UWORLD Review Flashcards
What key imaging feature helps distinguish between CNS lymphoma and Progressive Multifocal Leukoencephalopathy (PML)?
MRI in PML shows multiple, asymmetric NON-enhancing demyelinating lesions with NO mass effect.
How can HIV Encephalopathy be distinguished from PLM?
HIV encephalopathy usually presents with Dementia as main symptom not focal neuro findings.
On MRI lesions in HIV encephalopathy are symmetric in their distribution.
What is the leading cause of Hypophosphatemia in ICU pt?
Continuous Glucose Infusion
What is are some complication of Hypophosphatemia in ICU pts?
Failure to be weaned off Ventilator d/t respiratory muscle weakness.
Decreased cardiac contractility
Decreased BPG–> less Oxygen delivery to tissues (dissociation curve shifts left)
What is the proposed mechanism for Calcium Channel Blocker (CCB)-associated edema?
Preferential vasodilation of arteriole–>increased capillary hydrostatic pressure–>increased fluid movement into interstitium
What are main side effects associated with dihydropyridine CCB’s?
Headache
Dizziness
Flushing
Edema
At what anatomic site do ACEi’s work?
Post capillary (efferent) arteriole/venodilation
What is the most common complication associated with Statin use?
Medication-induced Myopathy
What is the treatment for late latent/unknown/gummatous/cardiovascular syphilis?
IM Benzathine Penicillin G weekly for 3 wks
What is the treatment for Neurosyphilis/Congenital
IV Aqueous Penicillin G for 10-14 days
What is the treatment for Primary/Secondary/Early latent (
IM Benzathine Penicillin G single dose
What is the most common complication of Polycythemia Vera?
Myelofibrosis
What type of leukemia are pts with Down Syndrome at increased risk of getting?
ALL
At what platelet count id Prophylactic platelet transfusion indicated?
Plt
What virus is associated with Adult T-cell Lymphoma?
HTLV-1
Endemic in Japan and Caribbean
What is the most common type of Hodgkin Lymphoma?
Nodular Sclerosing
Mixed Cellularity is second most common type
Which chemo drug is assoiciated with causing a reversible cardiotoxicity that affects left ventricular function?
Trastuzumab (Herceptin)
MOA: Causes decreased cardiac myocardial contractility.
What is the most likely diagnosis in a pt with a loud 4/6 holosystolic murmur with thrill at 4th ICS at left sternal border?
Ventricular Septal Defect (VSD)
Note: loud murmur = small restrictive VSD
soft murmur = large nonrestricitve VSD with grater shunting
Waht is the preferred method of imaging the esophagus and stomach?
Traditional Endoscopy
Note: wireless “pill” endoscopy is beneficial for areas of small bowel otherwise, views are limited in the esophagus, stomach, and cecum.
What is the indication for treatment of Paget’s Disease of the Bone?
Wt bearing bone involvement Hypercalcemia/hypercalcuria Intolerable Pain Neuro Involvement CHF
What are the features of Whipple”s Triad?
Low Blood Glucose
Sx of Hypoglycemia
Sx relief with glucose
Suggests true hypoglycemia
What is the most likely dx in a pt who presents with bitemporal hemianopsia, hyperpigmentation, and h/o abdominal adrenalectomy prior.
Nelson Syndrome
What is the best test to dx Nelson Syndrome?
Brain MRI Pituitary microadenoma (suprasellar pituitary enlargement d/t loss of negative feedback inhibition s/p bilateral adrenalectomy)
and
Elevated ACTH
What is the most likely diagnosis in a pt with IBD who c/o several episodes of bloody diarrhea, abdominal pain, fever, weakness, and tympanitic, distended abdomen?
Toxic Megacolon
What is the next best step in management in a pt with the above presentation?
Abdominal Xray
What is the treatment for pt with Toxic Megacolon?
Steriods iff d/t IBD IV Fluids NPO (bowel rest and hold meds that can decrease peristalsis) NG tube (decompression) Electrolyte correction
Antibiotics if d/t infection
Surgery if signs of perforation detected on imaging
What are the treatment options for a pt with PD?
Mild and 60yo: Amantadine
Severe (cannot perfom ADL's):
Levodopa/Carbidopa or
Dopamine Agonist:
Pramipexole or Ropinerol or CarbergolineWhat is the first Hemotologic parameter to change in response to Iron supplementation in a pt with Iron deficiency anemia?
Reticulocyte count will increase
What is the next step in treatment for a pt of Asian, Latin American, or Eastern European background who presents with dyspepsia without GERD sx or NSAID use and is
H. Pylori testing
What is the most likely diagnosis in a pt presenting with rapid ascites, hepatosplenomegaly, portal hypertension, jaundice, RUQ pain, and found to have hepatic vein and IVC thromboses and gastroesophageal varices?
Budd-Chiari Syndrome
What is the most likely dx in a pt presenting with Ataxia, confusion, and nystagmus–>ophthalmoplegia?
Wernicke’s Encephalopathy
What is the next step in management for a pt on Metformin with normal renal fnc who will have a procedure with contrast via lg bore needle?
Discontiune Metformin on day of procedure and restart in 2 days (after renal func assessed)
Lactic acidosis risk increases when contrast is used in pt taking metformin.
What are two underlying metabolic abnormalities resulting in HIV lipodystrophy?
Insulin resistance
Dyslipidemia
What conditions are patients who receive Diphtheria Antitoxin at increased risk of getting?
Serum Sickness
Anaphylaxis
(Antitoxin is made with horse serum so always have Epinephrine available when administering)
What metabolic tests are used to diagnose Pheochromocytoma?
Plasma free metanephrines OR
24-hr Urine metanephrines and catecholamines
What is the first line treatment for neuropathic pain associated with diabetic neuropathy?
Tight Gycemic control and if needed
SNRIs (Duloxetine)
Pregabalin
TCAs
What is the next step in management for a pt presenting with Whipple’s triad for hypoglycemia and elevated Insulin, C-peptide, and Proinsulin?
Oral Hypoglycemic assay
What is whipple’s triad for Hypoglycemia?
Symptoms of hypoglycemia
Low blood Sugar
Symptom resolution with the administration of glucose
What is the next step in management for a young pt who presents with dyspnea on exertion, no risk factors for coronary/atherosclerotic disease,physical exam findings of prominent S2 without murmurs/gallops, clear lungs, CXR showing prominent pulmonary arteries, and EKG showing right axis deviation?
Echocardiogram (to measure Rt pulm artery pressure, assess right ventricular and atrial function/size, and right heart valve mobility)
What tests should be done prior to diagnosing Idiopathic Pulmonary Artery Hypertension?
Pulmonary Function Tests (PFTs)
High resolution CT
Polysomnography
What is the next step in management for PAH once all other causes ruled out and pt diagnosed with idiopathic PAH?
Vasoreactivity Test (measure PA pressure following vasodilator administration)
If Vasoreactivity testing shows elevated PA pressure, what is next step in management?
Prostanoid (Epoprostenol)
Endothelin antagonist (Bosentan)
Phosphidiesterare-5 inhibitor (Sildenafil)
What is the drug of choice for Cluster Headache PREVENTION for greater than 2 months?
Verapamil (get baseline EKG for higher doses)
Which abortive therapy for cluster headache should be avoided in pts with Cornary Artery disease?
Sumatriptan
What is the next step in management for a pt diagnosed with Normal Pressure Hydroephalus?
LP to drain CSF (about 30-50ml) then assess cognition and gait
(Ventriculoperitoneal shunt is definitive treatment iff pt responds to removal of CSF with LP)
What is the next step in management for a pt suspected of active Tb?
Chest Xray
What is the next step in management of a pt suspected of active Tb with abnormal or normal CXR?
Sputm smears/microscopy (esp) and culture x3 for acid fast bacilli (cultures taken 8-24 hrs apart with at least one early morning sample)
What is one criteria to be considered non-infectious in a pt suspected of having Tb?
3 negative Sputum smear (marker for infectivity)
(note, this does not mean pt is not infected or does not need Tb treatmen. If they are symptomatic, treat empirically until cultures return)
What is the formula for SAAG?
Serum Albumin-Ascites Albumin
What conditions are associated with SAAG >/= 1.1?
CHF and Portal Hypertensive Etiologies Cirhosis Alcohol hepatitis Budd-Chiari Syndrome
What conditions are associated with a SAAG
Peritoneal Cancers Peritoneal Tb Serositis Nephrotic Syndrome Pancreatitis
What is the most likely diagnosis in a pt with rapidly progressing weakness of lower or upper extremities, decreased/absent DTR, sensory loss, and urinary retention following a URI?
Transverse Myelitis
What is the drug of choice for bite wounds?
Amoxicillin/clavulanate (PO) or Ampicillin/Sulbactam (IV)
What is the pathophysiology of scabies-related pruritis?
Delayed Type (IV) hypersensitivity rxn to the mite, its feces, and ova.
What are the features of Papilledema seen on Ophtho exam?
Blurred disc Margins
Serpintine engorgement of small veins
Obscured Vessels/Cotton Wool Spots
Splinter Hemorrhages
What are some red flag signs that indicate imaging should be the next step in management for a pt with headache?
Papilledema Sudden onset, worse headache of life Age >/= 50 Increased frequency or severity Worse with Exercise/Sexual Intercourse Neurologic Deficits Personality Changes Systemic Symptoms
What is one effective way to reduce Observer Bias?
Blinding
What is the formula for calculating Sensitivity?
a/a+c (Out of all the people with the disease, who had + test)
What is the formula for calculating Specificity?
d/d+b (Out of all people w/o the disease, who had a - test)
What is the formula for Positive Predicted Value?
PPV= a/a+b (out of all people w/ a positive test)
What is the formula for Negative Predicted Value?
NPV= d/c+d (out of all people w/ a negative test)
What are the three components of Leriche Syndrome?
Erectile Dysfunction
Lower Extremity Claudication
Diminished/Absent Femoral Pulses
What is the next step in management in a pt presenting with Erectile Dysfunction, chronic exertional buttock/thigh pain and a h/o DM2, hyperlipidemia, and active smoking?
Ankle-Brachial Index (to screen for PAD)
How is an ABI interpreted?
1.30 = Calcified, uncompressible vasculature–> Need further studies
What additional test should be done in a pt with Erectile Dysfunction and atherosclerotic disease risk factors (hyperlipidemia, smoking) prior to initiating therapy?
ABI Stress Test (exercise or pharmacologic)
In a normal distribution curve, what are the values for the Median, Mode, and Mean?
Mean=Median=Mode
What value(s) of central tendency is/are affected by outliars in very skewed curves?
Mean
What is the relationship between Mean, Median, and Mode in a positively skewed distribution curve?
Mode
What is the relationship between Mean, Median, and Mode in a negatively skewed distribution curve?
Mean
What is the best choice to measure central tendency when the data (Ordinal or Continuous) is skewed?
Median
What is the best choice to measure central tendency when the data (nominal) is skewed?
Mode
What is the best prognostic Indicator for acute pancreatitis severity?
APACHE II score
What is the next step in management for a pt with an APACHE II score of 8 or more?
CT scan at 72 hrs to check for pancreatic necrosis
What is the best way to distinguish between IgA nephropathy and Thin Membrane Disease?
Renal Bx
Note: Hematuria in Thin Membrane Dx not usually related to URI, while with IgA Nephropathy, hematuria is Syn-pharyngitic (1-3 days post URI)
What are the limitations of HHA services?
Cannot give medications
Cannot perform Health Evaluations
What is the most likely dx in a pt with Low TSH and Low FT4?
Central Hypothyroidism
What is the next step in management for a pt with low/borderline TSH, low FT4, and low/low normal Sodium?
ACTH levels
ACTH stimulation test (ck cortisol levels before and after)
Note, when central endocrine disorder suspected, also consider r/o other central endocrine disorders.
What is the most likely dx in a pt with back pain that is worse with extension and improved with flexion of lumbar spine and sitting, w/w/o pain radiating to buttocks (neurogenic claudication)?
Spinal Stenosis
What is the most likely dx when a pt presents with back pain that is worse with lumbar flexion of the spine and positive straight leg raise test?
Disc Herniation
What features are associated with severe C. diff colitis?
WBC > 15,000/uL
Temp > 38.3C (100.9F)
Albumin 1.5x Baseline
What is the treatment for mild-moderate C. diff colitis?
Oral Metronidazole
What is the treatment of choice for severe C.diff colitis?
Oral Vancomycin
When should IV metronidazole be added to therapy for C. diff colitis?
When severe AND Ileus is present
What are two alternative medications for the treatment of C.diff colitis when Vancomycin or metronidazole don’t work or are not available?
Oral Rifampin
OR
Oral Rifaximin
What is the next step in dx for a pt presenting with localized tenderness, pain that is worse with use , and swelling of the legs/feet in a pt who runs a lot or is a military recruit, or athlete?
Plain Xrays- will be normal (until about 4 wks later)
Stress Fracture==> clinical dx,
What is the best imaging modality to use to dx Stress Fracture?
MRI
What is the management of choice for lower extremity Stress Fracture?
Pneumatic Splinting Decreased Weight Bearing Gradual Exercise (up to 12 wks for mild cases but can extend if recurrent pain develops)
What clinical tests can be used to dx Carpel Tunnel Syndrome?
1)Phalen’s Sign (hyperFLEXION of wrists–>pain w/in 1 min)
2)Tinnel’s Sign (tapping over medial nerve at Carpel
Tunnel)
3) Hand elevation over head–>reproduces sx after 1 min
What 2 tests can be used to confirm the dx of Carpel Tunnel Syndrome and determine severity of the condition?
Nerve Conduction Studies
EMG
(Note: the dx is clinical but these tests can be done for more thorough workup and to guide therapy)
When can steroids be used in the treatment of Carpel Tunnel Syndrome?
When Splinting fails to improve sx’s (injected steroid preferred)
What is the next step in management for a pt in an MVA with multiple bruises/lacerations on/near his chest with normal cardiac and lung exam and normotensive?
12-lead ECG (most important test to r/o Blunt Cardiac Trauma)
What are the steps in management for a pt with blunt chest trauma?
1) ABC’s
2) Physical Exam
3) CXR
4) EKG:
if Abnormal-FAST exam/ Transesophageal echo/ CT
if Normal- No further testing
What is the treatment of choice for Akathisia?
B-Blockers added to antipsychotic regimen (Propranolol)
What is the treatment of choice for Lead(Pb) poisoning in a pediatric pt?
Mild (venous level 5-44ug/dL): No treatment
Moderate (45-69ug/dL): Meso2,3-dimercaptosuccinic acid, Succimer
Severe(>/= 70ug/dL): IM BAL(dimercaprol) + IVCalcium disodium edetate (EDTA)
What are the clinical features/lab findings associated with Lead colic?
Abdominal Pain
Constipation
Anemia
Basophilic Stippling
What are the indications for Parathyroidectomy in pts with secondary/tertiary hyperparathyroidism?(7)
1) Calcium>10.5mg/dL and no response to therapy
2) PTH >1000pg/mL
3) Moderate-severe Hyperphosphatemia and no response to treatment
4) Intractable Bone Pain
5) Intractable Pruritis
6) Episode of Calciphylasix
7) Soft Tissue Calcification
What metabolic test should be done prior to parathyroidectomy?
ALK Phosphatase to assess bone turnover (if low, surgery may not be best)
In what condition associated with secondary hyperparathyroidism is Pamidronate contraindicated?
Chronic Renal Failure
What is the treatment of choice for Squamous Cell Carcinoma of the skin?
Surgical Excision
What are some alternative treatments for Squamous Cell Carcinoma of the Skin when surgery is not desired?
Cryotherapy
Electrosurgery
Radiation Therapy (risk of future malig–>used in elderly who refuse surgery)
What is the limitation of Cryotherapy and Electrotherapy for the treatment of Squamous Cell Skin Cancer?
No histology to confirm tumor margins
What is the next step in management for an HIV+ pt who presents with non-productive cough, SOB, Hypoxia, and increased LDH, with an induced sputum Negative for Pneumocystis?
Bronchoalveolar Lavage (Most Accurate/ definitive)
Note: Sputum culture is the most common way to determine PCP
What is the indication for the addition of steroids to the treatment for PCP?
A-a gradient >35
and/or
PaO2 = 70mmHg
What dx should be suspected in a pt who presents with HYPOpigmented skin lesions (ash leaf spots), developmental/cognitive delay and seizure?
Tuberous Sclerosis Complex
What is the underlying cause of Tuberous Sclerosis Complex (TSC)?
Atusomal Dominant or Denovo Gene Mutation in TSC1 (hamartin) or TSC2 (tuberin) genes
These genes control cell differentiation–> benign tumors
What are the common sites of tumor development in TSC?
Skin: Ash Leaf Spots, Malar Angifibromas, Shagreen
Patches
CNS: Glioneuronal Hamartomas "Tubers"
Kidney: Angiolipoma
Cardiac: Rhabdomyomas (visible in utero)What test should be included in the initial work up of a pt with possible TSC?
Skin evaluation Fundoscopy Brain MRI Abdominal Ultrasound (renal) EEG (if seizure suspected)
What is the predominant cause of death in pt with TSC?
Neurologic Impairment (esp uncontrollable seizures, obstructive hydrocephalus, and aspiration pneumonia)
What type of therapy is associated with prologned life span in pts with TSC?
Antiseizure medication (Optimal Seizure control)
What is the second most common cause of death in pts with TSC?
Renal impariment/Failure
What are two examples of anti-Pseudomonal Cehalosporins?
Cefepime
Ceftazidime
What are other anti-pseudomonal antibiotics?
Amikacin (aminogylcoside) Carbepenems Piperacillin-Tazobactam Certain Fluoroquinolones Aztreonam Cilostin
When should Vancomycin be added to antibiotic epmiric therapy in a pt with Cyctic Fibrosis being treated for acute pulmonary exacerbation/pneumonia?
If there is a h/o MRSA
What is a clue in the neonate that would suggest diaphragmatic paralysis rather than diaphragmatic hernia?
Presence of Erb’s Palsy (phrenic nerve damage d/t shoulder traction/neuropraxia)
What are the 2 most common causes of phrenic nerve injury?
Birth Injury (associated with signs of brachial plexus injury) Cardiothoracic Injury/Surgery
What are the dignostic criteria for Bacterial Vaginosis?
3 out of 4:
1) Clue Cells on wet mount
2) Amine odor on KOH prep of discharge (+ Whiff test)
3) Vaginal pH>4.5
4) Homogenous vaginal discharge
How is Bacterial Vaginosis treated (in pregnancy)?
ORAL Metronidazole (must let mothers know it crosses placenta but not teratogenic effects)
OR
ORAL Clindamycin
(Note: only need to treat symptomatic pts (ie abnormal discharge), no need to screen asymptomatic pts)
What complications can be associated with untreated BV in pregnancy?
Increased risk of Preterm Birth, PROM, SAB
Increased risk of STD
When is a stress test indicated prior to the onset of sexual activity post MI?
Only if pt is of intermediate or indeterminate risk status–> do stress test to reclassify the pt prior to recommendation about sexual activity.
How are Somatic Symptom and Illness Anxiety Disorder (Hypochondriasis) distinguished?
Somatic Symptom Disorder : Actual Symptoms
Illness Anxiety Disorder: Minimal/No Symptoms but preoccupied with having serious disease/condition
What type of disease process should be suspected in an African-American pt found to have bilateral Hilar fullness on CXR?
Granulomatous disease
What does an isolated elevated Alk Phosphatase with normal AST, ALT suggest?
Infiltrative Liver Disease
What is the benefit of the findings of mild hepatomegaly w/o focal lesions and ascites on abdominal ultrasound?
Nonspecific BUT
Help r/o Underlying Mass as cause of infiltrative liver disease.
What are the most effective methods of contraception?
IUD (>99%) Progesterone Implant (>99%)
What condition should be suspected in a female pt presenting with post-void dribbling, dysuria, and dyspareunia, anterior vaginal wall fullness, who has had multiple vaginal deliveries?
Urethral Diverticulum
How can Stress incontinence be distinguished from Urethral Diverticulum?
Stress incontinence is associated with loss of urine upon increased abdominal pressure.
How is Urethral Diverticulum dx?
Transvaginal Ultrasound
What condition should be considered in pts with low iron, low vitamin D, and Low calcium w/ or w/o GI symptoms, a healthy diet, and a personal and FHx of autoimmune disease?
Malabsorptive Disease Processes (ex: Celiac Disease)
What are the screening (best initial) tests for Celiac Disease?
Anti-Tissue Transglutaminase Ab
Anti-endomysial Ab
What is the test of choice for definitive dx of Celiac Disease?
Small Intestinal Bx
What type of Bias is associated with a Funnel Plot that shows asymmetric data points?
Publication Bias
What is the drug of choice for immediate treatment of Metoclopramide-induced acute dystonia?
Diphenhydramine IV
What is an alternative medication for Metoclopramide-induced acute dystonia treatment id Diphenhydramine does not work?
Benztropine IV
What aspects of ADHD tend to resolve/diminish by adolescence?
Physical Hyperactivity
What features might be associated with ADHD that persists into adolescence and/or adulthood?
Inattention (often reported as boredom) Impulsivity Procrastination Forgetfulness Hyper-talkativeness
What is the treatment of choice for adolescents/adults with persistent ADHD?
Stimulants (even if pt has FHx of Drug abuse/addiction or personal drug use)
[Note: Stimulant medications are not associated with increased risk of substance use/abuse]
What test should be done prior to treating a UTI in a female of child-bearing age who is sexually active, regardless of contraception use?
Urine Pregnancy Test
Why should TMP-SMX be avoided in pregnancy?
Interferes with Folate metabolism.
Why should Fluoroquinolones be avoided in pregnancy?
Increased risk of fetal arthropathy
Which antibiotics are safe to treat uncomplicated UTI in pregnant pts?
Amoxicillin
Cephalexin
Ntrofurantoin (except at term, during labor/delivery, or if labor is imminent)
What are the concerns associated with use of St. Johns Wort?
St. Johns Wort:
- P450 inducer–> interfere with medications
- Increased risk of Serotonin Syndrome
What is the treatment of choice for a pt with optic neuritis and suspicious for Multiple Sclerosis acute exacerbation?
IV Steroids
[Note: Oral and IV steroids are equally efficacious for MS exacerbation, but IV preferred with optic neuritis bc increased risk of recurrence with oral steroids]
What is the treatment for acute MS exacerbation when steroid therapy is not effective?
Plasmapharesis
What is the first line treatment for severe spasticity (spasms/stiffness) associated with MS?
Muscle Relaxers:
Baclofen
Tizanidine
What is the treatment of choice for fatigue associated with MS?
Sleep hygeine Modifications
Exercise
Amantadine
Stimulants
What is the test of choice to dx HIV when screening test (ELISA) is negative or indeterminate and there is a high level of suspicion for primary infection?
HIV RNA PCR (detect viral load)
or
HIV p24 ag
Why shouldnt Western Blot be used to confirm HIV infection in a pt who presents with a negative ELISA and is suspected of having early/primary infection?
Increased False Negatives early in disease course (ie: b/f seroconversion)
What is the most likely dx in a pt who presents with altered mental status, extreme hyperglycemia (glc>1000), and absence of ketones and a normal anion gap with a h/o type 2 DM and recent illness or steroid/antipsychotic use?
Hyperglycemic Hyperosmolar Nonketotic State (HHS)
What is the management for a pt with HHS?
1) High Flow normal Saline (Add Dextrose 5% in water once glc=200)
2) IV continuous Insulin
3) Monitor K+, replace when Serum level = 5.2
4) Monitor Bicarb (for metabolic status)
Once a pt with HHS is stabilized, what should be changed regarding the Insulin during hospitalization?
Switch to Subcutaneous Basal-Bolus regimen with Sliding scale (short acting + long acting)
What signs when present in a baby or young child (not walking) would indicate increased intracranial pressure and should increase suspicion for Intentional Head Trauma/Shaken Baby Syndrome?
Lethargy
Apnea
Vomiting
H/o repeat ER visits for similar reasons
What is the next step in management for a baby presenting with signs of increased intracranial pressure and Intentional Head Trauma is suspected?
Heat CT (to r/o intracranial bleed)
How are Chronic Tic Disorder and Tourette Syndrome distinguished?
Chronic Tic Disorder: Motor OR Vocal tics for >/=1yr
Tourette Syndrome: Motor AND Vocal tics present simultaneously
What is the treatment of choice for Tourette Syndrome?
Antipsychotic (dopamine antagonist) ex Risperidone
[Note: first generation antipsychotics can also be used but they have worse side effect profile so Second Gen are preferred]
What condition should be suspected in a pt who presents with a h/o fall on outstretched hand with pain, swelling, tenderness over the radial dorsal aspect of wrist (Anatomic Snuff Box), decreased grip strength, and relatively intact range of motion?
Scaphoid bone Injury
What is the next step in management for a pt with suspected Scaphoid bone injury?
Xray of Wrist in full pronation and ulnar deviation
What are some key differences between Colles Fracture and Scaphoid Bone Fracture?
Colles Fracture:
- Visible Upward displacement/Angulation (dinner fork
deformity) –>Comminuted
- Initial XR confirms dx
Scaphoid Bone Fracture:
- Normal Xray
- Most common injury associated with fall on outstretched hand with forced dorsiflexion of wrist
What is the next step in management for a pt suspected of having a scaphoid bone fracture with a negative Xray?
MRI or CT of wrist
What is the management for a pt dx with nondisplaced Scaphoid bone fracture that does not require surgery?
Spica Cast
F/u xray in 7-10 days and every 2 weeks to check healing
What is the management for a pt with a Scaphoid Bone fracture with displacement?
Ortho consult for surgical repair
What are the most common complications of Scaphoid bone fractures?
Nonunion
Avascular Necrosis
What is the next step in management for a pt with an asymptomatic solitary thyroid nodule > 1.0 cm who has NO risk factors for cancer?
TSH or Ultrasound
What is the next step in management for a pt with an asymptomatic solitary thyroid nodule >1cm, with risk factors of cancer and/or clinical suspicion?
FNA
What is the next step in management for a pt with an asymptomatic solitary thyroid nodule>1cm, no risk factors for cancer, and no suspicious US findings?
TSH:
If normal or elevated–>FNA
If decreased
What is the next step in management when an asymptomatic pt presents with solitary thyroid nodule that has no suspicious US findings, decreased TSH?
Thyoid Scintigraphy: If Hyperfunctioning (hot)--> treat hyperthyroidism If Hypofunctioning (cold)--> FNA
What is the next step in management for a pt who is diagnosed with differentiated thyroid cancer(papillary or follicular)?
U/s of neck and cervical lymph nodes for staging to determine appropriate surgery?
What is the treatment for diagnosed differentiated thyroid cancers that are small solitary masses
Solitary, in situ malignancies Lobectomy
What are the indications for total Thyroidectomy as treatment for Papillary Thyroid Cancer?
1) Tumor >/= 1cm
2) Distant mets
3) Extension of tumor beyond Thyroid gland
4) Head/Neck Radiation exposure
What is the treatment of choice for a pt dx with Scleroderma renal Crisis?
ACE-inhibitors, Captopril (reverse angiotensin-induced vasoconstriction at Efferent (efflux) arteriole–> decrease GFR)
[NOTE: All other conditions of renal failure, avoid ACE inhib’s]
What is the treatment of choice for a pt presenting with Acute Scleroderma Renal Crisis with CNS manifestations?
Oral Captopril and ADD one dose of IV Nitroprusside (monitor bp bc do not want sudden major decrease as this would worsen renal perfusion –> ATN)
What is the next step in management for a pt who presents with unilateral moderate knee pain/tenderness, swelling, and erythema but able to bear weight and does not appear ill of have any constitutional signs with a h/o travel to the wooded areas of the northeast or upper midwest United States?
Arthrocentesis
and
Lyme Serology (ELISA then confirm w/ Western Blot)
All pts with Artrhitic Lyme will hv +IgG
What are some typical features of Late Lyme disease?
Arthritis (monoarticular, mild inflammatory signs, can bear weight, and well appearing)
Encaephalitis
Peripheral Neuropathy
What is the treatment of choice for Late Lyme Disease?
Oral Doxycycline or Amoxicillin (28dys) with full recovery and no sequelae w/in 6-12mos
Note: Avoid Doxycycline in children can cause tooth discoloration/skeletal problems
What is the most common cause of gastroenteritis in adults and children, especially associated with epidemics?
Norovirus
What are some typical features associated with Norovirus gastroenteritis?
Vomiting(mainly) Watery Diarrhea Fever (low grade) Headache Systemic signs (if severe) Culture Negative Stool Sx generally last 48-72 hrs
How is the dx of Tinea Versicolor confirmed?
KOH prep of skin scraping–>shows hyphae and yeast
What is the causal organism associated with Tinea Versicolor?
Malassezia species
What is the treatment of choice for Tinea Versicolor?
Topical Anti-fungal agents
Note: Use oral antifungals if extensive disease or refractory to topical agents
What should be done prior to any decision -making for a pt with Mental Retatrdation?
Determine guardianship status and capacity
What is the physician’s responsibility on reporting newly dx’d HIV?
Mandatory reporting to Department of Public Health
What is the best initial treatment for pts ages 3-5 newly diagnosed with ADHD?
Non-pharmacological interventions (Parent-Child Behavior Therapy)
What should be done prior to initiating ADHD therapy with stimulant medication?
Cardiac Hx and FHx of Cardiac problems (sudden death)
Physical Exam
Baseline Weight
Vitals (monitor throughout use)
When is an ECG indicated prior to starting stimulant therapy for ADHD?
ECG only if there are findings associated with possible Cardiac disease on H&P
What are 2 alternative non-stimulant medications that can be used to treat ADHD if stimulants are ineffective or side effects are intolerable?
Atomoxetine (Norepi reuptake inhibitor)
Alpha-2 agonist (Clonidine)
What level of unconjugated bilirubin is considered high in general?
18mg/dL and up
At what bilirubin level is the risk of neurologic dysfunction increased?
Serum Bili >25mg/dL
What Ab is most sensitive for the detection of CREST variant of scleroderma?
anti-Centromere Ab
What Ab is most sensitive to detect Primary Biliary Cirrhosis (PBC)?
anti-Mitochondrial Ab
What Ab is highly specific for SLE but have a very poor sensitivity?
anti-Smith Ab
What Ab’s are most likely seen in pt with Sjogren’s Syndrome?
anti-Ro/SSA Ab
anti-La/SSB Ab
What Ab has good sensitivity for SLE, can be used to as an indicator of disease activity, and is associated with the development of LUPUS Nephritis?
anti-dsDNA Ab
What is the treatment of choice for a pt dx with SLE who presents with mild cutaneous sx, serositis, and arthralgias w/o extensive solid organ involvement?
Low does , short term Prednisone + Hydroxychloroquine
What should be included in the initial workup of a pt with chronic diarrhea ( loose stools w/w/o increase in frequency for > 4wks)?
History (including travel, sexual hx, diet, associated sx) Physical (including rectal exam) Stool sample Gram Stain Cx Microscopy for leukocytes/ova/parasites Fecal Fat staining Occult Blood pH Electrolytes (calculate osmotic gap)
What are the characteristic Bx findings associated with Celiac Disease?
Villus Blunting (mucosal flattening)
Loss of normal villus architecture
Lymphocyte and Plasma cell mucosal infiltration
What bx findings are associated with Crohn’s Disease?
TRANSMURAL inflammation w/ Lymphocytic infiltration
What bx findings are associated with Ulcerative Colitis?
Superficial mucosal inflammation w/Plasma cell infiltration
What is the preoperative diabetes management in a pt with Type 1 DM who has a scheduled C-section?
Normal Insulin night before (even though NPO after 12)
Insulin Drip w/ D5 1/2 Normal Saline w/ 40 mEq KCl to keep blood glucose
What is the most likely dx in a pt who presents w/ abdominal pain, diarrhea, N/V, dizziness, sweating, and dyspnea who has a h/o of recent gastrectomy?
Dumping Syndrome (food moves faster from stomach to jejunum –> causes symptoms)
What is the initial management for a pt with Dumping Syndrome?
Goal: decrease the speed of food passage into Small Gut
- High Protein - Smaller, More frequent Meals
What types of wounds should not undergo primary closure?
Bites on hand (any place with decreased blood supply)
Puncture Wounds (Anywhere)
Pts presenting late after a bite
What are some risk factors associated with Intussusception?
Meckel's Diverticulum Henoch-Schonlein Purpura Celiac Disease Polyps Intestinal Tumor
How is Intussusception Dx’d when presentation is unclear?
Target Sign on Ultrasound
What is the most likely dx in a child netween age 6mos-3yrs with crampy, episodic, severe abdominal pain, sausage-like mass on right side of abdomen, and current jelly (very red) stools?
Intussusception (can also see vomiting and drawing up of legs during pain)
What is the most common lead point for Intussusception?
Hypertrophied Peyer’s Patch
What is the primary risk associated with non-surgical (Enema) reduction og Intussusception?
Perforation (even with air/water-soluble substances)
What is the pathophysiology resulting in the sx’s associated with intussusception?
Telescoping of Ileum into Cecum (rt-side)–> Edema/Obstruction/Pain–>Vascular Compression–> Bowel Ischemia–> Rectal Bleeding (current jelly stools)
What are the current Cervical Cancer screening guidelines for sexually active females?
If 65: No screening if prior negative screens and not high risk
Hysterectomy (no cervix): No screening if NO h/o:
-High grade precancerous lesion
-Cervical Cancer
-Diethylstilbestrol (DES) exposure
Immunecompromised: PAP at onset of sexual activity q 6mos 2 times, then annually if negative
What is the next step in management for an elderly pt with a hip fracture whose vitals are stable and was ambulatory prior to incident?
Ortho consult and surgical repair w/in 48 hrs (lower mortality and morbidity)
What are the criteria for non-operative management of hip fracture in the elderly population?
Those who are
- Non-ambulatory prior to injury
- Demented
- Have end-stage terminal illness
- Medically Unstable (can delay surgery up to 72 hrs)
What patterns are more commonly associated with benign solitary lung nodules on imaging?
Popcorn
Laminated (concentric)
Diffuse homogenous
Central
What structure is responsible for draining the testes?
Pampiniform Plexus
In addition to venous drainage, what does the pampiniform Plexus also maintain for the testes?
Appropriate temperature (2 degrees cooler than body-seminiferous tubules very sensitive to increase in temp)
What are pts with untreated varicocele at increased risk of developing?
Testicular Atrophy (dilation of pampiniform plexus–> increase in intrascrotal temp–> seminiferous tubular atrophy)
Note: Seminferous tubules make up majority of testicular mass
What is the location of the fluid location associated with a testicular hydrocele?
The potential space in the Tunica Vaginalis
What is the next step in management for a pt who presents with varicocele involving the right side and why?
CT abdomen and Pelvis (to determine cause of obstruction)
-Right venous drainage is at a larger angle directly into IVC therefore, facilitating continuous venous flow unless something is blocking flow.
Varicocele more likely on left side–> spermatic vein drains into renal vein at 90 degree angle.
What is the treatment of choice for pediatric sepsis?
Child = 28dys: Ampicillin + Gentamicin or Cefotaxime(esp for suspected meningitis)
Child>28 days: Cetriaxone or Cefotaxmine
+/-Vancomycin (meningitis)
Why should Ceftriaxone, Sulfonamides, and Sulfamethoxazole use be avoided in neonates (=28 days old)?
They cause:
bilirubin displacement from albumin–>elevated serum bili–>increased bili crossing BBB–>increased risk of kernicterus
Why should TMP-SMX use be avoided in children
Can cause Methemoglobinemia
What are the most common causes of pediatric sepsis/meningitis?
Child=28days:
- GBS (esp w/in first 24 hrs of life)
- E. coli
Child>28days:
- S. pneumo
- E.coli
- S.aureus
What should be included in the workup for all febrile neonates?
CBC Blood Culture Urinalysis Urine Culture Lumbar Puncture: CSF cell count and Culture
What features distinguish Guillan Barre Syndrome from Transverse Myelitis?
GBS:
No sensory level
No bladder/bowel dysfunction
Autonomic Dysfunction (severe)
Transverse Myelitis:
Sensory level present
Bladder/Bowel dysfunction present
What is the next step in management for a pt presenting with onset of progressive lower extremity weakness and paresthesias with bladder/bowel dysfunction, sensory level, and recent URI?
MRI (immediate)
What is the most likely dx for a pt presenting with
Transverse Myelitis
What is the treatment for Transverse Myelitis?
High-dose steroids for 3-5 days
What should be done to confirm eradication of H. Pylori infection and when should it be done?
Fecal Antigen Testing or Urea Breath Test after 4 weeks
[Note: Do not do serology bc may remain positive even a year or more post eradication ]
What is the purpose of an Intention-to-Treat (ITT) analysis?
Preserve Randomization (ITT principle states that individuals should be analyzed in the groups of their original randomization, regardless of compliance, completion, or receipt of the allocated intervention)
What is used to monitor disease progression in pts dx’d with Ankylosing Spondylitis?
Xray q3mos or ESR levels
- AP and Lateral view of Lumbar Spine - Lateral view of Cervical Spine - Pelvic area including sacroiliac joints and hip
What conditions are the most significant extrearticular manifestations of Ankylosing Spondylitis?(5)
Anterior Uveitis Restrictive Lung Disease (deceased CV joint mobility) Apical Pulmonary Fibrosis IgA Nephropathy Aortic Regurgitation
What is the initial step in management far a pt presenting with palpitations but no chest pain or SOB, normal lung and cardiac exam, and an ECG showing no organized P-waves, narrow complex tachycardia, and irregularly-irregular rhythm w/ varying R-R intervals?
If Stable: Rate/Ventricular response Control w/: -B-blockers -Ca-channel Blockers -Digoxin
What is the next step in management for a pt presenting with … and EKG does not show anything
Telemetry (if in pt) Holter Monitor (if outpt)
What is the next step in management for a pt who presents with palpitations, tachycardia and no h/o ischemic heart disease?
EKG
What is the next step in management for a pt who presents with palpitations, tachycardia, and EKG shows regular sinus rhythm with a ventricular rate of 160-180 bpm?
Stable:
-Rate Control w/ Vagal maneuvers–> if fails–> IV Adenosine
What is the best long term management for a pt with Supraventricular Tachycardia?
Radiofrequency Ablation (of the re-entrant pathway)
When should IVIG be administered for the treatment of ITP?
Platelet Count
By what mechanism does IVIG aid in the treatment of ITP?
IVIG consumes Fc receptors on Macrphages –>Ab’s bound to platelets cannot bind to/stimulate macrophages–>inhibit further platelet destruction
What is the most likely dx in a pt presenting with a h/o asthma who subsequently develops recurrent fevers, cough productive of brown mucoid sputum, malaise, and wheezing/bronchial obstruction?
Allergic Bronchopulmonary Aspergillosis (ABPA)
What is the next step in management for a pt presenting with ?
Skin prick test for mold (Aspergillus)
What is the nest step in management for a pt suspected of having ABPA with a positive skin prick test?
Serum IgE and precipitating Serum Ab to Aspergillus
[Note: if skin prick is negative ABPA is highly unlikely]
What are the clinical/radiographic, and immunologic criteria that aid in the dx of ABPA?(7)
1) History of Asthma
2) Immediate skin test reactivity to Aspergillus antigen
3) Precipitating serum antibodies to Asergillus fumigatus
4) Serum total IgE >1000
5) Peripheral eosinophilia >500/cubic cm
6) Upper lobe lung infiltrates (bilateral)
7) Central Bronchiectasis (CT only if skim and serum studies are positive
What is the pathophysiology that results in ABPA?
Hypersensitivity Rxn to Aspergillus colonization in hyperactive airways:
Colonization of airways w/ Aspergillua–>intense
IgE/IgG mediated immune response–>recurrent
fever, cough w/ brown mucoid expectorant, malaise,
wheezing
What is the best treatment for ABPA?
Oral Steroids (Prednisone) - to prevent recurrent inflammation which can lead to bronchiectasis and fibrosis
How is the response to treatment monitored in a pt with ABPA?
Decreased total serum IgE
Resolution of lung findings on imaging
Symptomatic improvement
What is the single most important risk factor in devloping post partum endometritis?
Route of delivery (c-section has increased risk)
What is the nest step in management for an adult pt who presents with multiple recurrent bacterial sinopulmonary and/or GI infections?
Quantitative Serum Immunoglobulin levels
What dx should be suspected in a pt who has recently emigrated from Mexico and presents with chronic diarrhea, weight loss, abdominal distention, and found to have a positive FOBT, Eosinophilia, and microcytic anemia?
Helminth/Parasite infection (chronic inglammation of gut–> bleeding–>iron deficiency anemia)
What is the next step in management for a pt diagnosed with uncomplicated Bicuspid Aortic Valve?
Echocardiogram (TTE) to screen First degree relatives
What is the treatment for a pt dx’d with Bicuspid Aortic Valve?
F/u Echo every 1-2 yrs
Balloon Valvuloplasty
When is valvuloplasty indicated in the management of Bicuspid Aortic Valve?
Severe Aortic Stenosis
Significant AV calcification /regurgitation
Peak Gradient >50
What are the characteristics of the murmur associated with Bicuspid Aortic Valve?
Mid-Systolic Ejection Murmur -best at left lower sternal border (may hear click)
What are the characteristic features of Alopecia Areata?
Well demarcated (round) patch of complete hair loss
Non-scarring
Any hair bearing area can be affected
+/-Exclamation Point Hairs
Personal/Family History of Autoimmune Disease
What is the most likely dx for a pt who presents with bilateral cataracts, basal ganglia calcifications in the context of chronic hyperphosphatemia and hypocalcemia?
Pseudohypoparathysoidism (targets are resistant to PTH)
What are the types of Pseudhypoparathyroidism?
Type 1A:
-Albright Hereditary Osteodystrophy features
(round face, short stature, short neck, short 4th and
5th metacarpals) AND
-Hypoparathyroidism
Type 1B: no Albright Hereditary Osteodystrophy features
What are the metabolic features assoiacted with Pseudohypoparathyroidism, Vitamin D deficiency, and Hypoparathyroidism?
PHP: High PTH, Nml Vit 25 D, Low Ca2+, High Phos
VDD: High PTH, Low Vit 25 D, Low Ca2+, Low Phos
HP: Low PTH, Nml Vit 25 D, Low Ca2+, High Phos
How are acute hyperphosphatemia and pseudohypoparathyroidism distinguished?
Pseudohypoparathyroidism is associated with evidence of chronic presentation:
- Intracranial Calcifications
- Cataracts
When should Sodium Bicarb be administered for pts with TCA intoxication?
If EKG shows wide QRS or Ventricular Arrhythmias
What is the treatment protocol for TCA intoxication?
Oxygen and Intubation
IV Fluids
Activated Charcoal (if no ileu and w/in 2hrs of ingestion)
Sodium bicarb (ventricular EKG abnormalities)
What should be given to a pt with TCA intoxication who presents with ventricular arrhythmia on EKG that is not improved with sodium bicarb?
Add Magnesium or Lidocaine
What are the 2 most common congenital heart defects in adults?
Bicuspid Aortic Valves (mid-systolic murmur, LLSB)
Atrial Septal Defects (mid-systolic murmur, LUSB +/- mid diastolic rumble)
What are the features associated with Atrial Septal Defect?
Wide-Fixed Split S2
NOMRAL Pulmonary Artery Pressures
Dilated Rt atrium and Rt Ventricle (L-> R shunt–>volume overload)
What are some characteristic features of Pick’s Dementia?
Irritable Mood/ Change in Behavior (Disinhibition)
Hyperorality
Impaired Executive Function(initiation, planning, goals)
Speech Abnormalities (echolalia, mutism, aphasia)
Symmetric Atrophy of Frontal and Temporal lobes
What are some typical features associated with Lewy Body Dementia?
Slow progressive Neurological decline
Persistent Visual Hallucinations
Varying cognitive function/ alertness
Parkinsonism motor deficits (rigidity, intention tremor)
Describe Pick bodies?
Sliver-staining cytoplasmic inclusions
What is the most common site of systemic Cryptocoocus infection?
CNS–> Encephalitis/Meningitis
What is the most common extraneural site for Cryptococcus infection to manifest?
Skin: Flesh to Red-colored papules w/ umbilicated center and hemorrhagic crust
Note: cutaneous lesions can be early sign of disseminated disease
What is the next step in management for a pt dx with cutaneous Cryptococcus?
CXR Blood cultures CSF cultures India Ink on CSF Serum and CSF Cryptococcoal Ag
How is the dx of Cutaneous Cryptococcosis confirmed?
Bx and histopathology of skin lesion (use PAS or Gomori methamine silver nitrate for histo)
What is the most likely dx in a neonate who presents with mild respiratory distress, pulmonary congestion w/o infiltrated on CXR, and born to a diabetic mother who had less than optimal glucose control during pregnancy?
CHF secondary to Hypertrophic Cardiomyopathy (d/t excess glycogen deposition in myocardium in response to increased insulin production in utero.)
Note: Interventricular Septum is most commonly affected
What are the characteristic features associated with Henoch-Schonlein Purpura?(10)
Palpable Purpura (legs buttocks) Arthritis/Arthralgias (late) Abdominal Pain/Intussusception GI bleed (edema/hemorrhage-->lead point) IgA Nephropathy (Hematuria +/- RBC casts/proteinuria) Normal/increased Creatinine NORMAL Platelets Normal Coags Elevated Inlammatory Markers (WBC, ESR) Sx onset- 5-10 dayf following URI
What is the most common cause of sudden, instantneous death d/t steering wheel injuries in MVA?
Aortic Rupture
What is the management protocol for a pt with sickle cell disease presetning with acute Vaso-occlusive Event?
IV Analgesia (Opiates) Hydration (1/4 or 1/2 Normal Saline)
Note: if outpt-give NSAIDS and Acetaminophen
When should Normal Saline be used to rehydrate a pt with Sickle cell disease with acute Vaso-occlusive Episode?
If pt. is Hypovolemic or Hypotensive
What should be included for long term management of a mp with sickle cell disease?
Vaccinations
Penicillin (until age 5)
Folic Acid Supplementation
Hydroxyurea (if multiple Vaso-occlusive episodes)
What are the diagnostic criteria for Acute Chest Syndrome?
Sickle Cell Disease pt w/
-New pulmonary infiltrate on CXR + 1 or more of
-Fever (>101.3F, 38.5C)
-Chest Pain
-Increased work of breathing, Wheezing, Cough,
Tachypnea
-Hypoxemia
What is the management for a pt with Acute Chest Syndrome in children?
Empiric Antibiotics:
-3rd Gen Ceph- Cefrtiaxone or Cefotaxime (S.pneumo)
-Macrolide-Azithromycin (Mycoplasma pneumoniae)
IV Hydration
Analgesics
What are the most common causes of Acute Chest Syndrome in children?
Infection
Asthma Exacerbation
Pulmonary Infarction
What are the most common causes of Acute Chest Syndrome in adults?
Bone Marrow or Fat Embolism
What clinical sign is pathognomonic for Rabies infection?
Hydrophobia
What dx should be suspected until proven otherwise in a presenting with unilateral headache, unilateral misosis and ptosis, but no anhidrosis (Partial Horner’s syndrome)?
Carotid Artery Dissection (note, sympathetic chain travels along carotid artery)
Note: if no Anhidrosis–> Internal Carotid Artery Invovled bc, sympathetic sweat fibers travel along External Carotid Artery.
What is the next step in management for a pt suspected of having a Carotid Artery Dissection?
CT Angiography of Head and Neck
Note: If CTA is negative but suspicion high–>MRA or Catheter Angiography (gold Standard)
What is the most common arrhythmia associated with Inferior Wall MI (leads II, III, AVF)
Sinus Bradycardia (d/t Rt Coronary artery thrombosis–> SA node (and inferior wall) ischemia)
What is the next step in management for a pt with recent Inferior Wall MI who develops symptomatic (dizziness, hypotension, confusion, syncope) bradycardia?
IV Atropine (to block vagal tone)
Can give IV fluids if Hypotension persists
Note: if asymptomatic–> No treatment, usually resolves spontaneously
What is the criteria for Arrest of first stage of Labor?
Cervical Dilation >/= 6cm, ruptured membranes, and
-No cervical change for >/=4 hrs w/ adequate
contractions
OR
-No cervical change for >/=6hrs w/ inadequate
contractions
What is the next step in management when a pt in labor is suspected of having arrest of labor and only an external monitor is placed?
Placement of Intrauterine Pressure Monitor (to assess adequacy of contraction strength and calculate Montevideo units)
At what lead level is chelation therapy indicated?
Venous Pb level >44mcg/dL
- Moderate: 44-69–>2,3 Dimercaptosuccinic acid
- Severe:>/= 70->Dimercaprol (BAL) + Ca Disodium edetate
What are two alternative medications used to treat chemo-associated nausea in pts for whom EPS effects of Metoclopromide (D2 receptor blocker) is a major concern?
Ondansetron (5HT3 antagonist)
Aprepitant (substance P antagonist; blocks NK1 Rec)
What are some risk factors associated with Carpel Tunnel Syndrome?(9)
Most Common:
- Diabetes
- Rheumatoid Arthritis
- Hypothyroidism
- Others:
- Wrist trauma
- Obesity
- Pregnancy
- Acromengaly
- Menopause
- End-Stage Renal Disease
What is the next step in management for a pt who has had unprotected sex within 5 days and has active STD but a negative urine/serum pregnancy test?
Offer Emergency Contraception:
-Ulipristal (anti-progestin - best oral emergency
contraceptive)
-Levonorgestrel
-Combined Oral Contraceptives
Note:
-Copper IUD cannot give to pt w/ active infection
Which type of emergency contraception is the most effective?
Copper IUD
- contraindicated in pts w/
- active gyn/pelvic infection
- undiagnosed vaginal bleeding
- Wilson’s Disease
What should be included in post-exposure prophylaxis for a sexual assault victim?
HIV: 3 drug Regimen (2NRTI + Protease Inhib)
HepatitisB: HepB (Hep B vaccine (unless vaccinated) +/- Immunoglobulin)
Gonorrhea: Ceftriaxone
Chlamydia: Azithromycin
Trichomonas Vaginalis:Metronidazole
Note: HIV and HEPB prophylaxis depend on risk factors
How so Juvenile Myoclonic Epilepsy and Childhood Absence Seizures differ?
Juvenile Myoclonic Epilepsy:
- Late onset Absence seizures w/ myocloic activity
- Life long Seizures
Childhood Absence Epilepsy:
- Early onset Absence Seizures (4-8yrs old)
- No myoclonic activity
- Starring spells usually resolve by adolescent years
What is the treatment of choice for severe Otitis Externa?
TOPICAL Ab’s (polymyxin B/Neomycin or Cipro) 7-10dys
What is the treatment for Mild and Moderate Otitis Externa?
Mild (minor pain, puritis, canal edema): Topical Acidifiers
Moderate/Severe
(pain pruritis, partial/complete canal occlusion d/t edema):
-Clean Ear w/ wire loop
-TOPICAL Ab’s
-Wick placement if canal completely occluded
Can add topical steroids for severe itching/pain with either severity.
What dx should be suspected in a pt with Celiac Disease who adheres to strict Gluten-free diet but presents with abdominal discomfort, weight loss, and Diarrhea?
Intestinal T Cell Lymphoma (pt. w/ Celiac are at increased risk)
- Jejunum commonly affected - Nodular or Ulcerative Tumors
Why is a neonatal TSH level not checked until at least 24 hrs post delivery?
Physiological surge in TSH immediately following delivery in baby
What is the next step in management for a neonate who has a low T4 and an elevated TSH from the heel pad sample?
Check Serum TSH and T4 from regular venous blood draw to confirm.
How long should a pt who develops a DVT d/t an associated cause but has no personal or family history or other risk factors for DVT be anticoagulated?
3-6 mos (surgery, pregnancy, trauma, OCP use)
Note: after 6 mos, risk significantly decreases
How long should a pt who develops idiopathic DVT be anticoagulated?
At least 6 mos w/ re-evaluation at end of 6mos course for further treatment according to risk factors
What is the next step in managament for a pt presenting with hyperpigmented skin, low LH, FSH, and Testosterone, elevated fasting and fingerstick glucose, liver dysfunction, and joint pain, stiffness involving the 2nd and 3rd metacarpophylangeal joints?
Serum Transferrin* and Ferritin (Fasting)
What are the classic features associated with Hemochromatosis?(5)
Central Hypogonadism Diabetes Skin Pigmentation Liver Dysfunction Arthropathy (Hook-like osteophytes on Xray)
What dx should be considered in an elderly pt who presents with recurring episodes of antibiotic sensitive pneumonia w/ a hx of smoking?
Bronchogenic Carcinoma resulting in Endobronchial Obstruction
What is the next step in management in a pt suspected of Endotrachial obstruction d/t mass?
CT Chest
What is best test to confirm a dx of Bronchogenic carcinoma in a pt with recurrent pneumonia and smoking history, raising suspicion for endotrachial obstructive mass?
Flexible Bronchoscopy
What should be included in the initial work up of a pt suspected of lead poisoning?
CBC
Reticulocyte Count
Serum Iron and Ferritin
Venous Lead level
Which antibiotics are commonly associated with adverse CNS events (ex, seizure)?(5)
Beta Lactams: -Penicillins -Cephalosporins -Monobactams -Carbapenems Fluoroquinolones
Who should be treated with antibiotics for Salmonella gastroenteritis?
Children
What is the most likely dx for a pt presenting with “swinging fever”, leukocytosis, abdominal discomfort/pain, and recent abdominal surgery?
Subphrenic Abscess (usually w/in 14-21 dys post op)
What is the best way to dx subphrenic (or any abdominal) abscess?
Abdominal Ultrasound
What are the medications of choice for treating a pt with Parkinson’s disease who develops psychotic symptoms?
Quetiapine
Clozapine (second choice d/t agranulocytosis and hematology f/u)
What is the likelihood of a pt who is High Risk for lung cancer (>/=30pack yrs and current smoker or smoker who quit /= 4mm) for screening actually having a malignant lesion?
With a positive Low-dose CT, the risk is
What acne treatments are acceptable to use in pregnancy and therefor do not require pregnancy test prior to prescribing?
Topical Erythromycin Topical Clindamycin (Inflammatory Acne) Azelaic Acid (Comedonal Acne)
What are the typical treatments for Comedonal Acne?
Salicylic Acid
Azelaic ACid
Glycolic Acid
Topical Retinoids
What is the treatment for Inflammatory Acne?
Mild: Topical Retinoids + Benzoyl Peroxide
Moderate: Mild Tx +Topical Antibiotics
Severe: Moderate Tx + Oral Antibiotics
What is the treatment for Nodular Cystic Acne?
Moderate:Topical Retinoids+ Peroxide+Topical Ab
Severe:Moderate +Oral Antibiotics
Unresponsive: Oral Isotretinoin
What features are associated with acute Opioid intoxication?
Miosis Decreased Mental Status Decreased Respiratory Rate/Shallow Breathing(crackles) Decreased Bowel Sounds Bradycardia Hypo/normothermia Respiratory Acidosis Hypoglycemia
Which pts are at increased risks of opiod intoxication with Morphine use?
Those with Liver disease or Renal Insufficiency/Failure
-Morphine metabolites M3glucuronide and
M6glucuronide are produced in liver and renal cleared.
M6glucuronide is more potent than Morphine so if not
cleared appropriately can lead to Opioid toxicity.
When should DVT prophylaxis begin in a pt with hip fracture?
On admission and stopped 12 hrs prior to surgery
What types of DVT prophylaxis should be used for pt with hip or any long bone fracture?
Low Molecular Weight Heparin
or
Low Dose Unfractionated Heparin
What is the underlying cause of the viral exanthem associated with infectious Mononucleosis?
Immune-complexes:
-circulating antibodies to penicillin derivatives (ex
ampicillin, amoxicillin)
What is the management for a pt dx with Thyroid cancer following surgical resection and Radioiodine ablation?
Levothyroxine hormone replacement
-Dose to maintain adequate TH levels and keep TSH low
What are the guidelines for Levothyroxine dosing s/p Thyroidectomy and ablation?
Initial 6-12 mos post:
-Enough Levo to maintain TSH 0.1-0.5uU/mL
Maintenance: Depends on Risk of Recurrence (TSH level)
Small tumor, Low Risk- TSH kept in Low Normal Range
Intermediate Risk- TSH kept at 0.1-0.5uU/mL
Large, High Risk- TSH kept
What are the typical features of Opioid withdrawal?
Lacrimation Yawning Mydriasis Abdominal Discomfort Nausea/Vomiting
