An HIV-positive patient presents with worsening dementia, fever, HA, and right hemiparesis. CT of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. What is the treatment of choice for this condition?
Sulfadiazine and pyrimethamine
Toxoplasmosis is commonly noted in HIV-positive patients and presents with multiple ring-enhancing lesions. Sulfadiazene is a sulfa Abx and pyrimethamine is an anti-parasite.
What is toxoplasmosis?
- Triad of: encephalitis + chorioretinitis + intracranial calcifications
in AIDS patients with CD4 < 100
- pregnant female with exposure to cat feces (reason we tell pregnant mothers not to change cat litter)
- Congenital toxoplasmosis is part of ToRCH syndrome (infection of developing fetus or newborn by any of a group of infections: (T)oxoplasmosis, (o)ther agents, (R)ubella, (C)MV, and (H)erpes Simplex
Diagnosis of Toxoplasmosis
CT of the brain shows ring-enhancing lesions
enzyme linked immunoassay (ELISA) positive for anti-toxoplasma IgG and IgM
A 52 yo female comes to the office because of black stools for the past 3 days. She is afebrile and has no pertinent PE abnormalities. What is the most appropriate initial diagnostic study?
stool for occult blood
(Melena suggests a source of bleeding proximal to the ligament of Treitz, not a lower GI bleed; sigmoidoscopy is used to evaluate only lower GI bleeds)
What is an example of pre-renal azotemia?
is the cause of prerenal azotemia which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored
azotemia (azo, "nitrogen" + -emia, "blood condition" ) is characterized by abnormally high levels of nitrogen-containing compounds (urea, creatinine, various body waste compounds)
a 65-year old patient with steroid-dependednt COPD presents with a HA that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever but has had photophobia and a stiff neck. What is the most likely diagnosis?
Cryptococcosis is an opportunistic fungal infection that affects immunocompromised patients, including those with HIV, chronic steroid use, organ transplants, diabetes mellitus, and chronic renal or liver disease. The most common clinical presentation is that of meningitis; fever is present in only about half of patients.
What is cryptococcosis?
caused by fungus cryptococcus neoformans, common in AIDS and immunocompromised patients. It is considered an AIDS defining illness. Budding yeast found in soil contaminated with pigeon/bird droppings.
transmitted through inhalation and causes illness in patients with cellular immune deficiency such as HIV, cancer, or long-term corticosteroid therapy
- meningocephalitis: most common cause of fungal meningitis (may present with AMS, HA, or meningismus)
- Pneumonia: cough with little sputum and pleuritic chestpain
Diagnosis of Cryptococcosis
Diagnose with CSF and serum serology
- India ink stain may be positive
- CSF shows pleocytosis (predominantly lymphocytes), increased opening pressure, INCREASED protein, and DECREASED glucose
- Computed tomography (CT) or MRI is indicated if cryptococcoma is suspected
Treatment of Cryptococcosis
Amphotericin B + Flucytosine for 2 weeks
followed by Fluconazole for 10 weeks
Prophylaxis if CD4 < 100 with Fluconazole
Axial T2-weight MRI shows clustered hyperintensities in the left caudate; these are consistent with enlarged Virchow-Robin spaces caused by small cryptococcomas
What is a common symptom associated with laryngotracheobronchitis (viral croup)?
viral croup is characterized by a history of upper respiratory tract sx followed by onset of a barking cough and stridor
A 23 yo female with a history of asthma for the past 5 years presents with complaints of increasing SOB x 2 days . Her asthma has been well controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler q4 - 6hrs. She is normally very active, however yesterday did not complete her 30 minute exercise routine due to increased dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. What initial diagnostic test is most appropriate prior to initiation of treatment?
A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.
a 3 yo boy is seen in the office with a 5-day history of fever, erythema, edema of hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is:
The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of the disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.
Kawaski Syndrome: fever > 5 days and 4 of the following
3. mucosal changes
4. edema of hands/feet
5. cervical adenopathy
How do you diagnose and manage Kawasaki Syndrome?
îESR/CRP, leukocytosis, reactive thrombocytosis (î platelets). Normochromic normocytic anemia. Sterile pyuria. Echo and angiography may be needed if heart involvement is suspected.
INTRAVENOUS IMMUNE GLOBULIN + HIGH-DOSE ASPIRIN
lowers fever, joint pain, & prevents coronary artery thrombosis/aneurysm
corticosteroids if refractory
What are the five axes of DSM-IV?
Axis 1: describes clinical disorders and "other conditions which may be a focus of clinical attention".
Axis 2: focuses on personality disorders and contains a rating scale for mental retardation.
Axis 3: labels any general medical conditions. (sometimes psychological problems can be the byproduct of an illness such as diabetes or heart disease)
Axis 4: specifies "psychosocial and environmental problems" such as poverty dysfunctional families, and other factors in the patient's environment that might have some impact on the person's ability to function
Axis 5: labeled the "Global Assessment of Functioning Scale". it is an overall rating of person's ability to cope with normal life. Rating goes from low scores such as 10 ("persistent danger of severely hurting self or others") to 100 ("superior functioning in a wide range of activities")
A 53 yo female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the LLL. a CXR is unremarkable and an EKH reveals sinus tach. What is the most likely diagnosis?
The patient's risk factors for pulmonary embolism include advanced age, surgery, and prolonged bed rest. While the dx of PE is difficulty to make due to nonspecific clinical findings, the most common Sx include pleuritic CP, dyspnea associated with tachypnea. CXR and EKG are usually normal.
Hint: small atelactasis is commonly asymptomatic while large atelactasis may produce signs of dyspnea and cough. Exam revelas absence of breath sounds in the area involved and dullness to perussion. A CXR would reveal various findings dependent on the location of the atelactasis, but would NOT be normal.
Clinical Manifestations of Pulmonary Embolism
Dyspnea MC symptom & Tachypnea MC sign***
classic triad, dyspnea + pleuritic chest pain + hemoptysis
post-op patient with sudden onset tachypnea, tachycardia + cough or hemoptysis
Factor V Leiden is the MC predisposing condition
Pulmonary Exam is usually normal; may have rales or pleural friction rub
+ Homan's sign (calf pain with dorsiflexion is a classic but nonspecific sign)
What is the best initial test for suspected PE?
Helical CT Scan (CT-PA)
PULMONARY ANGIOGRAPHY IS GOLD STANDARD DIAGNOSIS: ordered if HIGH SUSPICION & negative CT or VQ scans
V/Q Scan: low probability only rules out PE in patients with low clinical suspicion
Doppler US: 70% of patients with with PE will be + for lower extremity DVT. can miss pelvic DVTs. serial US may be performed to increase diagnostic specificity.
Ancillary Evaluation Tests for PE
1. CXR: most often normal. A normal CXR in the setting of hypoxia is highly suspicious for PE
classic (but rare) signs on CXR:
Westermark's Sign: avascular markings distal to the area of the embolus
Hamptons Hump: wedge-shaped infiltrate (represents infarction)
2. ECG: sinus tachycardia % nonspecific ST/T changes MC*
S1Q3T3 most specific for PE: wide deep S in lead I, isolated Q and T wave inversion in lead III
3. ABG: initially respiratory alkalosis (2ry to hyperventilation) ⇒ respiratory acidosis may occur with time. îA-a gradient
4. D-dimer: helpful ONLY if negative & low suspicion for PE (high sensitivity, poor specificity)
Management of Pulmonary Embolism
- Low Molecular Weight Heparin (LMWH) or Unfractionated Heparin (UFH)
need to monitor PTT with UFH but not needed with LMWH
Higher risk of Heparin Induced Thrombocytopenia (HIT) with UFH
- Warfarin (COUMADIN) for at least 3 months--should be overlapped with Heparing for at least 5 days AND INR 2.0 to 3.0 at least 24 hours
- Novel Anticoags--LMWH followed by Dabigatran (direct thrombin inhibitor) or Edoxaban (Factor Xa inhibitor) can be used instead of Warfarin and may be preferred
2. IVC FILTER: hemodynamically stable patients in whom anticoagulation is contraindicated or is unsuccessful*
3. THROMBOLYSIS OF CLOT: streptokinase, urokinase, alteplase
IND: massive PE, hemodynamically unstable PE. resolves emboli within 24 hours. usually preferred over embolectomy
CI: CVA or internal bleed w/i 2 months
4. THROMBECTOMY/EMBOLECTOMY: unstable/massive PE if thrombolysis is contraindicated or ineffective
Pulmonary Embolism Prophylaxis
the single most important step in managing PE. Prophylaxis is warrranted preoperatively in patients undergoing surgery with prolonged immobilization, pregnant women, history of prior DVT/PE.
Early Ambulation: low risk, minor procedures in patients < 40 yo
Elastic stockings/pneumatic compression devices/venodyne boots: moderate risk
Low Molecular Weight Heparin: patients undergoing orthopedic or neurosurgery, trauma
PERC Criteria for Pulmonary Embolism
(Pulmonary Embolism Rule Out Criteria)
If all the following is negative, you can effectively rule out PE if there is low suspicion for PE:
Age < 50 yo
Pulse < 100 bpm
O2 Sat > 95%
No prior PE
No recent trauma or surgery
No use of exogenous estrogen
No unilateral leg swelling
34 yo female with h/o asthma presents with complaints of increasing sthma attcks. patient states she has been well controlled on abuterol until one month ago. since that time she has had to use her inhaler 3 - 4 times a week and also has had increasing nighttime use averaging about 3 episodes in the past month. Spirometry reveals > 85% predicted.
What is the most appropriate intervention at this time?
the patient has progressed to mild persistent asthma. in addition to her beta-2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled Corticosteroids (ICS) such as beclamethasone are preferred for long-term control.
definition of intermittent, mild persistent, moderate persistent, and severe persistent asthma
In adults and IV drug abusers, which bone is most commonly affected with acute osteomyelitis?
bones of the vertebral spine are MC affected in a patient with osteomylitis. organisms reach the well-perfused vertebral body via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. the infection may originate in the urinary tract and IV drug use carries an increased risk of spinal infection
a 43 yo asymptomatic diabetic female is found to have an elevated total calcum level of 12.4 mg/dL. Which test must be assessed in order to evaluate this lab abnormality?
since approximately 50% of calcium is protein bound, total calcium levels should be interpreted relative to albumin levels
Which condition would cause a positive Kussmaul's sign on PE?
Kussmaul sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration. It can be seen in some forms of heart disease and is usually indicative of limited right ventricular filling due to right heart dysfunction.
frequent finding in patients with constrictive pericarditis or right ventricular infarction
What are the common clinical manifestations of constrictive pericarditis?
1. Dyspnea MC**
2. Right Sided HF signs: increased JVD, peripheral edema, hepatojugular reflex, N/V
Kussmaul's Sign: increased JVD with inspiration
3. pericardial knock: high pitched 3rd heart sound due to sudden cessation of ventricular filling in early diastole from thickened inelastic pericardium
60 yo pateint with presents with increased sputum production.
100 temp, RR 20, HR 88, pH 7.44, PaO2 75, PaCO2 40
PE remarkable for inreased AP diameter, diminished breath sounds without wheezes, rhonchi or other signs of respiratory distress
what would be an appropriate treatment for this patient?
broad spectrum antibiotic
sputum production is extremely variable from patient to patient but any increase in sputum with a h/o COPD reported by a patient must be regarded as potentially infectious and treated promptly
transudate vs exudate
transudate is fluid pushed through a capillary due to high pressure within the capillary.
exudate is fluid that leaks around the cells of the capillaries caused by inflammation
Which of the following conditions will produce a transudative pleural effusion?
a. Kaposi's sarcoma
b. bacterial pneumonia
the MC causes of transudative pleural effusions in the US are heart failure and cirrhosis
end-stage kidney disease
23 yo female with h/o palpitations presents for evaluation
admits to acute onset of rapid heart beating lasting seconds to minutes with associated SOB and CP
patient states she can relieve her symptoms with valsalva
What is the most appropriate diagnostic study?
useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardias (SVT)
The finding of egophony is most consistent with:
egophony occurs with consolidation caused by lobar pneumonia
A patient presents with edema, which is most noticeable in the hands and face.
Lab findings include proteinuria, hypoalbuminemia, and hyperlipidemia.
The most likely diagnosis is:
Proteinuria, hyperlipidemia, and hypoalbuminemia are consistent with nephrotic syndrome
Which of the following can be used to treat chronic bacteiral prostatitis?
b. cephalexin (KEFLEX)
c. Nitrofurantoin (MACROBID)
d. Levofloxacin (LEVOQUIN)
chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of fluoroquinolones or trimethoprim-sulfamethoxazole, both of which penetrate the prostate.
25 yo male presents with h/o syncope
patient admits to intermittent episodes of rapid heart beating that resolves spontaneously.
Lead EKG shows delta waves and short PR interval
Which of the following is the treatment of choice for this patient?
a. radiofrequency catheter ablation
b. verapamil (CALAN)
c. Percutaneous coronary intervention
d. Digoxin (LANOXIN)
radiofrequency catheter ablation
TOC on patients with accessory pathways, such as WPW
What are the types of endocarditis and what are the MC organisms associated with each?
acute bacterial endocarditis: S. aureus
subacute bacterial endocarditis: S. viridans
Endocarditis in IV drug userse: MRSA
prosthetic valve endocarditis: staphylococcus epidermis
What is the MC valve associated with acute bacterial endocarditis (NO IV DRUG USE)?
What is the MC valve associated with endocarditis in IV drug users?
What are clinical manifestations of infective endocarditis?
1. **fever**, ECG conduction abnormalities
2. Peripheral Manifestations:
Janeway Lesions: painless erythematous macules on palms & soles (emboli/immune)
Roth Spots: retinal hemorrhages with pale centers, petechiae (conjunctiva, palate)
Osler's Nodes: tender nodules on the pads of the digits
splinter hemorrages of proximal nail bed, clubbing, hepatosplenomegaly.
What is the "Modified Duke Criteria" for Infective Endocarditis?
need 2 MAJOR
1 MAJOR + 3 MINOR
Sustained Bacteremia-- 2 + blood cultures by organism known to endocarditis
endocardial involvement-- documented by either a + ECHO (vegetation, abscess, valve perforation, prosthetic dehiscence) or clearly established new valvular regurgitation (aortic or mitral regurg)
Predisposing condition: abnormal valves, IVDA, indwelling catheters
Vascular and embolic phenomena: Janeway lesions, septic arterial or pulmonary emboli, ICH
Immunologic phenomena: Osler's nodes, Roth Spots, + RF, acute glomerulonephritis
+ blood culture not meeting major criteria
+ ECHO not meeting major criteria (ex: worsening of existing murmur)
Treatment for the different types of infective endocarditis
acute (native valve): nafcillin + gentamicin x 4 - 6 weeks OR
vancomycin (if suspected MRSA) + gentamicin
subacute (native valve): penicillin or ampicillin + gentamicin
vancomycin in IVDA
prosthetic valve: vancomycin + gentamicin + rifampin (for staph aureus)
fungal: amphotericin B (treat 6 - 8 weeks)
patients often need surgical intervention for fungal cases
(penicillin and vancomycin have great gram + coverage. Gentamicin has great gram - coverage)
Prophylactic regimen for circumstances that put patients at high risk for infective endocarditis:
(such as prosthetic heart valves, congenital heart disease, dental procedures, respiratory procedures, and procedures involving infected skin/MSK tissue)
amoxicillin 2g 30 - 60 minutes prior to procedure
(clindamycin 600 mg if PCN allergic)
Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the common bile duct OR:
a. cystic duct
b. pancreatic duct
c. duodenal ampulla
d. common hepatic duct
obstruction of the cystic duct by gallstones causes the typical symptoms of biliary colic. once obstructed the gallbladder distends and becomes edematous and inflamed. gallstones can also migrate into the common duct through the cystic duct leading to a condition known as choledocholithiasis
An elderly patient with poorly-controlled Type 2 DM and renal disease develops a fever of 102 orally, productive cough, and dyspnea.
RR 32, labored breathing, and rales at the left base. 90% sats.
Which of the following is the net appropriate step in the management of this patient?
a. administer nebulized corticosteroids
b. admit to the hospital
c. oral antimicrobial therapy
d. endotracheal intubation
admit to hospital
CAP is the most deadly infectious disease in the US. Important risk factors for increased morbidity and mortality: advanced age, alcoholism, comorbid medical conditions, AMS, RR > 30, hypotension, and a
BUN > 30
An 80 yo female presents with pain in her vertebral column. Radiography reveals compression fracture of T12 that is consistent with osteoporotic compression fracture. Which of the following treatment modalities has the potential to cause analgesia of the fracture site with its use:
a. calcitonin nasal spray
d. combined estrogen and progesterone (Prempro) therapy
Alendronate is a bisphosphonate that inhibits bone resorption and is effective in building new bone for a pt with osteoporosis but NO ANALGESIA
raloxifene is a selective estrogen receptor modulator and has positive effects on bone density when used to treat osteoporosis but NO ANALGESIA
combined hormonal therapy may have positive effects on bone density but NO ANALGESIA
A patient with severe COPD presents to the ED with 3-day history of increasing SOB with exertion and cough productive of purulent sputum.
ABG reveals pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen 2L/min and an IV is started.
After 1 hour of treatment, his ABG reads pH 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg.
Which of the following is the most appropriate step in his treatment?
a. decrease O2 flow rate
b. administer oral corticosteroids
c. intubate the patient
d. administer salmeterol
intubate the patient
this person has increasing respiratory failure as indicated by the raising PaCO2 levels. intubation is required at this time.
admininstration of steroids is an important treatment modality but this patient is in respiratory failure and needs more immediate therapy
LABA therapy such as salmeterol is not utilized for rescue therapy
To further assess ascites in a patient, the PA instructs the patient to turn onto one side while performing percussion. Which of the following is the reason for this maneuver?
a. testing for shifting of dullness on percussion
b. shifting of internal organs making percussions easier
c. trying to elicit any pain while moving
d. trying to produce a caput medusa
testing for shifting of dullness on percussion
in ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while tympany shifts to the top as the gas-filled organs float to the top of ascitic fluid
a 25 yo female presents for the 8th time in 3 weeks to be sure she doesn't have meningitis. she read that there was a student on campus who had meningitis last month, and now she has headaches and is requesting to be tested to make sure she does not have meningitis. PE all normal.
What is the most likely diagnosis?
a. conversion disorder
d. somatization disorder
hypochondriasis is the chronic preoccupation with the idea of having serious disease, which is usually not amenable to reassurance
conversion disorder: onset of Sx or deficits mimicking neurologic or medical illness, but the etiology is psychological.
somatization disorder: complaints of pain, often related to GI and sexual dysfunction, and pseudoneurological symptoms
Diagnostic studies and treatment for ITP (idiopathic thrombocytopenic purpura)
autoimmune antibody reaction to platelets which results in splenic platelet destruction often after an acute infection
easy bruising and gingival bleeding
petechiae throughout chest, arms and legs
platelet count of 24,000
isolated thrombocytopenia (<100,000/uL) and otherwise normal CBC and peripheral blood smear
+ Direct Coombs Test
Treatment (observation unless < 30,000 or bleeding)
Corticosteroids initial treatment
IVIG for those with contraindications to corticosteroids
splenectomy for patients with refractory ITP
29 yo patient with idiopathic thrombocytopenia purpura (ITP) is treated with prednisone therapy. Despite therapy, platelet counts remain consistently below 20,000 over the course of 6 weeks. Which of the following is the most appropriate intervention for this patient?
Persistently low platelent counts (< 20,000) require effective long-term treatment, and splenectomy is the TOC
IVIG can be utilized for short-term treatment, but the platelet count is likely to return to baseline within a month
Which of the following clinical findings would be seen in a patient with food poisoning caused by Staphylococcus Aureus?
a. ingestion of mayonnaise-based salads 48 hours earlier
b. bloody diarrhea with mucus x 1 wk
c. abdominal cramps and vomiting x 48 hours
d. high fever x 1 wk
abdominal cramps and vomiting x 48 hours
abdominal cramps, N/V, and watery diarrhea typically last 1 - 2 days with staphylococcal food poisoning
a preformed toxin causes staphylococcal food poisoning and it has a short incubation period of 1 - 8 hours
staphylococcal food poisoning may be associated with low-grade fever or subnormal temperature
Which of the following diagnostic tests should be ordered initially to evaluate for suspected DVT of the leg?
c. duplex ultrasound
d. impedance plethysmography
Ultrasound is the technique of choice to detect DVT in the leg
a 26 yo man is stung by a bee, and shortly therafter, a wheal develops at the site of the sting. he soon feels flushed and develops hives, rhinorrhea, and tightness in his chest. He is seen in the urgent care center. Immediate therapy should be to:
administer intramuscular epinephrine
epinephrine HCl 1:1000 0.2 to 0.5 mL IM is indicated for intiial treatment of this systemic reaction. Additional injections may be given q 20 - 30 minutes
What is the first line treatment for symptomatic bradyarrhythmias due to sick sinus syndrome?
Which of the following views on plain films is preferred to identify spondylolysis?
the defect in the pars articularis (usually bilateral) is best visualized on oblique projections of plain films
a 15 yo softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray shows no associated avulsion fracture. What is the treatment of choice
continuous extension of the DIP via splinting for 6 to 8 weeks
TOC for a tear in the extensor tendon of the finger
57 yo male was working on a farm when some manure was slung hitting him in the L eye. He presents several days after with a red, tearing, painful eye. Fluorescein stain reveals uptake over the cornea looking like a shallow crater
which of the following interventions would be HARMFUL
opthalmic antibiotics, pressure patch, examination for visual acutiy, copious irrigation
pressure patch: patching the eye after an abrasion is associated with organic material contamination and is contraindicated due to increased risk of fungal infection
(opthalmic antibiotics and copious irrigation are indicated when treating a patient with a suspected corneal ulcer due to an infectious cause)
75 yo female falls on outstretched arm and sustains a humeral mid-shaft fracture. nerve impingement occurs due to the fracture, What is the most likely PE abnormality that will be encountered?
inability to extend the wrist against resistance
radial nerve is most likely entrapped by this fracture
wristdrop in radial nerve injury
axillary nerve injury results in numbness over the deltoid muscle, this nerve is more commonly injure in proximal humeral fractures and anterior shoulder dislocations
Which of the following PE findings would be conistent with a pleural effusion?
hyperresonance to percussion, increased tactile fremitus, unilateral lag on chest expansion, egophony
unilateral lag on chest expansion
hyperresonance to percussion suggestive of emphysema or pneumothorax
increased tactile fremitus and presence of egophony consistent with a consolidation
Bipolar patient in a manic episode. What is the most appropriate treatment?
inpatient olanzapine therapy
treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.).
Lithium, valproate, and olanzapine are considered effective in the manic stage; the depressive stage is treated with antidepressants
Clinical Manifestations of Alcohol Withdrawal
1. uncomplicated alcohol withdrawal: 6 - 24 hours after last drink, increased CNS activity: tremors, diaphoresis, insomnia, GI (N/V/D). uncomplicated = no seizures, hallucinosis or delirium tremens
2. withdrawal seizures: 6 - 48 hours after last drink
usually generalized clonic-tonic type
3. Alcoholic Hallucinosis: 12 - 48 hours after last drink
visual, auditory and/or tactile hallucinations. patient has a clear sensorium & normal vital signs
4. Delirium Tremens: 2 - 5 days after last drink
Delirium (altered sensorium), hallucinations, agitation
altered vital signs (tachy, HTN, fever), often diaphoretic
Management of Alcohol Withdrawal
1. IV BZDS: Diazepam (VALIUM), Chlordiazepoxide (librium), Oxazepam
2. IV fluids & supplementation: IV Thiamine & Magnesium (prior to glucose administration), multivitamins (including B12/folate), IV fluids + dextrose (intoxication may cause hypoglycemia)
3. avoidance of medications that can lower seizure threshold if possible (ex: Bupropion, Haloperidol, anticonvulsants, clonidine, BB)
Clinical Manifestations of Opioid Intoxication AND withdrawal
OPIOID INTOXICATION: euphoria and sedation (drowsiness, slow/slurred speech, impaired memory)
PE: pinpoint pupils (narcotics are miotics), respiratory depression, may also develop biot's breathing (quick, shallow inspirations followed by irregular periods of apnea), bradycardia, hypotension
OPIOID WITHDRAWAL: lacrimation, HTN, pruritus, tachycardia, N/V/D, piloerections (goosebumps), pupil dilation (mydriasis), flu-like Sx: rhinorrhea
Management of Opioid Intoxication
Acute intoxication: Naloxone (NARCAN) onset of action is ~ 2 minutes IV (~5 minutes IM); 30 - 60 minutes duration of action
MC used in patients with respiratory depression
Management of Opioid Withdrawal
symptomatic control: clonidine (decreases sympathetic symptoms), loperamide for diarrhea, NSAIDs for joint pains and muscle cramps, Buprenorphine + Naloxone
How to manage cocaine intoxication
Signs of cocaine intoxication
SYMPATHETIC STIMULATION: sweating, tachycardia, pupillary dilation, HTN
Early clues to impending delirium tremens include:
agitation and decreased cognition
mental confusion, tremory, sensory hyperacuity, visual hallucinations, autonomic hyperactivity, diaphoresis, dehydration, electrolyte disturbances, seizures, and CVD abnormalities are common signs and/or symptoms of FULL-BLOWN DELIRIUM TREMENS
A woman admits that her husband has abused her for over ten years. You should inform the woman that she is at most risk for injury or death....
just after leaving an abusive spouse
75% of domestic assaults/murders occur after separation
patient presents with an acutely painful and cold L leg. Distal pulses are absent. Leg is cyanotic. No signs of gangrene or other open lesions. Symptoms occurred one hour ago.
What is the most appropriate treatment?
Embolectomy within 4 - 6 hours is the TOC
male pt seen in the ED following MVC in which his knee hit the dashboard. pt has posterior knee dislocation that is reduced in the ED. The patient currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory?
the popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pulses
70 yo presents with HA and neck stiffness. On PE, patient is febrile, Kernig's sign is present, and no rash is noted. A spinal tap reveals a white count of 250/cm3 with 100% neutrophils, total protein 250 mg/dL and glucose 35 mg/dL. What is the most appropriate treatment?
ampicillin and ceftriaxone (ROCEPHIN)
ampicillin and ceftriaxone is used to treat bacterial meningitis, secondary to Listeria monocytogenes, which is commonly in the elderly.
Ceftriaxone will cover other common etiologic agents such as Streptococcal pneumonia.
74 yo female is being treated for mild HTN. She is found at home with R hemiparesis and brought to the ED.
Her daughter states the patient fell in her kitchen 2 days ago, but had no complains at the time. She did state her mother sounded a little confused this morning. The patient's left pupil is dilated. Which of the following diagnostic studies should be ordered first?
CT scan of the brain
the patient presents with a h/o minor trauma and progressive neurological abnormalities consistent with subdural hematoma
Diagnosis is confirmed with CT scan, which is less expensive and more sensitive for blood than MRI
Seizures that first manifest in early to middle adult life should be considered suspicious of which of the following causes?
seizures that develop during adolescence and adult life are predominantly due to
62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise unremarkable. Which of the following is the most likely diagnosis?
Courvoisier's law (or Courvoisier syndrome, or Courvoisier's sign or Courvoisier-Terrier's sign) states that in the presence of a palpably enlarged gallbladder which is nontender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones.
Which of the following is most common cause for acute MI
thrombus development at a site of vascular injury
acute MI occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when atherosclerotic plaque fissures, ruptures or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion
What rotator cuff tendon is most likely to sustain injury because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the acromion and coracoacromial ligament?
it is susceptible to injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is MC seen with the supraspinatus tendon, the long head of the biceps tendon and.or the subacromial bursa.
13 yo boy with leukemia presents with epistaxis for 2 hours. the bleeding site appears to be from Kiesselbach's area. The most appropriate intervention is:
intranasal petrolatum gauze
this will provide pressure to the bleeding point while the cause of bleeding is corrected
posterior nasal packing is indicated for posterior bleeds in the inferior meatus
silver nitrate is NOT USED IN KIDS because it increases the risk for nasal septal perforation
What is the most common cause of arterial embolization?
25 yo man presents with odynophagia and dysphagia. On endoscopin examination, small, white patches with surrounding erythema are noted. Silver stain is positive for hyphae. The best treatment option for this patient is:
The patient has Candida esophagitis and the treatment of choice is fluconazole
75 yo woman presents with complaint of vision loss. exam reveals a palpable cord in the temporal region. What is the most helpful initial test to order on this patient?
the patient is suspected of having temporal arteritis. This disease is MC noted in patients over age 50 and should be suspected in patients with sudden vision loss and a palpable cord in the temporal region. ESR is almost always increased in this disease
68 yo male with h/o afib treated with warfarin (coumadin) presents to the ED after vomiting large amounts of bright red blood. INR is 3. What is the most appropriate way to rapidly lower his INR?
administer Fresh Frozen Plasma
85 yo nursing home resident presents with abrupt onset of cough, sore throat, HA, myalgias, and malaise. On examination the patient's temperature is 102 degrees F, the rest of the exam is unremarkable. Nasal smear is positive for influenza B. Which of the following is the treatment of choice in this patient?
used to treat both influenza A and B
patient with a dirty laceration from a chicken coop is unsure of his immunization status. Besides cleaning and debriding the wound, what is the recommended clinical intervention with this patient?
Td or Tdap with TIG
is the recommended prophylaxis in a patient with a contaminated wound and unknown tetanus vaccination status
20 yo male presents with complain of brief episodes of rapid heart beat with a sudden onset and offset that have increased in frequency. he admits to associated SOB and lightheadedness. Denies Syncope.
ECG reveals delta waves prominent in lead II. Which of the following is the most appropriate long-term management in this patient?
is the procedure of choice for long-term management in patients with accessory pathways (WPW) and recurrent symptoms
26 yo woman requests screening after her bf was treated for STI. On examination you find a painless vulvar ulcer. What is the most likely diagnosis?
the primary lesion of syphillis presents as a painless ulcer or chancre. Secondary syphillis presents with a skin rash, lymphadenopathy and mucocutaneous lesions.
57 yo male recently on a high protein diet presents with an exquisitely tender, erythematous, warm right great toe. which of the following is the treatment of choice for this patient?
NSAIDs are the TOC for acute gouty attacks
corticosteroids are used in acute gouty attacks but are reserved for people with NSAID CI or allergy
allopurinol is useful in reducing uric acid levels but is not the TOC in acute gouty attacks
colchicine is not recommended for acute gouty attacks
60 yo female recently discharged after an 8 day hospital stay for PNA presents complaining of pain and redness in her R arm where the IV had been placed. Patient denies fever or chills. Exam reveals localized induration, erythema and tenderness. There is no edema or streaking noted. What is the most likely diagnosis and how is it diagnosed and treated?
short-term venous catheterization of a superficial arm vein is commonly the cause of thrombophlebitis
venous duplex ultrasound is the GOLD STANDARD for Dx
treat thrombophlebitis (phlebitis + thrombosis) with heparin x 1 month
(treat phlebitis with elevation, warm or cool compresses, and NSAIDs)
16 yo nulliparous acutely ill female presents with bilateral lower abdominal pain. She has a temperature of 100.4 degrees F and on examination has a tender, enlarged left adnexa. Cervical culture is positive for chlamydia. US reveals a complex tubular structure in the left adnexal area. What is the recommended treatment?
hospitalization with parenteral doxycycline and cefoxitin
patient has pelvic inflammatory disease and most likely tubo-ovarian abscess. It is recommended that the patient be hospitalized and treated with high dose IV antibiotic therapy. For patients with tubo-ovarian abscesses, surgical drainage is often necessary
2 yo presents with sudden onset of cough and stridor. on examination the child is afebrile and appears nontoxic with a RR of 42. What is the next step in the evaluation of this patient?
should be done FIRST when foreign body aspiration is suspected
29 yo female with a history of IV drug abuse presents with ongoing fevers for three weeks. She complains of fatigue, worsening DOE and arthralgias. PE reveals BP of 130/60, HR 90, RR 18, unlabored. Petechiae are noted beneath her fingernails. Fundoscopic exam reveals exudative lesions in the retina. Heart examination shows RRR, with no S3 or S4.
Lungs are CTAB and extremities without edema.
What is the best diagnostic study of choice for this patient?
transesophageal echocardiogram (TEE)
patient's signs and symptoms are consistent with infective endocarditis.
splinter hemorrhages in fingernal beds
osler nodes--painful lesions of fleshy portions of hands
roth spots = retinal hemorrhages
janeway lesions = non-tender, cutaneous evidence of septic emboli
palatal or conjunctival petechiae
Duke Criteria: 2 MAJOR, 1 MAJOR + 3 minor, 5 minor
MAJOR: 2 separate positive blood cultures, single positive culture for C. burnetii or antihase 1 IgG Ab titer
positive ECHO--presence of vegetation
new valvular regurgitation
minor: predisposing heart condition or IV drug use
vascular phenomena (arterial emboli, septic pulmonary infarcts, conjunctival hemorrhage, janeway lesions)
immunologic phenomena (glomerulonephritis, osler nodes, roth spots, RF)
18 yo female with DM presents to ED with altered level of consciousness, deep breathing and fruity odor to her breath. Which of the following medications is indicated for this patient?
has a rapid onset of action when given IV and is the initial choice in patients with DKA. following the initial dose, a continuous infusion promotes a steady, slow fall of glucose levels to normal, which can then be stabilized by decreasing the insulin
administer IV fluids fast
administer insulin IV slow
measure serum K+
Bony and cartilaginous enlargement of distal interphalangeal joints is commonly seen in which of the following medical conditions?
Herberden's nodes are commonly seen in primary osteoarthritis
68 yo male presents with jaundice, weight loss, and boring abdominal pain which radiates to the back. the gallbladder is palpable on PE. This is most consisten with what?
a large palpable gallbladder resulting from pressure from a tumor in the pancreatic head is known as Courvoisier's sign
49 yo female presents complaining of several episodes of CP recently. Initial ECG in ED shows no acute changes. 2 hours later, while the patient was having pain, repeat ECG showed ST segment elevations in leads II, III, and AVF. Cardiac catheterization shows no significant obstruction of the coronary arteries. Which of the following is the treatment of choice for this patient?
Nifedipine (PROCARDIA) CCB
the patient is most likely having a coronary artery vasospasm. This can be treated prophylactically with CCBs such as nifedipine.
and nitrates as needed
What is the most common etiology for spontaneous abortions (termination of pregnancy before 20 weeks)?
fetal chromosomal abnormalities
What are the clinical manifestations of a threatened abortion and how do you manage it?
MC cause of 1st trimester bleeding
bloody vaginal discharge, + contractions of uterus, uterus size is compatible with dates
supportive: rest @ home, return to ER if symptoms persist or passage of POC (products of conception), serial B-hCG to see if doubling
RhoGAM if indicated
What are the key features of an inevitable abortion and how is it managed
progressive cervix dilation > 3cm, effaced
+ rupture of membranes
No POC (products of conception) expelled
moderate bleeding > 7 days
Dilation and Evacuation (D&E) 2nd trimester
suction curettage in 1st trimester
What are the key features of an incomplete abortion and how is it managed?
Some POC expelled, some contained
heavy bleeding, retained tissue, BOGGY UTERUS
may be allowed to finish
D&E after 1st (D&C in 1st)
RhoGAM if indicated
What is the synthetic version of oxytocin that can be given to woman with incomplete abortions that will cause the uterus to contract and expel the rest of the POC?
Management of a missed abortion
D&E (D&C in 1st)
misoprostol (synthetic prostaglandin E1 analog that replaces protective prostaglandins with prostaglandin-inhibiting therapies, been shown to induce uterine contractions
25 yo female, G2P1001 presents to your office at 11 weeks gestation with vaginal bleeding, mild lower abdominal cramping, and bilateral pelvic discomfort. On examination, blood is noted at the DILATED cervical os. No tissue is protruding from the cervical os. The uterus by palpation is 8 - 9 weeks gestation. No other abnormalities are found. What is the most likely diagnosis?
the gross rupture of membranes in the presence of cervical dilation
50 yo male with h/o alcohol abuse presents with complain of worsening dyspnea. PE reveals bibasilar rales, elevated JVP, an S3 and lower extremity edema. CXR revelas pulmonary congestion and cardiomegaly. ECG shows frequent ventricular ectopy. ECHO shows LV dilation and EF 30%. What is the most likely diagnosis?
a. hypertrophic cardiomyopathy
b. dilated cardiomyopathy
c. restrictive cardiomyopathy
d. tako-tsubo cardiomyopathy
often caused by chronic alcohol use. it is characterized by signs and symptoms of left-sided HF, a dilated LV and decreased EF
What gram-negative bacteria has been linked to subsequent Guillain-Barré Syndrome?
pathophys: immune-mediated demyelination & axonal degeneration slows nerve impulses --> symmetric weakness & parasthesias. post-infection immune response cross-reacts with peripheral nerve components (molecular mimicry)
Hallmarks of Guillain-Barré Syndrome
ASCENDING weakness and parasthesias (usually symmetric). decreased DTRs (LMN lesion)
Autonomic Dysfunction: tachycardia, hypotension, breathing difficulties
CSF: high protein with a normal WBC
How to Manage Guillain-Barré Syndrome
1. Plasmapheresis: best done if early (removes harmful circulating auto-antibodies that cause demyelination)
2. IVIG: suppresses harmful inflammation/antibodies and induces remyelination. most recover within months
prednisone is CI in GBS because they may reduce scavengers that play a crucial role for nerve regeneration
prognosis: 60% recover within the 1st year
Which of the following Rh genotypes in a mother and father would represent a risk for hemolytic disease of the newborn
mother Rh-negative and father Rh-positive
if an Rh-negative woman carries an Rh-positive fetus, she may develop antibodies against Rh when fetal blood cells enter her circulation
Low Molecular Weight Heparin (LMWH) dosage is based on which of the following:
LMWH is based on a patient's weight in kilograms.
INR is used to monitor anticoagulant medications
PT is used to monitor warfarin efficacy
PTT is used to monitor heparin use but not to determine the dosage
What's the most common cause of ascites?
over 80% of patients with ascites have portal HTN secondary to chronic liver disease. Infection, malignancy, and nephrotic syndrome are common causes of non-portal hypertensive ascites.
55 yo male with h/o HTN and DM, presents to ED and wife states the patient developed progressive irritability and confusion today after complaining of a HA. PE revelas BP of 230/130 and papilledma. What is the most accurate diagnosis?
is significantly elevated BP with progressive retinopathy, including papilledema, encephalopathy, and headache
74 yo male with h/o CAD and afib presents to clinic for f/u of SOB. Patient's medications include amiodarone (CORDARONE) and metoprolol (LOPRESSOR). His CXR reveals patchy ground-glass infiltrates. What is the most likely diagnosis?
presents with ground-glass infiltrates on CXR and is often associated with certain medication use
Household contacts of a patient with bacterial meningitis are best treated with what?
Rifampin, Cipro, Levaquin, Zithromax, and Rocephin are the drugs of choice
Croup is most often caused by what virus?
What behavior is typical for a patient with schizoid personality disorder?
chooses solitary activities
persons with schizoid personalities are very withdrawn and do not seek or enjoy relationships and are indifferent to praise or criticism. They generally appear cold and unfeeling to others
62 yo female presents to ER with significant back pain without radiation after lifting a box weighing approximately 15 pounds. She denies any previous trauma or injuries. Past history includes hysterectomy at age 42 and a 49 pack year smoking history. Current weight is 107 pounds. Lumbo-sacral spine film indicates a spinal compression fracture at level L4. Which of the following tests would you perform to further assess the patient's findings.