HY review #2 part 2 Flashcards by Stephanie Escobar

Irrepressible need to sleep.
Affecting performance at work/school
Naps help
Dx/Dxt/Tx?
CSF findings?

Narcolepsy
Polysomnography

Tx: SCHEDULED NAPS + Stimulants (Modafinil, Dextroamphetamine)

(+) Cataplexy add Sodium Oxybate

CSF: Low levels of Orexin (Hypocretin-1)

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Complex motor behaviors during sleep
punching/ kicking in sleep

REM sleep behavior d/o

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How should a hospital investigate the death of a 19 yo M who received defibrillation for unstable V-Tach?

Root- cause analysis

(wrong care done → supposed to do SCV)

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When a patient makes sexually suggestive comments to the physician or behaves seductively, what should be done on NBMEs?

Use a chaperone when seeing pt

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A medical student notices pt has worsening fevers and abdominal pain 3 days post-op.
The student observed one of the residents break the sterile field during surgery and feels it is a direct cause of the infection.
What is the most appropriate action by the student?

Duty to Report
to hospital’s adverse event reporting system

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What should be offered to a 45M with Glioblastoma Multiforme who is now completely bed bound, cannot read or write, and is completely dependent on others for his activities of daily living?

Hospice

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How can goals of care be established in a palliative medicine setting?

Family meeting

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Newborn management of developmental dysplasia of the hip

pavlik harness

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Palpable RLQ abdominal mass in a 2 yo child with a 2 day h/o intermittent abdominal pain.
dx/NBSIM?

Intusucception
Air or Contrast Enema
(diagnostic & therapeutic intervention)

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Common neurologic complication in a child with Port wine stains on their face

Seizures
Sturge Weber syndrome
(Encephalo Trigeminal Angiomatosis)

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Subdural hematoma in a 2 yo child of a 17 yo mom
NBSIM?

Call CPS
child abuse (brain bleed)

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Medication that causes persistent erections (Priapism) or Myoclonus

Trazadone
(can cause serotonin syndrome)

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Classic pharmacotherapy for uterine atony

Oxytocin

(mcc of PP-hemorrhage)

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Classic presentation of Lateral Medullary infarct (Wallenberg syndrome) & affected artery

Medial Medullary infarct

Lateral Medullary
Ipsilateral pain/temp loss on face + contralateral on body
ipsilateral tongue deviation
Horner’s (ptosis & miosis)
PICA (rarely Vertebral a)

———————
Medial Medullary
Ipsilateral tongue deviation + contralateral Hemiparesis
Anterior Spinal Artery (rarely Vertebral a)

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45M obese & skin is “tanned”
PE reveals a bulge just beneath his occiput.
Purple striae over most of his lower abdomen.
The most likely cause of this patient’s problem is?

A hyperfunctioning pituitary adenoma

pituitary bc hyperpigmentation

Cushing Dz s/t Pituitary Adenoma secreting ACTH.
ACTH Dependent b/c Hyperpigmentation (Skin Tan) present
ACTH released with MSH b/c same precursor POM-C.

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6M has lethargy + acute onset high fevers
(+) Kernig’s and Brudzinski’s sign
CSF: 6000 WBCs + Neutrophilic + ↓ Glucose+ ↑ Protein
(+) growth on Thayer Martin agar.
3 days after admission, the patient passes away.
Recent CBC showed ↑ PT/PTT/D-dimer
Labs drawn 10s post mortem reveal
__ Cortisol __ ACTH __CRH
dx?

↓ Cortisol ↑ ACTH ↑ CRH

Meningococcal Meningitis
+ DIC s/t Adrenal Hemorrhage (Waterhouse Fredrikson Syndrome) causing 1º adrenal insufficiency (↓ Cortisol; ↑ ACTH)

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Pt remains hypotensive s/p multiple boluses of IV Norepinephrine with no improvement in his symptoms.
PMH (+) severe asthma on oral prednisone.
dx/NBSIM

Adrenal insufficiency
Administer high dose dexamethasone and norepinephrine.

s/t Adrenal ATROPHY from chronic Glucocorticoid (Prednisone) use! Give stress dose of steroid.

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Dx & __ Ca2+ __ PTH __ Ph

Primary hypoparathyroidism

Primary hyperparathyroidism

Secondary hyperparathyroidism

Tertiary hyperparathyroidism

hypercalcemia of malignancy

Primary hypoparathyroidism
↓ Ca2+ ↓ PTH ↑ Ph
DiGeorge
Thyroidectomy

Primary hyperparathyroidism
↑ Ca2+ ↑ PTH ↓ Ph
Adenoma
MEN 1 & 2A

Secondary hyperparathyroidism
↓ Ca2+ ↑ PTH ↑ Ph
CKD (↓ Vit D also)
1ºVit D def

Tertiary hyperparathyroidism
↑ Ca2+ ↑ PTH ↑ Ph
Kidney Transplant (gland already hypertrophied s/t CKD)

Hypercalcemia of malignancy
↑ Ca2+ ↓ PTH (Ph Varies)
Squamous cell carcinoma

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Gonorrhea & Chlamydia
Screening: Women < __ should get ____ NAAT for both.
Women > __, only screen if they have “risk factors” like multiple sex partners, immunocompromised etc.
Treatment if:
Neither bug has been ruled out:
Gonorrhea (w/ruled out chlamydia):
Chlamydia (w/ruled out gonorrhea):

<24 sexually active → annual NAAT
> 24 screen if high risk
Neither ruled out: CTX + Doxycycline (or Azithromycin, 2nd line)
Gonorrhea (chlamydia r/o): Ceftriaxone
Chlamydia (gonorrhea r/o): Doxycycline (or Azithromycin)

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BRF for encopresis (fecal incontinence) :
Ages:
Tx:

BRF → Constipation
Ages >4 yo
Tx → Stool softener

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3 yo M Has been known to have hand flapping behavior
PE is notable for a large jaw.
He has restricted social interests.
Dx:
MOI:
Mutation:
Prognosis:
Cardiac problem:
GI Problem:

Fragile X
Mode of Inheritance: XLD
FMRI gene → CGG tri-nucleotide repeat
Normal life expectancy
Cardiac: MVP
GI: GERD

(FYI Alports the other XLD of the only 2 tested)

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BRF for inherited intellectual disability:

Fragile X

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52M 3 days after cardiac catheterization for an LAD infarct (recent MI), begins to complain of R sided UE and R lower facial weakness.
Dx:
Pathophysiology:
MC cardiac cath complication:
Common cause of this complication:
Other PMH that could have cause this:

Left MCA stroke (Face + UE)
s/t Blood Stasis (forms emboli)
MC cath cx: Re-Stenosis
Cause: Medication non-Adherence
Other PMH: A-Fib

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23 yo Nigerian M with a 3 day history of increased urination and red urine. Has been admitted multiple times in the past for severe pain in his hands and feet.
Dx/Tx (3)?
Painless hematuria:
Pathophysiology:
Blood smear:

Sickle Cell Disease (SCD)
Hydroxy urea + Folate + Penicillin until age 5
Painless hematuria: Renal papillary necrosis
(s/t sickled cells occluding papilla)
Valine replaces Glutamic acid Beta Globin
Howell Jolly bodies → RBC w/ a single purple dot (nuclear remnants)

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Insidious onset of R hip pain + h/o Sickle Cell Disease (SCD):

Avascular Necrosis of Femoral Head

MCC sepsis/meningitis in Sickle Cell Disease (SCD):

Streptococcus Pneumo

Common vitamin deficiency in Sickle Cell Disease (SCD):

Folate Deficiency (s/t high RBC turn-over uses up folate)

Bone pain and fever + h/o SCD:

Salmonella osteomyelitis

RUQ pain worsened by meals in pt with SCD:

Indirect bilirubin gallstones (pigmented)

SCD pt with 5 day h/o worsening SOB & a **low** retic count?

aplastic crisis ——— Hemolysis causes high reticular count but low retics & low hb suggest aplastic crisis (likely s/t **Parvo B19** )

23 yo IVDU comes to the ED with a 2 day h/o severe lower back pain. His T is 102. PE is notable for urinary retention and decreased perineal sensation. Dx: Dx testing: Tx (2): Are steroids indicated:

Spinal epidural abscess (fever + back pain + neuro deficit) **MRI spine** with contrast **I&D** + antibiotics (**Vancomycin**) —— steroids **not** indicated here, only give if **cord compression s/t malignancy**

Note that spinal epidural **hematomas** can also present similarly to spinal epidural **abscess** (back pain + Neuro deficits + usually w/o fever) spinal epidural hematomas are commonly due to _____ complication and labs will be notable for ___.

Warfarin High INR

39 yo neuropathologist with a 5 week h/o of profound memory loss + myoclonus dx/dxt?

Creutzfeld Jakob CSF shows high 14-3-3 protein

29F who was recently started on phenelzine (MAO-I) after treatment failure with sertraline for MDD now has myoclonus Dx/Tx?

serotonin syndrome tx: Benzo (if not working → Cyproheptadine)

39 yo computer scientist with progressive dementia, “an increasing number of angry outbursts”, involuntary arm movements & myoclonus. Dx/Tx for sxs: Pathophys:

Huntington dz (AD) **Tetrabenazine** CAG repeats → caudate atrophy --- neurodegenerative movement d/o characterized by involuntary & irregular movements of the limbs, neck, head, and/or face (chorea). **No disease-modifying treatment** only management of chorea symptoms. Prognosis → death within 15–20y post sxs.

NBME and Strokes * Paralysis of entire 1 side of body (Hemiparalysis): Artery + Location of lesion? * What must be done before allowing food after a stroke:

* Contralateral **lenticular striate** artery (Posterior limb of internal capsule) * Swallow study

71 yo M with multiple falls. Trouble holding the pen still as he fills out clinic forms. Dx/Tx: Brain findings: Managing Psychosis (2)

Parkinson Depigmentation of substantia nigra pars compacts **First → Carbidopa+Levodopa** Then try: **Amantadine** Ropinirole, Selegiline (MAO-B) **Psychosis**: ↓ Carbidopa dose → add **Quetiapine** DI mentioned these? **Bromocriptine or Cabergoline**

Parkinson's (+) d/o → Dx? + Scaly, greasy, rash around the face, cheeks, and nose: +Orthostatic hypotension and ataxia: +Multiple “backward” falls, trouble looking upwards: +Syncopal episodes, seeing rats in her hospital room

Rash → Seborrheic Dermatitis (topical azole) Orthostatic → Multisystem atrophy Can't look up → Progressive Supranuclear Palsy Hallucinations → Lewy body dementia

**Anti-epileptic drug side effects** Hyponatremia/SIADH, febrile neutropenia: Nephrolithiasis: Hepatotoxicity, Teratogenic: ─── (Extra info) 2 Anti-epileptic drugs causing *Steven Johnson*?

Carbamazepine Topirimate Valproate ─── (Extra) Carbamazepine, Phenytoin

35 yo F with MCP/PIP arthritis & a Hb of 9. MCV is 80. Dx? Ferritin/TIBC/Trans Sat?

**Anemia of chronic disease (ACD)** s/t RA ↑ Ferritin (Binds Iron for storage in BM) ↓ TIBC (always opposite to ferritin –Iron is plenty available) ↓ Transferrin Sat (circulates iron in blood, but low bc iron stuck in BM) Chronic inflammation results in ↑ Hepcidin which stops Iron from being released from the bone marrow MQs. Hepcidin also ↓ iron absorption in the GI tract.

74M with pencil thin stools and a microcytic anemia; Dx? Ferritin/TIBC/Trans Sat? RDW:

**Iron deficiency anemia** s/t colon cancer ↓ Ferritin (Not much Iron around to store) ↑ TIBC (Ready to bind iron when available) ↓ Transferrin Sat: (Not much Iron in circulation) ↑ RDW (variation of RBCs in size/vol.)

Hep C screening guidelines:

18-79 yo one time HCV screen

32M with chronic heartburn that has not resolved with 2 trials of esomeprazole. NBSID: What if this test is (–) ve?

EGD+ biopsy 24 hr esophageal pH monitoring (gold standard for dx)

SOB, PaO2 of 80 6 hrs after a platelet transfusion for symptomatic ITP, CXR shows b/l interstitial infiltrates with diffuse crackles heard on lung auscultation. PCWP is 14 (nl < 18). BP is 75/40. How can this be differentiated from transfusion associated circulatory overload?

TRALI → **PCWP wnl** + Hypotension (basically ARDS post transfusion) TACO → PCWP ≥18 + **HTN** (Cardiogenic Pulm Edema s/t large volume transfusion)

Nephritic, nephrotic hypersensitivity reactions: T_ HSR Notable exception:

T3 HSR Good pasture (T2HSR)

Humeral neck fx: nerve? **cause**?

Axillary n. Dmg **Anterior Shoulder dislocation** weak shoulder abduction ↓ sensation **lateral shoulder**

Humeral Midshaft fx: nerve? sensation? other **cause** of this nerve dmg aside from fx?

Radial n. Dmg weak wrist & finger extension ↓ sensation **Dorsolateral hand/forearm** **improperly fitted crutches** & Mid shaft fx

Supracondyle (elbow) fx: nerve? sensation? other causes of this nerve being dmg?

Median n. Dmg ↓ sensation **lateral palm** + thumb/index/middle finger ↓ flexion of above fingers (carpal tunnel compression → distal)

Medial Epicondyle fx: nerve? sensation?

Ulnar n. Dmg ↓ grip strength, wrist flexion, finger spread ↓ sensation **medial palm** + 4th/5th fingers + **hypothenar** Cubital Tunnel Syndrome

Hook of the hamate fx: nerve? **cause**?

Ulnar n. Dmg (at the wrist) **bicycle handlebar** ↓ sensation medial 4th/5th fingers + **clumsy hand**

Anatomical snuffbox tenderness: fx/tx/cx?

Scaphoid fracture **Thumb spica cast** (prevents Avascular necrosis)

Head of the fibula fx: Nerve? Motor sxs (3)

Deep **Peroneal nerve** Foot drop → steppage gait ↓ Eversion and Dorsiflexion Numb at toe thong sandal zone (mnemonic: **PED**)

Can’t **initiate** shoulder abduction: Dx/muscle/Dxt

**Rotator cuff tear** **Supraspinatus** Neer test (int rotate & raise arm) Empty can test (arms up to shoulder, thumbs down)

Trouble reaching **overhead**: nerve/muscle/common cause?

**Long thoracic nerve** **Serratus Anterior** (SALT- Wings) breast surgery (**mastectomy**) Winged scapula can’t reach **180º**

**Spirochete** infection treated with penicillin + **truncal erythema** dx/tx?

Jarish Herxheimer rxn **Supportive care** (immune response to bursted cells)

71M with kidney transplant has had his Cr increase progressively from 1.2 – 3.5 over the past year. Dx: Organ biopsy findings: ── 3 weeks post transplant w/ rising Cr (+ biopsy finding):

Chronic rejection (≥1y) **Fibrosis** on bx ── s/p 3 weeks Acute Rejection (<1y) **Lymphocytes & Eosinophils** on bx

Diarrheal outbreak in a military barrack.

Noro virus

Flank pain, T 103, and pyuria. He is a diabetic. dx/tx (3)?

Pyelonephritis **FQ, CTX, TMP-SMX** or Gentamicin

Despite 96 hrs of appropriate antibiotic therapy for Pyelonephritis, the patient continues to have high fevers and worsening pain. NBSIM: Potential finding #1 & tx? Potential finding #2 & tx?

**CT Abd/Pel** #1: Air inside kidney's walls → **Emphysematous Pylo** → emergent **Nephrectomy** #2: Fluid inside kidney's walls → **Perinephric abscess** → **I&D** + IV **Cefepime**, Ceftazadine(3º) or **Carbapenem**

47M Fever + HA worsening + recent sinus infection + Babinski dx/dxt/tx(2)/contraindications?

Brain abscess **MRI** brain + contrast **I&D** + IV **Cefepime** or **Carbapenem** Contraindicated → Lumbar puncture

22M is 10d s/p bone marrow **transplant** develops diffuse skin **rash, diarrhea** & burning sensation on the palms and soles. ↑ LFTs Dx/Tx/Patho?

Diarrhea + Rash s/p Transplant = **GVHD** Tx: Steroids Donor T cells attacking recipient tissue

How do we perform a test of cure after treatment for a T. Pallidum infection? * Non-treponemal test → or * Treponemal antibody test →

Non-treponemal test * ↓ RPR & VDLR titers = cured * Same titers used for screening Treponemal antibody test * MHA-Tp & FTA-Ab = confirms the dx after (+) screen * Once (+) will always be (+) not used for test of cure

Pt w/ difficult asthma to treat has Fevers + wheezing + ↑ Eosinophilia/ IgE CXR: dilated bronchioles Dx/tx?

Allergic Broncho-Pulmonary Aspergillosis (ABPA) s/t Cystic Fibrosis tx: Steroids (Azole if recurrent)

**Neutropenic** pt + Fevers despite broad ABs treatment CT chest → focal consolidation surrounded by ground glass opacity Dx/Tx (2)?

Invasive aspergillosis (Halo sign) **Voriconazole → Amp B**

Pt presents with cough + **hemoptysis** + ↑ **Eosinophilia**/IgE CXR: mass in old TB cavitation Dx/Tx?

Aspergilloma Surgical Resection of mass (This can also have asymptomatic presentation)

53M with Diabetes has a **wood-like** induration of the skin on extremities that **spares** the digits after a recent spinal MRI **Dx & BRF?** Description: Shiny, Thickened & Hyperpigmented. Hard to the touch.

**Nephrogenic systemic Fibrosis** (s/t Gadolinium based contrast for MRI) BRF: **CKD** ─── Looks like scleroderma, but recent exposure to contrast gives away answer.

Wilms tumor (nephroblastoma) Peak age **2-5** **Unilateral** abdominal ___ mass ± Hematuria & Abd pain Associated with (2)

**non-calcified** * Beckwith-Wiedemann syndrome * WAGR Wilms tumor Aniridia (Iris is gone) GU abnormalities Retarded

Fetal macrosomia or **Hemihyperplasia** **Omphalocele** or Umbilical Hernia Macroglossia Dx? Suggested Regular Screening (2)?

Beckwith-Wiedemann syndrome ─── Serum α-fetoprotein (AFP) → Hepatoblastoma Abdominal & renal U/S → Nephroblastoma (Wilm's)

Peak age <2 Malignant solid & _____ abdominal mass. Arises from neural crest cells (adrenal glands) Crosses midline **Homer Wright Rosettes** (+) **Chromogranin**

Neuroblastoma Calcified

Paraneoplastic syndrome associated with **Neuroblastoma**

**Opsoclonus Myoclonus syndrome** Rapid, multidirectional, involuntary movements of the eyes and extremities

staggering gait in childhood HOCM Scoliosis dx/defect?

Friedreich ataxia (AR) GAA repeats

Hyperphagic, Obese boy with micropenis Intellectual disability Hypotonic at birth ↑ Ghrelin Dx/ paternal or maternal chrm defect? Explain uniparental disomy?

Prader willi Syndrome **Paternal** Chrm 15 → **Mutated/absent** Maternal Chrm 15 → Imprinted ─── **Uniparental disomy**: Mitosis/Miosis error → gets 2 **Maternal** Chrm 15 → both Imprinted (aka shut off)

Happy demeanor + frequent (inappropriate) laughing. Intellectual disability epileptic seizures Dx/ paternal or maternal chrm defect? Explain uniparental disomy?

Angelman syndrome **Maternal** Chrm 15 → **Mutated/absent** Paternal Chrm 15 → Imprinted ─── **Uniparental disomy**: Mitosis/Miosis error → gets 2 **Paternal** Chrm 15 → both Imprinted (aka shut off)

Diagnosis? Anterior vaginal wall muscle is weak (multiparous) so the bladder prolapses into vaginal canal ± past hymen → ___ incontinence tx: Physical therapy, Pessary, Surgery

Cystocele stress incontinence

Diagnosis? Posterior vaginal wall muscle is weak so rectum prolapses into vaginal canal. → ___ incontinence s/t ___

Rectocele stool incontinence (s/t constipation)

Diagnosis? Small bowel prolapses against the superior wall of the vagina resulting in a bulge at the high, upper vaginal wall

Enterocele (bowel herniates through cul-de-sac)

Diagnosis? Urethral diverticulum (out-pouching) where urine can collect. Urinary dribbling (leaks pee) after voiding. → Positive __ test

Urethrocele (+) Q tip test

HY review #2 part 2 Flashcards

(77 cards)