general Flashcards
(357 cards)
1
Q
polymayalgia rheumatica is associated with __________ (causes headache)
A
giant cell arteritis
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
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)
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
5
Q
3 complications of osteomyelitis
A
sequestrum, abscess, or, in children growth impairment
6
Q
imaging of choice for osteomyelitis
A
MRI (not visible on Xray for first two weeks)
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;
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)
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)
10
Q
Felty syndrome
A
rheumatoid arthritis + granulocytopenia + splenomegaly
- *can lead to life threatening infections **
tx: methotrexate
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!)
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)
13
Q
labs in piagets disease of the bone
A
elevated alk phos, normal serum calcium and phosphate
14
Q
most common lung cancer in non smokers,
A
adenocarcinoma
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
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
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
18
Q
diagnostic test to differentiate between chlamydia and gonorrhea
A
nuclea acid amplification test
19
Q
treatment for genital chlamydia
A
azithromycin or doxycycline
20
Q
treatment for mastitis
A
dicloxacillin & continued breast feeding (covers s.aureus)
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
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
23
Q
most common vaginal cancer
A
squamous cell carcinoma, usually caused by HPV type 16 or 18
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.
25
Pap smear recommendations
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.
26
syphilis screening
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
27
tx for endometriosis
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
28
steps of diagnosis for endometriosis
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!
29
morning sickness treatment options in order of preference
1. pyridoxine (B6)
2. doxylamine
3. diphenhydramine of dimenhydrinate
4. last resort: methylprednisolone (not in 1st trimester)
30
PID outpatient treatment
one dose IM ceftriaxone and then oral doxy
31
Foul-smelling, frothy, yellow-green, vaginal purulent discharge with pH>4.5
Trichomonas, protozoa with multiple flagella on saline wet mount
treat with metronidazole or tinidazole
32
screening for chlamydia trachomatis and N. gonorrhea
screening for sexually active women 24 and younger and older women at increased risk
nucleic acid amplification testing (NAAT)
33
treatment for yeast infection
topical nystatin, topical azoles or oral fluconazole
34
symptoms and treatment for Legionnaire's disease
watery diarrhea and atypical pneumonia (cough, low grade fever, sob), hyponatremia, patchy lung infiltrates
Levofloxacin
35
first line for acute bacterial rhinosinusitis
oral amoxicillin-clavulanic acid (penicllin +beta lactamase inhibitor)
36
superior vena cava syndrome is most commonly caused by _______cancer or ________________ (particularly young patients)
```
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.
```
37
granulommatous disease like sarcoidosis, tuburculosis, chrons, cat scratch fever, granulomatosis with polyangiitis, etc. are associated with high serum _____
high serum calcium
| macrophages produce more 1alpha hydroxylase which activates vitamin d leading to bone resorption
38
antiarrhythmic associated with pulmonary fibrosis and chronic interstitial pneumonitis!
amiodarone (blocks voltage gate K+ channels used for vtach and vfib, low negative ionotrope)
39
tx for vasomotor rhinitis
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.
40
complications of bronchiectesis
damage to broncheal vessels --> hemoptysis (usually self limited), hemorrhage
cor pulmonale
41
pathophys of bronchiectesis
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.
42
Light's Criteria
```
- 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
```
43
name some thangs that cause transudative pleural effusions
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
44
name some thangs that cause exudative pleural effusions
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
45
___________ 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
GERD
| PPIs (prazoles)
46
COPD pathophys
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.
47
tactile fremitus is ___________ in pneumonia
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
48
tactile fremitus is __________ in pleural effusion
decreased
49
painless genital ulcers which heal spontaneously within a few days followed by swelling of LNs in a few weeks +/- abscess, pus
Lymphogranuloma venereum
Chlamydia trachomatis serotypes L1, L2, L3
tx: doxycycline
untreated can lead to chronic lymphedema, strictures, infertility
50
very painful genital ulcers with necrotic base, usually one for men, multiple for women, often with painful inguinal lymphadenopathy
chancroid caused by Haemophilus ducreyi
| tx: azithromycin or single dose IM ceftriaxone
51
granuloma inguinale: cause, symptoms, treatment
large, painless ulcers, beefy red, bleed easily; may get bacterial superinfection and smell bad
caused by Klebsiella granulomatis (Donovan bodies)
tx: azithromycin
52
_____________ is associated with a positive Prehn sign (relief of pain when lifting the testicle)
epididymitis
53
prostate cancer most commonly mets to ____
bone
54
step 1 treatment
SABA PRN (albuterol, levalbuterol, terbutaline)
55
step 2 treatment for asthma
low dose ICS (fluticasone, budesonide, bethomeclasone, mometasone, etc)
56
intermittent asthma criteria
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
57
step 3 for asthma
```
low dose ICS+ LABA
Advair (fluticasone +someterol)
Symbicort (budesonide + formeterol)
Dulera (mometasone +formeterol)
consider adjunct tiotropium (antimuscrinic), allergen immunotherapy)
```
58
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
referral!
| Med dose ICS+LABA
59
Steps 5, 6 for asthma
referral! high dose ICS+LABA, maybe oral corticosteroids, maybe anti
60
name 2 long acting insulins
glargine (Lantus)
| Detemir (Levemir)
61
name 3 rapid acting insulins
novolog (Aspart)
humalog (Lispro)
Glulisine (Apidra)
if you get hit in the head with a log, it will hurt rapidly
62
name a short acting insulin
regular, human insulin Humulin R, Novolin R
63
name an intermediate acting insulin
NPH Humulin N, Novolin N
64
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
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
65
in nonblack pts, initial htn treatment should include
thiazide, ARB, ACEI, or calcium channel blocker
66
in black pts, initial htn treatment should include
thiazide or calcium channel blocker
67
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.
one month
68
Do not combine an ACEi with ______
ARB
69
causes of secondary hypertenstion
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
70
USPSTF recs for pap smears
every 3 years starting at 21; every 3 years after 30 or every 5 years if combined cytology with HPV testing
71
USPSTF recs for HIV screening
all preggers
| all ppl 15-65
72
USPSTF recs on osteoporeosis screening
screening in women > 65years unless increased risk
73
does acetaminophen have anti inflammatory properties?
no
74
does acetaminophen have bleeding effects?
no
75
acetaminophen has ____ toxicity
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)
76
2 major risks of NSAIDS
```
renal toxicity
GI bleeding (be careful in elderly, may prescribe ppi)
```
77
topical nsaids
lidocaine (otc), diclofenac (can be really expensive)
78
gabapentin, topiramate, and cymbalta can all be used to tx_____
pain
79
antibodies in primary biliary cholangitis?
asymptomatic at first --> pruritis, fatigue, sky high cholesterol, jaundice --> cirrhosis, portal hypertension, ascities, gi bleed
anti mitochondrial
80
name drug used to treat primary biliary cholangitis
ursodeoxycholic acid
| maybe liver transplant
81
ursodeoxycholic acid is used to treat
primary biliary cholangiitis
82
tx acute gout
cholcocine and nsaids like indomethacine
| allopurinal for prevention
83
celiac tests
```
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)
```
84
recurrent sinusitis/pneumonia/bronchitis + situs inversus + infertility
primary ciliary dyskinesia (Kartagener)
85
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
varicocele
GET US!
tx: laprascopic varicolectomy
86
____________ polyps carry the highest risk of malignant transformation of all types of colonic polyps
adenomatous
| villous adenomatous is the worse
87
contraindication for rotavirus vaccine
hx of intussusception
88
what pneumo vaccine to healthy adult over 65?
PPSV23
89
what pneumo vaccine to immunocompromised adult?
PCV13 then PPSV23 at least 8 weeks later
90
guidelines for when to treat osteoporosis
t score
91
treatment for osteoporosis
- 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
92
amitriptyline side effects
TCA, dry mouth, blurred vision, constipation , risk of overdose
93
pharma therapy for fibromyalgia
*always give exercise rx (moderate aerobic 20-30 min 2-3x wk)
amitriptyline, duloxetine, milnacipran, gabapentin, pregabalin (lyrica), cyclobenzaprine (muscle relaxant)
94
tx for postmenopausal vaginal dryness
topical estrogen cream
95
tx for bacterial vaginosis
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)
96
tx vulvovaginal candidiasis in pregnancy
intravaginal clotramazole
97
2 major complications of giant celll arteritis
blindness, aortic aneurism
98
what antibiotic for rheumatic fever
penicillin
99
Lupus symptoms
* 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
100
Sjorgens antibodies
anti Ro/SSA
| anti La/SSB
101
acute treatment of COPD exacerbation
bronchodilators (like albuterol and ipratropium (anticholinergic)),
systemic steroids,
antibiotics,
possibly O2
102
spirometry findings in COPD
reduced FEV1, reduced FVC,
| FEV1:FVC <70
103
Treat COPD pts based on their GOLD category. But my shortcut: if <= 1 exacerbation (no hospital) a year with mild symptoms, give them ______
light COPD: salbutemol or salmeterol
| more severe: tiotropium (LAMA) and maybe salmeterol too
104
Treat COPD pts based on their GOLD category. But my shortcut: if <= 1 exacerbation (no hospital) a year with mild symptoms, give them ______
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
105
guidelines for O2 therapy for COPD
when sat 88% at rest; use at least 15h a day to decrease mortality
106
abx for strep pneumo
penicillin (macrolide if they are allergic)
107
tx for peripheral arterial disease
1. superivised graded exercise therapy, smoking cessation
2. aspiring, clopidegrel, statin! manage BP and blood sugar
3. if still symptomatic, give cilostazol (phosphodiesterase inhibitor)
108
cilostazol
phosphodiesterase inhibitor, used for PAD if conservative treatment, aspiring, clopedigrel doesnt work
109
a septic joint on exam:
very limited range of motion
| ROM preserved if it's nearby cellulitis, bursitis, osteomyeolitis
110
lab findings in RA
RF
anti CCP (anti citrullinated protein antibody)
elevated sed rate and CRP
anemia
thrombocytosis
low albumin (correlates with severity of disease)
111
acute treatment for gout
nsaids (be careful in elderly, may need to add ppi)
maybe colchicine
maybe glucosteroids
112
long term treatment/prevention gout
allopurinol (reduces uric acid production)
| probenecid (increases uric acid secretion)
113
sulfasalazine
DMARD for RA
114
infliximab
anticytokine for RA
115
etanercerpt
anticyokine for RA
116
recent stomach bug or UTI followed by migratory arthritis, maybe conjunctivitis or iritis, dysuria
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)
117
tx for disseminated lyme disease
ceftriaxone
118
tx for localized lyme disease
doxycycline
119
name symptoms of stage II of lyme disease
carditis
migratory arthralgia --> lyme arthritis (large joints)
early neuroborreliosis: (usually cranial nerve like facial palsy)
erythema migrans
120
name symptoms of late lyme disease
months to years later
| chronic lyme arthritis, late neuroborreolosis: asepctic/lymphocytic meningitis, progressive encephelomyeolitis
121
which antihypertensive class increases gout risk?
hydrochlorothiazide
122
labs at initial prenatal visit
```
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
123
folic acid supplement: take ______ before conceiving
1 month at least, 400-800ug for low risk. 1mg for DM, 4mg if previous neural tube defect child
124
congenital rubella
```
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
```
125
syphilis in pregnancy
treat with penicilin If less than 1 year, 1 dose IM.
| If more than 1 year or unknown, penicillin IM each week x3
126
gonorrhea in pregnancy
may cause preterm labor, blindness
| ceftriaxone
127
Chlaymydia in pregnancy
may cause neonatal blindness, pneumonia
| azithromycin or amoxicillin
128
if mom is Hbsag pos in pregnancy
check LFTs and hep serology to determin if chronic or active. Baby will need Hep B vaccine and HepB IG right away
129
nuchal translucency can be given at _____ weeks pregnancy or combined test (NT, hCG, and PAPP-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
130
trisomy screen at weeks ______ of pregnancy
15-20
| tests reveal risk not dx. may be skewed by inaccurate dating. offer genetic amniocentesis
131
trisomy screen at weeks ______ of pregnancy
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
132
GBS culture in pregnancy at weeks __________
35-37 if positive you get penicillin during labor. helps to prevent early group B strep sepsis pneumonia or meningitis of newborn
133
name 2 vaccines you can get in pregnancy
tdap, flu
134
baby gives social smile at __ mo
2 months
| focus on face at 1 mo
135
baby sits well unsupported at --- months
6
136
baby says mama dada byebye at --- mo
9 months
137
baby crawls at ---- months
9
138
baby walks at --- months
12
139
baby babbles at ---- months
6
140
age 3 developmental milestones
rides tricycle, 3/4 of speech understood by strangers, , bridge of 3 cubes, repeats 3 numbers, plays in a group (3 kids)
141
vision screen rec to rule out amblyopia/stabismus
3-5 yo
| strabismus should be referred to a pediatric ophthalmologist
142
vaccines at birth
Hep B
143
vaccines at 2 mo
```
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
vaccines at 6 mo
```
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
vaccines at 4 mo
```
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
vaccines at 12-18mo
Dwarf People Holler and Hate Many Vaccines
```
Dtap
PVC
Hep A (one at 12 month, second dose 6 mo later)
Hib
MMR
Varicella
```
147
vaccines at 4-6 yo
```
Don't Poke Me, Val
Dtap
Polio
MMR
Varicella
```
148
a common complication of topical decongestants
rebound congestion
149
allergic rhinitis exam
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
tx allergic rhinitis
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
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
3. oral decongestant: pseudoephedrine . rebound congestion
152
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
leukotriene inhibitors like montelukast, zileuton. also used in asthma.
153
tx for anaphylaxis (cutaneous sympommts, dyspnea, visceral edema, hypotension)
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
tx for acute uticaria
eliminate trigger, second gen antihistamine like loratadine, ceterizine, fexofenadine, ranitidine
ranitidine+diphenhydramine particularly effective
155
most common cause of keratoconjunctivitis
adenovirus , usually with URI symptoms, tarsal conjunctival cobblestoning, morning crusting, modest discharge, usually bilateral
give antihistamines, decongestants. compress?
156
contraindications for bupropion
recent MAOi use, eating disorder, seizure disorder
157
pharmacological smoking cessation aid
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
fatigue, weakness, dyspnea, palpitations in geriatric pt
always consider anemia! check conjunctival pallor
| also CHF, afib, angina
159
glossitis, decreased vibratory and positional senses, ataxia, confusion, dementia, pearly grey hair at early age, paresthesia, headache palpitation
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
anemia workup
CBC with RBC indices
peripheral blood smear
reticulocyte count
161
lab findings in iron deficiency anemia
```
microcytic
low ferritin
low serum iron
low transferrin saturation
High TIBC
```
162
folate deficiency is most common among _____ and B12 is most common among people with ______
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
if qrs is upright in leads ______ of ecg, then axis is okay
I, II
164
how to calc hr on ecg
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
how to find axis on ecg
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
squared off flattening of st segment on ecg
ischemia
167
downslope of st segment on ecg plus u wave
hypokalemia
168
normocytic anemia may occur in renal disease because of....
decreased EPO production by the kidneys
169
lab findings in anemia of chronic inflammation
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
pernicious anemia
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
virus, E coli, shigella, salmonella, giardia, cambylobacter and amebiasis are most common causes of...
acute gastroenteritis
| 1. test stool for fecal leukocytes!
172
most pts with acute diarrhea have self-limited processes and do not require much workup. But you need to be more cautious when...
```
bloody diarrhea
kids or elderly
diarrhea >48 hrs
volume depletion
fever >100.4
severe abdominal pain
immunocompromised pts
```
173
travelers diarrhea treatment
- 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
vomiting and diarrhea 6 hours after eating...
s. aureus
175
test and tx for C. difficile
C. difficile toxin immunoassay
| metronidazole or vancomycin
176
hormonal replacement therapy for women can increase risk of...
bad cardiovascular outcomes
177
screen all women over ___ yo for hyperlipidemia
45
178
when should you get an ankle or foot xray?
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
management for ankle sprain
```
PRICE
protection
rest
ice
compression
elevation
& nsaids or acetominophen
```
180
provocative test for supraspinatus injury (rotator cuff)
empty can test
181
provocative test for subscapularis
lift off test
182
provocative test for infraspinatus and teres minor
external rotation with elbows flexed and arms at sides
183
provocative test for subacromial impingement of the supraspinatus tendon
hawkins impingement (flapping chicken wing)
184
how to test for large rotator cuff tear
drop arm test -- pt unable to slowly lower arm from raised position
185
how to test for anterior talofibular ligament tear
anterior draw ankle test
186
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)
calcaneofibular ligament
187
lachman test
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
anterior drawer test of knee tests for...
ACL tear
189
valgus test of knee
test medial collateral ligament (push inwards above knee, outwards at ankle; remember leg flexed to 30 deg)
190
varus test of knee
lateral collateral ligament
| pull lateral above knee, push medial at ankle or so. leg is flex at 30 deg.
191
when should you get a knee x ray
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
actinic keratosis and HPV raise risk for...
squamous cell carcinoma
193
most aggressive form of melanoma
nodular
| superficial spreading is most common form
194
dark spot under nail, on palm or sole of foot in African American pt or Asian american pt
acral lentiginous melanoma
195
work up for microscopic hematuria (no proteinuria)
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
name 3 first line tx for uncomplicated UTI
TMP-SMX
nitrofurantoin
fosfomycin
197
what arrhythmia occurs in hyperthyroid pts?
afib
198
pathophysiology of graves disease
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
propylthiouracil
anti thryorid drug for pregnant women
| can cause agranulocytosis
200
methimazol
first line antithyroid drug
| can cause agranulocytosis
201
thyroid storm symptoms
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
most common causes of hyperthyroidism
1. Graves disease
2. autonomous thyroid nodule (hyperfunctioning nodules rarely malignant)
3. early thyroiditis
4. overuse of thyroxine supplementation
203
difference in radionucleotide imaging of graves disease vs thyroiditis
thyroiditis is patchy uptake, reduced activity (just releasing everything already in there)
grave: huge uptake, huage activity
204
diminished relaxation phase of reflexes, low BP, nonpitting edema, hair loss, dry skin, depression, low energy, weight gain, slowed mentation, constipation, cold intolerance
hypothyroidism
205
most common cause of hypothyroidism
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
treatment for hypothyroidism
levothyroxine
207
are you more worried about cold or hot thyroid nodules on radionucleotide imaging?
cold : ( Gotta do a fine needle aspiration
208
carotid sinus syndrome
syncope, carotid sinus bulb stimulated in the neck , sinus pause, super rare, way less common than vasovagal
209
syncope workup
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
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
coarctation of aorta
| present in turner syndrome
211
hypertension in kid with increased urine VMA and HVA
neuroblastoma
212
anti centromere antibodies are marker for
scleroderma
213
outpt cap tx in adult
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
most common hereditary bleeding disorder
| normal PT, normal or increased PTT, increased bleeding time
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
microangiopathic hemolytic
| anemia, thrombocytopenia, mental status changes or neurological abnormalities, fever, and renal dysfunction
TTP
thrombocytopenic thrombotic purpura
give plasmopheresis!
splenectomy for refractory cases
216
Factor VIII is treatment for...
Hemophila A
217
functional ovarian cyst or physiological ovarian cyst
usually asymptomatic but can cause pelvic pain, fullness, constipation. Get ultrasound.
218
tuboovarian abscess
consider in pt with hx of PID who presents with fever lower abdominal pain leukocytosis
219
active pulmonary TB looks like lobar pneumonia with ipsilateral hilar lymphadenopathy and atelectasis. How do you treat?
```
R.I.P.E.
rifampin
isonizid
pyrazinomide
ethambutol
```
220
causes for short stature include endocrinopathies, growth hormone deficiency, malnutrition or abuse, or malignancy. What are the 2 most common causes?
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
what do you use to tx uti in preggars
bactrim, amoxicillin, augmentin, nitrofurantoin, cephalexin, other cephalosporins. Remember you treat even asymptomatic uti's if she's pregnant
222
parvovirus B19
fifth disease
slapped cheeks
erythema infectiousum
223
2 conditions associated with strawberry tongue
kawasaki and scarlet fever (GABHS)
224
name symptoms of kawasaki
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
treatment of kawasaki disease
serial ECHOs to watch for coronary artery aneurysm
aspirin (yep, in kids!)
IV IgG
corticosteroids
226
when deciding what gout prophylaxis , get 24 hr urine uric acid measurement. Undersecreters get _______ as prophylaxis and overproducers get_______
Undersecreters get probenecid
| overproducers get allopurenol.
227
causes of erythema multiforme
```
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
allergic triad
atopic dermatitis
allergic rhinitis
asthma
229
treatment for scabies
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
treatment for molluscum contagiosum
outside of genitals, let it ride. will resolve in immunocompetant host
231
what is the meaning of alpha fetoprotein
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
trigeminal neuralgia tx
oxcarbazepine or carbamazepine (antiepileptic drugs)
233
anti smooth muscle antibodies
autoimmune hepatitis
234
tx for autoimmune hepatitis
prednisone and azathioprine
235
first line tx for symptomatic bradycardia
atropine iv
236
hemolytic anemia, black gallstones, jaundice, splenomegaly in childhood
increased red blood cell distribution width
increased mean corpuscular hemoglobin concentration (MCHC)
spherocytosis
237
mutation in spherocytosis
defects in spectrin, ankyrin ...spherical RBCs get trapped in spleen...splenomegaly
238
Hemolytic uremic syndrome happens after infection with
shiga toxin enterohemorrhagic e coli O157:H7 (most often)
239
diarrhea followed by 1. renal probs 2. low platelets 3. hemolytic anemia (jaundice, dyspnea, fatigue)
hemolytic uremic syndrome
240
tx for functional constipation in kids
osmotic laxatives like polyethylene glycol
241
blood on urine dipstick but no rbcs on microscopy in setting of crush injury or extreme exercise
rhabdomyelosis, myoglobin cross reacts on urine dipstick
| give IV fluids to prevent ATN!
242
mupiricin is a topical abx used to treat...
impetigo
243
treatment for alopecia areta
steroids like clobetasol
| alopecia areta is autoimmune process
244
3 most common causes of chronic cough
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
vit K dependent clotting factors
II, VII, IX, X, S , C
246
in HIV pts when CD4 <200, begin prophylaxis for _____ with ________
pneumocystis carnii pneumonia
| trimethoprim-sulfamethoxazole
247
In HIV pts when CD4 <100, begin prophylaxis for _____ with _______
toxoplasmosis with trimethoprim-sulfamethoxazole
248
In HIV pts when CD4 <50, begin prophylaxis for _______ with__________
mycobacterium avium complex (MAC) with azithromycin or clarithromycin
249
PPD is positive in high risk pt (e.g. hiv+) if greater that __ mm
5
250
PPD is positive in medium risk pt (eg homeless) if grerater than __ mm
10
251
PPD is positive in low risk pt if greater than--- mm
15
252
treatment for recurrent candiasis in hiv+ pts
fluconazole
253
infant with rash involving the palms and soles, and the blood-tinged purulent nasal discharge (known as the “snuffles”, Lymphadenopathy and organomegaly
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
baby with deafness and cataracts as well as numerous purpuric skin lesions in mom without prenatal care
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
baby with hydrocephalus, chorioretinitis, and intracranial calcifications
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
baby with vesicular lesions on the skin, eyes, or mouth, ...can lead to life-threatening disseminated disease or encephalitis
congenital herpes ...especially in mom's with active infections in pregnancy or during vaginal delivery
257
symptoms of hypercalcemia
```
“Bones, Stones, Abdominal Groans, and Psychiatric Undertones,
bone fractures
kidney stones
vomiting, constipation
weakness, fatigue, altered mental status
```
258
causes of hypercalcemia
```
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
charcot's triad
```
RUQ pain
fever chills
jaundice
=
acute cholangitis
```
Reynold's pentad = the above plus shock and altered mental status
260
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:
chlamydia only: azithromycin
GC only: ceftriaxone + azithromycin
261
tx for syphilis
one time IM benzathine penicillin G
262
tx for acute dystonic reaction from antipsychotics
oral diphenhydramine
263
symptoms of neuroleptic malignant syndrome
fever, muscle rigidity and increased CPK, autonomic instability
treat with IV Dantrolene
264
tx for herpes encephelitis
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
tx for bacterial meningitis in adults
ceftriaxone if you're not worried about drug resistant strep pneumo
vancomyocin + cefotaxime if you're worried about drug resistant strep pneumo
266
hallmark signs of cryptoccocal meningitis
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
what do you do for a clot in the superficial femoral vein?
anticoagulation because it's actually a deep vein
268
what do you do for a superficial vein clot?
rest, NSAIDs, elevation, and heat
| they're more likely to be palpable
269
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
primary sclerosing cholangitis
| liver transplant = tx
270
vertigo + hearing loss following viral illness
labarynthitis (vestibular neuritis) self limited. oral corticosteroids may help it go away sooner. + antiemetics benzodiazopenes antihistamines
271
Describe cover-uncover test for strabismus
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
whats the most common mutation in retinoblastoma
mutations in both copies of RB tumor suppressor
273
severe acne vulgaris treatment
oral isotretinoin
teratogen
raises TGs
hepatoxicity
274
treatment for mild acne
topical retinoid, topical salicyclic acid, topical benzoyl peroxide
try for 3 months. if it doesnt work, add topical antibiotic like clindamycin
275
treatment for pseudotumor cerebrei
acetazolamide, may need surgery
| remember, the danger of the raised intracranial pressure is risk of blindness
276
cosyntropin stimulation test checks for...
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
fatigue, weakness, weight loss, diarrhea, nausea, hyperpigmentation on joints, face, neck; low cortisol levels after cosyntropin/ACTH administration
primary adrenal insufficiency (Addisons) : hydrocortisone to replace corticoids and flutracortisone to replace mineralocorticoids
278
methacholine challenge is for diagnosis of...
asthma
methacholine should decrease FEV1, seldom done because seems awfully mean
wheezing on physical exam means the problem is bronchioles
279
palivizumab
antibody prophylaxis for RSV
280
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.
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
complication of IBD where pt presents with decreased bowel sounds or maybe diarrhea/vomiting, severe abdominal pain, signs of sepsis, ab distension
toxic megacolon
seen on ab x ray - loss of haustration, multiple air fluid levels
icu - NPO, correct electrolytes
may need surgery
282
lots of neutrophils in blood or csf, think bacterial infection
lots of _____, think viral
leukocytes
283
calculate anion gap
cations - anions
Na+ -Cl- - HCO3-
normal is 6-12
284
normal anion gap
6-12
285
diabetic ketoacidosis
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
hyperosmolar hyperglycemic state
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
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
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
treatment for onchymyccosis
3 months oral terbinafine and itraconazole
| remember to do scrapings and KOH examination
289
what do you do for low grade vesiculouretral reflux in babies
abx prophylaxis for uti, routine screening cx every 3-4 months, they'll probably outgrow the reflux
290
how do you know if ascites is exudative or transudative
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
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
Legg-Calve-Perthes disease
292
Renal tubular acidosis type 1
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
Renal tubular acidosis type 2
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
Renal tubular acidosis type 4
```
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
Tx for renal tubular acidosis type I
want to correct academia by replenishing bicarb, correct hypokalemia
-give potassium citrate
296
Tx for renal tubular acidosis type II
give potassium citrate and thiazide diuretics
| vit D and calcium in kids
297
tx for renal tubular acidosis type IV
correct hypoaldosteronism
| give fludrocortisone, loop diuretics to increase sodium delivery, increase K+/H+ exchange
298
underlying deficiency in renal tubular acidosis type IV
Deficiency of or inability to respond to the hormone aldosterone
299
underlying deficiency in renal tubular acidosis type ii
innability to reabsorb bicarbonate from the urine
300
underlying deficiency in renal tubular acidosis type 1
Inability to excrete acid in urine
301
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....
thiamine
| wernicke's encephalopathy
302
vital signs in delirium tremens
htn
tachycardia
low fever
303
young, asymptomatic patient with cervical lymphadenopathy
) 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
pell epstein fevers (cyclical fever) associated with...
hodgkin lymphoma
305
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.
aml
306
the most effective tx for allergic rhinitis is
nasal corticosteroids like nasal beclomethasone
307
community acquired MRSA treatment
trimethaprim-sulfamethoxazole, clindamycin
308
abortive treatment for cluster headaches
100% oxygen
309
2 most common causes of pancreatitis in US
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
the most common cause of isolated bloody nipple discharge in a healthy young
female
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
Multiple ring enhancing lesions throughout the brain on CT
toxoplasmosis
312
Cortical atrophy and ventricular enlargement on brain ct in setting of memory loss
alzheimers
313
classic triad of symptoms in normal pressure hydrocephalus
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
focal segmental glomerulosclerosis
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
primary focal segmental glomerulosclerosis
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
secondary focal segmental glomerulosclerosis
some of the glomeruli die and the remaining glomeruli have compensatory hypertrophy and increased capillary pressure to try to maintain GRF
317
membranoproliferative glomerulonephritis
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
dense deposit disease
c3 nephritic factor antibody targets C3 convertase (which is increased in activity)
immunoflorescent pattern: linear ribbon of compliment C3 in basement membrane
319
membranous disease (nephrotic syndrome)
subepithelial deposits
| HIV, hep b hep c , syphilis, captopril, lung cancer, colon cancer, or primary/idiopathic
320
Three Ps of MEN 1
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
MEN-2A
medullary thyroid cancer, phenochromocytomas, and hyperparathyroidism, so the mnemonic here is “2 MPH” (think “two miles per
hour”).
322
MEN-2B
medullary thyroid carcinoma and pheochromocytoma, but NOT hyperparathyroidism.
323
diagnosing zollinger ellison syndrom
```
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
Parvovirus B19 can cause ______ in pts with hereditary spherocytosis or sickle cell disease
aplastic anemia
325
in friedrich ataxia you die of...
cardiomyopathy
trinucleotide repeat
326
nephrotic syndrome with subepithelial deposits of IgG and complement (spike and dome); thickened capillary loops
membranous (most common nephrotic syndrome among adults)
327
membranous nephrotic syndrome is associated with...
hep B, solid tumors like lung cancer
328
is poststreptococcal glomerulonephritis nephrotic or nephritic?
nephritic (hematuria, htn)
329
lupus tends to cause membranous neprotic syndrome
thckened capillary loops, hypercholesterolemia, edema from salt retention, proteinura
330
most common nephrotic syndrome among HIV+, african american, obesty, sickle cell patients, heroin use
focal segmental glomerulosclerosis
331
Nodular glomerulosclerosis with Kimmelstiel-Wilson nodule
diabetic nephropathy
| even though diffuse glomerulosclerosis is the most common finding
332
most common cause of acute kidney injury (not pre renal)
acute tubular necrosis
muddy brown casts & epithelial cell casts
due to ischemia and/or toxins
333
if you find low testosterone in a man, what test do you do next
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
Patients being treated with amiodarone (Cordarone) should be monitored periodically with serum
levels of
TSH
335
pathogenesis of TTP
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
pathogenesis of TTP
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
external rotation of the shoulder involves
infraspinatus teres minor
338
which diuretics increase risk of gout
thiazides
| loop diuretics
339
acei can cause ____kalemia
hyperkalemia
340
thiazides can cause ____kalemia
thiazides can cause hypokalemia
341
what kind of medication can you give to help a kidney stone pass faster
alpha 1 blocker
tamsulosin
doxazosin
prazosin
342
what labs predict pancreatitis severity
BUN creatinine hematocrit
343
hemoglobinapathies like sickle cell falsly lower A1c. instead get...
serum fructosamine
344
TMP-SMX can cause ---- that predisposes to infection
agranulocytosis
| look for low leukocytes
345
ampicillin sulbactum is empiric treatment for lung abscess (think aspiriation)
strep pneumo, gram negative anaerobes
346
first line allergic conjunctivitis
ketorolac, ketotifen (antihistamin)
2nd line is glucocorticoid like flourometholone
347
elevated LH:FSH ratio is marker in common syndrome...
PCOS
348
serious side effect of metformin
lactic acidosis
| watch for kidney or heart problmes...more risk of lactic acidosis
349
first step in nonmassive hemoptysis
CXR
350
dry cough, uveitis, symmetrical arthritis, no autoantibodies
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
antibody in granulomatosis with polyangiitis
c-ANCA
352
extra articular manifestation of ankylosing spondylitis
cardiac stuff, uveitis, prostitisi, nephropathy, inflammatory bowel disease
no antibodies
HLA B 27
353
af am woman with nephritis, history of miscarriages, and pleuritis
think SLE!
she will have low complement levels
+anti ds DNA
354
```
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
```
chronic lymphocytic leukemia
355
most common cause of epididymitis in sexually active men <35
CT, GC
356
CREST syndrome antibodies
anti centromere
357
infertility workup for woman
1. progesteron level at luteal phase
then...
2. hysterosalpingography to make sure tubes are patent
then...
3. FSH, prolactin, estradiol
then...
referral
