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1

Infant w/ several week h/o increasing dyspnea, cough, poor feeding. Nontoxic and afebrile. Conjunctivitis. Tachypnea and crackles. CXR: hyperinflation and diffuse interstitial infiltrates. Eosinophilia.

Chlamydia trachomatis

Seen in infants 3-16 weeks of age
Prominent cough
PE:
-diffuse crackles w/ few wheezes
-conjunctivitis in 50%
CXR
-hyperinflation and diffuse interstitial or patchy infiltrates

2

BPH w/ lower UT sx pharmacological options

-Alpha-adrenergic blocker
-5-alpha-reductase inhibitor (if evidence of prostatic enlargement or PSA > 1.5)
-PDE-5 inhibitor
-antimuscarinic therapy

First 3 proven as effective monotherapies

3

Mallet fracture management

Forced flexion injury of DIP resulting in small bone fragment @dorsal surface of proximal distal phalanx

Splint the DIP in extension

4

Presentation and management of necrotizing fasciitis

Presentation: severe pain and skin changes outside the realm of cellulitis, including bullae and deeper discoloration

Management: Immediate surgical consultation for operative debridement

5

Nursemaid’s elbow (radial subluxation) presentation and management

Most common ortho condition of elbow in kids 1-4

Arm slightly probated, flexed, and close to body. Tenderness near lateral elbow

Reduce the subluxed radial head (elbow at 90 degrees, hand fully supinated by examiner, elbow brought into full flexion)

6

Asthma step-up from short-acting bronchodilator

Inhaled medium-dose corticosteroids

7

Most appropriate first-line therapy for primary dysmenorrhea

NSAIDs
-started @onset of menses and continued for first 1-2 days of menstrual cycle

8

What to do in an outbreak of Influenza A (H1N1) in a long-term care facility

Chemoprophylaxis w/ appropriate meds for all residents who are asymptomatic, and treatment for all residents who are symptomatic. All staff should be considered for chemoprophylaxis

9

Neonate w/ flesh-colored papules on an erythematous base on face and trunk containing eosinophils

Dx? Management?

Erythema toxicum neonatorum

Usually resolves in first few weeks of life

10

SEs of inhaled corticosteroids for COPD

Increased risk of bruising, candidal infection of the oropharynx, and pneumonia.

Decrease risk of COPD exacerbations but have no mortality benefit and do not improve FEV1 consistently.

11

Polymyalgia rheumatica dx and tx

>50 y.o., bilateral shoulder pain and stiffness accompanied by upper arm tenderness, soreness about both shoulders, difficulty raising arms above shoulders. Accompanying systemic sx of fatigue, lo-grade fever, weight loss, decreased appetite, depression. Elevated CRP and ESR.

15mg prednisone

12

Tx of infected diabetic foot ulcer with systemic sx

IV Piperacillin/tazobactam (Zosyn) and vancomycin (Vancocin)

13

Drugs that cause SIADH

SSRIs (esp. in >65), chlorpropamide, barbiturates, carbamazepine, opioids, tolbutamide, vincristine, diuretics, NSAIDs

SIADH = euvolemic pt w/ hyponatremia, decreased serum osmolality, and elevated urine osmolality

14

Most common cause of unintentional deaths in children

Motor vehicle accidents (58.2% of childhood deaths)

Drowning: 10.9%
Poisoning: 7.7%
Fires: 5.7%
Falls: 1.4%

15

Treatment of acute mild/mod pericarditis

NSAIDs (glucocorticoids in severe or refractory cases)

Acute, sharp chest pain relieved only by leaning forward. Pericardial friction rub. Diffuse ST-elevations.

16

First-line tx for previously healthy infants and school-age children w/ mild/mod CAP

Amoxicillin

Most common pathogen: Streptococcus pneumoniae

(Azithromycin would be appropriate in an older child since Mycoplasma pneumoniae is more common)

17

Tx for non-obese children with obstructive sleep apnea

Adenotonsillectomy

18

Tx of anemia of CKD

Oral ferrous sulfate or erythropoieten

19

Signs and sx of hip labral tear

Dull or sharp groin pain which may radiate to lateral hip, anterior thigh, or buttock. Insidious onset or acutely after traumatic event. 50% have mechanical sx like catching or painful clicking w/ activity. FADIR and FABER tests good SN but low SP. MRA is diagnostic.

20

Which vaccine may cause febrile seizures up to 2 weeks after vax?

MMR (measles component)

Postimmunization seizures are more likely to occur in kids w/ past hx of seizures or 1st degree relative w/ epilepsy.

21

What is a pathogen more common in corticosteroid-dependent COPD pneumonia than in other patients?

Pseudomonas aureuginosa

22

Cow’s milk is not recommended for children until the age of?

12 months

Whole cow’s milk doesn’t supply kids with enough vitamin E, iron, and essential fatty acids. It also overburdens them with too much protein, sodium, and potassium. Also fails to provide adequate calories for growth. (Skim and low-fat do the same.)

23

Tx for acute flare-up of multiple sclerosis

Methylprednisolone (Medrol)

24

Tx serotonin syndrome

Discontinue offending agent, supportive care, IV benzodiazepine (lorazepam or diazepam). If no response, cyproheptadine

25

When to give antibiotics in asplenics?

Anytime there is a fever

26

JNC8 HTN

1. In >60, start drugs at >150 or >90 (treat to <150, <90)

2. In <60, start drugs at >90 (treat to <90)

3. In <60, start drugs >140 (treat to <140)

4. In >18 w/ CKD, start drugs at >140 or >90 (treat to <140 and <90)

5. In >18 w/ DM, start drugs at >140 or >90 (treat to >140 and >90)

6. In nonblacks (including w/ DM), initial drugs include THIAZIDE DIURETICS, CALCIUM CHANNEL BLOCKERS, ACE INHIBITORS, or ARBs.

7. In blacks (including w/ DM), begin w/ THIAZIDE DIURETIC or CCB

8. In >18 w/ CKD, initial (or add-on) drugs should include an ACE inhibitor or an ARB to improve kidney outcomes. [Regardless of race or DM]

9. If BP goal not met w/in 1mo of tx:
-increase dose of initial drug
OR
-add a second drug (thiazide, CCB, ACEi, or ARB)
If BP cannot be attained w/ 2 drugs, add and titrate a third drug
(Do not use ACEi and ARB in same pt)
If goal BP still cannot be reached OR if can’t use one of the drugs from 6 d/t contraindication, antihypertensive drugs from other classes may be used
Refer to HTN specialist

27

Lifestyle management in pre-diabetes and diabetes

Advise in pre-diabetes and new-onset diabetes

Diet and exercise

May include
-DM education
-frequent individual and group counseling from dieticians, behavior psychologists, exercise specialists
-caloric restriction
-regular exercise

Weight loss strategies
-weekly self-weighing
-regular breakfast consumption
-reduced intake of fast food

28

Non-insulin DM drugs and MoA

-Alpha glucosidase inhibitors: inhibit enzyme at intestinal brush border; slow absorption of carbohydrates

-Biguanides: decrease hepatic glucose production; increase insulin sensitivity peripherally; and decrease intestinal absorption of carbohydrates
[Metformin]

-DPP4 inhibitors: increase GLP-1; increase insulin secretion from beta-cells and decrease glucagon secretion from alpha-cells in pancreas
[Alogliptin, linagliptin, saxagliptin, sitagliptin]

-GLP-1 receptor agonists: increase insulin secretion from beta-cells and decrease glucagon secretion from alpha-cells in pancreas; suppress hepatic glucose production; delay gastric emptying
[Albiglutide, dulaglutide, exenatide, liraglutide]

-Meglinitides: close K+ channels in beta-cells; stimulate release of insulin from the pancreas

-SGLT2 inhibitors: lower renal threshold for cluse and reduce reabsorption of filtered glucose from tubular lumen; increase urinary glucose excretion

-Sulfonylureas: bind to K+ channels in beta-cells; stimulate release of insulin from the pancreas
[Glimepiride, glipizide, glyburide]

-Thiazolidinediones: increase hepatic glucose uptake; decrease hepatic glucose production; increase insulin sensitivity in the muscle and adipose tissue
[Pioglitazone, rosiglitazone]

29

Criteria for type 2 diabetes

A1c > 6.5
OR
Fasting plasma glucose >126
OR
Random plasma glucose >200 w/ sx of hyperglycemia
Two-hour plasma glucose >200 during an oral glucose tolerance test

30

Management approach to type 2 diabetes

Initial drug monotherapy: METFORMIN

If still not at target A1c [<7] after 3 months:
Two drug combinations w/ metformin (no particular order)
-SU, TZD, DPP4 inhibitor, GLP-1 receptor agonist, insulin (basal)

If still not at target A1c after 3 months:
Add a third drug not already part of the patient’s regiment
-SU, TZD, DPP4 inhibitor, GLP-1 receptor agonist, insulin (basal)

If still not at target:
-more complex insulin strategies