI
Management for this?
Sexual dysfunction
Switching to the non-SSRI antidepressants bupropion or mirtazapine,
augmentation with sidenafil or buprion and
cautious dose reduction in patients taking high SSRIs
Stimuli for secretion of ADH hormone
Osmotic - serum osmolality is > ~285
Nonosmotic - hypotension, hypovolemia, hypoxia or hypoglyemia
SIADH management
Asymptomatic
Versus
Mild symptoms
versus severe symptoms
Asymptomatic/Mild symptoms - Fluid restriction
Severe symptoms are at high risk of rapid neurolgoic deterioration and death - Hypertonic 3% saline
Initial manifestations of salicylate intoxication are?
After a few hours?
Tinnitus, restlessness, N/V and mild GI discomfort
after a few hours, fever, Metabolic acidosis and hyperventilation
Normal anion gap
8-16
Therapy of Salicylate overdose
Aimed at eliminating the offending agent through gastric lavage and administration of activated charcoal.
Important to determine salicylate serum levels. Values greater than 35 mg/dl indicate significant acidosis and alkalinizaiton of the urine is indicated to enhance aspirin excretion.
Lead time bias
A test diagnoses a disease earlier and as a result, the time of diagnosis until death seems prolonged even though there actually is no improvement in survival.
Length bias
The survival benefits of a screening test are overstated due to the detection of a disportionate number of slowly progressive benign cases.
Colonic diverticulosis
How does it commonly present?
What does it result from?
Presents with painless hematochezia, resuling from outpouching of the colon walls at points of weakness where the vasa recta penetrates the circular muscle layer of the colon.
Bleeding occurs as the exposed artery is injured, usually from erosion or trauma.
Colonic angiodysplasia versus Diverticular bleeding
Colonic angiodysplasia (AV malformation) decreases the development of dilated, tortuous submucosal vessels and is also a common cause of hematochezia.
However, DB is more likely in a patient with a hx of diverticulois and no prediospoing factors for colonic angiodysplasia (ex: End stage renal disease, VWD, aortic stenosis)
Hemorrhoidal bleeding is usually characterized by?
small-volume bright red blood that covers the stool.
Diagnosis of diverticular bleeding
colonoscopy or tagged RBC scan
The most common pathogen isolated from cultures of corenal foreign bodies is?
Most common cause of bacterial infection in contact lens wearers?
Coagulase negative Staphlococcus.
Pseudomonas
Ischemic colitis versus angiodysplasia
Both present with hematocheiza and more commonly see in patients over 60.
Ischemic colitis is sually associated with adominal pain and bloody diarrhea;
Angiodyspagia presents with painless bleeding.
Chronhs disease and colonoscopy findings
What area is commonly spared in chronh disease
aphthous ulcers, cobblestoning or skip lesions (normal bowel interrupted by areas of disease).
rectum is commonly sparred
HIV and PCP infection
CD counts
Xray finding
Intital treatment of cohice
CD counts <200
Diffuse bilateral ground glass opacities
Trimethoprim-sulfamthoxazole
Management of:
- Patients with supratherapeutic international normalized INR <5 on warfarin and no serious bleeding
– Patients with supratherapeutic INR >or=5 and no serious bleeding
- Patients with supratherapeutic international normalized INR <5 on warfarin and no serious bleeding - HOLD WARFARIN AND RESTART WHEN INR IS THERAPEUTIC
– Patients with supratherapeutic INR >or=5 and no serious bleeding - ORAL VITAMIN K IN ADDITION TO HOLDING THEIR WARFARIN. Oral vitamin K is preferred route at any supratherapeutic INR unless there is serious bleeding.
Choice of treatment in Graves hyperthyroidism
When do you use Antithyroid drugs versus Radioactive iodone and thyroidectomy.
Antithyroid drugs
Mild hyperthyroidism,
older age with limited life expectancy,
preparaton for radioactive iodine or thyroidectomy
Radioactive iodine
- modteratre to severe with/without opthalmopathy
- patient presence in mild hyperthyroidism
- *Give predisone along with radioactive idiodne for those with opthalmopahty. concurrent use is less likely to worsen opthamalopathy*
thyroidectomy
- cancer suspicion
- Coexisting primary PTH
- Pregnant patients who cannot tolerate thionames
- severe opthalmopathy
- restrosneral goiter with obstrcutive symptoms
The best laboratory tests for assessing thyroid function within the first few weeks to month after radioactive idione administration are?
Total T3 and Free T4 (free T3 assays are less well validated and not routinely used)
Measurement of TSH does not accurately reflect thyroid functional status as TSH may remain suppressed for several weeks to months following RAI therapy, even when the patient is euthyroid or hypothyroid state.
Strongest risk factor for suicide?
hx of sucide attempts
Patients with a previous sucide attempt are 5-6 times more likelyt o make anotehr attempt than those who have not made a previous attempt
Treatment of psoriasis
Topical corticosteriods (high potency - Fluocinoide, Betamethasone) - mild to moderate used for thick plaques on extensor surfaces
Phototherapy - for extension disease >10% of body surface area
Methotrexate - effective for severe psoriasis, psoriatic arthritis, and psoriasis involving the nail
Low potency (hydrocortisone) may be used on the face and intertrignious areas (but are not as effective on extensor areas with thick psoriatic plaques)
Viral versus allergic Conjunctivitis
Allergic conjunctivitis can also present with bilateral eye redness and watery discharge.
However, they also have the hallmark ocular itching (pruritis) (not found in viral).
In additiona, allergic conjuncivitis does not cause gritty or burning sensation.
Viral versus bacterial conjunctivitis
in contrast to viral conjunctivitis, bacterial conjunctivitis causes a more profuse purlent discharge that accumulates after being wiped away.
Also, bacterial conjunctivitis generally presents in isolation rather than in the setting of other viral symptoms (rhinorhea, pharyngitis etc)
When is viral conjunctivitis no longer contagtous
Eye drainage caused by viral conjunctivits is the primary route of viral shedding.
Patients are highly contagious due to the large amount of virus present in the eye discharge.
Children should remain at home, even if they are afrebrile, until their eye drainage has reolved.
common drugs associated with risk of lupus include
procainamide, hydralazine, minocycline and antiti necrosis factor (TNF) alpha therapy (etanerceipt, infliximab)
Lyme disease presentation and phases
tick-borne illness
characterstic skin rash & ertyhema migrans at hte site of the bite in the early localized phase
The next phase, early disseminated disease - multiple ertyhema migrans lesions
In addition, Weeks to months after inital infection - neurologic (ex: peripheral neurophaty, cranial nerve palsies, lymphocitic meningitis) and/or cardiac involvement (ex; myopericarditis, AV bock)
Late disease (months to years) is associated iwth arthritis of the large joints and mild neurological manifestations (encephalopahty or polyneuropthy)
Diagnosis of Creutzfeldt-Jakob disease
Creutzfeldt-Jakob disease caused by abnormal proteins called prions.
As the prions build up in cells, the brain slowly shrinks and tissue fills with holes until it resembles a sponge.
Consequence, those lose the ability to think and move properly and suffer from mmemory loss. It is always fatal, usually within one year of onset of illness
periodic sharp wave complexes oberved on electroencephalogy and present of 14-3-3 protein in the CSF.
Alzheimers disease is due to degeneration in which part of the brain?
drug treatment?
Decreased levels of acetylcholine due to degeneration of the basal nucleus of meynert in the forebrain and diffuse deficiency of choline acetyltransferase, which is responsible for the synthesis of acetylcholine.
Acetylcholineserase inihibitors circumvent this problem by inhibiting ht ecounterregulatory brakdown of acetylcholine, thus increasing the overall level of acetylcholine.
Donepezil offers benefits in once-a-day dosing ,improving in behavioral and cognitve domans, and has fewer side effects.
Use of IV atropine
sinus bradycardia verus sinus bradycardia in the absence of a pulse
IV atropine is indicated in patients with symptomatic bradycardia (ex: hypotension, heart failure)
However sinus bradycardia in the absence of a pulse respresent PEA rather than symptomatic bradycaria.
Atropine is not used in patients with PEA cardiac arrest. PEA requires prompt cardiopulmonary resuscitaiton aong with epinephrine every 3-5 mins.
What are primary pediatric cariogenic risk factors?
Bedtime bottle use and frequent exposure to sugary snacks.
As soon as a child’s first teeth erupt, fluoride toothpaste should be used judiciously and dental plaque, white spots and cavities should be assessed on examination.
What is a signficant risk factor for pancreatic adenocardinoma?
Smoking
What occurs in approx. 10% of patients after an episode of acute pancreatitis?
Pancreatic inflammatory fluid collections (ex: pancreatic psudocysts).
What is helpful in determinging the predominant pathophysiologic mechanism of normocytic/normochromic anemia?
normocytic/normochromic anemia can be caused by what two groups of disorders?
What does a low/high count indicate?
Reticulocyte count
Normocytic/normochromic anemia can be caused by two large groups of disorders:
1. Diseases with decreased RBC production
2. Hemolytic disorders
An elevated reticulocyte count indicates hemolysis as the cause of anemia. Other findings assoicated with increased RBC destruction should be sought (elevated indirect bilirubin level, decreased haptoglobin, increased LDH, splenomegaly)
A low reticulocyte count indicates a hypoproliferative state (renal disease, hypothyroidism and aplastic anemia may be present)
What type of anemia is anemia of chronic disease?
What measuresments may be helpful in the diagnosis?
normocytic/normochromic
ESR and serum C-reactive protein measurements
What is the most common cause of inherited or heridity thrombophilia?
Factor V Veiden
Accounts for approx 40-50% of the inherited thrombophilias.
Rh(D) incompatibility is possible only in what kind of mother and father?
Rh(D) negative mother & Rh (D) positive father
Pearly penile papules versus Condyloma acuminata
Condyloma acuminata or anogenital warts, is the most common viral sexually transmited disease in the U.S.
The condition is caused by infection with the HPV. Patients may be assymptomatic or may complain of pruritis, bleeding, burning or tenderness.
These lesions are typically skin-colored or pink and vary in appearance from smooth flattened papules to verrucous, papilliform growths.
Pearly penile papules are a normal variant and are not spread by sexual contact or activity.
These asymptomatic papules are more comon in unciricumcised males and typically appear as one or multiple rows of small, flesh-colored, dome-topped or filiform papules positioned circumferentially around the corona or suclucs of the glans penis.
Amyotrophic Laterial Scerlosis
How does the patient present?
What is usually preserved, even with advanced disease?
Most common form of progressive motor neuron disease
Presents with progressive weakness accompanied by both upper and lower motor neuron deficits.
Inital sign of the disease with LMN involvement is developing asymmetric weakness, usually first evident distally in one of hte limbs
Lower (anterior horns in the spinal cord and brainstem neurons) - atrophy, fasciculations
Upper (corticospinal) - hyperactive reflexes
Ocular motility, snesory, bowel, blader and cognitive functions are preserved
Vascular dementia is characterized by?
presence of behavioral disturbance and cognitve defects associated with clinical or radiograph evidence of a stroke.
The decline in the level of cognitiion is relatively abrupt and progresses in a stepwise fashion.
Binswanger’s disease
aka subcortical leukoencephalopathy
type of vascular dementia that involves white matter infracts.
Patients with this disease usually present with apathy, agitation and bilateral corticospinal or bulbar signs (diffculty with chewing & swallowing)
Main treatmetn for Guillian-barre
plasmapheresis and IV immunoglobulins
Brain stem tumors versus ALS
BST may compress the cervical cord and produce weakness, fasciculations in the upper libms and spasticity int he legs.
The presentation may closely resemble ALS;; however, absence of pain and sensory changes and normal bowel and bladder function favors ALS
What is currently approved for the management of ALS?
What is its role?
Riluzole
a glutamate inhibitor.
Although it cannot arrest the underlying pathological process, it may prolong the survival and delay the need for tracheostomy.
Classical physical examination of Group A streptococcal pharygiits
Treatment?
Strep pyogenes
tonsillar exudates, tender anterior cervical lymphadenopathy and palatal petechaie.
10-day course of oral penicillin, helps prevent acute rheumatic fever.
What is the first step in management of a patient with sudden-onset, severe headache, elevated BP and vomitting?
What if this is negative or equivocal, what should then be performed?
CT scan of the head without contrast to rule out Subarachnoid hemorrhage (SAH)
If CT scan is negative or equioval, a lumbar puncture (LFP) with CSF analysis
This is helpful if mengiitis is in the differential as it can be difficult to clinically differentiate between meningitis and subarachnoid hemorrhage.
The presence of xanthochromia on LP is diagnostic of SAH.
*Xanthochromia, from the Greek xanthos=yellow and chroma =colour, is the yellowish appearance of cerebrospinal fluid that occurs several hours after bleeding into the subarachnoid space caused by certain medical conditions, most commonly subarachnoid hemorrhage.
Symptoms of opiod withdrawal?
What do you use to treat this?
rhinorrhea, lacrimation, diarrhea and boady aches. Elevated blood pressure and pulse can also occur.
Opioid agonists (methadone, buprenorphine) or nonopiod agents such as clonidine).
Due to their high level of required supervision, opiod agonists hsould be used only for detox in supervised inpatient or outpatient settings.
Methadone is preferred over buprenorphine (also an opiod agonist) due to potential worsening of withdrawal from buprenoprhine (from its parital opiod antgagonist effects)
Febrile Seizures confer an increased risk for?
recurrence (30% chance) and slight risk for (<5%) for susequent develop of epilepsy (ex: afebrile seizures) but no effect on intellectual outcome
Common cause of decreased vision in elderly patients
cortical cataracts and associated macular degeneration.
Elderly patients should be througly evalauated for the severity of macular degeneration, as they may not benefit from cateract surgery
Macular degeneration refers to aging of the retinal tissue which comprises the macula. The macula is the area of the retina that provides us with our central vision. When the cells of the macula degenerate it causes blurriness or darkness in our central vision. This is very different from other disease processes, such as glaucoma, which causes visual damage mainly in the periphery. Fortunately, macular degeneration does not tend to affect the side or peripheral vision.
Typical CSF findings in SAH
How does it difffer from traumatic tap?
elevated opening pressure,
xanthochoromia (pink/yellowish tint due to hemoglobin degradation products) or
consisently elevated RBC count in 4 CSF tubes.
An elevated RBC count in the first tube, followed by declining numbers of RBCs with each sucessive tube suggestes traumatic tap.
Wet versus dry macula degeneration
“Dry” macular degeneration (atrophic) - most common type, on and does not involve any bleeding behind the retina. Vision loss is usually very gradual and occurs over many years.
“Wet” macular degeneration (exudative) - accounts for about 10% of all cases. It results when abnormal blood vessels form in the macula and bleed into the retinal tissues. It is the bleeding and scarring process that can then result in visual loss. Wet macular degeneration can cause vision to decline much more rapidly than the dry type. The loss of vision with wet macular degeneration is usually more severe than with the dry type.
Most common cause of viral meningitis or encephalitis in the pediatric population?
How does it differ from adults?
What infections are common in the rural areas?
Pediatric - Enterovirus and Arbovirus
Adults - HSV
Most arbovirus infections are zoonosis (transmitted through animal vectors); for this reason these infections are common in the rural areas?
Allergic bronchopulmonary aspergillosis (ABPA) is what?
Pathophysiology
Clinical features?
hypersensitivity disorder that occurs in patients with asthma or cystic fibrosis. Associated with noninvasive colonization of the airways by the Aspergillus species.
Exaggerated IgE and IgG mediated immune system to the Aspergillus fungus in the context of preexisting asthma
Asthma exacerbations, fleeting infilgrates on lung imaging and central bronchiectasis.
ABPA Treatment
Glucocorticoids and itraconazole are used to control inflammation and prevent irreversible damage.
Eosionophilc granulomatosis with polyangitis
Eosionophilc granulomatosis with polyangitis (churg-straus disease) is an uncommon auto-immune vasculitis.
It is often associated with diffcult to control asthma.
Other clinical findings include allergic rhinitis with nasal polyps, chornic sinusiits, mononeuropathy multiplex, and skin manifestations (ex: granulomas, palpable purpura)
Strongest predictor of stent thrombosis after coronary stent placement?
premature discontinuation of dual antiplatelet therapy (aspirin and P2Y receptor blocker)
Patients should be aggrestively sceened and counseled for medication compliance to reduce the risk of stent thrombosis.
Small Bowel obstruction management
The presence of air in the distal colon makes the diagnosis of complete obsruction less likely.
PARTIAL SBO should be initally managed with observation and supportive treatment.
If the patient fails to imporve the next 12-24 hours, early surgical intervention is recommended.
Signs of impending strangulation (incercareated hernia) or mescenteric ischemia should undergo urgent surgical intervention.
Lithium
What confirms toxicity?
Chronic lithium toxicity clinical findings?
What can it be precipated by?
has narrow therapeutic index and serum levels greater or equal to 1.5 confirm toxicity.
Confusion, ataxia, neuromuscular excitablity
precipitated by volume depletion and drug interations with thiazide diuretics, ACE inhibitors, and NSAIDS.
Ex: thiazide diuretics, such as chlorthalidone, increase sodium excretion in the distal tubule giving slight volume depletion.
The resulting increased proximal tubular reabsorption of sodium also promotes lithium reasorbption, leading to lithium toxicity.
Management of Lithium toxcity
IV hydration
Lithium toxcity presenting with severe neurologic symptoms is an absolute indication for urgent hemodialysis.
Other indications for hemodialysis include lithium level >4 or an increasing lithium level despite saline administration.
Stress urinary incontience
What is it?
When does it occur?
Treatment?
involuntary leakage of urine due to increaed intrabdominal pressure.
Occurs when pelvic trauma, loss of pelvic connective tissue or high impact activity can cause inadequate urethral support and urethral hypermobility.
Inital treatment - pelvic floor exercises (kegel) and life style changes (caffeine restriction, weight loss and smoking cessation)
No improvement - candidates for surgical management, typically a mid-urethral sling procedure.
Sydeham chorea in children
is one of the major manifestions of acute rheumatic fever and is the most commonly acquired chorea in children.
It is characterized by emotional liability and irregular, rapid jerking of the face, hands and feet.
Tourette syndrome versus syndenham Chorea
Tourette syndrome is characterized by involuntary motor and vocal tics that begin at age 2-15.
The PE is otherwise normal and chorea is not seen.
Patients with syndenam chorea should be started on?
Penicllin as son as possible to eliminate carriage of Group A streptococcus.
Penicllin should be continued until adulthood with the goal of preventing recurrent rheumatic fever.
How does Laryngeal edema typically present?
Administration
What can prevent this?
Post-extubation stridor and respiratory failure.
Intubation causes direct damage to the laryngeal mucosa, leading to inflammation that may cause significant edema
Administer multiple-dose regimen of glucocorticoids prior to extubaion can prevent laryngeal edema and extubation failure.
Reintubation should be considered early to secure the airway in all patients with signs of impending respiratory failure.
The most commonly used pharmacotherapies for smoking cessation include?
Contraindications to each?
nictoine replacement, bupropion, and varenicline.
varenicline - avoid in patients with unstable psychiatric symptoms or a hx of suicidal ideation since there are reports that it may increase these symptoms in some patients.
bupropion - contraindicated in patients with seizures
Diagnostic test that has the greatest sensitivity and NPV for the diagnosis or exclusion of osteomyelitis of the foot?
What is useful in the diagnosis of osteomyelitis in patients who have contraindications (ex: pacemaker) to MRI?
MRI of the foot
If CI, then use CT scans (they have greater sensitivity than plain radiographs,b ut are less sensitive than MRI)
Patients with diabetic foot ulcers who have underlying osteomyelitis usually require what to determine the pathogenic organisms?
Bone biopsy for culture and sensitiivty
Superficial wound swabs and cultures from debrided tissues are not sufficient.
*Because diabetic wound colonization rates are high, superficial wound cultures have little predictive value in identifying underlying pathogic organisms and should not be used to guide therapy.
Organisms commonly involved in patients with diabetic foot ulcers with underlying osteomyelitis
Gram Positive cocci such as Staph. Aureus are isolated most commonly, but Pseudomonas aeruginosa and anaerobic bacteria (ex: Clostridium) are also frequently involved, particlarly when wounds are deep and chronic.
Case fatality rate
How does it differ from mortality rate?
Proportion of people with a particular condition who end up dying from the condition
Mortality rate - probablity of dying from a particular disease in the general population.
A mortality rate — often confused with a CFR — is a measure of the number of deaths (in general, or due to a specific cause) in a population, scaled to the size of that population, per unit of time. (For example, a rate of 50 deaths per 10,000 population in a year resulting from diabetes. The mortality rate, therefore, would be 50:10,000 or 5:1,000.)
Standardized mortality ratio
are used to determine if the observed number of deaths in a group exceed what would be expected in a similar group (ex: similar age, gender) exclusind the variable of interest (ex: smoking status, cholesterol levels).
For treatment of acne in women who may become pregnant, preferred medications include?
What should be avoided?
What is absolutely contraindicated in pregnancy?
Erythomycin, clindamycin (inflammatory acne), or azelaic acid (comedonal acne) - Category B
Tropical tretinoin and benzoyl peroixde should be avoided - Category C
Tazarotene and isotretinoin are potent teratogens that are absolutely CI in pregnancy = Cateory X
Recommendation for postexposure HIV prophylaxis following high risk exposure to an HIV-infected individual
with highly active antiretorvial therapy for 28 days is recommended
Triple drug therapy is preferred and should be started within 72 hours of exposure.
Will neeed to repeat HIV testing in 4-6 weeks.
Most patients with Autosomal dominant polycystic Kidney disease have progressive?
What must be monitored?
progressive decline in renal function.
The ideal goal for BP control in any patient with Chronic kidney disease, including ADPKD, is less than 130/80mm Hg.
Ace Inhibitors are considered the DOC for controlling HTN and preventing progression of renal failure in these patients.
Approximately 10% of patients with Autosomal dominant polycystic kidney diseae have what?
When do you do routine screening for these?
intracranial berry aneurysms.
Routine screening restricted to patietns with a postiive family hx of subarachnoid hemorrage.
Good pressure control is also helpful in preventing rupture of the berry aneurysm and subsequent intracranial bleeding.
What is the most common extrarenal manifestation of ADPKD?
Hepatic cysts
Their incidence increases in the 2nd - 5th decades of life, by 5- of age, approx. 70-80% of patietns with ADPKD will have hepatic cysts.
Although berry aneurysms have an increased frequently (10-15%) in patients with ADPKD, cyst formation in the brain rare.
Precedure of choice for screening the asymptomatic family members of a patient with ADPKD?
The presence of at what is required to make diagnosis of ADPKD?
Ultrasonography
The presence of at least 3-5 cysts in each kidney is require to make a diagnosis of ADPKD.
Pathophysiology of PCOS
Increase testosterone
Increase Estrogen (peripheral conversion of androgens to estrone in addipose tissue which contributes to chronic anovulation and infertility) –> Weight loss will help
LH/FSH imbalance
Diagnosis of cervical insufficiency?
Treatment?
HX of > or = 2 painless, second-trimester losses or presentation of painless advanced cervical dilation in the second trimester of the current pregnancy.
Cerlage placement, a procedure in which a suture is placed to reinforce the cervix.
Fetal fibronectin testing
Indicated to determine the risk of preterm delivery in patietns with preterm contractions.
It does not predict the recurrence of preterm delivery in asymptomatic patients.
Indications for ureteral stone removal?
What do you do for all other stone sizes?
Stones > or = to 10mm, persistent pain, acute Renal failure or signs of sepsis.
Antibotics are indicated in presence of infection.
Stones <5mm usually pass spontaneously.
Stones up to 10mm can be given a trial of medical therapy (gentle hydration, pain control, alpha blockers) and do not require hospital admission if symptoms are controlled.
Presentation for postpartum endometritis?
Treatment?
Fever, uterine fundal tenderness >24 hours after a cesarean delivery; purulent vaginal discharge.
Broad-spectrum antibiotic regimen - Clindamycin plus gentamicin
- Clindamycin covers aerobic gram+, gram - rods, and pencillin resistant anaerobes.*
- Gentamicin covers gram -, some gram + (staph)*
Treatment is continued until the patietn is afebrile >or=24 hours.
Risk factors for Postpartum endometritis
Most significant is?
Hx of bacterial vaginosis, Group B strep colonization, prolonged rupture of membranes, protracted laber, operative vaginal delivery and cesarean delivery
either associated with an increased vaginal bacterial load or faciliates the bacterial ascent into the uterus.
Most significant is cesarean delivery.
Management of patietns with sickle cell disease who have a severe vaso-occlusive epidsode and are hemodynamtically stable should be treated with?
promptly with IV opiods (ex: morphine)
and should be given within 30 minutes of arrival.
IV fluids are indicated for hypovolemic or hypotensive patietns as inital fluid recuscitation. If the BP is normal for age, then pain medications should be given first.
Acute chest syndrome in sickle cell disease is defined by?
presence of a new pulmonary infiltrate on chest-xray and 1 or more of the following:
Fever, hypoxiemia, chest pain, tachypnea, or increased work of breathing.
Inital treatment includes third genration cephalosporin (ex: ceftriazone) to cover Strep Pneumo and macrolide (ex: azithromycin) to cover Mycoplasma pneumonaie, pain control and IV fluids.
Transfusion reaction timeline
0-secs/mins = Anaphylaxis
minutes to 1 hour = Acute hemolytic
1 hour to 6 hours = Febrile nonhemolytic, TRALI (transfustion related acute lung injury)
Days to 10 days = Delayed hemolytic
Febrile nonhemolytic transfusion reaction
When does it happen?
How does the patient present?
What can prevent this?
most common adverse reaction that occurs within 1-6 hours of transfusion.
Patients usually develop fever, chills and malaise without hemolysis.
Leukoreduction of donor bloood can prevent febrile nonhemolytic reaction and reduce the risk of human leukocyte antigen alloimmunization and CMV (which resides in leukocytes) transmission.
- *When RBC and plasma are seperated from whole blood, small amounts of residual plasma and/or leukocyte debris may remain in the red cell concentrate.*
- During blood storage, these leukocytes release cytokines, which when transfused can cuase transient fevers, chills and maliase without hemolysis.*
What type of Specialized RBC treatments should patients with IgA deficiency receieve?
Residual plasma in Red cell concentrates contains proteins, cincluding immunoglobulin A (IgA).
IgA deficient patients develop antibodies against IgA.
These antibodies can react with IgA-containing products and induce an anaphylactic reaction (angioedema, hypotension and respiratory distress) that can progress rapidly to loss of consciousness, shock and respiratory failure.
To reduce this risk, red cells should be washed to remove as much of the plasma as possible for patietns with IgA deficiency prior to allergic tranfusion reaction.
Serum Sickness
What type of hypersensitivity?
What occurs?
A minority of what type of patients develop that and what is it characterized by?
Immune complex-mediated hypersensitivty reaction (Type III)
Occurs when circulating antibodies combine with antigen in the blood and tissues and overload normal clearance mechanims. This then activates the complement and cause disease.
Minority of patients with acute Hep. B infection develop an S-S like syndrome that is attributed to complement activation by circulating immune complexes compoed of Hep. B surface antigen.
Characterized by fever, polyarthritis and dermatitis. Other extrahepatic manifestions of Hep. B infection explained by circulating immune complexes include polyarteritis nodosa and glomeruloneprhritis.
Chronic Adrenal insufficiency versus hypoaldosteronism
Hypoaldosterism usually presents with asymptomatic hyperkalemia with mild metabolic acidosis.
Hyponatremia is generally not seen unless there is concurrent cortisol insufficiency.
In addition, hyperpigmentation is not seen as there is no increased production of ACTH/melandocyte stimulating hormone.
Diagnosis of Overflow incontinence
post-void residual volume (>200 mL is diagnostic)
Type II error represents?
What is it dependent on?
What is the correlation?
Failure to reject a null hypothesis when it is false.
Depdendent on the power of the study, which is dependent on the sample size.
As the sample size and power increase, the likelihood of a type II error decreases.
What is the placebo effect?
phenomenon whereby a patient’s symptoms are alleviated by an otherwise ineffective treatment (placebo), most likely due to the individual expecting the treatment to work.
External Validity of a study
Reflects the applicablity of the obtained results beyond the cohort that was study.
dependent on the adequacy of the sample.
If the sample is representative of the desired population, then the results will generalize.
Basic premise of intention-to-treat principle?
Purpose?
Intention-to-treat analysis is a technique used in randomized controlled trials (RCTs), where patients are compared–in terms of their final results–within the groups to which they were initially randomized, independently of receiving the allocated treatment, having dropped out of the study or having violated the initial protocol (for whatever reason).
Purpose of of ITT is to preserve randomization
*Randomized controlled trials often suffer from two major complications, i.e., noncompliance and missing outcomes. One potential solution to this problem is a statistical concept called intention-to-treat (ITT) analysis. ITT analysis includes every subject who is randomized according to randomized treatment assignment. It ignores noncompliance, protocol deviations, withdrawal, and anything that happens after randomization.
Lichen Plancus
What is it?
What are the classic skin lesions?
What is required to confirm the diagnosis?
chronic, inflammatory, autoimmune disease that affects the skin, oral mucosa, genital mucosa, affects mostly middle age adults.
Characterized by 4 p’s” Purple, polygonal, pruritic, papules
Onset is usually acute, affecting the flexor surfaces of the wrists, forearms, and legs. The lesions are often covered by lacy, reticular, white lines known as Wickham striae.
A skin biposy may be requried to confirm the diagnosis.
Colon Cancer Screening
What age do you start and when do you repeat for the following:
General population
Single Family Member Hx
HNPCC
FAP
Previous Adenomatous polyp
Previous hx of colon cancer
Symptoms of scombroid poisioning include?
flushing, a throbbing headache, palpitations, abdominal cramps, diarrhea and oral burning.
These typically begin 10-30 minutes after ingesting the fish and are self-limited.
patients sometimes describe a bitter taste, but this is not always present.
Hepatorenal syndrome
What is it?
What is needed to confirm that the renal failure is not secondary to intravascular volume depletion.
What is the treatment of choice after the diagnosis is confirmed?
a common cause of acute renal failure in patients with cirrhosis, but should be considered a diagnosis of exclusion.
A fluid bolus - failure to respond would be consistent with hepatorenal syndrome
Tx: combination of octreotide and midodrine or norephine along with albumin
- Midodrine is a systemic vasoconstrictor, and octreotide is an inhibitor of endogenous vasodilator release (which produces splanchnic vasoconstriction); combined therapy theoretically improves renal and systemic hemodynamic*
- When patients are treated with norepinephrine, terlipressin, or midodrine plus octreotide, an immediate goal of therapy is to raise the mean arterial pressure by approximately 10 to 15 mmHg to a level of >82 mmHg.*
Treatment of syphillus by stage
Primary, secondary, Early latent (< 1 year)
Latent, Unknown, gummatous or cardiovascular symphilis
Neurosyphillis
Congenital syphillis
Primary, secondary, Early latent (< 1 year) - Benzathine penicllin G IM in one dose
Latent, Unknown, gummatous or cardiovascular symphilis -
Benzathine penicllin G IM weekly for 3 weeks
Neurosyphillis - Aqueous pencillin G, IV every 4 hours for 10-14 days
Congenital syphillis - Aqueous penicillin IV every 8-12 hours for 10 days
Porphyria Cutanea Tarda
deficiency of what enzyme?
Characterized by?
What can it be triggered by
Uroporphyrinogen decarboxylase, an enzyme in the heme pathway
painless blisters, an increased fragility of the skin on the dorsal surface of the hand, facial hypertrichosis and hyperpigmention.
Can be triggered by ingestion of certain substances (ex: ethanol, estrogens) and should be discontinued if suspect.
Common side effects of noninsulin antihyperglyemic agents
insulin secretagogues
biguanides
thiazolidediones
DPP-4 inhibibtors
GLP-a receptor agonists
alpha-glucosidase inhibitors
SGLT-2 inhibitors
Pick’s Disease
characterized by?
Neuroimaging findings?
slowly progressive frontal lobe dementia
characterized by speecah abnormalities (logorrhea, echolalia, aphasia, mutism), impaired executive thinking, irritable mood, hyper-oral behavior and disinhibtion.
Neuroimaging studies reveal the classifcal finding of prominent symmetric atrophy of the frontal and/or temporal lobes.
*Lewy body dementia has “halLEWYcinations”, and picks disease has personality changes.
Lewy Body dementia
Lewy Body - second most common form of neuroegenerative dementia after Alzhemier rdisease.
It is gradually a progressive dementia associated with varying cognitive function and alertness, persistent visual hallucinations and some motor features of parkinsonism (ex: rigidity, intention tremor).
Falls are common.
Microscopic fiindings in the brainsteam and cortext include lewy bodies, which are cytoplasmic inclusions.
Herpangina
caused by?
Characterizecd by?
Dx?
Treatment?
Coxsackie Group A virus
Vesicles on the posterior oropharynx. Fever, systemic symptoms.
Dx: Clinical
Tx: Symptoms resolve in one week. Supportive (hydration and analgesics)
Group A streptococcal pharyngitis versus Infectious Mononucleosis presentation
Both have tonsillar exudates, and fever
GROUP A STREP:
anterior cervical lympadenopathy
INFECTIOUS MONO
-diffuse cervical lympahdenopathy
+/- hepatosplenomeglay
Indirect inguinal hernia is due to?
Management in the pediatric group?
failure of the processus vaginalis to obliterate.
surgically repaired as early as possible. They do not resolve with age.
The risk of potential complications, including incarceration, is particularly high if it remains unrepaired during the first few months of life.
Potential complicatons of Vitamin B12 deficiency that are reversible with vitamin supplementation in the majority of cases?
Dementia and subacute combined degeneration
Signs of dorsal spinal column dysfunction (impaired vibration, positive romberg sign) and lateral corticospinal tract abnormalities (ex: spastic paresis, hyperrefexia) which are fairly specific for SCD.
Seborrheic dermatitis is characterized by?
Treatment options?
erythematous plaques with loose, greasy-looking scales on the scalp (“dandruff”), central face, and ears.
SD predominately affects areas with heavy concentraiton of sebaceous glands, including the scalp (where it is referred to as “dandruff”), central face (eyebrows and nasolabial fods) and ears.
Treatment options: topical antifungals (ex: ketocoazole, selnium sulfide), keratolytic agents (salicyclic acid), coal tar, topical glucorticoids and topical calcineurin inhibitors (ex: pimecrolimus and tacrolimus).
Pancoast Syndrome
consists of?
What indicates a worse prognosis?
Shoulder pain (50-90%), Horner syndrome (15-50%) and hand muscle atrophy and weakness (10-20%).
Asymmetric lower-extremity Deep tendor reflexes, espeically in the setting of back pain suggests that the tumor has spread to the spinal cord.
Spinal cord compression deveops in 25% of patients with pancoast tumor during the course of the disease and may result in paraplegia.
Early recognition and appropriate therapy are imperative to preserve neuroligc function and patient autonmy.
Horner Syndrome - ipsilateral ptosis, miosis, enopthalmos & anhidrosis) from involvement of the paravertebral sympathetic chain (considered a poor prognositic sign but is not immediately dangerous)
PSVT findings on EKG
narrow complex tachycardia with regular R-R intervals and may show retrograde P waves that are tpically interverted in the inferior leads.
Potential cause of headaches typically seen in overweight women of childbearing age?
Best next step in management?
What confirms the diagnosis?
Idiopathic intracranial hypertension, aka pseudotumor cerebri
Opthalmoscopic exam - papilledema
A negative neuroimaging study (except an empty stella) and elevated opening pressure on lumbar puncture can help confirm the diagnosis.
(opening presure gerater than 20-25 cm H20)
Common finding in majority of infants with shaken baby syndrome
bilateral retinal hemorrhage
Sciatic nerve versus femoral nerve injury
In contrast to the femoral nerve injury, the medial calf and arch of the foot may be spared in sciatic nerve injury seconary to the preserved innervation of by the saphenous nerve (branch of the femoral nerve).
The knee jerk is normal but the ankle jerk is unobtainable.
Weakness affecting most of the lwower leg musculaature, including the hamstrings. Hip flexion, extension, abduction adduction and knee extension are normal.
The most common cause of compression or injury to the sciatic nerve in this region is trauma which includes hip dislocation, fracture or replacement.
Other ethiologies include wayward buttock injections, compression by external sources (ex: prolonged sitting) and deepseating mass in the pelvis (ex: hematoma0
A patient with common peroneal nerve injury will usually present with?
acute foot drop accompanied by weakness in foot dorsiflexion and eversion.
In additiona, the patient may also complain of paresthesia and/or sensory loss of over the dorsum of the food and lateral shin (superifical peroneal nerve territory).
The injury is usually located at the knee on the lateral aspect of the fibular head
Femoral nerve injury is characterized by
inability to extend the knee,
loss of knee jerk reflex
sensory loss over anterior and medal aspects of the thigh, medial aspect of the shin and arch of the foot
Interpretation of key phrases:
Gram positive cocci in clusters
Gram positive cocci in pairs and chains
Gram negative coccobacilli
Lactose-postive gram negative rods
Lactose-negative gram negative rods
Branching gram positive rods, modified acid fast stain positive
Acid fast bacilli
Yeast
Germ-tube negative yeast
Germ-tube positive yeast
Round yeast
