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family med > general > Flashcards

general Flashcards

1
Q

polymayalgia rheumatica is associated with __________ (causes headache)

A

giant cell arteritis

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2
Q

creatinine kinase levels in polymyalgia rheumatica?

A

creatinine kinase will be normal because muscles are spared in polymyalgia rheumatica. mm biopsy will also be normal. the mm pain is referred pain from joints and connective tissue. however, inflammatory markers ESR and CRP will be elevated and pt may have low grade fever

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3
Q

typical pt demographic of polymyalgia rheumatica; aggrevating/relieving factors

A

usually women >50; worse at morning/night. Improved with activity. Treated with low dose corticosteroid, activity, diet (bonus: often triggered by adenovirus, parvovirus)

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4
Q

hematogenous osteomyelitis is most common in which demographics

A

children; IV drug users; may also cause vertebral osteomyelitis in adults >50. Most common pathogen is staph aureus.
treatment in adults: IV Vancomyocin PLUS IV antipseudomonal fluroquinolones or antipseudomonal cephalosporins
in kids >3mo IV nafcillin/oxcillin or cefazolin

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5
Q

3 complications of osteomyelitis

A

sequestrum, abscess, or, in children growth impairment

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6
Q

imaging of choice for osteomyelitis

A

MRI (not visible on Xray for first two weeks)

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7
Q

exogenous osteomyelitis

A

usually due to multiple pathogens. Can be due to trauma, contiguous from a wound like a diabetic ulcer (think Staph epidermidis and Streptococci!); contiguous spread from cellulitis, prosthetic device;

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8
Q

blood test findings for rheumatoid arthritis

A 
RF factor (IgM) and anti-CCP antibody
you may also see anemia because the liver over produces hepcidin, decreasing iron absorption and causing iron trapping in macrophages)
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9
Q

extra articular complications of rheumatoid arthritis

A 
interstitial lung fibrosis
pleural effusion
anemia
athrosclerosis
muscle breakdown
rheumatoid nodules
general inflammatory signs (weakness, malaise, fatigue, decreased appetite, fever)
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10
Q

Felty syndrome

A

rheumatoid arthritis + granulocytopenia + splenomegaly

  • *can lead to life threatening infections **
    tx: methotrexate
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11
Q

articular manifestations of rheumatoid arthritis

A

morning stiffness; symmetrical inflammation and pain of joints especially starting with smaller joints
rheumatoid hand: ulnar deviation of the fingers, swan neck finger, Boutonniere deformity; **Atlanto-axial sublexation (be sure to get an Xray if someone has neck pain with RA!)

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12
Q

differential for rheumatoid arthritis might include…

A

OSTEOARTHRITIS (but this will usually be asymmetrical in weight-bearing joints without constitutional symptoms! plus a little bit older crowd)

PSORIATIC ARTHRITIS (look for psoriatic skin lesions and nail changes)

GOUT (usually just one joint, often a big toe, acute attacks, asymmetrical)

PSEUDOGOUT (again asymmetrical and usually just one joint)

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13
Q

labs in piagets disease of the bone

A

elevated alk phos, normal serum calcium and phosphate

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14
Q

most common lung cancer in non smokers,

A

adenocarcinoma

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15
Q

CREST syndrome

A 
Calcinosis cutis (little nodules usually over pressure points)
Reynaud's phenomenon
Esophogeal hypomotility
Sclerodactyly
Telangectasia

dx: ana , anti centromere
diffuse scleroderma has anti scl 70 (antitopoisomerase I antibody) , anti RNA polymerase III

Tx: methotrexate, PPIs for GERD, organ specific symptom relief

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16
Q

angina pectoris, erythema nodosum, decreased or absent bilateral brachial and radial pulse, syncope

A

Takayasu arteritis I can’t taka ya pulse
autoimmune granulommatous inflammation of aorta and major branches
high ESR, angiography is gold standard for dx
tx: corticosteroids, may need methotrexate, cyclophosphamide or even surgical bypass

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17
Q

what virus associated vasculitis should you consider in a young person with stroke or MI?

A

Polyarteritis nodosa
associated with Hep B, Hep C
Clinical features
Nonspecific symptoms: fever, abdominal, muscle, and joint pain
Renal involvement; hypertension, renal impairment
Coronary artery involvement; increased risk of myocardial infarction
Skin involvement; rash, ulcerations, nodules
Usually spares the lungs!!

Blood tests
Hepatitis B serology
Hepatitis C serology
↑↑ ESR
ANCA-negative
Angiography: 
Treatment
corticosteroids, cyclophosphamide
Antiviral therapy against HBV and HCV
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18
Q

diagnostic test to differentiate between chlamydia and gonorrhea

A

nuclea acid amplification test

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19
Q

treatment for genital chlamydia

A

azithromycin or doxycycline

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20
Q

treatment for mastitis

A

dicloxacillin & continued breast feeding (covers s.aureus)

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21
Q

USPSTF guideline on mammography

A

biennial screening women 50-74
if women have several risk factors like early menarche, nulliparity and first degree relatives with cancer, screening can begin at 40

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22
Q

USPSTF guineline on abdominal aortic anuerysm screening

A

one time screening for abdominal aortic aneurysm for men 65-75 who have ever smoked

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23
Q

most common vaginal cancer

A

squamous cell carcinoma, usually caused by HPV type 16 or 18

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24
Q

colorectal cancer screening

A

Either colonoscopy every 10 years, an annual fecal occult blood test, or sigmoidoscopy every 5 years is indicated in every adult ≥ 50 years of age.

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25
Q

Pap smear recommendations

A

A Pap smear should be conducted to screen for cervical cell dysplasia every 3 years starting at 21 years or every 5 years at 30 years, if combined with HPV testing.

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26
Q

syphilis screening

A

basically everyone should get screened for syphillis, especially pregnant women!!
initial tests: RPR (rapid plasma reagin) or VDRL
confirmatory test: fluorescent treponemal antibody absorption test FTA-ABS

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27
Q

tx for endometriosis

A

mild/mod pain w/o complications: empirical treatment with nsaids and hormonal contraceptives
severe symptoms: GnRH agonist (buserelin, goserelin) and estrogen-progesteron OCPs
surgical intervention: fist line is laprascopy; 2nd line is hysterectomy +/- salpingo oophorectomy

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28
Q

steps of diagnosis for endometriosis

A

Physical exam: check for rectovaginal masses and adnexal masses
transvaginal ultrasound: evidence of ovarian cysts (chocolate cysts); uterus usually not enlarged
laproscopy is confirmatory but you can treat empirically if it’s mild/moderate without complications!

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29
Q

morning sickness treatment options in order of preference

A
  1. pyridoxine (B6)
  2. doxylamine
  3. diphenhydramine of dimenhydrinate
  4. last resort: methylprednisolone (not in 1st trimester)
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30
Q

PID outpatient treatment

A

one dose IM ceftriaxone and then oral doxy

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31
Q

Foul-smelling, frothy, yellow-green, vaginal purulent discharge with pH>4.5

A

Trichomonas, protozoa with multiple flagella on saline wet mount
treat with metronidazole or tinidazole

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32
Q

screening for chlamydia trachomatis and N. gonorrhea

A

screening for sexually active women 24 and younger and older women at increased risk
nucleic acid amplification testing (NAAT)

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33
Q

treatment for yeast infection

A

topical nystatin, topical azoles or oral fluconazole

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34
Q

symptoms and treatment for Legionnaire’s disease

A

watery diarrhea and atypical pneumonia (cough, low grade fever, sob), hyponatremia, patchy lung infiltrates
Levofloxacin

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35
Q

first line for acute bacterial rhinosinusitis

A

oral amoxicillin-clavulanic acid (penicllin +beta lactamase inhibitor)

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36
Q

superior vena cava syndrome is most commonly caused by _______cancer or ________________ (particularly young patients)

A 
lung cancer (small cell, squamous) or non-hodgkin lymphoma in young pts
symptoms include  headache that worsens with leaning forward, engorged veins over the anterior chest, and swelling that is limited to the head, neck, and upper extremities.
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37
Q

granulommatous disease like sarcoidosis, tuburculosis, chrons, cat scratch fever, granulomatosis with polyangiitis, etc. are associated with high serum _____

A

high serum calcium

macrophages produce more 1alpha hydroxylase which activates vitamin d leading to bone resorption

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38
Q

antiarrhythmic associated with pulmonary fibrosis and chronic interstitial pneumonitis!

A

amiodarone (blocks voltage gate K+ channels used for vtach and vfib, low negative ionotrope)

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39
Q

tx for vasomotor rhinitis

A

azelastine nasal spray (astelin, astepro)
vasomotor rhinitis = A condition characterized by an increase in blood flow to the nasal mucosa, which results in nasal congestion, rhinorrhea, and postnasal drip. Not attributable to a known allergic process. Triggers include drugs (e.g., NSAIDs), emotional stimuli (e.g., anxiety, excitement), strong odors (e.g., cigarette smoke, perfume), and cold, dry air.

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40
Q

complications of bronchiectesis

A

damage to broncheal vessels –> hemoptysis (usually self limited), hemorrhage
cor pulmonale

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41
Q

pathophys of bronchiectesis

A

Bronchiectasis is an irreversible and abnormal dilation in the bronchial tree that is generally caused by cycles of bronchial inflammation in addition to mucous plugging and progressive airway destruction. Although the widespread use of antibiotics has made bronchiectasis rare, conditions such as cystic fibrosis (CF), severe or protracted pneumonia, immunodeficiency, and COPD continue to cause it. The most important clinical finding is a chronic cough with copious mucopurulent sputum. Other symptoms may include dyspnea, rhinosinusitis, and hemoptysis. Physical examination reveals crackles and rhonchi on auscultation, often accompanied by wheezing. High-resolution computer tomography is the best diagnostic test and shows thickened bronchial walls, a signet-ring appearance, and “tram track” lines. Treatment focuses on alleviating symptoms and preventing exacerbations, and includes pulmonary physiotherapy and antibiotics to treat underlying infections. In rare cases, massive hemoptysis may complicate bronchiectasis and necessitate surgery or pulmonary artery embolization.

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42
Q

Light’s Criteria

A 
- Plueral fluid protein: serum protein
<= 0.5 transudative; >0.5 exudative
-Pleural fluid LDH: serum LDH
<= 0.6 transudative; > 0.6 exudative
-Pleural fluid LDH
<2/3 the upper limit of normal serum LDH, suggests transudative; >2/3 uln suggest exudative. Really high ldh like >1000 suggests malignancy, rheumatoid effusion, empyema
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43
Q

name some thangs that cause transudative pleural effusions

A

Stuff that ups hydrostatic pressure like CHF or CKD (Na+ retention)
stuff that loses protein content (decreases oncotic pressure) like cirrosis or nephrotic syndrome or protein losing enteropathy

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44
Q

name some thangs that cause exudative pleural effusions

A

exudative pleural effusions suggest local lung parenchymal damage
malignancy, TB, other infection, Dressler’s, pneumonia, PE, autoimmune disease especially the ones that affect vascular collegen like sarcoidosis, RA, vasculitis, SLE, pancreatitis, trauma, chylothorax, hemothorax, pseudochylothorax

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45
Q

___________ is a trigger for asthma and associated with difficult to treat asthma. think about empiric therapy in pts with risk factors like obesity who’s asthma worsens when lying down or after meals

A

GERD

PPIs (prazoles)

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46
Q

COPD pathophys

A

The hallmark pathophysiologic mechanism in COPD is irreversible progressive obstruction of expiratory airflow due to chronic bronchitis and/or emphysema. In emphysema, chronic exposure to cigarette smoke destroys the alveolar walls, enlarging the airspace. These airways eventually collapse and cause obstruction, leading to air trapping and hyperinflation. In chronic bronchitis, cigarette smoke causes the proliferation of mucinous-secreting cells (goblet cells) and impairs ciliary function. These effects lead to excess mucous secretion, mucus plug formation, and airflow obstruction.

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47
Q

tactile fremitus is ___________ in pneumonia

A

increased
say 99, use ulnar side of hand on their back
also ask patient to whisper “123” it will sound clearer where there is consolidation. THis is called whispered pectoriloquy

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48
Q

tactile fremitus is __________ in pleural effusion

A

decreased

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49
Q

painless genital ulcers which heal spontaneously within a few days followed by swelling of LNs in a few weeks +/- abscess, pus

A

Lymphogranuloma venereum
Chlamydia trachomatis serotypes L1, L2, L3
tx: doxycycline

untreated can lead to chronic lymphedema, strictures, infertility

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50
Q

very painful genital ulcers with necrotic base, usually one for men, multiple for women, often with painful inguinal lymphadenopathy

A

chancroid caused by Haemophilus ducreyi

tx: azithromycin or single dose IM ceftriaxone

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51
Q

granuloma inguinale: cause, symptoms, treatment

A

large, painless ulcers, beefy red, bleed easily; may get bacterial superinfection and smell bad
caused by Klebsiella granulomatis (Donovan bodies)
tx: azithromycin

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52
Q

_____________ is associated with a positive Prehn sign (relief of pain when lifting the testicle)

A

epididymitis

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53
Q

prostate cancer most commonly mets to ____

A

bone

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54
Q

step 1 treatment

A

SABA PRN (albuterol, levalbuterol, terbutaline)

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55
Q

step 2 treatment for asthma

A

low dose ICS (fluticasone, budesonide, bethomeclasone, mometasone, etc)

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56
Q

intermittent asthma criteria

A

intermittent: sx less than or = twice a week, nighttime wakings less than or = twice a month, one or less exacerbations a year, no interference with normal activity

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57
Q

step 3 for asthma

A 
low dose ICS+ LABA
Advair (fluticasone +someterol)
Symbicort (budesonide + formeterol)
Dulera (mometasone +formeterol)
consider adjunct tiotropium (antimuscrinic), allergen immunotherapy)
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58
Q

step 4 for asthma
daily symptoms, nightly wakings, extreme interference with daily activity, FEV1<60% predicition, 2 or more exacerbations a year, SABA use several times a day

A

referral!

Med dose ICS+LABA

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59
Q

Steps 5, 6 for asthma

A

referral! high dose ICS+LABA, maybe oral corticosteroids, maybe anti

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60
Q

name 2 long acting insulins

A

glargine (Lantus)

Detemir (Levemir)

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61
Q

name 3 rapid acting insulins

A

novolog (Aspart)
humalog (Lispro)
Glulisine (Apidra)
if you get hit in the head with a log, it will hurt rapidly

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62
Q

name a short acting insulin

A

regular, human insulin Humulin R, Novolin R

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63
Q

name an intermediate acting insulin

A

NPH Humulin N, Novolin N

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64
Q

According to JNC 8 guidelines, In the general population, pharmacologic treatment should be initiated
when blood pressure is
___ mm Hg or higher in adults 60+ years and
____mm Hg or higher in adults younger than 60 years.
and _______mmHg for adults with diabetes or CKD

A

150/90 for adults >60
140/90 for adults <60
140/90 for adults with htn and diabetes or CKD, regardless of age
consider ACEi or ARB as initial treatment if CKD

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65
Q

in nonblack pts, initial htn treatment should include

A

thiazide, ARB, ACEI, or calcium channel blocker

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66
Q

in black pts, initial htn treatment should include

A

thiazide or calcium channel blocker

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67
Q

According to JNC 8 guidelines, if the target blood pressure is not reached within _____ after
initiating therapy, the dosage of the initial medication should be increased, or a second medication should be added.

A

one month

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68
Q

Do not combine an ACEi with ______

A

ARB

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69
Q

causes of secondary hypertenstion

A

RECENT
Renal (renal artery stenosis, glomerulonephritis–remember nephritic syndrome is low level proteinuria, microhematuria, oliguria and htn)
Endocrine (Conn (hyperaldosteronism), Cushing (hypercortisol), hyperthyroidism)
Coarctation of the aorta
Estrogen (oral contraceptives)
Neurologic (raised intracranial pressure, neurostimulants like cocaine, pcp, meth)
Treatment (NSAIDS, corticosteroids)

and also Obstructive sleep apnea

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70
Q

USPSTF recs for pap smears

A

every 3 years starting at 21; every 3 years after 30 or every 5 years if combined cytology with HPV testing

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71
Q

USPSTF recs for HIV screening

A

all preggers

all ppl 15-65

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72
Q

USPSTF recs on osteoporeosis screening

A

screening in women > 65years unless increased risk

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73
Q

does acetaminophen have anti inflammatory properties?

A

no

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74
Q

does acetaminophen have bleeding effects?

A

no

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75
Q

acetaminophen has ____ toxicity

A

liver
there’s a lot of liver pathology like NASH, alcoholic, hep C so it’s good to check CMP before starting acetaminophen for pain (it does have narcotic sparing effects)

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76
Q

2 major risks of NSAIDS

A 
renal toxicity
GI bleeding (be careful in elderly, may prescribe ppi)
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77
Q

topical nsaids

A

lidocaine (otc), diclofenac (can be really expensive)

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78
Q

gabapentin, topiramate, and cymbalta can all be used to tx_____

A

pain

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79
Q

antibodies in primary biliary cholangitis?
asymptomatic at first –> pruritis, fatigue, sky high cholesterol, jaundice –> cirrhosis, portal hypertension, ascities, gi bleed

A

anti mitochondrial

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80
Q

name drug used to treat primary biliary cholangitis

A

ursodeoxycholic acid

maybe liver transplant

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81
Q

ursodeoxycholic acid is used to treat

A

primary biliary cholangiitis

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82
Q

tx acute gout

A

cholcocine and nsaids like indomethacine

allopurinal for prevention

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83
Q

celiac tests

A 
IgA tTG (anti tissue transglutaminase antibody) * screen test can be falsely neg
IgA levels (lowered)
if IgA tTG is negative but you still suspect celiac, do IgG deaminated gliadin peptide (DGP)
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84
Q

recurrent sinusitis/pneumonia/bronchitis + situs inversus + infertility

A

primary ciliary dyskinesia (Kartagener)

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85
Q

Vague discomfort and swelling in the scrotal region with multiple palpable cords (“bag-of-worms”) that enlarge on standing or with a Valsalva maneuver, usually in teens

A

varicocele
GET US!
tx: laprascopic varicolectomy

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86
Q

____________ polyps carry the highest risk of malignant transformation of all types of colonic polyps

A

adenomatous

villous adenomatous is the worse

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87
Q

contraindication for rotavirus vaccine

A

hx of intussusception

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88
Q

what pneumo vaccine to healthy adult over 65?

A

PPSV23

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89
Q

what pneumo vaccine to immunocompromised adult?

A

PCV13 then PPSV23 at least 8 weeks later

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90
Q

guidelines for when to treat osteoporosis

A

t score

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91
Q

treatment for osteoporosis

A
  • bisphosphonates are first line: alendronate or risendronate. oral daily. 30 min before eating/reclining. GI side effects.
  • smoking cessation
  • alcohol and caffeine moderation
  • daily sunlight
  • PT/Exercise with strength and balance training
  • fall risk assessment
  • vitamin D supplement
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92
Q

amitriptyline side effects

A

TCA, dry mouth, blurred vision, constipation , risk of overdose

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93
Q

pharma therapy for fibromyalgia

A

*always give exercise rx (moderate aerobic 20-30 min 2-3x wk)
amitriptyline, duloxetine, milnacipran, gabapentin, pregabalin (lyrica), cyclobenzaprine (muscle relaxant)

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94
Q

tx for postmenopausal vaginal dryness

A

topical estrogen cream

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95
Q

tx for bacterial vaginosis

A

metronidazole (don’t need to treat partners bc not sti, it’s from imbalance of vaginal flora, douching is risk factor, caused by gardenella vaginalis)

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96
Q

tx vulvovaginal candidiasis in pregnancy

A

intravaginal clotramazole

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97
Q

2 major complications of giant celll arteritis

A

blindness, aortic aneurism

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98
Q

what antibiotic for rheumatic fever

A

penicillin

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99
Q

Lupus symptoms

A
  • Fever
  • Joint problems
  • ANA+, anti dsDNA, anti Smith
  • oral ulcers, alopecia
  • skin stuff : malar rash, discoid lupus, subacute or acute cutaneous lupus,
  • proteinuria! nephritis!
  • low white blood cells, low platelets, low complement, hemolysis
  • antiphospholipid antibodies (hypercoag?) anticardiolipin, lupus anticoagulant, anti beta2gp1
  • psych issues! seizure delirium
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100
Q

Sjorgens antibodies

A

anti Ro/SSA

anti La/SSB

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101
Q

acute treatment of COPD exacerbation

A

bronchodilators (like albuterol and ipratropium (anticholinergic)),
systemic steroids,
antibiotics,
possibly O2

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102
Q

spirometry findings in COPD

A

reduced FEV1, reduced FVC,

FEV1:FVC <70

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103
Q

Treat COPD pts based on their GOLD category. But my shortcut: if <= 1 exacerbation (no hospital) a year with mild symptoms, give them ______

A

light COPD: salbutemol or salmeterol

more severe: tiotropium (LAMA) and maybe salmeterol too

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104
Q

Treat COPD pts based on their GOLD category. But my shortcut: if <= 1 exacerbation (no hospital) a year with mild symptoms, give them ______

A

light COPD: albuterol, ipatropium, salbutemol or salmeterol
more severe: add tiotropium (LAMA) and maybe salmeterol too to prn saba
**for frequent exacerbations, add inhaled steroids like fluticasone

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105
Q

guidelines for O2 therapy for COPD

A

when sat 88% at rest; use at least 15h a day to decrease mortality

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106
Q

abx for strep pneumo

A

penicillin (macrolide if they are allergic)

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107
Q

tx for peripheral arterial disease

A
  1. superivised graded exercise therapy, smoking cessation
  2. aspiring, clopidegrel, statin! manage BP and blood sugar
  3. if still symptomatic, give cilostazol (phosphodiesterase inhibitor)
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108
Q

cilostazol

A

phosphodiesterase inhibitor, used for PAD if conservative treatment, aspiring, clopedigrel doesnt work

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109
Q

a septic joint on exam:

A

very limited range of motion

ROM preserved if it’s nearby cellulitis, bursitis, osteomyeolitis

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110
Q

lab findings in RA

A

RF
anti CCP (anti citrullinated protein antibody)
elevated sed rate and CRP
anemia
thrombocytosis
low albumin (correlates with severity of disease)

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111
Q

acute treatment for gout

A

nsaids (be careful in elderly, may need to add ppi)
maybe colchicine
maybe glucosteroids

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112
Q

long term treatment/prevention gout

A

allopurinol (reduces uric acid production)

probenecid (increases uric acid secretion)

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113
Q

sulfasalazine

A

DMARD for RA

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114
Q

infliximab

A

anticytokine for RA

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115
Q

etanercerpt

A

anticyokine for RA

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116
Q

recent stomach bug or UTI followed by migratory arthritis, maybe conjunctivitis or iritis, dysuria

A

reactive arthritis – this is an autoimmune process!
HLA-B27, usually young men
dx: CRP, ESR, CBC with diff, maybe arthrocentesis,
tx: nsaids (if really severe, glucocorticoids or dmards)

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117
Q

tx for disseminated lyme disease

A

ceftriaxone

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118
Q

tx for localized lyme disease

A

doxycycline

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119
Q

name symptoms of stage II of lyme disease

A

carditis
migratory arthralgia –> lyme arthritis (large joints)
early neuroborreliosis: (usually cranial nerve like facial palsy)
erythema migrans

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120
Q

name symptoms of late lyme disease

A

months to years later

chronic lyme arthritis, late neuroborreolosis: asepctic/lymphocytic meningitis, progressive encephelomyeolitis

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121
Q

which antihypertensive class increases gout risk?

A

hydrochlorothiazide

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122
Q

labs at initial prenatal visit

A 
Hep B surface antigen
HIV
Syphilis
GC, CT cervical swab
rubella antibody ( negative - stay away from sick ppl; if acutally get rubella at <16 wks, counsel to terminate)
Pap smear if patient is due 
urinanalysis and urine cx
CBC
blood type and Rh status with antibody screen

don’t forget to screen for DV, substances, vitamins, preterm labor risk, genetic risk, family hx, depression

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123
Q

folic acid supplement: take ______ before conceiving

A

1 month at least, 400-800ug for low risk. 1mg for DM, 4mg if previous neural tube defect child

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124
Q

congenital rubella

A 
cataracts
congenital hearing loss
cardiac defect
blueberry muffin rash
growth restriction
hemolytic anemia, thrombocytopenia, hepatosplenomegaly, jaundice
later: CNS problems like ID, microcephaly. skeletal abnormalities 
miscarriage
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125
Q

syphilis in pregnancy

A

treat with penicilin If less than 1 year, 1 dose IM.

If more than 1 year or unknown, penicillin IM each week x3

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126
Q

gonorrhea in pregnancy

A

may cause preterm labor, blindness

ceftriaxone

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127
Q

Chlaymydia in pregnancy

A

may cause neonatal blindness, pneumonia

azithromycin or amoxicillin

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128
Q

if mom is Hbsag pos in pregnancy

A

check LFTs and hep serology to determin if chronic or active. Baby will need Hep B vaccine and HepB IG right away

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129
Q

nuchal translucency can be given at _____ weeks pregnancy or combined test (NT, hCG, and PAPP-A)

A

10-13 weeks
if positive that means increased risk not a diagnosis.
you’ll offer karyotype, follow up ultrasounds, chorionic villas sampling or second trimenster screenin

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130
Q

trisomy screen at weeks ______ of pregnancy

A

15-20

tests reveal risk not dx. may be skewed by inaccurate dating. offer genetic amniocentesis

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131
Q

trisomy screen at weeks ______ of pregnancy

A

15-20
tests reveal risk not dx. may be skewed by inaccurate dating. offer genetic amniocentesis
triple screen: hCG, unconjugated estriol, alpha fetoprotein
quad screen adds inhibin A

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132
Q

GBS culture in pregnancy at weeks __________

A

35-37 if positive you get penicillin during labor. helps to prevent early group B strep sepsis pneumonia or meningitis of newborn

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133
Q

name 2 vaccines you can get in pregnancy

A

tdap, flu

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134
Q

baby gives social smile at __ mo

A

2 months

focus on face at 1 mo

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135
Q

baby sits well unsupported at — months

A

6

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136
Q

baby says mama dada byebye at — mo

A

9 months

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137
Q

baby crawls at —- months

A

9

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138
Q

baby walks at — months

A

12

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139
Q

baby babbles at —- months

A

6

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140
Q

age 3 developmental milestones

A

rides tricycle, 3/4 of speech understood by strangers, , bridge of 3 cubes, repeats 3 numbers, plays in a group (3 kids)

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141
Q

vision screen rec to rule out amblyopia/stabismus

A

3-5 yo

strabismus should be referred to a pediatric ophthalmologist

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142
Q

vaccines at birth

A

Hep B

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143
Q

vaccines at 2 mo

A 
don't hate pediatric RNs for poking plus HepB
dTap
Hib
PCV (PCV13)
rotavirus
Polio
Hep B
(same at 4 mo (minus HepB) and 6 mo (incl Hep B))
144
Q

vaccines at 6 mo

A 
don't hate pediatric RNs for poking plus HepB
dTap
Hib
PCV (PCV13)
rotavirus
Polio
Hep B
(same at 4 mo (minus HepB) and 6 mo (incl Hep B))
145
Q

vaccines at 4 mo

A 
don't hate pediatric RNs for poking 
dTap
Hib
PCV (PCV13)
rotavirus
Polio
(same at 2 and 6 mo except you get Hep B at those but NOT at 4 mo)
146
Q

vaccines at 12-18mo

A

Dwarf People Holler and Hate Many Vaccines

Dtap
PVC
Hep A (one at 12 month, second dose 6 mo later)
Hib
MMR
Varicella
147
Q

vaccines at 4-6 yo

A 
Don't Poke Me, Val
Dtap
Polio
MMR
Varicella
148
Q

a common complication of topical decongestants

A

rebound congestion

149
Q

allergic rhinitis exam

A

look for allergic shiners, nasal crease, septal deviation, boggy nasal mucosa thats pale bluish grey. cobblestoning of persterior pharynx. tonsillar hypertrophy. look for lymphadenopathy. pulm.

150
Q

tx allergic rhinitis

A
  1. allergen avoidance/removal
  2. antihistamines 2nd gen loratidine, cetirizine, ranitidine
  3. oral decongestant: pseudoephedrine . rebound congestion
  4. intranasal corticosteroids like fluticasone
  5. leukotriene inhibitors like monelukast, zileuton
  6. oral corticosteroids
  7. desensitization
151
Q

Tx for allergic rhinitis

  1. allergen avoidance/removal
  2. antihistamines 2nd gen loratidine, cetirizine, ranitidine
  3. __________________
  4. intranasal corticosteroids like fluticasone
  5. leukotriene inhibitors like monelukast, zileuton
  6. oral corticosteroids
  7. desensitization
A
  1. oral decongestant: pseudoephedrine . rebound congestion
152
Q

tx for allergic rhinitis

  1. allergen avoidance/removal
  2. antihistamines 2nd gen loratidine, cetirizine
  3. oral decongestant: pseudoephedrine . rebound congestion
  4. intranasal corticosteroids like fluticasone
  5. _________________________
  6. oral corticosteroids
  7. desensitization
A

leukotriene inhibitors like montelukast, zileuton. also used in asthma.

153
Q

tx for anaphylaxis (cutaneous sympommts, dyspnea, visceral edema, hypotension)

A

aqueous epinephrine 1:1000, in a dose of 0.2-0.5 ml subq or im, can give every 15-20min
IV fluids
intubation

154
Q

tx for acute uticaria

A

eliminate trigger, second gen antihistamine like loratadine, ceterizine, fexofenadine, ranitidine
ranitidine+diphenhydramine particularly effective

155
Q

most common cause of keratoconjunctivitis

A

adenovirus , usually with URI symptoms, tarsal conjunctival cobblestoning, morning crusting, modest discharge, usually bilateral
give antihistamines, decongestants. compress?

156
Q

contraindications for bupropion

A

recent MAOi use, eating disorder, seizure disorder

157
Q

pharmacological smoking cessation aid

A

bupropion (risk: suicidal ideation) - start 1-2 wks before quit date, can use patch with it, use up to 6 mo
chantix (varenicline) start 1 wk before quit day, use up to 6 mo,$$
pregnant ppl should try to not use pharm if possible, bupropion and varenicline are category C

158
Q

fatigue, weakness, dyspnea, palpitations in geriatric pt

A

always consider anemia! check conjunctival pallor

also CHF, afib, angina

159
Q

glossitis, decreased vibratory and positional senses, ataxia, confusion, dementia, pearly grey hair at early age, paresthesia, headache palpitation

A

vit B 12 deficiency
folate deficiency can also cause similar symptoms but neuro exam is normalish? both cause megaloblastic anemia. always test both vit B 12 and folate levels and remember their metabolism is interdependent.
also note that profound iron deficiency can cause glossitis, dysphagia, spoon nails (koilonychias)
hypothyroidism can also cause macrocytic anemia!

160
Q

anemia workup

A

CBC with RBC indices
peripheral blood smear
reticulocyte count

161
Q

lab findings in iron deficiency anemia

A 
microcytic
low ferritin
low serum iron
low transferrin saturation
High TIBC
162
Q

folate deficiency is most common among _____ and B12 is most common among people with ______

A

alcoholics often folate deficient
B12 deficiency in pernicious anemia, gasterectomy, malabsorption disease, vegans. confirmed by elevated MMA (methylmelonic acid)
give IM B12 daily for 7 days, weekly for 4 weeks, then monthly for rest of life or oral B12
oral folate until correcte

163
Q

if qrs is upright in leads ______ of ecg, then axis is okay

A

I, II

164
Q

how to calc hr on ecg

A

count the big boxes between 2 qrs complexes and divide by 300
each small box is 0.04s, each large box is .20 seconds
regular hr is 60-100

165
Q

how to find axis on ecg

A

find lead where impulses equal above and below line. it’s 90 degrees from that. find the lead with highest R. That tells you the direction (i.e. which 90 degree angle)
normal axis is -30 to +90. negative to -30 is left axis deviation and above +90 is right axis deviation

166
Q

squared off flattening of st segment on ecg

A

ischemia

167
Q

downslope of st segment on ecg plus u wave

A

hypokalemia

168
Q

normocytic anemia may occur in renal disease because of….

A

decreased EPO production by the kidneys

169
Q

lab findings in anemia of chronic inflammation

A

the body has a ton of iron stores but can’t use them because inflammation has messed with the reticuloendothelial system! therefore
serum ferritin (iron storage) will be high! (low in iron deficiency)
TIBC low (because plenty of iron around)
serum iron (normal or low)
transferrin saturation - low or normal
normo or microcytic

170
Q

pernicious anemia

A

most common cause of B12 deficiency. macrocytic anemia. burning in feet, ataxia, confusion, glossitis, early grey hair. fatigue!!
autoantibodies against intrinsic factor
elevated methylmalonic acid(MMA) confirms B12 deficiency
also Gastric Endoscopy to look for atrophic gastritis

171
Q

virus, E coli, shigella, salmonella, giardia, cambylobacter and amebiasis are most common causes of…

A

acute gastroenteritis

1. test stool for fecal leukocytes!

172
Q

most pts with acute diarrhea have self-limited processes and do not require much workup. But you need to be more cautious when…

A 
bloody diarrhea
kids or elderly
diarrhea >48 hrs
volume depletion
fever >100.4
severe abdominal pain
immunocompromised pts
173
Q

travelers diarrhea treatment

A
  • only people with increased risk of complications like those with underlying IBD, renal disease, immune compromise need prophylaxis (ciprofloxacin)
  • tx traveler’s diarrhea with ciprofloxacin 500mg bid 1-3 days unless a kid or pregnant!
  • 2nd line is azithromycin (safe for kids and preg.)
  • rifaximin can be given if nonbloody and NO fever
174
Q

vomiting and diarrhea 6 hours after eating…

A

s. aureus

175
Q

test and tx for C. difficile

A

C. difficile toxin immunoassay

metronidazole or vancomycin

176
Q

hormonal replacement therapy for women can increase risk of…

A

bad cardiovascular outcomes

177
Q

screen all women over ___ yo for hyperlipidemia

A

45

178
Q

when should you get an ankle or foot xray?

A

bony tenderness of the posterior edge or tip of the medial or lateral malleolus or if the patient is unable to bear weigh immediately or when examined
get foot exray if bony tenderness over the navicular bone or base of 5th metatarsal or pt cant bear weight(Ottawa ankle rules)
start with xray. if thats normal and symptoms persist, you might get MRI to look at ligaments/tendons

179
Q

management for ankle sprain

A 
PRICE
protection
rest
ice
compression
elevation
&amp; nsaids or acetominophen
180
Q

provocative test for supraspinatus injury (rotator cuff)

A

empty can test

181
Q

provocative test for subscapularis

A

lift off test

182
Q

provocative test for infraspinatus and teres minor

A

external rotation with elbows flexed and arms at sides

183
Q

provocative test for subacromial impingement of the supraspinatus tendon

A

hawkins impingement (flapping chicken wing)

184
Q

how to test for large rotator cuff tear

A

drop arm test – pt unable to slowly lower arm from raised position

185
Q

how to test for anterior talofibular ligament tear

A

anterior draw ankle test

186
Q

what does it mean to have positive inversion stress test of ankle? (invert ankle with one hand while stabilizing lower leg with the oth3er, excessive translation or palpable clunk of talus on tibia)

A

calcaneofibular ligament

187
Q

lachman test

A

knee in 20deg flexion. stabilize upper leg and pull forward on tibia. excessive translation with no solid end point suggest ACL tear
anterior cruciate ligament tested with Lachman

188
Q

anterior drawer test of knee tests for…

A

ACL tear

189
Q

valgus test of knee

A

test medial collateral ligament (push inwards above knee, outwards at ankle; remember leg flexed to 30 deg)

190
Q

varus test of knee

A

lateral collateral ligament

pull lateral above knee, push medial at ankle or so. leg is flex at 30 deg.

191
Q

when should you get a knee x ray

A
  1. > 55 yo
  2. patella tenderness
  3. head of fibula is tender
  4. can’t flex knee to 90 degrees
  5. cant bear weight for four steps regardless of limping
    start with xray. if thats normal and symptoms persist, you might get MRI to look at ligam2. ents/tendons
192
Q

actinic keratosis and HPV raise risk for…

A

squamous cell carcinoma

193
Q

most aggressive form of melanoma

A

nodular

superficial spreading is most common form

194
Q

dark spot under nail, on palm or sole of foot in African American pt or Asian american pt

A

acral lentiginous melanoma

195
Q

work up for microscopic hematuria (no proteinuria)

A

3+ RBCs per HPF on 2/3 urine samples (always confirm dipstick with microscopy). Do workup with 1+ sample if risk factors like smoking, exposure to benzenes or aromatic amines, hx gross hematuria, >40yo, hx urologic probs, hx irritaiting voiding sx, hx UTI, analgesic abuse, hx pelvic irradiation
your concern is to rule out maliginacy including Renal cell carcinoma and transitional cell carcinoma
1. Repeat UA. urinary sediment. Red cell casts and dysmorphic rbcs –> renal glomerular disease. Eosinophils –> interstitial nephritis perhaps from analgesics or other drugs
2. Get urine cx.
3. serum creatinine to test renal function
4. upper UT imagining: CT, or US or intravenous pyelogram
5. lower UT imagining: cystoscopy

196
Q

name 3 first line tx for uncomplicated UTI

A

TMP-SMX
nitrofurantoin
fosfomycin

197
Q

what arrhythmia occurs in hyperthyroid pts?

A

afib

198
Q

pathophysiology of graves disease

A

IgG autoantibodies to TSH receptors
tx:
methimazol (propylthiouracil if pregnant)
beta blockers
definitive tx: radioactive iodine ablation (may have to tx hypothyroidism then)
Graves might go into remission for adolescents after pharma tx

199
Q

propylthiouracil

A

anti thryorid drug for pregnant women

can cause agranulocytosis

200
Q

methimazol

A

first line antithyroid drug

can cause agranulocytosis

201
Q

thyroid storm symptoms

A

fever, confusion, restlessness, psychotic like behavior, tachycardia, HTN, dysrhythmias, signs of high output heart failure like dyspnea, peripheral vasoconstriction
usually graves disease but can also be acute thyroiditis

202
Q

most common causes of hyperthyroidism

A
  1. Graves disease
  2. autonomous thyroid nodule (hyperfunctioning nodules rarely malignant)
  3. early thyroiditis
  4. overuse of thyroxine supplementation
203
Q

difference in radionucleotide imaging of graves disease vs thyroiditis

A

thyroiditis is patchy uptake, reduced activity (just releasing everything already in there)
grave: huge uptake, huage activity

204
Q

diminished relaxation phase of reflexes, low BP, nonpitting edema, hair loss, dry skin, depression, low energy, weight gain, slowed mentation, constipation, cold intolerance

A

hypothyroidism

205
Q

most common cause of hypothyroidism

A

Hashimotos (autoimmune) followed by hypothalamic/pituitary dysfunction
to determine hypothal v pituitary prob: TRH test. Give TRH. If pituitary is healthy and happy it will release TSH in 30 minutes.

206
Q

treatment for hypothyroidism

A

levothyroxine

207
Q

are you more worried about cold or hot thyroid nodules on radionucleotide imaging?

A

cold : ( Gotta do a fine needle aspiration

208
Q

carotid sinus syndrome

A

syncope, carotid sinus bulb stimulated in the neck , sinus pause, super rare, way less common than vasovagal

209
Q

syncope workup

A

history, physical, ecg, orthostatic BPs/HR – suprine, sitting, standing at least 1 min between. Get hr!!!
orthostatic hypotension can be neurodegenerative incl diabetic
postural orthostatic tachycardia syndrome –really toned then have to stop working out all of a sudden

210
Q

a kid with hypertension in arms, rib notching on xray, diminished femoral pulses, short 2/6 midsystolic murmur is heard at the left paravertebral interscapular area

A

coarctation of aorta

present in turner syndrome

211
Q

hypertension in kid with increased urine VMA and HVA

A

neuroblastoma

212
Q

anti centromere antibodies are marker for

A

scleroderma

213
Q

outpt cap tx in adult

A

azithromycin is reasonable Once you’ve decided that a patient can be managed as an outpatient, you should select a drug regimen that covers the likely causative agents. In this setting, the most
likely bug is S. pneumoniae, with the next most likely bugs being H.influenzae and Moraxella catarrhalis. You also need to consider the “atypical” causes of pneumonia like Mycoplasma,
Chlamydia, and Legionella. (In fact, the CXR shown was taken from a patient with Mycoplasma.) A significant number of S.pneumoniae strains are resistant to beta-lactams, as are many H.flu
strains and almost all Moraxella strains. Atypical pneumonias are also impervious to beta-lactams and cephalosporins, so your antibiotic choices are limited to macrolides, quinolones, and
tetracyclines. Although erythromycin or tetracycline could work, macrolides like clarithromycin or azithromycin (answer D) cover H.flu better and would be the best choice among those listed.
Doxycycline or a “respiratory” fluoroquinolone like levofloxacin or moxifloxacin are reasonable outpatient monotherapies, as well.

214
Q

most common hereditary bleeding disorder

normal PT, normal or increased PTT, increased bleeding time

A

von wilebrand deficiency (autosomal dominant)
give desmopressin for mild disease (increases release of von willebrand factor)
these are oozy bruisy pts versus hemophila or clotting factor deficiency pts that have big bleeds like hemoartrosis.
Petechiae suggest Platelet deficiency; Cavity or joint bleeding suggests Clotting factor deficiency
The PT, aPTT, and bleeding
time also localize this patient’s bleeding disorder to her platelets. The PT and aPTT measure the function of the coagulation cascade. (In particular, the PT measures the extrinsic pathway and is
used to monitor warfarin therapy, while the aPTT measures the intrinsic pathway and is used to monitor heparin therapy.) Meanwhile, the bleeding time evaluates platelet function. This patient
has a borderline elevation of her aPTT (caused by mild deficiency of Factor VIII, which is carred on von Willebrand factor) but her primary abnormality is an elevated bleeding time, indicating
platelet dysfunction

215
Q

microangiopathic hemolytic

anemia, thrombocytopenia, mental status changes or neurological abnormalities, fever, and renal dysfunction

A

TTP
thrombocytopenic thrombotic purpura
give plasmopheresis!
splenectomy for refractory cases

216
Q

Factor VIII is treatment for…

A

Hemophila A

217
Q

functional ovarian cyst or physiological ovarian cyst

A

usually asymptomatic but can cause pelvic pain, fullness, constipation. Get ultrasound.

218
Q

tuboovarian abscess

A

consider in pt with hx of PID who presents with fever lower abdominal pain leukocytosis

219
Q

active pulmonary TB looks like lobar pneumonia with ipsilateral hilar lymphadenopathy and atelectasis. How do you treat?

A 
R.I.P.E.
rifampin
isonizid
pyrazinomide
ethambutol
220
Q

causes for short stature include endocrinopathies, growth hormone deficiency, malnutrition or abuse, or malignancy. What are the 2 most common causes?

A

familial short stature and constitutional delay of growth, and both of these present with a normal growth velocity. The best test to differentiate familial short
stature from constitutional delay is bone age.For familial short stature, bone age should match chronological age, while in
constitutional delay, bone age will lag behind chronological age. Bone age taken by taking xrays of hand and wrist.
A child that has small stature but is overweight for their height may have growth hormone deficiency. Conversely, a child that is
underweight for their height may have malnutrition.

221
Q

what do you use to tx uti in preggars

A

bactrim, amoxicillin, augmentin, nitrofurantoin, cephalexin, other cephalosporins. Remember you treat even asymptomatic uti’s if she’s pregnant

222
Q

parvovirus B19

A

fifth disease
slapped cheeks
erythema infectiousum

223
Q

2 conditions associated with strawberry tongue

A

kawasaki and scarlet fever (GABHS)

224
Q

name symptoms of kawasaki

A

strawberry tongue
lymphadenopathy (often unilateral)
desquamanation of skin (look especially at hands and feet)
rash
high fever >5 days
peripheral edema
**remember the complication we’re afraid of is coronary artery anuerysm

225
Q

treatment of kawasaki disease

A

serial ECHOs to watch for coronary artery aneurysm
aspirin (yep, in kids!)
IV IgG
corticosteroids

226
Q

when deciding what gout prophylaxis , get 24 hr urine uric acid measurement. Undersecreters get _______ as prophylaxis and overproducers get_______

A

Undersecreters get probenecid

overproducers get allopurenol.

227
Q

causes of erythema multiforme

A 
abx
mycoplasma
yersinia
HSV
hepatitis viruses
over bacteria and viruses
NSAIDs
other drugs
idiopathic

treat/stop underlying trigger; topical steroid, antihistamine. may need hospitalization if severe mucosal involvement

228
Q

allergic triad

A

atopic dermatitis
allergic rhinitis
asthma

229
Q

treatment for scabies

A

permethrin
oral ivermectin. Lindane cream can be used, but is second-line in the pediatric population due to its toxicity. The key to successful
eradication is to treat all family members and close contacts at the same time. Fomite transfer is not as much of a concern as it is for head lice, but precautions should be taken including bagging
personal items for 3 days and then washing them

230
Q

treatment for molluscum contagiosum

A

outside of genitals, let it ride. will resolve in immunocompetant host

231
Q

what is the meaning of alpha fetoprotein

A

you can think of an increased AFP as being caused by any defect in which the fetal body cavity is left open. These
include neural tube defects like anencephaly (answer C) or myelomeningocele and abdominal wall defects like gastroschisis or omphalocele. Obviously, of course, a larger fetus produces more
AFP than a smaller one, so the interpretation of MSAFP results depends on having accurate gestational dates. Therefore, the two most common non-pathological reasons for an elevated
MSAFP are multiple gestations and inaccurate dates. Finding a DECREASED MSAFP is also a sign of diseases – usually chromosomal abnormalities. Both trisomy 18 (answer D) and Down’s
syndrome or trisomy 21 (answer E) are associated with decreased AFP (usually <0.5 MoM). Fragile X syndrome (answer A) is the most common inherited cause of mental retardation after
trisomy 21. It is a trinucleotide repeat disorder, and must be diagnosed with molecular DNA testing. There is no specific pre-natal screening available, although mothers who are thought to be at
risk of being carriers may elect to have themselves cytogenetically tested.

232
Q

trigeminal neuralgia tx

A

oxcarbazepine or carbamazepine (antiepileptic drugs)

233
Q

anti smooth muscle antibodies

A

autoimmune hepatitis

234
Q

tx for autoimmune hepatitis

A

prednisone and azathioprine

235
Q

first line tx for symptomatic bradycardia

A

atropine iv

236
Q

hemolytic anemia, black gallstones, jaundice, splenomegaly in childhood
increased red blood cell distribution width
increased mean corpuscular hemoglobin concentration (MCHC)

A

spherocytosis

237
Q

mutation in spherocytosis

A

defects in spectrin, ankyrin …spherical RBCs get trapped in spleen…splenomegaly

238
Q

Hemolytic uremic syndrome happens after infection with

A

shiga toxin enterohemorrhagic e coli O157:H7 (most often)

239
Q

diarrhea followed by 1. renal probs 2. low platelets 3. hemolytic anemia (jaundice, dyspnea, fatigue)

A

hemolytic uremic syndrome

240
Q

tx for functional constipation in kids

A

osmotic laxatives like polyethylene glycol

241
Q

blood on urine dipstick but no rbcs on microscopy in setting of crush injury or extreme exercise

A

rhabdomyelosis, myoglobin cross reacts on urine dipstick

give IV fluids to prevent ATN!

242
Q

mupiricin is a topical abx used to treat…

A

impetigo

243
Q

treatment for alopecia areta

A

steroids like clobetasol

alopecia areta is autoimmune process

244
Q

3 most common causes of chronic cough

A

The most likely culprits in an otherwise healthy person are, in order, postnasal drip, asthma, and GERD. S
treat postnasal drip with antihistamine and decongestant
In the appropriate setting, chronic
cough can be a sign of CHF or intrinsic lung disease. Smokers can have chronic cough related to emphysema, chronic bronchitis, or the irritation of the tobacco smoke itself.

245
Q

vit K dependent clotting factors

A

II, VII, IX, X, S , C

246
Q

in HIV pts when CD4 <200, begin prophylaxis for _____ with ________

A

pneumocystis carnii pneumonia

trimethoprim-sulfamethoxazole

247
Q

In HIV pts when CD4 <100, begin prophylaxis for _____ with _______

A

toxoplasmosis with trimethoprim-sulfamethoxazole

248
Q

In HIV pts when CD4 <50, begin prophylaxis for _______ with__________

A

mycobacterium avium complex (MAC) with azithromycin or clarithromycin

249
Q

PPD is positive in high risk pt (e.g. hiv+) if greater that __ mm

A

5

250
Q

PPD is positive in medium risk pt (eg homeless) if grerater than __ mm

A

10

251
Q

PPD is positive in low risk pt if greater than— mm

A

15

252
Q

treatment for recurrent candiasis in hiv+ pts

A

fluconazole

253
Q

infant with rash involving the palms and soles, and the blood-tinged purulent nasal discharge (known as the “snuffles”, Lymphadenopathy and organomegaly

A

congenital syphilis
All TORCH infections can cause poor feeding, fever, deafness, mental retardation, hepatosplenomegaly, and thrombocytopenia, and so you should always
consider them when you see an infant with one of those conditions

254
Q

baby with deafness and cataracts as well as numerous purpuric skin lesions in mom without prenatal care

A

congenital rubella - blueberry muffin baby
All TORCH infections can cause poor feeding, fever, deafness, mental retardation, hepatosplenomegaly, and thrombocytopenia, and so you should always
consider them when you see an infant with one of those conditions

255
Q

baby with hydrocephalus, chorioretinitis, and intracranial calcifications

A

congenital toxoplasmosis
All TORCH infections can cause poor feeding, fever, deafness, mental retardation, hepatosplenomegaly, and thrombocytopenia, and so you should always
consider them when you see an infant with one of those conditions

256
Q

baby with vesicular lesions on the skin, eyes, or mouth, …can lead to life-threatening disseminated disease or encephalitis

A

congenital herpes …especially in mom’s with active infections in pregnancy or during vaginal delivery

257
Q

symptoms of hypercalcemia

A 
“Bones, Stones, Abdominal Groans, and Psychiatric Undertones,
bone fractures
kidney stones
vomiting, constipation
weakness, fatigue, altered mental status
258
Q

causes of hypercalcemia

A 
CHIMPANZEES
Calcium oversupplementation
Hyperparathyroidism
Immobility or iatrogenic (thiazides!)
Milk alkali syndrome
Paget's disease
Acromegaly or Addison's
Neoplasms
Zollinger Ellison when associated with MEN 1 
Excess vitamin D
Excess vitamin A
Sarcoidosis
259
Q

charcot’s triad

A 
RUQ pain
fever chills
jaundice 
=
acute cholangitis

Reynold’s pentad = the above plus shock and altered mental status

260
Q

Testing positive for only Chlamydia mandates
treatment for only Chlamydia, BUT testing positive for only gonorrhea mandates treatment for BOTH gonorrhea and Chlamydia. Chlamydia is the most common STI, and patients with gonorrhea
(which is much less prevalent than Chlamydia) tend to be co-infected with chlamydia.
if you test postive only for chlamydia you get:
if you test positive only for gC you get:

A

chlamydia only: azithromycin

GC only: ceftriaxone + azithromycin

261
Q

tx for syphilis

A

one time IM benzathine penicillin G

262
Q

tx for acute dystonic reaction from antipsychotics

A

oral diphenhydramine

263
Q

symptoms of neuroleptic malignant syndrome

A

fever, muscle rigidity and increased CPK, autonomic instability
treat with IV Dantrolene

264
Q

tx for herpes encephelitis

A

Acyclovir is used to treat herpes encephalitis, which can present with increased lymphocytes in the CSF. However, the hallmark of herpes encephalitis on CSF analysis is a markedly
elevated RBC

265
Q

tx for bacterial meningitis in adults

A

ceftriaxone if you’re not worried about drug resistant strep pneumo

vancomyocin + cefotaxime if you’re worried about drug resistant strep pneumo

266
Q

hallmark signs of cryptoccocal meningitis

A

elevated opening pressure on lumbar puncture! this is opportunistic infection seen in HIV or immunocompromised pts. Treatment is Amphotericin B and flucytosine
confirm with latex agglutination or India ink preparation

267
Q

what do you do for a clot in the superficial femoral vein?

A

anticoagulation because it’s actually a deep vein

268
Q

what do you do for a superficial vein clot?

A

rest, NSAIDs, elevation, and heat

they’re more likely to be palpable

269
Q

pANCA, pt with ulcerative colitis or chron’s disease, pruritis, maybe portal hypertension leading to hepatosplenomegaly, onion skin fibrosis of bile ducts, beading on ERCP

A

primary sclerosing cholangitis

liver transplant = tx

270
Q

vertigo + hearing loss following viral illness

A

labarynthitis (vestibular neuritis) self limited. oral corticosteroids may help it go away sooner. + antiemetics benzodiazopenes antihistamines

271
Q

Describe cover-uncover test for strabismus

A

cover-uncover test is used to test for strabismus. In a normal patient, there should be no movement of the eyes when either one is covered and then uncovered. If the patient’s eyes are
misaligned, however, the non-dominant eye will jump and re-fixate once the dominant eye is uncovered. tx is occlusion of dominant eye

272
Q

whats the most common mutation in retinoblastoma

A

mutations in both copies of RB tumor suppressor

273
Q

severe acne vulgaris treatment

A

oral isotretinoin
teratogen
raises TGs
hepatoxicity

274
Q

treatment for mild acne

A

topical retinoid, topical salicyclic acid, topical benzoyl peroxide
try for 3 months. if it doesnt work, add topical antibiotic like clindamycin

275
Q

treatment for pseudotumor cerebrei

A

acetazolamide, may need surgery

remember, the danger of the raised intracranial pressure is risk of blindness

276
Q

cosyntropin stimulation test checks for…

A

response of adrenal glands…cosyntropin is synthetic ACTH so it should cause the adrenals to release cortisol if they are acting correctly. This is diagnostic for Addisons (primary adrenal insufficiency) or if they adrenals are hypoprofused (secondary adrenal insufficiency – commonly caused by abruptly stopping steroid meds)

277
Q

fatigue, weakness, weight loss, diarrhea, nausea, hyperpigmentation on joints, face, neck; low cortisol levels after cosyntropin/ACTH administration

A

primary adrenal insufficiency (Addisons) : hydrocortisone to replace corticoids and flutracortisone to replace mineralocorticoids

278
Q

methacholine challenge is for diagnosis of…

A

asthma
methacholine should decrease FEV1, seldom done because seems awfully mean

wheezing on physical exam means the problem is bronchioles

279
Q

palivizumab

A

antibody prophylaxis for RSV

280
Q

What we call pre-renal “failure” is really a normal physiological mechanism that occurs in response to decreased renal perfusion
pressure. Although the kidneys are failing to do their job of removing wastes from the body, the kidneys themselves haven’t “failed” – if they were getting enough blood, they’d be able to do their
job just fine! Therefore, here’s an easy way to remember that the key feature of pre-renal disease is an elevated BUN/creatinine ratio. Remember that the body’s normal BUN/Cr is 10-15:1. In
ATN, that ratio doesn’t change, because the body retains both BUN and creatinine equally. However, in pre-renal failure, the body retains more BUN than creatinine, leading to an increase in the
BUN/Cr ratio. Therefore, if the kidneys are able to retain more BUN than creatinine, they must be intrinsically working okay – the diagnosis is pre-renal disease, not ATN. If you want a more
detailed explanation, keep reading; otherwise, feel free to skip to the next teaching point! Unlike creatinine, which is freely filtered at the glomerulus and is not reabsorbed or metabolized by the
kidney, about half of the filtered BUN gets passively reabsorbed, mainly at the proximal tubule. Remember that when there is decreased blood flow to the kidney, almost of the reabsorption of
sodium and water occurs at the proximal tubule instead of other “downstream” segments of the nephron. Thus, urea nitrogen gets reabsorbed at the proximal tubule as well, leading to an
increase in BUN that is greater than the increase in creatinine.

A

Other than pre-renal disease, there are a couple of other conditions that can increase the BUN out of proportion to the
creatinine. One is a GI bleed – reabsorption of RBCs in the gastrointestinal tract will increase the BUN. Corticosteroids and tetracyclines (which inhibit protein anabolism) also can increase the
BUN. 4) You can think about the FeNa in much the same way as the BUN/Cr ratio. If the FeNa is low – less than 1% - then the kidneys are avidly holding on to sodium. If they’re able to do that,
the kidneys themselves must be doing okay, and the problem must be that they’re not getting enough blood. Patients with ATN have an elevated FeNa (>2%) because the kidney becomes like a
leaky sieve and allows sodium to escape. 5) One important limitation of the FeNa is that it is affected by diuretics, which cause increased loss of sodium in the urine. In patients taking diuretics,
the fractional excretion of urea (FeUrea) should be measured instead. 6) Hyaline casts are occasionally seen in normal urine, and so they are commonly mentioned as a distractor on the
USMLE. Other casts are always pathological. The finding of “muddy brown” or granular casts is pathognomonic for ischemic ATN. Cytotoxic effects of iodinated contrast material (answer A) is the
mechanism of contrast nephropathy. Always consider this as a possibility in any patient who receives i.v. contrast – especially patients who are elderly or have diabetes or pre-existing chronic
renal insufficiency. T

281
Q

complication of IBD where pt presents with decreased bowel sounds or maybe diarrhea/vomiting, severe abdominal pain, signs of sepsis, ab distension

A

toxic megacolon
seen on ab x ray - loss of haustration, multiple air fluid levels
icu - NPO, correct electrolytes
may need surgery

282
Q

lots of neutrophils in blood or csf, think bacterial infection
lots of _____, think viral

A

leukocytes

283
Q

calculate anion gap

A

cations - anions
Na+ -Cl- - HCO3-
normal is 6-12

284
Q

normal anion gap

A

6-12

285
Q

diabetic ketoacidosis

A

primarialy DM1
high anion gap acidosis
hyperglycemia–> hyerperosmolality–>osmotic diuresis–>dehydration,
insulin deficency–> body has to rely on lipolysis –> ketone production–> ketosis and using up bicarb as a buffer __> high anion gap acidosis
Insulin deficiency → hyperosmolality → K+ shift out of cells + lack of insulin to promote K+ uptake → intracellular K+depleted → total body K+ deficit despite normal or even elevated serum K+ There is a total body potassium deficit in DKA. This becomes important during treatment, when insulin replacement leads to rapid potassium uptake by depleted cells and patients may require potassium replacement.
fruity breath, abdominal pain, dehydration,
somnulence
coma
all happens in less than 24 hrous
tx: fluid resuscitation, insulin, bicarb if pH <6.9

286
Q

hyperosmolar hyperglycemic state

A

more common in DM2
characterized by symptoms of marked dehydration (and loss of electrolytes) due to the predominating hyperglycemia and osmotic diuresis.
N/V, polyuria, polydipsia, altered mental status, coma, slower onset than DKA

287
Q

Severe asthma attack. try IV methylprednisolone and nebulized albuterol and supplemental O2. Rising CO2 in the face of sustained tachypnea is a
very ominous sign - it shows that the patient’s airways are so constricted that he is no longer able to get rid of CO2! If a normal patient began breathing at 35-40/minute (like this patient) they
would very soon have a pCO2 in the teens or 20s as they blew off their CO2. This patient also appears to be fatiguing as well - his respiratory rate has dropped from 42 to 35

A

pulsus paradoxus is a bad sign in an asthma attack – a drop of more than 10 mmHg during inspiration
a lack of wheezing on auscultation during severe asthma attack is actually a bad sign “silent chest”–> not moving enough air to make wheezes
you don’t need imaging for asthma attack

288
Q

treatment for onchymyccosis

A

3 months oral terbinafine and itraconazole

remember to do scrapings and KOH examination

289
Q

what do you do for low grade vesiculouretral reflux in babies

A

abx prophylaxis for uti, routine screening cx every 3-4 months, they’ll probably outgrow the reflux

290
Q

how do you know if ascites is exudative or transudative

A

serum albumin -ascites albumin >1.1 is transudative and caused by portal hypertension: right sided CHF, cirrhosis, budd chiari
serum albumin - ascites albumin <1.1 is exudative and caused by other things like pancreatitis, peritonitis, mets,

291
Q

idiopathic avascular necrosis of the hip that occurs in children ages 3-12 with a peak incidence is 5-7 years old. It predominantly affects males and
10% of cases are familial. Patients present with a limp and Trendelenburg gait (pelvis tilts downward on unaffected side while trunk sways toward affected side during stance). Pain is mild and
usually referred to anteromedial thigh or the knee, but can lead to disuse causing atrophy of the thigh and buttock. Physical exam reveals limited internal rotation and abduction of the hip. Initial
radiographs are usually normal, but bone scans can show decreased perfusion to the femoral head, and MRI will show marrow changes

A

Legg-Calve-Perthes disease

292
Q

Renal tubular acidosis type 1

A

mild dehydration, hypokalemia –> muscle cramps, paralysis, fatigue, kidney stones, calcifications in kidneys
caused by autoimmune disorders, inherited, meds like amphotericin B, lithium, analgesics
distal convoluted tubes; alpha interculated cells cant secrete protons or they are leaky from lithium and amphotericin B and protons are diffusing from tubule into cell to blood.

293
Q

Renal tubular acidosis type 2

A

cant reabsorb bicarb in proximal convoluted tubule
academia, hypokalemia
nausea, vomiting, muscle cramps and paralysis, fatigue, kidney stones, calcifications, urine may still be acidified
-Fanconi syndrome (aminoaciduria, uric aciduria, proteinuria, glucosuria, phosphaturia) (genetic or from tetracyclines)

294
Q

Renal tubular acidosis type 4

A 
aldosterone resistance or aldosterone deficiency in collecting duct --> hyperkalemia -> arrhythmia
ENAC transporter mutation
Addisons (no aldosterone)
severe hypovolumeia 
lupus

less ammonium in the urine

295
Q

Tx for renal tubular acidosis type I

A

want to correct academia by replenishing bicarb, correct hypokalemia
-give potassium citrate

296
Q

Tx for renal tubular acidosis type II

A

give potassium citrate and thiazide diuretics

vit D and calcium in kids

297
Q

tx for renal tubular acidosis type IV

A

correct hypoaldosteronism

give fludrocortisone, loop diuretics to increase sodium delivery, increase K+/H+ exchange

298
Q

underlying deficiency in renal tubular acidosis type IV

A

Deficiency of or inability to respond to the hormone aldosterone

299
Q

underlying deficiency in renal tubular acidosis type ii

A

innability to reabsorb bicarbonate from the urine

300
Q

underlying deficiency in renal tubular acidosis type 1

A

Inability to excrete acid in urine

301
Q

key lab abnormalities seen in alcoholics include
hypoglycemia; macrocytic anemia; elevated AST and ALT, with a 2:1 ratio of AST/ALT; low magnesium; elevated PT; and low albumin. Don’t give iv fluid with glucose to an alcoholic without first giving …… or you’ll maybe precipitate….

A

thiamine

wernicke’s encephalopathy

302
Q

vital signs in delirium tremens

A

htn
tachycardia
low fever

303
Q

young, asymptomatic patient with cervical lymphadenopathy

A

) or an incidentally-found widened mediastinum. The presence of symptoms generally indicates a worse prognosis. Typical symptoms include
the “B symptoms” of fever, night sweats, and unexplained weight loss. More rarely, patients complain of pruritus (especially after a hot shower) or severe pain following alcohol ingestion. If any of these
findings are described on the USMLE, it’s almost always a tipoff that the diagnosis is Hodgkin’s. -There are several commonly used staging systems for Hodgkin’s lymphoma, but the only one that you’re
likely to be tested on is the simple Ann Arbor system. Under this classification, stage I disease involves only a single lymph node region, stage II disease involves two or more lymph node regions on the
same side of the diaphragm, stage III disease involves lymph node regions on both sides of the diaphragm, and stage IV describes disseminated disease.

304
Q

pell epstein fevers (cyclical fever) associated with…

A

hodgkin lymphoma

305
Q

symptoms related to pancytopenia (like easy bruising, anemia, or neutropenia). The CBC should show a high WBC, and microscopic examination
should show numerous circulating myeloid blasts. If you suspect this diagnosis, the next step is a bone marrow biopsy.

A

aml

306
Q

the most effective tx for allergic rhinitis is

A

nasal corticosteroids like nasal beclomethasone

307
Q

community acquired MRSA treatment

A

trimethaprim-sulfamethoxazole, clindamycin

308
Q

abortive treatment for cluster headaches

A

100% oxygen

309
Q

2 most common causes of pancreatitis in US

A

gallstones
alcohol abuse
There are a number of less frequent but still important causes
like drugs (especially thiazides and steroids), hyperlipidemia, and instrumentation (like ERCP). 2) The treatment for pancreatitis is supportive care, designed to correct fluid and electrolyte
disturbances. This is a very serious disease, with an overall mortality of around 10%!

310
Q

the most common cause of isolated bloody nipple discharge in a healthy young
female

A

intraductal papilloma

If lesion is palpable: Core needle biopsy is confirmatory and rules out malignancy.
Shows papillary cells with fibrovascular core
Otherwise: ductogram
Treatment: surgical excision

311
Q

Multiple ring enhancing lesions throughout the brain on CT

A

toxoplasmosis

312
Q

Cortical atrophy and ventricular enlargement on brain ct in setting of memory loss

A

alzheimers

313
Q

classic triad of symptoms in normal pressure hydrocephalus

A

memory loss
gait disturbance
urinary incontinence

A CT in this patient would likely show ventricular enlargement
(hydrocephalus) WITHOUT cerebral atrophy
(alzheimers pts can have gait disturbance and urinary incontinence but it would be much much later in course of disease)

314
Q

focal segmental glomerulosclerosis

A

most common nephrotic syndrome in adults, esp latinx and blacks
unresponsive to steroids
associated with heroin, sickle cell, hiv
some glomeruli, some sclerosis
not immune mediated no immunofluroscence

315
Q

primary focal segmental glomerulosclerosis

A

most common nephrotic syndrome in adults, esp latinx and blacks
unresponsive to steroids
associated with heroin, sickle cell, hiv
some glomeruli, some sclerosis
not immune mediated no immunofluroscence

316
Q

secondary focal segmental glomerulosclerosis

A

some of the glomeruli die and the remaining glomeruli have compensatory hypertrophy and increased capillary pressure to try to maintain GRF

317
Q

membranoproliferative glomerulonephritis

A

subendothelial immune deposits - preformed antigen-antibody complexes. Why? who knows? but we don’t get inflammation but rather mesangial proliferation
tram tracking of basement membrane
immunofluroscent: granular pattern IgG and C3

318
Q

dense deposit disease

A

c3 nephritic factor antibody targets C3 convertase (which is increased in activity)
immunoflorescent pattern: linear ribbon of compliment C3 in basement membrane

319
Q

membranous disease (nephrotic syndrome)

A

subepithelial deposits

HIV, hep b hep c , syphilis, captopril, lung cancer, colon cancer, or primary/idiopathic

320
Q

Three Ps of MEN 1

A

MEN-1 is the “three P’s”: patients tend to have Parathyroid hyperplasia, Pancreatic islet tumors, and Pituitary tumors in
addition to gastrinomas and Zollinger ellison syndome (one or many gastrin-secreting tumors
cause the overproduction of gastric acid, leading to symptoms of mucosal ulceration, diarrhea, malabsorption, and GERD)

321
Q

MEN-2A

A

medullary thyroid cancer, phenochromocytomas, and hyperparathyroidism, so the mnemonic here is “2 MPH” (think “two miles per
hour”).

322
Q

MEN-2B

A

medullary thyroid carcinoma and pheochromocytoma, but NOT hyperparathyroidism.

323
Q

diagnosing zollinger ellison syndrom

A 
fasting gastrin (elevated)
basal acid secretion (elevated)
secretin stimulation test (paradoxical increase of gastrin with admin of secretin in ZE pts)
octreotide or somatostatin scan
remember association of ZE with MEN 1
324
Q

Parvovirus B19 can cause ______ in pts with hereditary spherocytosis or sickle cell disease

A

aplastic anemia

325
Q

in friedrich ataxia you die of…

A

cardiomyopathy

trinucleotide repeat

326
Q

nephrotic syndrome with subepithelial deposits of IgG and complement (spike and dome); thickened capillary loops

A

membranous (most common nephrotic syndrome among adults)

327
Q

membranous nephrotic syndrome is associated with…

A

hep B, solid tumors like lung cancer

328
Q

is poststreptococcal glomerulonephritis nephrotic or nephritic?

A

nephritic (hematuria, htn)

329
Q

lupus tends to cause membranous neprotic syndrome

A

thckened capillary loops, hypercholesterolemia, edema from salt retention, proteinura

330
Q

most common nephrotic syndrome among HIV+, african american, obesty, sickle cell patients, heroin use

A

focal segmental glomerulosclerosis

331
Q

Nodular glomerulosclerosis with Kimmelstiel-Wilson nodule

A

diabetic nephropathy

even though diffuse glomerulosclerosis is the most common finding

332
Q

most common cause of acute kidney injury (not pre renal)

A

acute tubular necrosis
muddy brown casts & epithelial cell casts
due to ischemia and/or toxins

333
Q

if you find low testosterone in a man, what test do you do next

A

LH/FSH if LH/FSH is low or normal, then you know it’s secondary hypogonadism (i.e. a central problem). You’ll want to check prolactin, TIBC (think hemochromatosis), maybe brain MRI. If LH/FSH are high, then it’s primary hypogonadism and something wrong with the testes…like klinefelters for example and you’ll want karyotyping

334
Q

Patients being treated with amiodarone (Cordarone) should be monitored periodically with serum
levels of

A

TSH

335
Q

pathogenesis of TTP

A

deficiency or autoantibodies against ADAMTS13, usually aquired, like most autoimmune stuff middle age women. Risk factors are pregnancy, systemic illness like HIV, SLE, cancer, infection.
ADAMTS13 doesn’t cleave von Willebrand factor complexes, which then hang around and stick to the endothelia of microvasculature all over the place causing tiny clots –> shearing of RBCs –> ischemia, especially in brain and kidney
Remember pentad of clinical signs: Thrombocytopenia (all the platelets get used up), Neuro signs, Microangiopathic hemolytic anemia (jaundice!), Impaired renal function, Fever

336
Q

pathogenesis of TTP

A

deficiency or autoantibodies against ADAMTS13, usually aquired, like most autoimmune stuff middle age women. Risk factors are pregnancy, systemic illness like HIV, SLE, cancer, infection.
ADAMTS13 doesn’t cleave von Willebrand factor complexes, which then hang around and stick to the endothelia of microvasculature all over the place causing tiny clots –> shearing of RBCs –> ischemia, especially in brain and kidney
Remember pentad of clinical signs: Thrombocytopenia (all the platelets get used up), Neuro signs, Microangiopathic hemolytic anemia (jaundice!), Impaired renal function, Fever
urgent tx = plasmopheresis or even splenectomy

337
Q

external rotation of the shoulder involves

A

infraspinatus teres minor

338
Q

which diuretics increase risk of gout

A

thiazides

loop diuretics

339
Q

acei can cause ____kalemia

A

hyperkalemia

340
Q

thiazides can cause ____kalemia

A

thiazides can cause hypokalemia

341
Q

what kind of medication can you give to help a kidney stone pass faster

A

alpha 1 blocker
tamsulosin
doxazosin
prazosin

342
Q

what labs predict pancreatitis severity

A

BUN creatinine hematocrit

343
Q

hemoglobinapathies like sickle cell falsly lower A1c. instead get…

A

serum fructosamine

344
Q

TMP-SMX can cause —- that predisposes to infection

A

agranulocytosis

look for low leukocytes

345
Q

ampicillin sulbactum is empiric treatment for lung abscess (think aspiriation)

A

strep pneumo, gram negative anaerobes

346
Q

first line allergic conjunctivitis

A

ketorolac, ketotifen (antihistamin)

2nd line is glucocorticoid like flourometholone

347
Q

elevated LH:FSH ratio is marker in common syndrome…

A

PCOS

348
Q

serious side effect of metformin

A

lactic acidosis

watch for kidney or heart problmes…more risk of lactic acidosis

349
Q

first step in nonmassive hemoptysis

A

CXR

350
Q

dry cough, uveitis, symmetrical arthritis, no autoantibodies

A

get CXR…look for hilar lymphadenopathy and chronic sarcoidosis. Biopsy is diagnosis (noncaseating granulomas)
increased calcium levels, ACE levels, restrictive PFT pattern;
if symptomatic…glucocorticoids

351
Q

antibody in granulomatosis with polyangiitis

A

c-ANCA

352
Q

extra articular manifestation of ankylosing spondylitis

A

cardiac stuff, uveitis, prostitisi, nephropathy, inflammatory bowel disease
no antibodies
HLA B 27

353
Q

af am woman with nephritis, history of miscarriages, and pleuritis

A

think SLE!
she will have low complement levels
+anti ds DNA

354
Q 
B symptoms (fever night sweats...)
smudge cells on peripheral blood smear
lymphocytic leukocytosis with suppression of other blood lines should point to...
 B-cell antigens CD5, CD19, CD20, and CD23 on flow cytometry
A

chronic lymphocytic leukemia

355
Q

most common cause of epididymitis in sexually active men <35

A

CT, GC

356
Q

CREST syndrome antibodies

A

anti centromere

357
Q

infertility workup for woman

A
  1. progesteron level at luteal phase
    then…
  2. hysterosalpingography to make sure tubes are patent
    then…
  3. FSH, prolactin, estradiol
    then…
    referral

family med (1 decks)

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