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1

Steps in delivering bad news

SPIKES
S - set up place, privacy, introductions
P - perception "what do you think is happening?"
I - Invitation to "how much would you like to know?"
K - give knowledge and info
E - empathetic statements, explore feelings, thoughts
S - strategy for follow-up/care

2

Abdominal mass in kid
1. NOT cross midline
2. Crosses midline

1. Wilms - WAGR, US --> CT abd and chest

2. Neuroblastoma - 1st yr of life

3

Brain mass w/ concentric whorls and psamomma bodies

Meningioma

4

Stealing of objects of low monetary value or NOT needed for personal use

Kleptomania = psychotherapy
- shame, guilt --> return or give away items

5

Tx syphilis in pregnancy

PCN - desensitize if needed

6

Hx UC, watery diarrhea, burning erythematous rash on arms and legs b/l, hyperpigmented like a sunburn, tender + poor concentration, irritable

Niacin deficiency/Pellagra
- corn based diets

7

Dysmenorrhea --> chronic pelvic pain, bleeding, globular enlarged uterus <12wks in multip women over 40 y/o

Adenomyosis
- 50% have concurrent fibroids
- get bx to exclude endometrial CA

Fibroids = more irregular shaped uterus
- more mass effect sx - constipation, urinary frequency & NOT pain

8

Infertility, dysparenunia, dysmenorrhea in younger woman

Endometriosis

9

Diffuse thickening of GBM and subepithelial spikes

Membranous

10

Cause of back pain
1. Normal neuro, negative straight leg
2. Radiculopathy, possible + straight leg, neuro deficit
3. Old woman w/ fall
4. Better w/ activity, rest NOT help
5. Worse at night, >50, cauda equina possible
6. IVDU or DM w/ recent infection, fever, exquisite tenderness

1. Mechanical - degen, spasm
2. Disk herniation
3. Compression fx
4. Ankylosing - IBD, reactive, psoriatic = apophyseal joint arthritis
5. CA
6. Osteomyelitis

11

Persistent nosebleeds, ruby papules on lips, clubbing, polycythemia

Osler-Weber-Rendu = AVMs
---> shunt blood --> hypoxemia = clubbing and polycythemia, hemoptysis

12

Newborn w/ diffuse granular CXR, air bronchograms, hypoxemia dx and cause?

RDS
- prematurity, DM, C/S, asphyxia

13

Excess bleeding w/ normal PT, PTT, LFTs, platelet count
Inc Cr, BUN, BT

Uremic coagulopathy = renal failure --> platelet dysfxn

Tx = DDAVP which inc VIII & vWF

14

1st tx step in pt in HCV

Liver bx to guide tx
- severe inflammation and fibrosis --> cirrhosis BUT usually respond better to tx
- antivirals = peg-IF + ribavirin

15

HBV & HCV progression to HCC

HBV = w/o cirrhosis
HCV = w/ cirrhosis = get US q6mo

16

Smoker + clubbing and sudden onset b/l wrist pain

Hypertrophic osteoarthropathy
---> CXR for lung CA, TB etc...

17

Young male w/ pain over heel, iliac crests, tibial tuberosities, shoulder pain stiffness

Enthesititis - inflammation where tendon meets bone = ankylosing spondylitis
- Assoc w/ limited spine mobility

18

Steps in tx of acne

Topical retinoids + benzoyl/salicyclic acids

Topical Erythromycin or Clinda

Oral Abx

Oral isotretinoin

19

Heat stroke vs. Heat exhaustion

Stroke = >104, AMS
Exertional --> ICE WATER IMMERSION
Non-exertional --> evaporative cooling

20

Re-warm cold extremity

Warm water

21

SB resection, TPN, alopecia, no taste, pustular lesions around mouth

Zinc deficiency

22

HTN + hypoK 1st step

Measure renin & aldosterone

23

Dec renin, inc aldo w/ A:R >20 cause, Aldo >15

Primary hyperaldosteronism --> adrenal CT

24

Inc in both renin and aldo w/ A:R ~10

Secondary hypseraldosteronism
- diuretic, CHF, renin tumor, coarctation, malignant htn or renovascular htn

25

HIV pt CD4 <50 w/ yellow-white eye opacities and retinal hemorrhage

CMV

26

HIV pt w/ necrotizing retinitis, white fluffy lesions around retina

Toxo

27

Types of abortion
1. Bleeding, closed cervix, no heart tones
2. Cramping, bleeding, open cervix, possible heart tones
3. Cramping, bleeding, products visualized, open cervix
4. Bleeding, closed cervix, + heart tones

1. Missed --> Pelvic US --> C&D
2. Inevitable
3. Incomplete
4. Threatened

28

PAS+ and diastase resistant hepatocyte inclusions

alpha-1-antitrypsin

29

Brief LOC + lip smacking, swallowing, picking + post-ictal confusion, normal EEG

Complex partial seizure

30

EEG 3Hz spike and wave

Absence
- may have automatisms like lip smacking but DONT have post-ictal confusion
- Atypical is <2.5Hz

31

Kids, U/L or B/L jerking in the AM

Juvenile myoclonic epilepsy - sleep deprivation

32

EEG slow spike and wave

Lennox-Gaustat

33

Vit D, Ca, Phos, PTH finding in pts with celiac or other intestinal malabsoprtion syndrome

Low Vit D d/t malabs --> Low Ca, Phos abs
High PTH

34

EPS Sx & Tx
1. Acute neck, mouth, tongue, eye contractions
2. Restlessness
3. Tremor, rigidity, bradykinesia, masked face

1. Acute dystonic rxn = benztropine, diphenhydramine
2. Akasthisia = propanolol
3. Parkinsonism = anticholinergic or amantadine

35

Complication in bronchiectasis

Hemoptysis
- massive may require bronchial a. embolization

36

Excessive anxiety over one or more unexplained sx & willing to undergo invasive testing

Somatic sx disorder

37

Fear of having a serious illness despite negative testing and no actual sx

Illness anxiety disorder (hypocondriasis)

38

Stress w/ neurologic sx not consistent with any known neurologic disease, person may be indifferent

Conversion disorder (functional neurologic sx disorder)

39

Young woman, ovulation induction, hx ovarian cyst w/ sudden R sided pelvic pain, adnexal tenderness, (-) hcg

Adnexal torsion --> doppler US --> emergency laparoscopic surgery

40

Type of study w/ 2+ experimental interventions (ACE, BBs) each w/ 2+ variables studied independently (high BP, low BP)

Factorial design

41

Type of study where 2 groups try one tx and then switch

Cross-over

42

Dec in Non-ionoized/albumin-bound/inactive Ca for every 1g/dL dec in serum albumin

0.8mg/dL

43

Hyperreflexia on L, L hemiparesis, eyes deviated to R lesion

Right cerebral lobe

Basal ganglia eyes point toward hemiparesis

44

1+ proteinuria, RBCs and RBC casts, normal complement levels, recent URI, #1 GN in adults

IgA nephropathy

45

Eosinophiliuria, WBC casts

Drug-induced interstitial nephritis

46

Acid-base findings in aspirin toxicity (tinnitus, fever, tachypnea, N/V)

Mixed resp alkalosis and metabolic acidosis
pH 7.36
PCO2 22
HCO3- 12

47

CA, PA or UT construction site w/ baby floppy, sluggish, drooling, ptosis, weak suck and gag reflex

C. botulinum SPORE ingestion for enviro ---> human derived Ig

Toxin in honey ---> equine derived Ig

48

Tx for acute thoracic aortic dissections

Labetalol

Ascending (type A) = surgery + medical
Descending (type B) = medical alone

49

ARDS pt on vent w/ PEEP 15, FiO2 0.6 --> tachy, SBP 90, inc CVP, absent breath sounds

Tension pneumothorax d/t excessive PEP

50

AIDS, chemo pt w/ exophytic purple skin masses w/ a collarette of scale on lower abd + several liver masses + bx ---> severe hemorrhage

Bartonella - Bacillary angiomatosis

51

Microcytic anemia with normal RDW

B-thal
- microcytosis <75
- target and tear-drop cells

(Fe has inc RDW)

52

Child fatigued and pallor, recent diarrhea tx w/ medication, purpura and petechiae, low platelets, RF, schistiocytes, giant platelets, inc LDH, indirect bili, retic count, urine w/ RBCs, WBCs, casts

HUS = microangiopathic hemolytic anemia

53

SOB, cough, DOE, dec breath sounds, bibasilar crackles occasional wheezes

CHF vs. COPD

CHF - resp alkalosis, hypocapnia, hypoxia

COPD - widespread wheezes + resp ACIDOSIS, hypoxia

54

Kid w/ Giardia and recurrent sinopulmonary infections since 6mo

abn B-lymphocyte maturation

Lack of IgA = Giardia

55

Kids w/ staph, aspergillius infections

CGD - NADPH oxidase

56

Electrolyte abn in SAH or intracranial hemorrhage

HypoNa - SIADH-like syndrome, resolves in 1-2wks

57

Complication of nephrotic syndrome, 4+ proteinuria, edema, fatty casts

Hypercoagulability (renal vein thrombosis)
- loss of AT-III, protein C, S
- inc fibrin, platelet aggregation

Iron deficiency d/t ferritin loss
Vit D deficiency
Dec TBG
Inc infections

58

Hepatitis, etOH, Wilson disease w/ inc PT/INR >1.5, inc bili, inc AST, ALT 10x normal --> dec AST ALT + WORSENING PT/INR

Acute liver failure
- PT = #1 prognosticator in ALF

59

Stabbing in R face, ataxia falling to R, miosis, ptosis on R, dec gag reflex, hoarsness, loss of pain and temp on R face + LEFT trunk/limbs

Lateral Medullary syndrome
- PICA

60

Weakness of mastication, impaired sensation over face, impaired jaw reflex

Lateral Mid-Pons

61

CL arm and leg hemiparesis, tactile and position sense, IL tongue deviation

Medial medullary syndrome

62

CL ataxia of trunk and limbs and face

Medial pons

63

Drugs post UA/NSTEMI or PCI

Aspirin
BBs
ACE
Statin
Clopidogrel - 30d or 1yr w/ drug stent

LMWH 48hrs/prior to PCI in acute MI

64

Villous atrophy

Celiac
- IgA deficiency --> (-) endomysial or tissue transglutaminase ab

65

NST score tx
1. Oligohydramnios
2. 8
3. 6
4. 4
5. <4

1. deliver
2. Normal = repeat in 1 wk
3. Contraction stress test --> delivery or repeat next day
4. Lung mature = deliver; Steroids and repeat next day
5. Deliver

66

Enuresis tx

1st = avoid fluids late, gold stars...
2nd = alarm
3rd = Oral Desmopressin

67

C-D systolic murmur on LSB w/o radiation

HOCM = IV septum hypertrophy

68

Defect in tubular HCO3 reabsoprtion

RTA-II
- acetazolamide or Fanconi anemia

69

Low tubular ammonium

RTA I
- can't excrete H+ --> no ammonium

70

ASA + nasal blockage + bronchoconstriction

ASA sensitivity syndrome (pseudo-allergy) --> inc LTs
--> tx w/ LT-inhibitors

71

Chronic NSAIDs w/ worsening renal function mech

Papillary necrosis & TUBULOINTERSTITIAL nephritis

72

RA tx and tests to run before tx

#1 = MTX - HBV, HCV, TB

>6mo of symptoms w/ MTX --> TNF-a or possibly hydroxychloroquine or sulfasalazine

73

Angiogram, stent + blue toes, livedo reticularis + ARF + eosinophils but low complement

Cholesterol emboli

74

1st step in NEC

Abx to prevent sepsis

75

Endocarditis valve abn

Mitral REGURG or MVP

76

Adolescent cough to vomit dx and tx

Pertussis
Nasopharyngeal culture
Azitho or clarithromycin

77

Smoker, post-prandial pain, FOBT (+) --> adenocarcinoma next step?

CT scan

78

Amenorrhea, normal exam, obesity, normal TSH, prolactin, LH, FSH

Anovulation d/t obesity, no progesterone = no bleed

79

B/L carpal tunnel 1st step

TSH for hypothyroidism

80

Most likely polyp to be cancerous

VILLOUS > tubulovillous > tubular adenoma

hyperplastic = non-neoplastic
Hamartomatous = juvenile or peutz-jager

81

HTN <20wks, edema

?Mole
Normal US = chronic HTN

82

Tx Hepatic Encephalopathy

K+ repletion (hypo --> inc ammonium production)
Lactulose
Rifaximin (if lactulose no work)
Protein + diets

83

HTN urgency
HTN emergency

Urgency - >180/120 w/o end organ damage

Emergency
- Malignant HTN w/ papilledema or retinal hemorrhage
- HTN ecephalopathy w/ neurologic signs

84

Dx & Tx of Histoplasmosis

Dx = urine ag

Tx = Itraconazole or amphotericin B if >103.1

85

Parkinsonism, postural hypotension, impotence, dry mouth/skin, neuro signs

Multiple system atrophy

86

Blurred vision now vision loss in 1 eye, subclavicular bruit, HA, high ESR, blurred swollen optic disc

Giant cell arteritis --> high-dose steroids

87

Cough, non-caseating granuloma, peratracheal adenopathy

Sarcoid = steroids

88

Low O2 mech in PNA

V/Q mismatch or shunt

Alveoli filled w/ debris = no O2

89

Periodic sharp waves on EEG

Crutzfeld-Jacob

90

Retrosternal pain radiating to back w/ stress and hot or cold food, relieved w/ nitro

Esophageal dysmotility

91

Infant w/ dec activity, dec feeding, unable to wake for feedings you should suspect

Sepsis