uworldnotesstep2 Flashcards
primary reason to screen AFP
for neural tube defects
treatment for secondary pneumothorax in COPD
observation and O2 if minoremergent tube thoracotomy if serious
most likely reason for a ↓AFP
trisomy 18/21
side effects of azathioprine
dose related disarrhea, leukopenia, hepatoxicity
lab results that would suggest rhabdomyolysis
↑ K
↑ CPK
pt with alcohol hx and develops postural instability and wide based gait what is the dysfunction
decrease in purkinje cells in the cerebellar vermis
“proximal muscle weakness”
“can’t walk upstairs”
polymyositis
pt with hx of stomach ulcers and kidney stones - what genetic disease does this suggest
MEN1
primary hyperparathyroidism causing hypercalcemia
treatment for polymyositis
glucocorticoids (prednisone)
glucocorticoid-sparing agent - methotrexate or azathioprine
cancer assocated with lambert easton
small cell lung CA
pt presents with small kidneys and elevated BUN/Cr - most likely chronic dx
HTN
tan colored lesions on the eyes
NF1 - lisch nodules, tan colored hamartomas
side effects of what drug - nephrotoxicity, HTN, glucose intolerance, gingeval hypertrophy, hirsuitism, and GI manifestation
cyclosporine
pt with dementia - sudden onset with myoclonus
prion diseae
general ways to get a thrombocytopenia
decreased platelet production increased platelet destruction Other
what are these?non immune direct effect that starts within 2 days of commencing heparinantibody to platelet factor 4 causing platelet aggregation, thrombocytopenia, thrombosis, platelets decreased by at least 50% 5-10 days after starting heparin
HIT 1 and HIT 2
50% loss of platelets and antibody to platelet factor 4
HIT2
67 year old man with no health problems and does not take any medications - which vaccines does he need
PCV13 + PPSV23 at a later time because he is ≥65
pt with loss of sensation fo the foot dorsum - nerve
common peroneal/fibular nerve on the anterolateral leg
up until what point can you administer charcoal following toxic acetaminophen exposure
up to 4 hours
coming from a low income country is highly indicative of which bacterial infection
h. pylori
in a quad screen - decreased AFP, beta hcg, estriol
Edwards (trisomy 18)
most common cause of purpura in a child
Henoch Schonlein purpura (HSP)
proximal muscle weakness with ↑CRP
polymyositis
risk factors for developing acute otitis media
formula intake, exposure to cigarette smoke
immunoglobulin associated with celiac disease
IgA - anti-epidermal transglutaminase antibodies are IgA associated
who should receive Tdap/Td?
all adults should receive one Tdap and Td boosters every 10 years. If vaccination hx is unknown, replace one Td with Tdap
when should a quad screen be done
15-20 weeks
what drug should you never give in uremic pericarditis
heparincan cause a hemorrhage
hyperdense biconvex lesion that does not cross suture lines
epidural hematoma
what two organ dysfunctions would you see in cocaine OD - why?
Renal failure and heart failure
renal because of ↑K and ↑CPK causing rhabdomyolysis
cardiac failure because of valvular damage and ↑K
difference in meconiums bt hirschprungs and ileus
ileus - inspissated and viscous causing obstructionhirscprung - normal
pt with pH of 7.28, CO2 of 38 - what is this and what shouldn’t you give them
metabolic acidosis - don’t give bicarb becuase they are compensated if the pH is <7.2
cancer associated with actinic keratosis
squamous cell carcinmona
coronary artery aneurysm in a child
kawasaki disease
what dysfunction can you diagnose by rocking the pt back and forth at the hips
gastric outlet syndrome
loss of glomerular capsule, glomerular and peritubular fibrosis, microhematuria and proteinura
glomerulosclerosis
most common causes of ESRD
1) diabetic nephropathy2) HTN
what life treatning condition is found comorbid with cocaine overdose in >20% of cases
rhabdomyolysis - ↑CPK, ↑K
differentiate in symptoms between cauda equina and conus medullaris syndrome
cauda equina - saddle anesthesia, hyporeflexia, gradual onset of pain, lower motor neuronconus medularis - fast onset, perineal anesthesia, hyperreflexia, symmetrical weakness
expain why this isn’t mets:extra axial well circumscribed/round homogeneously enhanced dural lesion
mets to brain would have multiple ring enhancing lesions at the gray-white matter junction
which is the worse of the HIT’s
HIT 2
what does a decrease of angiotensin II/aldosterone cause with Na
increase in naturiesis
only vasculitis with normal platelet counts
HSP
what should you do before starting vasopressors in someone with septic shock
give IV saline 0.9%
pt with prolonged QRS and prolonged PR
bradyarrhythmia
drug use that increases your risk for rhabdomyolysis
cocaine abuse especially if the pt was imobilized for some time before being found
what arrhythmia would you see with digitalis toxicity
atrial tachycardia w/AV block
pt with CPK >35,000IU/L
most likely dx
rhabdomyolysis with acute renal failure
what will you see on microscopy of diabetic nephropathy
increased extracellular matrix, basement membrane, mesangial expansion
50 year old patient with no reliable vaccination hx - Td or Tdap?
Tdap and then Td every 10 years!
what is meconium illeus virtually diagnostic for
cystic fibrosis
when someone is in septic shock what are the appopriate steps to take
1) secure the airway 2) IV 0.9% saline with CRYSTALLOID 3) treat the infection
production of a reactive oxygen species by interaction of drug metabolites and UV
phototoxic reaction
pt with recent onset optic neuritis, intranuclear opthalmoplegia and fatigue
MS
what causes jaundice by decreased activity of the UDP-glucuronyltrasnferase enzyme
gilbert syndrome
pt presents with decreased DTRs, symmetrical proximal muscle weakness, and autonomic dynsfunction - dx?
Lambert Easton secondary to small cell lung cancer
dysfunctions that cause decreased platelet production leading to thrombocytopenia
EBV, CMV, chemo, myelodysplastic syndrome, alcohol, Fanconi anemia, vitamin B12/folate deficiency
pt presents with extra axial well circumscribed and round and homogenously enhanced dural lesion - dx
meningioma - calcification, hyperdense, dx with non contrast CT
which nerve is affected by a hit to the anterior thigh
femoral nerve
palpable purpura mostly contained to the buttocks, legs, and thighs
HSP
who should receive which pneumococcal vax
adults 19-64 with no medical hx: NO vaccine necessary adults 19-64 with heart disease, DM, or liver disease should have PPSV23 adults 19-64 who have CSF problems, cochlear implants, sickle cell anemia, asplenia or HIV should have PCV13 and then PPSV23 at a later date All patients over 65 should have PCV13 + PPSV23 at a later date
which one is which?high fever (>104)cervical lymphadenopathycecphalocaudal rash with gradual spreadlow fever (<104)post auricular and suboccipital lymphadenopathycephalocaudal rash with rapid onsetarthralgias (esp in women)
first: measlessecond: rubella
renal vascular lesions in HTN
arteriolosclerosis of afferent and efferent renal arterioles
what is the precipitating factor that makes toxic shock syndrome so dangerous
massive release of cytokines
10 year old female patient with pruritic anal and vaginal areas particularly at night - dx
pinworm infection (enterobius vermicularis)
where is the defect in hirscprungs vs meconium ileus
H - sigmoid-rectum (will find meconium in the rectal vault)MI - ileum
most effective primary meds for parkinsons
levodopa/carbidopa
what kind of AKI will show a ≥50% increase in Cr from normal
prerenal AKI
how does the RAAS system work in response to hypoperfusion
hypoperfusion causes the juxtaglomerular apparatus to release renin. Renin cleaves angiotensin into angiotensin I. ACE converts angiotensin I to angiotensin II which is a potent vasoconstrictor and causes adrenal cortex to produce aldosterone which retains Na/H20 and secretes K in order to increase BP
s/e of mycophenelate
bone marrow suppression
pt has persistant pneumothorax and pneumomediastinum following chest tube placement
tracheobronchial rupture
pt complaining of morning stiffness and has elevated CRP and sed rate what won’t you see on PE
joint inflammation - this patient has polymyalgia rheumatica
pt with non painful and non pruritic skin lesions increasing gradually in size on the trunk
NF1
diastolic murmur at the apex in a young woman
mitral stenosis
other than azithromycin and TMP-SMX - what other potential prophylaxis for HIV with CD4 <50
pt lives in ohio river valley - histoplasma, tx: itraconazolept has herpes hx - acyclovirpt with yeast flare - fluconazole
treatment for complicated gallstone disease (acute cholecystitis, choledocholilithiasis, gallstone pancreatitis)
cholecystectomy within 72 hours
what is this
osgood schlatter disease with fractured tubercle
what increases your risk of developing impetigo following a bacterial infection
eczema, abrasions, insect bites
what are some causes of pseudothrombocytopenia
platelet clumping due ot EDTA abciximab inadequate sample
pt with GI pain, weight loss of 10 lbs, recent onset memory deficits, peripheral neuropathy, and microcytic anemia - dx
acute lead poisoning
progressive dyspnea, decreased exercise tolerance, Afib, rapid ventricular response, LV systolic dysfunction
tachycardia mediated cardiomyopathy
what can help LV function in someone with tachycardia
rate control drugs
less likely but still common reaosns for ↑AFP in pregnancy
ventral wall defects - oomphalocele, gastroschisis
most likely cause of a phototoxic drug reaction
doxycycline (tetracyclines)
pt ingested toxic levels of acetominaphen in the last 2 hours - next steps
administer charcoal (if within 4 hours) + take acetaminophen level
based on level determine whether n-acetylcysteine is needed
what disease process does this describe
parathyroid hyperplasia or adenomas with symptomatic hypercalcemia from primary hyperparathyroidism, burning upper abdominal pain from zollinger ellison syndrome and pituitary adenomas
MEN1
40 year old pt with no relevant medical hx presents with thrombocytopenia seemingly unrelated to anything - potential casue
HIV - 5-10% of patients present initially with this
what is the mechanism of renal failure in cocaine use
ATN secondary to rhabdomylosis from excessively filtered myoglobin
definitive diagnosis for polymyositis
muscle biopsy
pt with increased aPTT, new thrombocytopenia and arterial thrombosis
heparin induced thrombocytopenia
what echo finding would you expect with mitral stenosis
left atrial dilation
what are the two main dx for non passage of meconium
1) Hirschprungs disease2) meconium ileus
nerve on the medial thigh
obturator
what labs might you find in kawasaki disease
↑CRP, sed rate leukocytosis with neutrophilia, thrombocytosis, sterile pyuria
next step after finding an ↑AFP
u/s
complications of impetigo
PGSN
male patient with hx of COPD has sudden onset of chest pain and hyperresonance with unilateral decrease in breath sounds
COPD with acute exacerbation with secondary spontaneous pneumothorax - chronic destruction of alveolar sacs causes large alveolar blebs and rupture/leak of air
best way to diagnose turners
KARYOTYPE not Barr bodeis
causes of uterine atony
prolonged laborover distended uterusmultiple gestationforcep assistedHTN
where does aldosterone work
on the distal collecting duct to increase Na/H20 and blood volume
most common cause of post partum hemorrage
uterine atony
12 year old male presents with increased indirect bilirubin following surgery for appendicitis with overt scleral icterus
diagnosis
Gilbert syndrome
paraneoplastic syndrome associated with presynaptic volatage gated Ca channels
lambert easton - small cell lung cancer
how does TSST-1 differ from RMSF
in RMSF the petechiae rash starts in the extremities
what should you look for on xray when you suspect secondary pneumothorax in COPD
visceral pleural line beyond which no pulmonary markings exist
treatment for rhabdomyolysis
aggressive hydration
manitol and urine alkalinazation
main danger associated with CPK >20,000IU/L
acute renal tubular necrosis from myoglobinuria
what cardiac condition frequently coexists with mitral stenosis
Afib - 70% co-occurrence
posterior shoulder dislocation associations
the 3 E’sElectricityEpilepsyEtoh
when is suction curretage the right answer in an abortion
when the woman is hemodynamically unstable from heavy bleeding or sepsis - expectant management otherwise
pt with no medical hx is newly diagnosed with ITP what commonly coexisting condition should you also check for
HIV
mutation most associated with polycythemia vera
JAK2 mutation
when is AFP measured
16-18 weeks
why is tacrolimus better with side effects than cyclosporine
no hirsuitism or gingival hypertrophy in tacrolimus
if someone is in prerenal AKI how do you know whether to give fluids or diurese
give fluids if there are no obvious signs of fluid overload (e.g. ↑JVD, crackles) - give isotonic if not fluid overloaded
treatment for impetigo
muprocin
23 year old female with sickle cell - which vaccine(s) does she need
PCV13 + PPSV23 at a later time because she is immunocompromised
femoral nerve damage could result in what dysfunctions
knee extension and hip flexion
pt with asymmetric t wave inversion in V5-V6 with an increase in glucose, BUN of 90 and creatinine of 5.6 - dx
uremic pericarditis - anytime you see chest pain and BUN > 60 that’s what it is
why do you go for rate control and not typical drugs from CHF in someone with tachycardia induced cardiomyopthy
tachy induced cardiomyopathy is potentially reversible - the key is to try and get the person back to a normal sinus rhythm
why does cocaine cause ischemia, seizures, agitation
it is a potent vasoconstrictor
in a quad screen - decreased AFP, estriol, increased beta hcg and inhibin A
downs
treatment for lambert easton
guanidine or 3,4-diaminopyridine
drug types (2) that cannot be given to people on PDE5-I. Why?
nitratesalpha blockers (-zosin)cause hypotension
treatment for cauda equina and conus medularis syndromes
IV glucocorticoids and neurosurgery consult
when would you need to use a catheter during a u/a
when the pt is <2 years of age
pt with dementia - presents with trouble walking, urinary incontinence, and dementia
NPH
pt presents with +ANA and +anti-Jo-1
polymyositis
woman being treated for acne presents, after a day at teh beach, with a rash covering her face, arms, chest and legs - why isn’t this a reaction to benzoyl peroxide
benzoyl peroxide would only cause the rash to the face - this is systemic, therefore she is being treated with doxy for acne
pt with no hx of alcohol use but elevated LFTs and acute pancreatitis - dx and tx
gallstone pancreatitis - remove gall bladder
woman with UTI and pyelonephritis - what are the U/A findings
nitrates and leukocyte esterase
damage to the posterior thigh might damage which nerve
tibial nerve
what syndrome can you diagnose by hearing a succession splash 3+ hours after last meal
gastric outlet syndrome
most common reason for someone in septic shock to have metaboic acidosis
lactic acidosis from organ failure
pt with pain in the eye presenting with photophobia, blurred vision, tearing, redness, corneal vesicles, dendritic ulcers
herpes simplex keratitis
pt with recent cold and chronic warfarin use presents with INR of 5.6
why
pt was probably taking acetaminophen for the cold symptoms and that increased the amount of warfarin in the system
dysfunctions that cause platelet destruction
SLE, heparin use, ITP, TTP-HUS, antiphospholipid syndrome
most common bilirubin disorder of inheritance
gilbert syndrome
pt with back pain and breathing difficulties and PFTs showing restrictive respiratory distress
ankylosing spondylitis - chest wall motion restriction from spinal spondylitis that causes decreased VC and decreased TLC
pt with negative nikolsky, fever of 6 days in duration, red eyes, bright red tongue, polymorphous rash, desquamation of the palms and soles and cervical lymphadenopathy
Kawasaki disease!
what type of cancer is Paget’s disease of the breast
adenocarcinoma
pt with myalgias, fever, vomiting, diarrhea, hypotension, diffuse maculopapular rash that looks like a sunburn - dx
toxic shock syndrome from s aureus
treatment for uremic pericarditis
dialysis - will reduce chest pain and effusion
management of vtach?
pulseless vtach - defibrillation
vtach with a pulse - syncronized cardioversion
anti hypertensive that increases natiuresis, decreases serum ATII, and aldosterone
direct renin inhibitor
treatment for neuroleptic malignant syndrome
stop the offending agent
bromocriptine or dantrolene
what is the danger of leukoplakia
1-20% progress to squamous cell carcinoma
MCC of urinary retention after labor
bladder atony
what do nitrates and leukocyte esterase signifiy on a U/A
nitrates: enterobacteriacae (shifting nitrates to nitrites) esterase signifies pyuria
how TSST-1 differs from meningococcemia
in TSS there are no bullae or necrotic petichiae rash
pt with dementia - early loss of short term memory and decreased hippocampal volume
alzheimers
pt on psychoactive medication presents with leukocytosis and elevated CK
neuroleptic malignant syndrome most likely from a first generation anti psychotic
when is an epidural hematoma treated surgically
when its symptomatic
how does the FEV1/FVC ratio change in a restrictive vs obstructive pattern
obstructive - FEV1/FVC: <70 of normalrestrictive - FEV1/FVC: >70 of normal
two drugs that are calcineurin inhibitors
cyclosporin and tacrolimus
treatment for prerenal AKI
IV fluid
MOA of cyclosporine
inhibits transcription of IL-2
pt with dementia - visual hallucinations and parkinsons
lewy body dementia
contact lens users with conjunctivitis
pseudomonal keratitis, tx with broad spectrum abx
pt with middle ear effusion, bulging tympanic membrane - dx and tx
acute otitis media tx: amoxicillin or if it doesn’t work after 10 days; augmentin
which nerve deals with adduction of the thigh
obturator
what is an elevated CPK level
>20,000IU/L
what is a potentially toxic dose of acetominaphen
>7.5g
causes of syncope
sinus bradycardia, SA block, AV block, sinus pauses, non-sustained vtach, increased or decreased QTc
where is the orthopedic fault in osgood-schlatter disease
traction apophysis of the tibial tubercle which causes anterior soft tissue swelling, lifting of the tubercle and fragmentation of the tubercle
most common comorbid condition in meconium ileus
cystic fibrosis
treatment for polycythemia vera
serial phlebotomy and hydroxyurea
what does nephrosclerosis lead to if untreated
glumerulosclerosis
drug OD that causes ↑HTN, seizures, hyperthermia, vertical nystagmus
PCP
pt who ingested caustic substances - tests
serial CXR/KUB to check for perforationwhen perforation is ruled out - upper GI endoscopy in 12-24 hours
pt presents with hearing loss and frequent discharge; granulation tissue and skin debris is seen in the ear canal
cholesteatoma
what kind of IV fluids should you give for hypernatremia
intially normal saline
white granular patch on the buccal mucosa in a pt with a hx of alcoholism or smoking
leukoplakia
what organ dysfunctions might be seen in a ↑AFP neonate
congenital nephrosis and obstructive uropathy
pt with chronic pancreatitis with wt loss and abdominal pain - what sx would lead you to which pancreatic diagnoses
jaundice suggests pancreatic head cancer no jaundice suggests pancreatic cancer of the tail or body
treatment for bladder atony lasting more than 6 hours
indwelling catheter placement
how to differentiate between uterine atony and retained placenta
on u/s if there is a “thin uterine stripe” this means the uterus is empty and cannot have retained products
vast increase in Cr, decreased urine output, BUN:Cr >20:1, oliguria (<500ml/24hrs)
prerenal AKI
loss of sensation to the plantar foot - nerve?
tibial nerve
vasculidity most similar to IgA nephropathy that presents with purpura
HSP
most common causes of acute otits media
s pneumo h flu (non typable) moraxella
10 year old girl with chronic ear drainage despite aggressive antibiotic therapy over the last few weeks
cholesteatoma
treatment of tachycardia induced cardiomyopathy
aggressive rate control with AV nodal blocking agents, antiarrhythmic drugs, catheter ablation of arrhythmia
“soft and boggy uterus” - dx
uterine atony
pt who is 6 hours post partum has not voided since labor and is leaking urine
diagnosis
bladder atony
pt is pregnant with second child and fetus dies in utero, mother is AB(-), mother is hemodynamically stable. What is the next best course of action
give RhoD because the mother is AB(-)
how do you treat a meningioma
surgical resection
ectopy and AV block together are basically specific for what diagnosis
digitalis toxicity
loss of sensation to the plantar foot? dorsum of foot?
plantar loss - tibialdorsum loss - common peroneal
in a quad screen - increase in AFP
neural tube deficits
what type of saline should you give in compensated metabolic acidosis
if met acidosis is >7.2 give isotonic saline
what would you see on epithelial scraping of herpes simplex
multi nucleated giant cells
most likely reason to see an ↑ AFP
neural tube defect
pt with gradual onset of severe back pain, bilateral pain, saddle anesthesia, hyporeflexia, bowel/bladder dysfunction and assymmetrical weakness - what is the dx
cauda equina syndrome
new diagnosis of polymyositis should be a red flag for what
cancer
polymyositis is often part of a paraneoplastic syndrome
why should you give someone in septic shock crystalloid saline
because crystalloid is more like albumin and allows for more fluid uptake
disease where rapid growth in adolescent has the quadriceps muscle put traction on the apophysis of the tibial tubercle
diagnosis
Osgood-Schlatter disease
other name for common peroneal
fibular nerve
what is the Uhthoff phenomenon in MS
symptoms worsen in hot weather
pt who has recently had an T2 MRI shows: multifocal, oviod, subcortical, inperventricular, juxtacortical, and infratentorial lesions in the spinal cord
MS
most common causes of nonbillious impetigo
s aureus group A strep s pyogenes
neural tube defects and abdominal wall defects are characterized by what lab result
↑AFP
what is this
leukoplakia
RUQ pain and tenderness, fever, leukocytosis, +Murphy sign
acute cholecystitis
morning stiffness in the shoulders, neck, pelvic girdle
polymyalgia rheumatica
pt with progressive weakness, difficulty swallowing and mildly decreased strength in the deltoid muscle; otherwise unremarkable PE
polymyositis
pt with recent onset transient visual disturbances, HTN, thrombosis, itching after the shower, facial plethora, splenomegaly, normal oxygen sats and decreased EPO
polycythemia vera
what is this?palpable purpura, arthralgias, abdominal pain, renal dysfunction
HSP
pt with dementia - white matter change and executive dysfunction
vascular dementia
main side effect with early levodopa/carbidopa use
hallucination
medical treatment for dermatitis herpeteformis
dapsone
which drug should you give in a PCP OD
benzodiazapines
patient who initially had an eruption of papules has had a sudden progression to pustules and honey colored crusting around the mouth - dx
impetigo
pt with dementia - presents with personality change and disinhibition
frontotemporal dementia
difference in treatment between large and small thyroid cancer
large - surgery + radioactive iodinesmall - surgery
what age group has the most presenting epidural hematomas
children and adolescents
how does TSST-1 differ from SJS
SJS has purpura and necrosis and more influenza like symptoms initially
treatment for actinic keratosis
cryotherapy for small lesionsfluorouracil for larger lesions
gold standard diagnosis for MS
T2 MRI
urine dipstick tests + for blood but no RBCs are seen on microscopy
diagnosis
rhabdomyolysis
explain the physiology of the increased resorption of urea in prerenal AKI
↓ perfusion → ↓GFR → ↑Cr → ↑tubular resorption of Na/H20 which leads to ↑resorption of urea
what are these lab findings suggestive of: microcytic anemia, and ↑ zinc protoporhyrin
acute lead poinsoning
pt with thrombocytopenia without coexisting anemia or leukopenia
ITP
what poisoning would you commonly see hyperuricemia
lead poisoning
pt with morning stiffness in the neck and shoulders, 10lb weight loss, ESR of 77, ↑CRP, normocytic anemia - dx and association
polymyalgia rheumatica - giant cell arteritis!
34 year old woman with T2DM - which vaccines does she need
PPSV23 because she is immunocompromised by being diabetic
how does TSS differ from scarlet fever
in scarlet fever the pt will be a child and the rash has a flexural pattern
renal microscopy of HSP
deposition of IgA in the mesangium
differentiate between pneumothorax and atelectasis
if it were atelectasis there would be foreign body aspiration, pneumonia with mucous plug, malignancy and tracheal deviation. Pneumothorax is from a ruptured bleb and rarely is seen with tracheal deviation
how does 3,4-diaminopyridine help pt with lambert easton
improves ACh circulation
which imaging modality should you use for pancreatic cancer of the head? of the tail?
head - u/stail - CT
most superior drug in treating treatment resistant schizophrenia
clozapine
in a quad screen - fluctuation of inhibin A
trisomy 13/Patau
treatment for polymyalgia rheumatica
glucocorticoids - prednisone 10-20mg
stages of treatment for uterine atony
1) bimanual massage2) IVF/O23) oxytocin4) methylgonavine/carboprost (not in asthma!)5) hysterectomy in unstable or heavy blood loss
symptoms of graves disease - differentiate from a paraneoplastic syndrome
Graves - wt loss, tachycardia, proptosis, impaired extraocular motion, decreased convergence, diplopia, orbital tissue expansion, lymphocytic infiltrationparaneoplastic: myasthenia gravis/lambert easton would not have occular irritation, painful movement, or proptosis
hypertrophy and intimal medial fibrosis of renal arterioles
nephrosclerosis
initial therapy for warfarin associated hemorrhage
IV vitamin K
prothrombin complex concentrate (2, 7, 9, 10)
FFP if PCC is not available
most common co-morbid condition with hirschprungs disease
downs
pt with HIV and CD4 <50 - prophylacic measures
TMP-SMX for PCP pneumoniaazithromycin for MAC
25 year old female pt with fever, joint pain, rash that started on the face and moved rapidly to the body that has spared the palms and soles with posterior auricular and suboccipital lymphadenopathy
Rubella - German measles
when would you see HIV associated dementia
CD4 <200
long standing HIV
poor HIV control
pt with ↑ apathy, ↓ attention, subcortical dysfunction, ↓ smooth limb movement, ↓ number of cortical neurons, ↓ memory
this happened rather quickly (6 months)
HIV associated dementia
39 year old female pt presents with heavy periods, dysmenorrhea, chronic pelvic pain, and what was described as “tender, boggy, globular uterus”
dx and tx
adenomyosis
hysterectomy
pt with infertility and irregular menses is ______ until proven otherwise
PCOS
what hormone pattern will you see in a pt with PCOS
imbalance of LH/FSH → leading to failure of follicle maturation
what hormonal pattern will you see in PCOS
hyperandrogenism
↑ ovarian steroids
↓ estrone
↓ sex binding hormone
LH/FSH imbalance
treatment for infertile woman with PCOS
weight loss
clomiphene
pt with hepatic steatosis, no history of alcohol use at all, AST/ALT <1; u/s of the liver reveals a hyperechoic texture
NAFLD
treatment for NAFLD
diet/exercise
consider bariatric surgery if BMI ≥ 35
abnormal LFTs + metabolic syndromes + no alchol consumption (ever)
NAFLD
hepatic steatosis in the absence of secondary hepatic fat accumulation
NAFLD
hepatomegaly + AST/ALT ratio of <1 with hyperechoic u/s texture
NAFLD
pt is recently postpartum presents with pain on the lateral side of the wrist and has passive thumb stretching pain
DeQuervains tenosynovitis
tendons involved in deQuervains tenosynovitis
abductor pollicis longus
extensor pollicis brevis
you suspect your pt has Sjogrens; they also have significant difficulty swallowing solid food lately
how to diagnose
even with esophageal motility issues diagnose based on + antiRO(SSA) and + antiLA(SSB)
what is a schrimer test for
in the diagnostic process of sjogrens and schirmer test will show ↓ lacrimation on filter paper under the lower eyelid
lymphocytic infiltrate of the salivary glands is most likely part of what disease process
sjogrens
most common gyenocological malignancy
endometrial cancer
most important risk factor for development of endometrial cancer
obesity
explain how obesity contributes to the development of endometrial cancer
↑ estrogen (in adipose tissue) ↑ hyperplasia → adenocarcinoma
most likely cause of a retroperitoneal hematoma (especially when the patient has been in the hospital)
cardiac catheterization
diagnostic imaging for retroperitoneal hematoma
CT non contrast for abdomen and pelvis
acsending flaccid paralysis and muscle weakness with respiratory involvement
diagnosis
Guillian Barre
when you suspect Guillian Barre what else should you measure
PFTs - 30% of pts will have respiratory failure
gold standard for measuring respiratory failure in GBS
FVC
≤ 20mL/kg demonstrates impending respiratory arrest
baby is born 6 weeks premature - when should her vaccines be given
chronologically or gestationally
ALL vaccines should be given chronologically
what vaccine cannot be given if a premature baby is <4lbs 6oz
Hep B
pt with fever, vomiting, nausea, abdominal pain, jaundice, pruritis, dark urine, pale stools, tender hepatomegaly, AST/ALT >1000 U/L, ↑ alk phos and bilirubin
diagnosis
HAV
treatment for HAV
self limited, treat supportively
3-6 weeks recovery
when is HAV less likely to be self limited
>50
preexisting liver condition
which hepatitises are symptomatic in the acute phase
HAV is usually symptomatic (>70%)
HBV/HCV are usually asx
presence of an S3 and ↑BNP is diagnostic of
LV dysfunction in CHF
how is BNP created
proBNP cleaves into two to create the active BNP and inactive N-terminal proBNP
what lab is elevated in LV systolic dysfunction in CHF
BNP
low frequency sound best heard over the cardiac apex
S3
99% of people with CHF also have this
S3 heart sound
most common precipitating bacterial infection prior to developing GBS
c jejuni
2/3 of the time _______ started with a respiratory or GI infection
Guillian Barre
circumfrential burn to the esophaagus
pill induced esophagitis
main causes of pill induced esophagitis
tetracyclines (doxy)
NSAIDs
bisphosphanates
potassium Cl
Iron
difference in mechanisms as to why tetracyclines and NSAIDs cause pill induced esophagitis
tetracyclines cause this from the acid effect
NSAIDs disrupt the GI protective barrier
pt presents with a recent onset tremor that is worse with action motions and worse in the upper extremities; pt has no noticible neurological deficits
essential tremor
treatment for essential tremor
propranalol
2nd line = anticonvulsants like primidone and topiramate or benzodiazepines like alprazolam
most affected brain regions by strokes precipitated by HTN
basal ganglia
thalamus
pons
stroke type - atherosclerotic risk factors and fluctuating symptoms
ischemic thrombotic type
stroke type - hx of cardiac dz, abrupt but worse at the start, multiple infarcts seen on CT
ischemic embolic type
stroke type - uncontrolled HTN, illicit drug use, sx get worse after starting, presents with vomiting and headache, bradycardia and decreased alertness
intracerebral hemorrahage
stroke type - pt with hx of berry aneurysm/AVM presents with stiff neck and severe headache
subarachnoid hemorrhage
left sided weakness and slurred speech
affected area
left cerebral hemisphere lesion - motor cortex/Broca’s
pt with painless purple skin on the legs, AKI and occular problems, labs show eosinophilia and hypocomplementemia
cholesterol crystal embolism
from disruption of atherosclerotic aortic plaques
most common cause of cholesterol crystal embolism
disruption of atherolsclerotic plaques most likely from cardiac catheterization or intraaortic balloon pump
skin finding in cholesterol crystal embolism
livedo reticularis
painless purple skin that blanches
also called “blue toe”
1 year old child drinks cows milk more than anything else
iron deficiency anemia
most common nutritional deficiency in children
iron
2 year old female pt diagnosed as iron deficient
next steps
give PO iron
2 year old female pt who was diagnosed as iron deficient has not imporved after 3 months of PO iron
next step?
hemoglobin electrophoresis
colonoscopy
serum creatinine
most common urinary tract onstruction in newborn males
posterior urethral valves
pt presents for prenatal u/s and results are concerning for bladder distention, bilateral hydroureters, and bilateral hydronephrosis
most likely diagnosis
posterior urethral valves
baby is still born at 16 weeks gestation and autopsy finds bilateral hydronephrosis, oligohydramnios, flattened facies, abdominal distention and club feet
diagnosis
Oligohydramnios with Potter sequence most likely secondary to posterior urethral valves
most common location of ectopic foci for afib generation
pulmonary veins
reentrant circuit around the tricuspid annulus
cardiac sound
atrial flutter
female pt with fever, fatigue, wt loss, migratory non deforming arthralgias is also found to have ↓C3/C4
SLE
pt with arthralgias and a non tender ulcer of the buccal mucosa and cervical lymphadenopathy
SLE
pt with fever, wt loss, pleurisy, athralgias, and proteinuria
SLE
pt presents with advanced RA + splenomegaly + neutropenia
Felty syndrome
infant pt presents with poor urinary stream, straining with voiding, urosepsis, failure to thrive and renal failure
how to make the diagnosis
voiding cystourethrogram and cytoscopy
treatment for posterior urethral valves
ablation and urinary diversion
early surgical intervention in utero (permanent kidney damage can occur)
oligohydramnios can cause what
pulmonary hypoplasia, postnatal respiratory distress
pt with 15lb weight loss, lower extremity edema, gynecomastia, spider angiomas, distended abdomen with shifting dullness
diagnosis
cirrhosis - probably from HCV (more than HBV), chronic alcoholism, NAFLD, hemochromotosis
pt with pedal edema, ascities, bilateral gynecomastia, spider angiomata - why isn’t this cor pulmonale
will cause fatigue and leg edema but not gynecomastia or spider angiomata
first suspicion in someone with ascites, spider angiomatas, gynecomatia, splenomegaly
cirrhosis - most likely viral hepatitis
reasons you might see early post operative period renal transplant dysfunction
uretral obstruction, acute rejection, cyclosporine toxicity, vascular obstruction, acute tubular necrosis
subtypes of systemic sclerosis
limited (better)
diffuse (worse)
type of scleroderma interstitial lung disease is associated with
diffuse cutaneous - >40%
esophageal dysmotility is seen in what kind of scleroderma
both diffuse and limited
what kind of scleroderma is skin thickening seen in
diffuse cutaneous
which scleroderma has a worse prognosis
diffuse cutaneous because it has organ involvement
systolic-diastolic abdominal bruit + ↑BP
renovascular HTN
how can you diagnose RAS
renal duplex Doppler u/s
CT angio
MR angiography
pt has resistant HTN with ≥ 3 drugs (1 is a diruetic at max dose)
RAS
risk of developing which cancers in cryptorchid gonads
dysgerminoma or gonadoblastoma
give the X,Y for a phenotypically female individual with androgen insensitivity syndrome
46 X,Y
recomendation for phenotypic female with androgen insensitivity syndrome
bilateral gonadectomy after puberty
why is gonadectomy recommended AFTER puberty in androgen insensitivity disorder
attainment of full height
pt with cough, wheezing, nasal polyps; current med list: aspirin, atorvastatin, metformin, benadryl
cause of exacerbation
aspirin exacerbated respiratory disease
asthma like symptoms and flushing and wheezing 90 mins after taking _______ is ________
aspirin
aspirin exacerbated respiratory disease
↑ production of proinflammatory leukotrienes and ↓ production of anti inflammatory prostoglandins and arachodonic acid is diverted to produce leukotrienes via the 5-lipoxygenase pathway
what is this
AERD mechanism
non IgE mediated reaction that results in asthma like symptoms or exacerbation of existing symptoms
AERD
treatment of AERD
desensitization and use of leukotriene receptor antagonists
pt with hx of gout has 3 day hx of progressively worsening pain, swelling, and redness of the knee, no hx of trauma. Fever of 101, HR is 110/bpm, hx is positive for recent travel to New Hampshire for camping
differentiate between septic arthritis, gout and Lyme disease
this is probably septic arthritis - you should do a synovial fluid analysis first
could be gout or lyme disease but septic arthritis is far more serious and needs to be ruled out before proceeding!
pt has hx of untreated HTN and DM2, presents with 2 months of left sided weakness, gait dysfunction with frequent falls, and nausea and vomiting
what is this? why isn’t it the other?
this is a brain tumor
this is not a lacunar infarct because of the nausea/vomiting because that is the result of ↑ICP which is not involved in chronic results from a stroke
pt with 2 months of left sided weakness, and gait dysfunction presents with this finding - diagnosis
brain tumor
that is papilledema suggesting ↑ICP
why would someone in HHS have normal to elevated K
total body K is decreased from excessive urinary loss - pseudohyperkalemia
pt with hx of DM2 presents with weakness and blurred vision
K 5.9, glucose 1070, bicarb 22, serum osmolality 480
why is the K normal
total body K is being depleted and pushed into cells
what can make things worse for someone in HHS
aggressive insulin therapy to correct the hyperglycemia can cause even more total body K depletion
in additon to modafinil, pt with cataplexy narcolepsy should also take what medications
antideprresant and sodium oxybate to suppress REM sleep
initial treatment for narcolepsy
sleep hygiene, scheduled naps, avoidance of alcohol and drugs that cause drowsiness
if these don’t work move to modafanil
most likely explanation for a pt who presents with recent onset of digital clubbing
occult malignancy
conditions commonly assocated with digital clubbing
bronchogenic carcinoma, metastatic cancer, malignant mesothelimona, lymphoma
lung absess, empyema, bronchiectasis, cystic fibrosis, chronic cavitary infections
pulmonary fibrosis, asbestosis, AVM
cyanotic congential heart disease
most common causes of digital clubbing
lung malignancies
cystic fibrosis
right to left shunt
mechanism of digital clubbing
megakaryocytes skip the normal route because of a lung tumor in the pulmonary circulation and enter systemic circulation getting lodged in the fingers releasing PDGF and VEGF causing hypertrophy of the surrounding tissue
what doesn’t cause digital clubbing
hypoxemia
what is happening here
treatment
uneven T99 SPECT stress test at rest and activity shows iscemia of the heart
antiplatelet therapy like aspirin
