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1
Q

Most common cause of community-acquired bacterial meningitis?

A

S. pneumoniae

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2
Q

Typical pathologic cause of community-acquired bacterial meningitis?

A

Hematogenous dissemination; may occur +/- concurrent pneumococcal pneumonia

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3
Q

Rx community-acquired bacterial meningitis?

A

3rd generation cephalosporin (eg, ceftriaxone), vancomycin, and dexamethasone (decrease inflammatory morbidity) +/- ampicillin if >50 or immunocompromised

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4
Q

Presentation - AMS, fever, generalized muscle rigidity, autonomic instability (abnormal vitals, sweating)

A

Neuroleptic malignant syndrome

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5
Q

Rx NMS?

A

1 - Stop the causative medication (antipsychotics) or restart dopamine agents

Supportive care, ICU
Dantrolene or bromocriptine if refractory

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6
Q

Rx severe serotonin syndrome?

A

Cyproheptadine

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7
Q

Features of atypical depression?

A

Hypersomnia, hyperphagia, heavy feeling in limbs, hypersensitivity to rejection, mood reactivity (ability to respond to positive events)

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8
Q

Features of melancholic depression?

A

Weight loss
Insomnia
Pervasive anhedonia
Inability to respond to positive events

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9
Q

What 2 interventions together reduce perinatal HIV transmission to <1%?

A

Maternal combination antiretroviral therapy during pregnancy (initiate ASAP regardless of CD4 count or viral load) + neonatal zidovudine therapy

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10
Q

Antepartum HIV management?

A
  1. HIV RNA viral load at initial visit, every 2-4 weeks after change in therapy, monthly until undetectable, then every 3 months
  2. CD4 cell count Q3-6 months
  3. Resistance testing if not previously performed
  4. ART ASAP
  5. Avoid amniocentesis unless viral load if 1000 copies or less
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11
Q

Intrapartum HIV management?

A
  1. Avoid artificial ROM, fetal scalp electrode, operative vaginal delivery
  2. If load is 1000 or less: ART + vaginal delivery
  3. If load is >1000: ART + zidovudine + C/S
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12
Q

Postpartum HIV management?

A

Mother: continue ART
Infant + load 1000 or less: zidovudine for 6+ weks
Infant + load >1000: multi-drug ART

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13
Q

3 drug ART regiment during pregnancy?

A

2 NRTIs (zidovudine, tenofovir, etc.) + 1 NNRTI or 1 PI

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14
Q

DDx - dyspepsia

A 
NSAIDs
Gastric or esophageal cancer
Functional dyspepsia
GERD
Symptomatic infection with H. pylori
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15
Q

Who should get an endoscopy in the setting of dyspepsia?

A

> 55 or alarm symptoms (weight loss, bleeding, anemia, dysphagia, persistent vomiting, etc.)

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16
Q

How does hypomagnesemia cause hypocalcemia?

A

Induces resistance to PTH and decreases PTH secretion

Note that phosphorus levels are normal or low in Mg deficiency despite PTH deficiency, possibly due to intracellular phosphorus depletion

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17
Q

Serum calcium concentration falls by ___ mg/dL for every ___ gm/L decrease in albumin.

A

0.8; 1.0

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18
Q

How does hypophosphatemia cause hypocalcemia?

A

Trick question, it doesn’t.

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19
Q

3 common drug categories causing interstitial nephritis?

A

ABX (PCN, TMP-SMX, cephalosporins, rifampin, etc.)
NSAIDs
Diuretics

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20
Q

Manage acute interstitial nephritis?

A

D/C offending drug

+/- systemic glucocorticoids

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21
Q

Type of rash seen in disseminated gonococcemia?

A

Vesicopustular rash

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22
Q

Distinguish between Meniere disease, BPPV, and vestibular neuritis.

A

BPPV: BRIEF EPISODIC (<1 minute), caused by head movement, +Dix Hallpike

Meniere: RECURRENT EPISODIC (20 min-several hours) + hearing loss/tinnitus/ear fullness

Vestibular neuritis: ACUTE SINGLE EPISODE (days), after a viral syndrome, +head thrust test

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23
Q

Rx acute cholangitis?

A

ABX coverage of enteric bacteria (broad-spectrum)

Biliary drainage by ERCP within 24-48 hours

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24
Q

Findings of acute fatty liver of pregnancy?

A

3T -> RUQ pain, jaundice, elevated transaminases, thrombocytopenia (<100,000), profound hypoglycemia

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25
Presentation - acute chest pain, SOB, cough, subcutaneous emphysema, crunching sound over the heart (Hamman sign)
Spontaneous pneumomediastinum Risk factors - asthma or respiratory infection, tall thin, adolescent boys
26
Dx spontaneous pneumomediastinum?
CXR - confirm presence of mediastinal gas and r/o pneumothorax
27
___ classically occurs in exclusively breastfed infants without vitamin D supplementation.
Nutritional rickets
28
Findings of nutritional rickets in infants?
Craniotabes (skull bones that depress with pressure) Widened wrists (growth plate enlargement) Radial/ulnar bowing Delayed fontanel closure Lower extremity bowing only with weight-bearing
29
Autosomal recessive lysosomal storage disorder that presents with dysostosis multiplex, a range of skeletal findings including shortened and thickened long bones, coarse facial features, developmental delay, and frequent infections
Hurler syndrome
30
Rx epiglottitis
Endotracheal intubation | ABX: ceftriaxone (Hib and Strep) + vancomycin (S. aureus)
31
Empiric therapy for neonatal sepsis?
Ampicillin and Gentamin (covers GBS, E. coli)
32
Antimicrobial prophylaxis given to patients with CGD?
TMP-SMX | Itraconazole
33
Most common cause of otitis externa?
P. aeruginosa | Other - S. aureus
34
Rx otitis externa?
Topical ABX (eg, FQ) +/- topical glucocorticoid Consider wick placement to facilitate medication delivery
35
Secondhand smoke is associated with increased rates of what 3 diseases in chidlren?
Childhood middle ear disease Dental caries Lower respiratory tract infections
36
Maternal hyperglycemia increases the risk of what 4 fetal complications in the first trimester?
Congenital heart disease Neural tube defects Small L colon syndrome Sponatneous abortion
37
Maternal hyperglycemia increases the risk of fetal hyperglycemia and hyperinsulinemia, which increases risk of what complications in the second and third trimesters?
1. Polycythemia (increased metabolic demand, fetal hypoxemia, erythropoiesis) 2. Organomegaly 3. Neonatal hypoglycemia 4. Macrosomia -> shoulder dystocia -> brachial plexopathy, clavicle fracture, perinatal asphyxia
38
What causes Lyme disease and what part o the US is it endemic to?
Spirochete Borrelia burgorferi, transmitted via Ixodes scapularis tick Northeastern US
39
Rx Lyme disease if there are neuro/cardiac manifestations?
IV ABX (ceftriaxone, etc.)
40
Autoimmune disorder that may cause AV block, systemic symptoms, skin lesions (eg, Gottron papules, heliotrope eruption), and mylagias with significant symmetric proximal muscle weakness
Dermatomyositis
41
Most common cause of osteomyelitis?
Hematogenous spread of S. aureus
42
Initial evaluation of suspected osteomyelitis?
``` Labs (CBC, ESR, CRP) Blood Cx X-Rays MRI if X-ray normal Start empiric treatment based on these findings ```
43
Gold standard of definitive diagnosis of osteomyelitis?
Bone biopsy and/or culture
44
Common causes of neonatal osteomyelitis?
E. coli | GBS
45
Cause of osteomyelitis of the foot after a puncture wound of the plantar surface?
P. aeruginosa (also cause in IV drug use)
46
Initial management of large, progressively expansive, or symptomatic pleural effusions?
Diagnostic thoracentesis and fluid analysis
47
Presentation - erythema involving the central face, facial flushing, telangiectasis, burning discomfort, symptoms precipitated by hot drinks, alcohol, heat, emotion, etc.
Erythemato-telangiectatic rosacea
48
Two other presentations of rosacea?
Papulopustular: papules and pustules on central face Ocular: conjunctival hyperemia, lid margin telangiectasias
49
In addition to avoidance of triggers, sun protection, and gentle cleansers/emollients, what medications can be used for papulopustular and erythematotelangiectatic type rosacea, respectively?
Topical metronidazole Laser or topical brimonidine (vasoconstrictive alpha-2 agonist)
50
Distinguish rosacea from carcinoid syndrome.
Rosacea - flushing lasts must longer | Carcinoid - 20-30 seconds of flushing (+diarrhea, +hypotension and cyanosis if severe)
51
Define second stage arrest of labor.
Lack of fetal descent after 4+ hours of pushing in a primagravida with an epidural (3+ without), or 3+ hours in a multigravida with an epidural (2+ without)
52
Management of second-stage arrest?
Operative vaginal delivery (vacuum-assisted)
53
Ideal fetal head position for delivery?
Occiput anterior (flexed head presents a small diameter, facilitates cardinal movements of labor)
54
Because hepatitis C virus may spontaneously clear in up to half of affected patients, the diagnosis of chronic infection is a 2-step process requiring what tests?
Positive serologic Ab test | Confirmatory molecular test (HCV RNA)
55
Pathopysiologic mechanisms of NAFLD?
1. Increased transport of free fatty acids rom adipose tissue to the liver 2. Decreased oxidation of FFA in the liver 3. Decreased clearance of FFA from the liver 4. Peripheral insulin resistance -> increased peripheral lipolysis, triglyceride synthesis, hepatic uptake of fatty acids 5. FFA increase oxidative stress and production of pro-inflammatory cytokines
56
What two immunosuppressive medications have the same mechanism of action (calcineurin-inhibitors -> inhibits transcription of IL-2 and several other cytokines)?
Cyclosporine | Tacrolimus
57
AE of cyclosporine?
``` Nephrotoxicity* (most common) HTN (Rx with CCBs) Hyperkalemia Gum hypertrophy Hirsutism Tremor and other neurotoxicity Glucose intolerance Infection Increased risk of SqCC of skin, lymphoproliferative diseases GI manifestations ```
58
Tacrolimus has similar AE to cyclosporine - how does it differ?
Does not usually cause hirsutism or gum hypertrophy Higher incidence of neurotoxicity, diarrhea, glucose intolerance
59
MOA - azathioprine?
Purine analog that is enzymatically converted to 6-mercaptopurine and inhibits purine synthesis
60
AE azathioprine?
Dose-related diarrhea Leukopenia Hepatotoxicity
61
MOA - MMF
Reversible inhibitor of inosine monophophate dehydrogenase (RLS in de novo purine synthesis)
62
Major toxicity of mycophenolate?
Bone MARROW suppression
63
What is mupirocin?
Topical ABX used to treat superficial skin infections like impetigo, eradicate MRSA from nares
64
What is topical 5-fluorouracil used for?
Treatment of skin conditions caused by rapid cell division such as actinic keratoses and superficial basal cell carcinomas
65
List the 2 non-treponemal syphilis tests and the important features.
RPR VDRL - Quantitative (titers -> decreased titers confirms treatment) - May be negative if early (higher false-negative rates)
66
List the 2 treponemal syphilis tests and the important features.
FTA-ABS TP-EIA - Qualitative (reactive/non-reacive) - Greater sensitivity in early infection - Remain positive after treatment
67
What is a pathergy test useful for?
Diagnosing Behcet syndrome
68
What are the most appropriate diagnostic tests for acute Hepatitis B infection and why?
HBsAg (elevated first) and anti-HBc IgM Both elevated during initial infection, anti-HBc will remain elevated during the window period (lag between disappearance of HBsAg and appearance of anti-HBs)
69
Which hepatitis B serologic marker is a good indicator of infectivity?
HBeAg (but a poor test for acute infection)
70
What are the 3 goals of treating hyperkalemia?
1. Stabilize the cardiac membrane with calcium 2. Shift potassium intracellularly 3. Decrease the total body potassium contet
71
What is the fastest way to lower serum potassium concentration? Other options?
Insulin/glucose administration Beta-adrenergic agonists, sodium bicarbonate
72
ECG changes of hyperkalemia?
Tall peaked T waves* with shortened QT interval PR prolongation and QRS widening Disappearance of P wave Conduction blocks ectopy or sine wave pattern
73
How is cardiac membrane stabilized in hyperkalemia?
Calcium infusion (calcium chloride or gluconate, NOT calcium carbonate -> oral)
74
How is potassium removed from the body in hyperkalemia?
Diuretics (furosemide) Cation exchange resins (sodium polystyrene sulfonate) Hemodialysis
75
Presentation - bone pain and fractures, constitutional symptoms, recurrent infections
Multiple myeloma
76
Lab and radiologic findings in multiple myeloma?
``` Normocytic anemia Renal insufficiency Hypercalcemia (may lead to fatigue, constipation, depression) Monoclonal paraproteinemia (M-soke) Osteolytic lesions/osteopenia ```
77
Dx multiple myeloma
Serum/urine protein electrophoresis (M-spike) Peripheral blood smear (rouleaux) Serum free light chain analysis Confirm with BM biopsy
78
DDx for liver abscess?
``` Amebic abscess (E. histolytica, an intestinal protozoan) Pyogenic (bacterial abscess) Hydatid cyst (Echinococcus) ```
79
Expected findings in Echinococcus cysts?
NO fever Frequently asymptomatic Require contact with animals (dogs, sheep) +/- eosinophilia
80
Expected findings in bacterial liver abscess?
Fever, RUQ pain Older patients with underlying medical conditions (DM, hepatobiliary disease, etc.) Following peritonitis
81
Rx amebic liver abscess?
Metronidazole (>90% cure with oral therapy) Luminal agent (paromomycin, also required to eradicate colonization) DO NOT DRAIN unless mass effect, imminent rupture, dx uncertain
82
Rx Echinococcus liver cyst?
Aspiration of cyst + albendazole
83
Clostridium septicum bacteremia is strongly associated with underlying ___. What other cause of bacteremia has a similar link?
Colon cancer; Group D streptococci (S. bovis)
84
S. aureus and S. bovis bacteremia should prompt evaluation with ___.
TTE; organism often seeds native and damaged valves
85
Candidemia should prompt ___ evaluation.
Ophthalmologic
86
Common cause of heel pain in children who play running/jumping sport, presents with tenderness at the base of the heel?
Calcaneal apophysitis (aka Sever disease)
87
Histopathology - cells in rosette pattern (aka Call-Exner bodies)
Granulosa cell tumor
88
Lab findings in alcoholic hepatitis (AST, ALT, GGT, elevated ferritin)
Elevated AST>ALT (2:1) - total almost always <500 Elevated GGT Elevated ferritin
89
Presentation - chronic, crampy abdominal pain, bloating, and watery diarrhea after meals
Lactose intolerance
90
Insufficient bile salt absorption by the ___ can result in diarrhea in the immediate post-op period after cholecystectomy.
Terminal ileum
91
Use of PPIs has been associated with ___ infections.
C. difficile
92
What causes SIBO?
Bacteria from the colon inappropriately being present in the small intestine (usually associated with underlying motility disorders or anatomical abnormalities)

Dedicated - Step 2 (22 decks)

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