Week 2 Flashcards
Young woman with monocular vision loss, eye pain with movement, washed out color, afferent pupillary defect think
MS!
Comorbidities with Absence seizures
ADHD, anxiety
Tx. Ethosuximide
(seizures provoked with hyperventilation, brief less than 20 seconds, and show symmetric 3Hz spike wave activity on NL background)
Sxs of interstitial cystitis (painful bladder syndrome)
More common in women, associated with psych d/o (anxiety, pain syndromes), bladder pain with filling relieved by voiding, increased frequency, urgency, dyspareunia, bladder pain with no other attributable causes for >=6 weeks, normal UA. Tx Not curative focus on quality of life, behavior mod and trigger avoidance, amitriptyline, analgesics for exacerbations
Neonate with bilious vomiting, abdominal distention, do abdominal xray shows gasless abdomen what next
Upper GI series (barium swallow) fastest and most accurate method of dx malrotation with midgut volvulus. See ligament of treitz on R abdomen and corkscrew pattern. Tx with surgery.
Tx Hoarding d/o
CBT
PTHrP associated with which cancer
SCC of lung
Paraneoplastic syndrome associated with Small Cell Carcinoma
ACTH production and SIADH
Nephrotic syndrome associated the most with renal vein thrombosis
Membranous GN
Abdominal pain, fever, hematuria in someone with nephrotic syndrome think …
Renal Vein thrombosis 2/2 loss ATIII
Progressive bilateral loss of central vision think
Age related macular degeneration
hypercalcemia, los phos, los mag, met alk, AKI, low PTH 2/2
Milk Alkali syndrome (excessive Ca++ and absorbable alkali) 2/2 renal vasoconstriction and decreased glomerular blood flow
Hazard ratio
Are proportions that indicate the chance of an event occurring in the treatment group compared to the change of the event occurring in the control group. <1 more likely control, Closer to 1, less difference.
tendency of study population to affect the outcome since they are aware they are being studied
Hawthorne effect
Tx acute decompensated HF w/pulmonary edema with NL or elevated BP
Oxygen, assisted ventilation as needed, IV diuresis, possible vasodilator therapy
Chronic cough >8 weeks worse at night, not better with antihistamine think
ASTHMA, do a spirometry
Role of hCG in pregnancy
secreted by syncytiotrophoblast and is responsible for preserving the corpus luteum during early pregnancy in order to maintain progesterone secretion until the placenta is able to produce progesteron on its one
1 day old with head circumf >95%, hydrochephalus, jaundice, diffuse IC calcifications, HSM, rash
DX Toxoplasmosis from raw or undercooked meat, unwashed veg/fruit, cat feces
tx pyrimethamine, sulfadiazine, folate
Levels of glucose with GDM
fasting 95, 1 hour PP <140, 2 hour PP<120
1st line tx diet, 2nd insulin, metformin, glyburide
Knee pain in young ado male athletes
Osgood Schlatter disease, quadriceps tendon puts traction on apophysis of tibial tubercle where patellar tendon sits
increased MCHC, spherocytes, negative coombs
HEREDITARY SPHEROCYTOSIS, AD
Pts with severe bladder outlet obstruction due to BPH can develop AKI. Next step.
Renal US for assessment hydronephrosis in those with worsening kidney function.
Fundo findings in CRVO
Venous dilation and tortuosity due to venous occlusion, scattered diffuse hemorrhages due to backup of blood and increased resistance, leading to ischemic damage, blood and thunder appearance due to diffuse hemorrhages, cotton wool spots, disk swelling.
67 year old male with LOC, lightheadedness over past month, ECG shows prolonged PR interval, prolonged QRS, normal QTc. What is most likely cause of syncope?
Bradyarrhythmia 2/2 high grade AV block
How does RTA present in infancy?
Failure to thrive due to chronic, normal, anion gap metabolic acidosis.
Type 1 RTA
distal. due to impaired H+ excretion, urine PH >5.5, low normal K. 2/2 genetic d/o, med tox, AI
Type 2 RTA
proximal. due to poor HCO3 rasorption. Urine pH <5.5, low normal K. 2/2 fanconi syndrome. glucosuria, phosphaturia, aminoaciduria.
Type 4 RTA
aldosterone resistance. pH <5.5, high serum K, 2/2 obstructive uropathy, CAH.
How to remove vaginal foreign body objects.
Calcium alginate swab or irrigation with warmed fluid should be attempted after a topical anesthetic has been applied. If fails then sedation and gen anesthesia.
Atelectasis on ABG
Respiratory Alkalosis
pH 7.49/ PO2 70/ PCO2 27
What are the preoperative strategies to reduce postoperative pulmonary complications (atelectasis, infection, PNA, bronchospasm, COPD exacerbation, prolonged mechanical ventilation)
Smoking cessation 8 weeks or more before surgery
Symptom control of COPD before
Treatment of respiratory infections before surgery
Pt education for lung expansion maneuvers, cough, deep breathing, IS, chest PT
Post operative strategies reduce post op pulmonary complications?
IS, Deep breathing, epidural anesthesia instead of parental opioids, continue positive airway pressure
Fever, flank pain, hemoglobinuria, renal failure, with in 1 hour of transfusion?
Acute hemolytic reaction caused by ABO incompatibility .
+ direct combs, pink plasma
Fever and chills within 1-6 hours transfusion?
febrile nonhemolytic reaction 2/2 cytokine accumulation during blood storage
Respiratory distress and signs of noncardiogenic pulmonary edema w/in 6 hours of transfusion?
TRALI (caused by donor anti-leukocyte antibodies)
When to do a NST?
high risk pregnancies starting at 32-34 weeks or loss of perception of fetal movements in any pregnancy.
Rash of TSS
Fever, hypotension, and a diffuse red macular rash involving the palms and soles. 2/2 exotoxin. Tx with fluid and antibx.
+ hepatojugular reflux caused by
failing right ventricle that cannot accommodate an increase in venous return with abdominal compression . 2/2 constrictive pericarditis, right ventricular infarction, and restrictive CMvfcjk.
Post exposure prophylaxis for pertussis
ALL CLOSE CONTACTS despite vaccination status. <1 month, Azith 5 days
>= 1 month, Azith 5 days, Clarith 7 days (can cause pyloric stenosis under 1 mo), eryth 14 days
Tx in Catarrhal stage may help shorten the course of illness.
Flushing, telangiectasias, cyanosis, diarrhea, cramping, R>L valvular lesions, bronchospasm, niacin deficiency THINK OF
- Carcinoid syndrome.
- Dx with 24 hour urinary 5HIAA.
- NET found in distal small intestine, proximal colon, and lung.
What is isolated systolic HTN?
SBP >140 with DBP<90. Associated with 7x increased in risk of cardiovascular morbidity and mortality than primary HTN. 2/2 increased stiffness or decreased elasticity of aortic and arterial walls in elderly patients.
Antiphosphlipid syndromes
vascular thrombosis and/or pregnancy complications + >= Anticardiolipin antibody, lupus anticoagulant, anti beta2glycoprotein antibody
Tx. Anticoag
Management STEMI
- Oxygen for arterial sat if <90
- Nitrates (not if hypotensive of RV infarct or severe aortic stenosis)
- Antiplatelet (dual) ASA + P2Y12 receptor blocker
- Anticoagulant (unfractioned heparin, LMWH)
- Beta Bockers (not in overt HF, high risk cardiogenic shock, bradycardia)
- Prompt reperfusion with PCI (<90 min 1st medical contact to PCI)
- Statin ASAP
Man is unable to recall important autobiographical info after wife says she wants divorce
Dissociative amnesia
After overwhelming or intolerable events
w/Fugue associated with seemingly purposeful travel or bewildered wandering
Normal pH pleural fluid
Transudative fluid pH
NL 7.6
Trans 7.4-7.55
Sudden onset contralateral sensory loss involving all sensory modalities, weeks to months later have sever paroxysmal burning pain over the affected area that is exacerbated by light touch (allodynia)
Lacunar Stroke of posterolateral thalamus
Lateral Meduallary infarct
from PICA, loss of pain/temp over ipsi face, and contralateral body, ipsi bulbar muscle weakness, vertigo/nystagmus and horner syndrome
HIV pt with AMS, EBV + CSF, solitary weak ring enhancing periventricular mass on MRI
Primary CNS lymphoma
Tx Swimmers ear, otitis externa
Remove debris, topical Ab (FQ) +/- topical steroid
Tx of Acute OM
Amoxicillin and Amoxicillin-Clavulinic acid
Findings in SBO that make it “complicated” and need emergency surgery
Fever, hemodynamic instability (hypotension, tachycardic), guarding, changes in pain, leukocytosis, sig met acidosis. Delay surgery = perforation risk and death.
HTN >140/90 prior to conception or in 1st 20 weeks of pregnancy
Chronic HTN (primary or secondary)
Gestational HTN
new onset elevated BP at >20 weeks gestation. No proteinuria or end organ damage.
complications of HTN in pregnancy
Preeclampsia, placental abruption, fetal growth restriction, preterm labor, and still birth.
Virilization in female fetuses, (XX), normal internal geitalia with ambigous external genitalia. Adolescence delayed puberty, OP, undetectable E levels (no breast development) and high gonadotropin levels = polycystic kidneys
Congenital aromatase deficiency
T cant become E
MOA of hypoxemia in PNA
R–>L intrapulmonary shunting and extreme V/Q mismatch. Increased concentration of FiO2 does not correct hypoxemia caused by intrapulmonary shunting.
Young person (29 yo) with HTN, Headaches, epistaxis, upper body dev, lower body underdev (claudication), brachial/femoral pulse delay. Left interscapular systolic or continuous murmur think…
Coarctation of the aorta (congenital or acquired)
dx. ECG LVH, CXR inferior notching of the 3rd-8th ribs, echo dx
Tx 3rd degree AB block
Complete heart block, temporal dissociation of P waves and QRS, manage with temporary pacemaker insertion while undergoing eval for causes
Eye with vesicles and dendrictic ulcers in the cornea
Herpes simplex keratitis
HTN, mood swings, depression, poor sleep, mild HA and muscle weakness. Kidney stones. High Ca++ think.
Hyperparathyroidism (MEN2, pheo?)
Slurred speech, unsteady gait, drowsiness
BENZO OD. No nystagmus like with phenytoin or ETOH.
Before staring trastuzumab for HER2+ breast carcinoma do what test?
Echo, bcus associated with risk of cardiotox
Advanced bone age, coarse axillary and pubic hair, severe cystic acne. Also Gonadotropin independent (peripheral) precocious puberty, LH levels are low at baseline and do not increase after stimulation with stimulation with GnRH agonist. THINK.
Late onset non classic CAH cause by 21 hydroxylase deficiency. Increase 17hydroxyprogesterone.
Prader willi 2/2
Losing paternal copy of 15qll-q13
Pregnany women with sxs appendicitis … what next
Abdominal US
Dx preeclampsia after HTN already seen
Need urine protein/creatinine ratio or a 24 hour collection for total protein. >3 or 24 hour urine >300mg
pts with hx BAT or MVC, abnormal CXR, left lower lung opacity, elevated hemidraphragm and mediastinal deviation
Diaphragmatic rupture
Child <24 months with first febrile UTI what next?
Renal and blader US
Most common cancer ass with asbestos
Bronchiogenic carcinoma
Febrile neutropenia start with
antipseudomonal, cefepime, meropenem, zosyn intitally
Malignant necrotizing otitis externa tx
IV cipro 2/2 Pseudomonas
Middle ear effusion without signs of active infection, dull TM, hypomobile on pneumatic otoscopy
Serous otitis media, non infectious effusion, middle ear effusion with out evidence of an acute infection. Conductive hearing loss.
Dx and tx leprosy
Macular anesthetic skin lesions with raised borders, nodular painful nearby nerves with loss of sensory/motor function.
Dx Full thickness biopsy of skin lesion. Not culturable.
Tx. Dapson and rifampin. Clofazimine if multibaciliary.
Most common site for ulnar nerve entrapment
Ulnar nerve at medial epicondylar groove. 2/2 leaning elbows on desk @work
Persistent ST segment elevation after a recent MI and deep Q waves in the same lead segments. Sxs of HF. Think?
Ventricular Aneurysm (VA) from transmural MI Dx with Echo where you see thinned dyskinetic LV portion in the area of prior MI
Modified Wells Criteria
3 points: DVT clinical signs, alt dx less likely than PE
1.5 points: Previous PE or DVT, HR >100, recent surgery or immobilization (not travel)
1 point: Hemoptysis, cancer
<4 PE unlikely, > 4 PE likely
Causes of wernickes encephalopathy
- Chronic alcoholism
- Malnutrition (AN)
- Hyperemesis gravidarum
2/2 thiamine deficiency.
- Encephalopathy, occulomotor dysfunction, postural and gait ataxia.
Breast Abscess from untreated mastitis (6 weeks after delivery and breastfeeding). How to treat?
Needle aspiration and antibiotics (dicloxacillin, cephalexin). Dx clinically. Vs treat with warm compress - not enough for an abscess.
Suspect toxic megacolon, next step in management?
Abdominal X ray (>6cm dilated R colon)
Tx. with bowel rest, NG suction, antibiotics, +/- corticosteroids if IBD associated, surgery if unresponsive to medical management.
post menopausal woman with breast tenderness and vaginal spotting, NL mammograms, no ERT, pelvic exam shows large non tender 10cm solid left ovarian mass and thick endometrium. What is most likely dx? what to do next in management?
Most likely: granulosa tumor of the ovary, in children presents with precocious puberty, post meno with bleeding, endometrial hyperplasia and large adexnal mass. Dx with increased estrogen and pelvic ultrasound showing ovarian mass and thick endometrium. Next step: endometrial biopsy for eval of concomitant endometrial malignancy.
Thyroid hormone changes in pregnancy if women is euthryoid?
Thyroid hormone production increases during pregnancy to cope with metabolic demands, increase total T3, T4, NL or mildly elevated free T4. Suppressed TSH. 2/2 Estrogen causing increased TBG, leading to increased TOTAL (not free) thyroid hormone levels.
What is the most likely effect of the abnormal flat diaphragm in COPD?
Increased work of breathing. Elasticity decreases and compliance increases in COPD. Have increased TLC, FRC, and RV. Diaphragm has more difficulty contracting to expand the thoracic cavity. increased WOB.
Evidence of hemolysis in AIHA.
Jaundice, elevated ID, increased LDH, decreased serum haptoglobin. Splenomegaly. Reticulocytosis. Smear shows spherocytes and etc.
Warm AIHA
2/2 drugs (penecillins), viral infections, AI (SLE), immunodeficient states, CLL. Direct coombs + with anti IgG, anti C3, or both. Tx steroids or splenectomy if refractory disease. Complications venous thromboembolism, lymphoproliferative d/o.
Cold AIHA
Infections (mycoplasma, infectious mono), lymphoproliferative diseases, symptoms of anemia, livedo reticularis and acral cyanosis with cold exposure that disappears with warming, direct coombs + with anti C3 or IgM but not IgG. Tx avoid cold, rituximab +/- fludarabine. Complications ischemia, gangrene, LP d/o
GVHD
2/2 activation of donor T lymphocytes against host major and minor HLA antigens. Subsquent cell mediated immune response. See maculopapular rash involving palms, soles, and face that may generalize. Target skin, liver (elevated LFT and jaundice), intestine (bloody diarrhea)
Classic findings PE on ECG
Prominent S in lead 1, Q in lead III, T inverted in lead III (S1Q3T3). Afib also associated (bad along with low ox sat)
Case control study when you select “neighbors of patients with the same age and race as controls”. This study design helps control which of the following?
Confounding. Matched variables should be the potential confounders of the study (age, race).
What is the most rapid means of normalizing prothrombin time?
FFP
Tx pediatric constipation
Oral laxative (polyethylene glycol, mineral oil)
Glucagonoma
Necrolytic migratory erythema on face, perineum, extremities, lesions enlarge and coalesce over 7-14 days with central clearing and blistering, crusting and scaling at borders, DM (mild), Diarrhea, anorexia, ab pain, constipation, weight los, ataxia, demantia, proximal muscle weakness, association with venous thrombosis.
Dx glucagon >500, normocytic normochromic anemia, CT for pacreatic tumor location.
6 yo body w/Prolonged QT (>440 M, >460 females) , fmhx sudden death, congenital sensorineural deafness, fainting while running, what dx?
Jervell and Lange Nielsen syndrome (AR). Tx with propranolol and (when symptomatic) pacemaker. Caused by molecular defect in K channels. Risk of syncope, arrythmias like torsades.
Complication of bronchiolitis in <2 year old
apena
Respiratory failure
Next step in work up of gastric adenomarcinoma after biopsy?
CT Scan A/P
Then PET/CT
PT with elevated direct bilirubin, elevated Alkphos, what next?
Abdominal ultrasound or CT bcus this is cholestatic picture in setting of intrahepatic or extrahepatic biliary obstruction.
Tourettes puts you at risk for
COPD and ADHD
Dense deposits within glomerular BM, postive C3, no ig. What type of glomerulopathy?
Membranoproliferative GN type 2, caused by persistent activation of alternative complement pathway. Caused by IF antibodies (C3 nephritic factor) directed against C3 convertase of the alternative complement pathway.
66 year old with constipation, backpain, anemia, elevated BUN/Cr, what is causing constipation?
elevated calcium “electrolyte abnormalities” 2/2 MM
Mole may be melanoma if different from other pigmented lesions “ugly duckling sign”
up to 90% senstivity for melanoma, ex. palpable nodularity, occasionally itches
What is SE of EPO in CKD?
Worsening HTN (less common with SC route EPO vs IV), headaches, flu like sxs, red cell apalasia
Who to hospitalize involuntarily?
Acutely psychotic patients who have suicidal/homicidal ideation, command hallucinations to hurt self or others, and danger to self or other and or gravely disabled.
Most likely organism in Joint infections:
- Early Onset <3mo
- Delayed Onset 3-12mo
- Late onset >12mo
- Early - Staph A, GNR, Anaerobes
- Delayed - Coagulase negative staph (staph epi), propionibacterium, enterococci
- Late - Staph A, GNR, Beta hemolytic strep
Acute stress d/o after exposure to actual or threatened trauma. How long does it last?
> =3 days, <=1month
Mechanism of anemia of prematurity.
2/2 decreased EPO due to increased O2 concentration in tissues, exacerbated by short RBC span (40-50 days) and frequent phlemotomy.
Normal babies have RBC nadir 2-3month
Signs of dixogin tox?
D/N/Fatigue, scotoma, blurry vision, changes in color or blindness. Hypokalemia 2/2 loops can increase pts susceptibility to toxicity of digoxin.
Hypernatremic, hypovolemic, symptomatic, what fluids to give? What is euvolemic?
Hypovolemic? NS
Euvolemic? Free water
Not symptomatic but hypovolemic? 5% dextrose
DONT CORRECT greater than 0.5 mEq/dL/hr without exceeding 12 in 24 hours. Can cause cerebral edema.
Causes and sxs of constrictive pericarditis?
Idiopathic, viral, cardiac surgery or radiation therapy, TB
Sxs: Fatigue on exertion, edema, ascites, increased JVP, pericardial knock(mid diastolic), pulsus paroxodus, kussmauls sign. ECG a fib or low voltage QRS, pericardial thickening and calcification. JVP prominent X and Y descents. (RIGHT HEART FAILURE)
Normal LD features
soft, mobile, <2cm (0.5-1cm NL), no systemic symptoms
ABNORMAL firm hard immobile >2cm B Sxs
Symmetric proximal muscle weakness, CK elevated, myalgias, decreased DTR think ..
Hypothyroidism, hypothyroid myopathy, check TSH and free T4. Polymyositis doesn’t have myalgias or decreased DTRs.
Standard therapy for STEMI
Oxygen in sat <90, B blocker (not if decomp hypotensive, heart block, chonic HF, pulmonary edema or bradycardia), ASA 325, P2Y12 inhibitor, Statin, Acei/ARB, nitrates sublingual
When to give and not give IV NG in STEMI?
Give: persistent pain (sever then add morphine)
Not: Hypotension, Right ventricular infarct, severe aortic stenosis
What to give for unstable sinus brady in STEMI?
atropine
What do give if have pulmonary edema with STEMI?
furosemide but not if pt hypotensive of hypovolemic
Delivery of a nonviable fetus (ancephaly, b/l renal agenesis, holoprosencephaly, acardia, thanatophoric dwarfism, IUFD)
ALWAYS vaginal delivery without fetal monitoring even after SROM in breech prezo.
Management stress fracture in 21 yo in 2nd month basic training?
rest, reduced weight bearing 4-6 weeks, and analgesics NO MRI
HTN, palpable kidneys on exam, Multiple renal cysts, intermittent flank pain, hematuria, UTI, kidney stones think?
ADPKD
which murmurs get softer with squatting?
Softer with handgrip?
HCM, MVP
HCM, AS
PROM (before 37 weeks) always give ?
Antibiotics
In metabolic alkalosis why is their hypoca++
2/2 less H+ being bound to albumin, leaving more room for Ca++ to bind, less ionized calcium
Hyperemesis gravidarium, not gaining enough weight in pregnancy puts you at greatest risk for?
Fetal growth restriction and preterm delivery
What can decrease the risk of ovarian cancer?
Bilateral salpingo-oophorectomy OCP <30 1st live birth BF Tubal ligation (BRCA1 60%, BRCA20% lifetime risk ovarian cancer)
What are the risk factors for shoulder dystocia?
- Fetal Macrosomia
- Maternal Obesity
- Excessive pregnancy weight gain
- Gestational DM
- Post term pregnancy >42 weeks
Tx Tinea Capitis
Oral Riseofulvin or terbinafine
7 Year old with breast and hair development, advanced bone age, high LH, next step?
This means it is central precocious puberty (gonadotropin dependent), next step should be brain MRI with contrast (more in boys, but do regardless of neuro deficits). Tx with GnRH agonist therapy to prevent premature epiphyseal plate fusion and maximize adult height potential.
What to avoid in acute angle glaucoma?
ATROPINE
Tx with mannitol, acetazolamide, pilocarpine, timolol
To see avascular necrosis you need what study?
MRI, often 2/2 steroids, SLE, EtOH, Antiphospholipids, hemoglobinopathies, infections, renal xplant, decompression, (osteonecrosis of femoral head)
Deformed joint, lacking decreased sensation (pain, temp, prop), loss of neurologic input, arthritis or arthopathy, mild pain, fractures, degen joint disease and loose bodies? What is this?
Charcot joint, neurogenic arthropathy 2/2 B12 def, DM, Peripheral nerve damage, spinal cord injury, syringomyelia, tabes dorsalis, tertiary syphilis
Which adults ages 19-64 get PPSV23 alone?
Chronic heart, lung, liver dz, DM, current smokers, alcholics
Which adults get PCV13+PPSV23?
CSF leaks, cochlear implants, sickle cell, asplenia, immunocompromised (HIV, malignancy), CKD
TX SAD
SSRI/SNRI
CBT
Only BBlock or benzo for performance only subtype
Management of battery ingestion?
In esophagus - remove immediately with endoscopy
Past esophagus - will pass in 90% cases, just observe with stool exam and or f/u xray
CN tox signs and sxs?
Flushing (Cherry red) and cyanosis (later), HA, AMS, seizure, coma, Arrhythmias, tachypnea then pulm depression and pulm edema, ab pain, N/V, metabolic acidosis
Tx CN tox?
Sodium thiosulfate
RF what treatment?
IM Benzathine penecillin G q4 weeks
= no carditis - 5y/21yo
- carditis but no residual heart disease = 10y/21yo
- carditis and persistent heart or valvular dz 10y/40yo
(whichever is longer)
TX mild hyperthryoidism
Methimazole or other antithyroid drug
Why give Sodium bicarbonate in TCA OD?
QRS widening or Vtach. Helps with alleviating depressant action on myocardial NA channels.
How long should someone with a single episode of MDD who responds to acute treatment continue AD tx for?
4-9 months more at same dose that they used to achieve remission
Summer - early fall, 3-10 year old with fever, pharyngitis, gray vesicles/ulcers on posterior oropharynx?
Coxsackie A virus
All year, 6mo-5 yo, fever, pharyngitis, erythematous gingiva with clusters of small vesicles on anterior oropharynx?
oral acyclovir, HSV1
+PPD, negative CXR and no Bsxs
Latent TB, tx with 9 months of Isoniazid and pyridoxine
Type of bias when the investigators decision is adversely affect by knowledge of the exposure status
Observer bias
+ skewed
Hump on left, Mean>med>mode
- skewed
Hump on right
Mean
Regular wide complex tachy with fusion beats? (Sustained monomorphic ventricular tachycardia) Tx if stable
Tx if unstable
Stable: IV amiodarone
US: Synchronized cardioversion
What causes NPH?
decreased CSF absorption
What causes Lead poisoning in adults? What are signs and sxs?
Occupational, painter, batteries, ammunition, construction, home whiskey brewing
Sxs: GI pain, constipation, anorexia, neuropathy, cog deficits, anemia
Lab: microcytic Anemia, elevated venous lead, elevated zinc protoporphyrin, basophilic stippling on smear
How to evaluate +2 protein on urine dipstick in child?
repeat dipstick 2x to rule out persistent proteinuria
Glucocrticoid induce myoptathy vs Polymylagia rheumatica?
PR has elevated ESR and NORMAL muscle strength vs steroid induced has muscle weakness/atrophy and NO tenderness or pain. Also steroids more lower extremities.
Anemia, microthrombocytopenia, recurrent infections
XLR Wiscott Aldrich syndrome defect in WAS protein gene, impaired cytoskeleton changes in leukocytes and platelets
TX HSCT
Primary adrenal insufficiency
K+ high Na+ low Low BP Non anion gap met acidosis Also see eosinophila
What to give pregos with APS?
LMWH and ASA
Digoxin tox sxs and cause
- can be caused by adding amiodarone (verapamil, quinidine, propafenon)
- Arrythmia, anorexia, N/V/Ab pain, fatigue, confusion, weakness, color vision alterations
Decreased libido in menopause from
decreased testosterone
Woman on peritoneal dialysis with abdominal pain for 2 days, abdomen distended and diffusely tender abdomen and rebound tenderness, leukocyte count 18,000. Next step
Gram stain of abdominal fluid
82 year old with 6 weeks increasing forgetfulness, left stove on, trouble remembering, trouble sleeping, decreased appetite, similar sxs 2&5 years ago successfully tx with meds, poor hygiene, psychomotor retardation, flat affect, poor memory, increased BUN/CR. Dx?
MDD
32 y/o with 10 day hx persistent cough worse at night and activity, smoker, expiratory wheezes b/l, peak expiratory flow rate mildly decreased, xray of the chest shows no abnormalities, next step?
inhaled B2adrenergic agonist, asthma?
52 year old with hiccups, smoked 2 backs of cigarettes daily for 30 years, hilar mass, Na 120, next step?
Fluid restriction
7 year old with fever and sore throat 1 day, T 101.5, rapid strep negative, next step?
Throat culture, incase its is GAS she need penicillin.
57 year old with nec pain, fallen because of muscle weakness, normal vitals, diffuse hyperreflexia, tenderness C spine, Ca 11, Xray shows mets to spine, what next?
Spinal cord decompression and cervical stabilization
Blunt trama to thorax, sternum, SBP 80, pulse 80, R 10, ECG shows multifocal premature ventricular contractions, PO2 100, 1L LR, PO2 decreases to 60, PCWP from 14 to 24, explanation of patients poor response?
Myocardial contusion
Treatment acute gout attack?
Inmethacin, NSAIDS.
NF1 associated with what tumors
Optic glioma
Pheo
Side effect Li
Nephrogenic DI
Hypothyroidism
Solid organ transplant, what prophylaxis do you give them to prevent opportunistic infections?
TMP/SULFAMETHOXAZOLE for PCP/TOXO/LISTERIA
Measles rash
First prodrome cough, runny nose conjunctivitis, fever, koplik spots, then maculopapular rash cephalocaudal and centrifugal spread, spares palms and soles. Vit A helps.
AFP and BHCG elevated and mediastinal mass in male?
Nonseminomatous germ cell tumor (Seminomas dont make AFP)
Prezo of amyloidosis
- Asymptomatic proteinuira or nephrotic syndrome
- Restrictive DM
- Hepatomegaly
- Peripheral neuropathy or autonomic neuropathy
- Organ elargement
- Bleeding diathesis
- Waxy, thickening, easy sking bruising
- Dx: abdominal fat pad aspiration biopsy
Clinical features of polymyositis vs PR:
Poly: Proximal muscles weakness,, pain mild or absent
PR: Age>50, systemic signs and symptoms, siffness >pain in shoulders, hip, girdle, neck, GCA,
Painless hard mass in testicle + suggestive US, what next?
Dx made so now remove testicle
What causes hereditary angioedema?
C1 inhibitor deficiency, dysfunction or destruction. leads to elevated C2b and bradykinin.C4 low.
Establish Dx Ankylosing spondylitis.
Xray sacroilliac joints
Hypotonic hypnatremia and euvolemia, low serum osm <275, high urine osm >100, elevated urine sodium (>40)
SIADH
from CNS probs, Meds (carbamazepine, SSRIs, NSAIDS), PNA, SCLC, pain/nausea
Tx. Fluid restriction and salt tablets, 3% severe hyponatremia
Dysmenorrhea and heavy menstrual bleeding with progression to chronic pelvic pain
ADENOMYOSIS, boggy, tender, uniformly enlarge uterus on examination.
Person has an erythematous, tender, nodule at the lid margin, within a few days a pustule may appear at lid margin which may rupture and discharge pus and relieve the pain. What is it?
External Hordeolum (stye) - acute inflammatory d/o or eyelash follicle or tear gland, can have Staph A or be sterile
Tx. with warm compress
May have residual granulomatous nodule afterwards, Chalazion
Definition of primary amenorrhea
- isolated amenorrhea with well developed secondary sexual characteristics - NL to age 16
- No secondary sexual characteristics - 14
Primary amenorrhea, uterus present, what next?
Measure FSH
Amphetamine use in pregnancy associated with?
Preterm delivery, preeclampsia, placental abruption, fetal growth restriction, and intrauterine fetal demise
When does odds ratio generally approximate the RR?
WHen the disease is rare (low prevealence) because then incidence in also low (new cases). This is the rare disease assumption
1 week old w/central cyanosis, with left axis deviation (born with RAD), small or absent R waves in the precordial leads, hypoplastic left ventricle, underdevelopment pulmonary valve and/or artery, decreased pulmonary markings, tall peaked P waves. Need ASD/VSD (holosytolic murmur LLS border) to survive.
Tricuspid valve atresia, associated with CHD RF or fmhx CHD
Why does placing knee in chest position help child with Tetralogy of fallot?
It increases systemic vascular resistence, which decreases the R–>L cyanotic shunting
When do we deliver babies with placenta previa?
36-37 weeks, C section
Tx MG crisis?
Intubate, plasmaphersis, IVIG, steroids
45 y/o sexually active with insomnia, fatigue, weight gain, amenorrhea, enlarged uterus
r/o pregnancy 1st with BHCG
Dx of acute liver failure
ALT/AST >1000
Signs of hepatic encephalopathy
INR > 1.5
SE 2nd gen antipyschotics (Pines)
Weight gain, dyslipidemia, hyperglycemia (new onset DM)
Regular and baseline BMI, glucose and lipids, BP, waist circumference needed
Tx Isolated enuresis in children >= 5
Behavior - less sugar/caffiene drinks, void during day and before bedtime, fluids in early morning, less before night, reward system
1st line intervention when behavior mod fails - best long term outcome
pharma - 1st desmopressin, 2nd TCA imipramine
Cauda equina syndrome
- 2/2 disk herniation, rupture, spinal stenosis, tumors, infection, hemorrhage, or -iatrogenic
- Compression of nerve roots
- cause LMN signs, usually bilateral severe radicular pain, saddle hypo/anesthesia, asymmetric motor weakness, hyporeflexia/areflexia, late onset bowel and bladder dysfunction
Conus Medullaris syndrome
sudden onset severe back pain, perianal hypo/anesthesia, symmetric motor weakness, hyperreflexia, early onset b/b dysfunction
Methods to control confounding
matching, restriction, randomization
Child with recurrent awakening with bad dream content, remembers the dream fully alert, can be consoled
Nightmare d/o in REM 2nd half of night
Incomplete awakening unresponsive to comfort, no recall of dream, amnesia for episode in am, marked autonomic arousal
sleep terror d/o, no REM, 1st 1/3 night
Attributable risk percent (ARP)
risk exposed - risk unexposed/(risk exposed)
4-1/(4) =75%
ARP=(RR-1)/(RR)
19 yo with dry cough that distrubs sleep, sore throat, fatigue, rash, CXR shows increased interstitial marking and small R sided pleural effusion, what is it?
Mycoplasma pneumo
normal leukocyte count
subclinical hemolytic anemia (cold agglutins)
TX OCD
SSRI
CVT (exposure and response prevention)
17 year old with L adnexal fullness on PE, US showed 8cm L ovarian cyst with calcifications and hyperechoic nodules
Cystic teratoma (dermoid ovarian cyst, mature)
Cysts that prevent in pregnancy (esp molar) 2/2 being stimulated by high BHCG, multiseptated and b/l
theca lutein cysts
Sudden onset severe unilateral lower abdominal pain, N/V, unilateral tenderness on exam
Ovarian torsion
Short stature and primary amorrhea in 15 year old
High FSH, low Estrogen
STEMI, II,II,AVF with 3/6 holosytolic murmur @apex think?
Inferior MI with papillary muscle displacement leading to MR and pulmonary edema, excessive blood leaks back into atrium, in diastole increased Left evntricular filling pressure. (LVEDP)
Reversible RF for premature atrial contractions?
Tobacco and EtOH, beta blockers are often helpful in symptomatic patients
36 year old with morning HA, HBP, bilateral nontender upper abdominal masses, next step?
abdominal US for ADPKD
Recent skin infection, now Headache, low grade fever, periorbital edema, vomiting, binocular palsies, periorbital edema, hypoesthai, hyperesthia in V1/V2?
Cavernous sinus thrombosis (CN III,IV,VI,V1,V2)
DX MRI
Heinz bodies and bite cells, hemolysis after oxidant drug, infection, or fava beans
G6PD XLR, in AA men
Malignant otitis externa
Sever infection in eldery diabeteic pts associated with pseudomonasm ear pain and drainage, not responsive to topical meds, granulation tissue, can progress to eosteo and CN damage, facial droop. Dx CT/MRI
Asymptomatic endometriosis tx
no treatment
Tx gastroschesis with
increase AFP, immediate surgery
Ompalocele associated w/
cardiac dz, NT defects, trisomy in 1/2 of these pts
also need emergent surgery
Bsxs in someone wit hashimotos, also compression of surrounding structure
Thyroid lymphoma
Increased homocysteine found after DVT. What therapy is needed?
Heparin, warfarin, B6 to help metabolism of homocysteine. Also folate and B12 if low.
Infection of lacrimal sac, sudden onset pain and redness in medial canthal region, sometimes purulent. Also can have staph a/strep.
Dacryocystitis
Serotonin syndrome vs NMS
ST: Neurmuscular irritability, tremor, hyperflexia, myoclonus vs rigidit in NMS, not as high of a fever usually in ST, and GI sxs in SST (vomiting, diarrhea)
Why dose cold water stop paroxysmal supraventricular tachycardia (PVST)? (Atrioventricular nodal reentrant tachy AVNRT most common - develops in young pts with structurally normal heart, palpitations most common prezo)
Bcus AVNRT is due to 2 conduction pathways (slow and fast) in the AV node, so vagal manuvers increase parasympathetic tone in the heart and results in temporary slowing of conduction in the AV node and increase in the AV node refractory period
What do they give during inpt treatment PID?
IV cefotixin or cefotetan plus oral doxy (or parenteral IV clinda plus gent)
What to check in a 4 month old with Beckwith Wiedemann syndrome?
Alteration in Cr 11p15 (sporadic or inhertied) genes in ILGF2, see macrosomia, macroglossia, hemihyperlasia, medial abdominal wall defects (umbilical hernia, omphalocece), visceromegaly. Newborns monitor for HYPOglyemica. Since also at risk for HEPTAOBLASTOMA and WILMS TUMOR screen with ABDOMINAL US and alpha fetoprotein q3months from birth to 4 years, ABDOMINAL US q3 months 4-8 yo, then renal US 8 through ado
16 year old girl with irregular and very heavy periods, PT and PTT normal Hg 10, what next?
High dose OCP, this is AUB 2/2 immature hypothalamic-pituitary-ovarian axis causing anovulation
+ urine bilirubin assay is typically indicative of a buildup of …
Conjugated bilirubin
20 year old with jaundice and dark urine, so sxs, urine positive bilirubin, negative for urobilinogen, NL LFT, alk phos, what is happening?
Increased Conjugated bilirubin + NL liver =Dubin johnson or Rotors sydrome, gets conjugated but defective liver excretion (rotors syndrome)
Bilateral hemiparesis (LCST @ level cord injury)
Diminished bilateral pain and temperature sensation (LST 1-2 levels below cord injury
Intact proprioception, vibratory sensation, light touch
Anterior cord syndrome, usually with injury to anterior spinal artery from trayma
Central cord syndrome presents as
Decreased sensation and motor function in the arms with relative sparing of the legs after forced hyperextension (fall, whiplash) or ass with bladder dysfunction, seen in eldery
Things that can precipitate angle closure glaucoma
anticholinergics (trihexylphenidate, tolterodine) sympathomimetics decongestants dim light (things that dilate eye)
What can you use to treat early lyme disease?
Doxy
Amoxicillin - use in children
Cefuroxime
Riboflavin deficiency
Angular cheilosis, stomatitis, glossitis
Normocytic anemia
Seborrheic dermatitis
Most pulmonary embolisms come from?
Deep leg veins, proximal iliac, femoral, popliteal >90%
Extrahepatic manifestations of chronic Hep c?
Mixed cryoglobulinemia (palpable purpura, arthralgias, GN, low complement), membranoprolif GN, PCT (increased urine and plasma porphyrins, tx phlebotomy or hydroxychloroquin), lichen planus
Sxs Zinc deficiency
alopecia, pustular skin rash (perioral and ext), hypogonadism, impaired wound healing, impaired taste, immune dysfxn
Tx tine corporis (ringworm) with
Topical clomitrazole or teribinafine
then if extensive or second line, Terbinafine, griseofulvin
What causes lacunar (pure motor hemiparesis bcus in internal capsule) strokes?
microatheroma formation and lipohyalinosis in the small penetrating arteries of the brain, affect internal capsula and result in pure motor hemiparesis. HTN, High lipids, DM, smoking = RF
Bradycardia, hypotension, wheezing, hypoglyecmia, deirum, seizures, cardiogenic shock, what next?
Atropine and IVF, if that doesn’t work then give glucagon for refractory hypotension (BBLOCK TOXX)
Why do you need more levothyroxine in pregnancy or when on estrogen?
Because increase TBG concentration but can’t make more thyroxine.
What meds for MI or UA can make asthma worse?
ASA, non selective B blocker
Fever, hyperthryoid sxs, painful tender goiter, elevated ESR/CRP, low RI uptake
Subacute thyroiditis, de quervian. likely 2/2 postviral fever and hyperthyorid symtpoms
Sympathetic opthalmia
“Spared eye injury”
Immune mediated inflammation of one eye (the sympathetic eye) after penetrating injury to the other eye. Anterior uveitis, panuveitis, papillary edema, blindness. 2/2 uncovering of hidden antigens (autoantibodies)
Penile fracture, what breaks and what test to do? Management?
rupture of corpus cavernosum due to tear in tunica albuginea. Dx clinically, do a retrograde urethrogram when suspect urethral injury, which is a common complication. Do when see blood at meatus, hematuria, dysuria, urinary retention.
Old guy with ventricular arrythmias and CAD and ischemic CM gets put on antiarrythmic then becomes dyspneic, NP cough, and B/L inspiratory crackels and CXR shows localized or diffused ground glass opacities…
Amiodarone induced pulmonary fibrosis
Drug induced acne from
Glucocorticoids, androgens, immunomodulators anticonvulsants, TB drugs
NNT equation
1/ARR
ARR=(Risk with out tx aka the control - risk with)
Bruton XLAG
All Ig are decreased, B cell count is decreased too so have scant LN and tonsils & recurrent bacterial and enteroviral infections after 6 month due 2 decreased mom IgG
CYP 450 inhibitors (increase levels of warfarin and its effect, increase bleeding risk)
Acetaminophen, NSAIDS Abx/Afungals (metronidazole) Amiodarone Cimetidine Cranberry juice, ginko biloba, vitamin E Omeprazole Thyroid Hormone SSRI (fluxotiene)
CYP 450 inducers (decrease warfarin effect, decrease efficacy)
Carbamazepine, Phenytoin Ginseng, St johns wart OCP Phenobarbital Rifampin
Immunocompromised person with systemic symptoms, lung nodules, and brain abscess, which culture shows partially acid fast, filamentous, branching rods. What is it? What is tx?
Nocardia (can also go to skin)
Tx TMP/SMX, when brain involved at carbapenems. Tx for 6-12 months.
What to do about testes in someone with complete androgen insensitivity? (46,XY)
- Perform gonadectomy after puberty
- Person would have cryptorchid testes secreting, no axillary or pubic hair, no penis scrotum, no uterus/ovaries. Bcus of cryptorchid gonads have a 1-5% chance of developing a dysgerminoma or gonadoblastoma after puberty. Benefits of undergoing gonad stimulated puberty (adult height)>risk malignancy. Usually identify with female gender
Treatment of catatonia?
Benzodiazepines or ECT
Dx: Lorazepam challenge test resulting in partial, temporary relief 5-10 minutes confirms diagnosis
Arsenic poisoning? Sources, manifestations, tx?
Source: Pesticides, insecticides, contaminated water (wells), pressure tx wood.
Manifestations: Acute: garlic breath, vomiting, watery diarrhea, QTC long/Chronic: hypo/hyperpigmentation, hyperkeratosis, stocking glover neuropathy
Tx: Dimercarprol, DMSA, Succimer
What is associated with the highest rate of aneurysm expansion and rupture?
Active smoking
Also large diameter, rapid rate expansion
NASH associated with?
Insulin resistance
Young individual with fleshy immobile mass on midline hard palate? Cause? Tx?
Torus Palatinus, congenital, no surgery needed unless growth becomes symptomatic or interferes with speech
Guy just returned from hiking trip to colorado, now has progressive ascending paralysis (18 hours ago)? paresthesias and fatigue/weakness. What next?
Look for a tick! Tick borne paralysis, may be asymetrical, NL sensation. 2/2 neurotoxin release (tick needs to feed 4-7 days)
Causes of asymmetric FGR?
2,3rd trimester placental insufficiency (HTN) results in restriction of abdominal growth>head growth. Also 2/2 maternal malnutrition.
In COPD what ABG changes exist and why not more acidotic?
Respiratory Acidosis 2/2 chronic hypoventilation, not super acidotic bcus kidneys compensation with HCO3 retention
Meningococcal vaccination
Primary @age 11-12, Booster at age 16-21
High risk: Complement deficiency, asplenia, college students in residential housing, military recruits, travel to endemic areas, exposure to community outbreaks
Dx Hip dysplasia in infant?
<4months: Hip US
>4months: Hip Xray
Cause of hemophilic arthropahy?
Caused by iron/hemosiderin deposition leading to synovitis and fibrosis within the joint.
Preso as chronic worsening joint pain and swelling, contractures of the joint, limited range of motion
<45 with AUB (period is heavy, lasts >7 days, comes often <21 days or less frequently >35 days) + Obesity, chronic anovulation, failed medical management, or lynch syndrome?
DO AN ENOMETRIAL BIOPSY
What should you suspect in any patient with pancytopenia following drug intake, exposure to toxins or virus?
Aplastic anemia
Precoucious puberty, cafe au lait spots, multiple bone defects (polyostotic fibrous dysplasia)
McCune Albright Syndrome
May be assocaited with hyperthy, prolactin or GH secreting Pit adenomas, and adrenal hypercortisolism. Sporadic, attributed to defect in G protein cAMP kinase function, leads to automous activity of that tissue.
3 week hx of coughing at night after URI at night, without expectoration?
Upper airway cough syndrome (postnasal drip)
Tx with oral 1st generation antihistamine Chlorpheniramine or combined antihitamine decongestant
Person with IE, susceptibilities comes back and show strep mutan high sus to Penecillin. Next step?
start on IV ceftriaxone (IE needs IV not penecillin orall) could also start on IV penecillin G
Tx acute Renal xplant rejection treat with?
IV steroids.
Order of tx in inflammatory acne (inflamed papules <5mm), pustules, erythema
Tx 1st topical retinoids and benzoyl peroxide
2nd Add topical antibiotics (eryth,clarith)
3rd Oral abx
If Nodular then can add oral isoretetinon
Tx bartonella henselae
Azith
What vaccines do adults with HIV need?
If have chronic liver disease (HCV,HBV), MSM, IVDU = Hep A
All need Hep B
HPV 11-26
Flu yeary
Meningococcus all pts 11-18, aspenia, complement deficiency, large groups living in close proximity
Pneumococus PCV 13 once, PPSV24 8 weeks later, 5 years later and age 65
Tdap once q 10 years and repeated with each pregnancy
Treatment for specific phobia
CBT (behavior therapy) with exposure, short acting benzos acutely
Beta 1 agonist does what in decompensated HF?
Decrease LVESVolume
(Dobutamine)
Methamphetamines assocaited with CM, low out put state, stimulates myocardial contractility leading to improved Ejection Fraction, reduced LVESB
65 year old with nephrotic syndrome, RA, enlarged kidneys, hepatomegaly, think?
Amyloidosis, amyloid deposits with congo red and apple green birefringence under polarize light. MM #1 cause AL amyloidosis
Chronic hyperthyroid myopathy
proximal muscle weakness in the setting of clinical features of hyperthyroidism, muscle atrophy.
TREATMENT OF asterixis in the setting of uremic encephalopathy (not hepatic)
Dialysis
Most effective emergency contraceptive method?
Copper IUD
secondary amenorrhea, hCG -, what next?
check prolactin, TSH, FSH
What meds can cause acute dystonia?
Metoclopramide, prochlorperazine, akathisia (after DA agonsit) or antipsychotics
Decompensated CHF, what happens to kidneys?
Constriction of efferent renal arterioles, due to acti RAAS and increased ADH
Progressive pancytopenia and macrocytosis, dx 8, cafe au lait, microcephaly, micropthalmia, short stature, horseshow kidnesys, absent thumbs
Fanconi anemia
Pure red cell aplasia, short stature, webbed neck, cleft lip, shielded chest, triphalangeal thumbs
Diamond Blackfan syndrome
Sensorimotor PN in DM what type of fibers?
Small - pain and paresthesias
Large - numbess, loss of proprioception, virbration, diminished reflexes
