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Question

Bacterial Vaginosis

Answer 1

Gardnerella (anaerobic bacteria, coccobacillus), fishy (bad odor, amine odor), thin gray white. Wet mount with clue cells. Clue cells = epithelial cell coated with bacteria cells. Positive KOH test. pH >4.5. No vaginal inflammation (itching, redness). From an imbalance in vaginal flora, lactobacilli colonization decreases. Leads to an increased pH and overgrowth of anaerobic bacteria. Increased incidence in women having sex with women, douching and smoking.

Answer 2

Odor, thin, frothy, yellow green discharge. Elevated pH >4.5. Friable macular cervical lesions (strawberry cervix), postcoital bleeding. Vagina will be inflammed (red and itchy). Dx: Wet mount showing motile, flagellated, ovoid protozoa. Lots of PMNs.

Answer 3

2-3 minuntes

Answer 4

Progesterone, stops proliferation. Smoking, metabolites estrogen in the liver.

Answer 5

Nifedipine (CCB), Indomethacin (COX inhibitor) Terbutaline (Beta agonist) Nifedipine (CCB): 1st line, 32-34 weeks, s/e: tachycard, flushing, H/A, N. Indomethacin (cyclooxygenase inhib): 1st line, <32 weeks, s/e mom: platelet dysfunction and gastritis, s/e baby: closes PDA (don’t give after 32 weeks), oligohydramnios. Indomethacin is a non specific cyclooxygenase inhibitor, it decreases prostaglandin production and leads to fetal vasoconstriction. Leads to decreased renal perfusion and fetal oliguria. Therefore, give indomethacin for <48hrs. Terbutaline (Beta agonist): short term tocolytic, s/e: tachy, hypotension, hyperglycemia, pulmonary edema.

Answer 6

Toxoplasm gondii. From undercooked or cured meat or cat feces contact. Symptomatic babies have macrocephaly, hydrocephalus and lesions in the ventricles and basal ganglia (diffuse intracerebral calcifications). We don’t test for toxo in the USA, only after a Pt has symptoms. Can experience chorioretinitis in adulthood from reactivation on the infection. Dx: Toxo IgM or IgA in serology. Tx = Sulfadiazine + Pyrimethiamine (TMP variation) + Folate for 1 year. (CMV is periventricular calcifications & normal head & hearing loss vs. Toxo is diffuse calcifications & big head).

Answer 7

S.pneumo, H.Influenza, N.Meningitidis

Answer 8

Defective prosthetic cardiac valves. DIC. HUS – Hemolytic uremic syndrome. TTP – Thrombotic thrombocytopenic purpura.

Answer 9

Autosomal dominant (means family hx). Hemangioblastomas of the CNS or retina (risk of vision loss, retinal detachment or glaucoma). Renal cell carcinoma (or family hx of adrenal tumor). Risk of pheochromocytomas (adrenal medulla tumor). Associated with MEN2A&B and NF type1. Mt in VHL tumor suppressor gene. Start looking for tumors as of a young age. benign highly vascular tumors, risk of rupture and intracranial hemorrhage. Dx: Do VHL testing in a patient with a retinal or cerebellar hemangioblastoma. Tx: Laser therapy for the retinal hemangioblastoma.

Answer 10

Pustular rash, synovial fluid <50K, blood cultures negative

Answer 11

Narrow therapeutic window. Cause CNS stimulation (H/A, insomnia, seizure), GI problems (Nausea, vomiting) & cardiac toxicity (arrhythmia). Theophylline is metabolized by cytochrome oxidase in the liver. Levels affected by liver problems, respiratory infections or drugs that increase the concentration (cimetidine, ciprofloxacin, erythromycin, clarithromycin, verapamil).

Answer 12

Na restriction

Answer 13

>70yo calcification <70yo Bicuspic Aortic valve. EF <50, replace. Pulsus parvis and tardes. Single soft S2 R upper ICS Severe valve <1cm^2

Answer 14

1.Get a TSH & Thyroid u/s always. 2a. If normal or elevated TSH (elevated tsh means it making product and might be cancer), do an FNA. 2b. If >1cm & high risk sonography (microcalcifications, irregular margins & internal vascularity), do a FNA Bx. 2c. if >2cm and not a cyst on u/s, do a FNA Bx. 3. If TSH low, next step, radionuclide thyroid scan using iodine-123. 3a. A hypofunctioning “cold” nodule = decreased isotope uptake = higher risk of cancer, next step FNA. 3b. Hyperfunctioning “hot” nodule = increased isotope intake, low risk of cancer. FNA not needed.

Answer 15

>18 Prerenal BUN>CRE >20:1

Answer 16

R bundle branch block R.V infarction, pulmonary HTN. RV taking longer to close.

Answer 17

L bundle branch block Anterior or lateral infarction, Aortic Stenosis. LV now taking so long to close that P2 closes before it.

Answer 18

Secretory = <50 mOsm/kg Normal stool osmotic gap 290 mOsm/kg. Osmotic diarrhea >125 mOsm

Answer 19

Causes: Gout, tumor lysis and/or acidic urine pH. chronic diarrhea (loose HCO3-), leads to acidic overall and acidic urine. Tx uric acid stone: hydration, alkalinization of urine with Potassium citrate and low-purine diet. Alkalinization will solubilize the uric acid.

Answer 20

Front of the cord damaged. Loss of motor fn. Preserved position, vibration and touch (posterior of cord).

Answer 21

1/2 side of cord damaged. Loss of pain & temp 2 layers lower on opposite side (signals cross right away). Loss of motor & position, vibration same side (from and back of cord).

Answer 22

Cape like distribution. Loss of motor arms b/l (center of cord) at level of injury. Incomplete loss of motor below that.

Answer 23

Cabergoline> Bromocriptine Dopamine inhibits Prolactin. Tx for prolactinoma.

Answer 24

1. test cortisol levels (low dose dexamethasone suppression, late night salivary cortisol, 24hrs urine free) 2. ACTH level. 3. If elevated ACTH, do high-dose dexamethasone suppression test. If surpresses, pituitary was making. Low THen High Adrenal adenoma: labs show low ACTH, feedback inhibition. Low DHEAS, DHEAS is driven by ACTH

Answer 25

Frontal lobe - Broken Speech - Broca

Answer 26

SLE drug. S/E: Retinal toxicity 5 years later. Check eyes.

Answer 27

Renal insufficiency & lactic acidosis. 30% of patients on Metformin get B12 deficiency after >5 years. Some patients only have the neurologic findings alone and don’t have the macrocytosis problems. Metformin might alter the Ca-dependant B12 absorption.

Answer 28

Tinnitus, tachypnea, GI irritation (stops protective mucosa). Respiratory alkalosis: stim respiratory center in the medulla and causing tachypnea, breathe off CO2. Gapped metabolic acidosis: uncoupling of ox phos leading to anaerobic metabolism. (MUDPILES). Together: low CO2 & low HCO & near-norm pH. Tx: Alkalinization of the urine with NaHCO3 & dialysis.

Answer 29

Isolated or Fanconi syndrome (glucose, amino acids & phosphate in urine). Impaired HCO3- reabsorption in the proximal tubule. The distal tubule will still works, so urine pH will be <5.5 (acidic).

Answer 30

Genetic problem, has kidney stones (nephrolithiasis). Complication of Sjogren syndrome. Distal RTA. Impaired H exretion in the distal tubule. Will get Hypokalemia from reduced K+ reabsorption. Urine pH >5.5, can’t acidify urine.

Answer 31

Problem with Na/K exchange in distal tubule (get hyperK, hyperCl). Reduced aldosterone, leads to H+ & K+ excretion in the collecting duct. HyperK is typical. Urine pH is <5.5 Tx: Give Bicarb HCO3.

Answer 32

young person, likely MRSA necrotizing pneumonia Tx: Vanco or linezolid & admit to ICU

Answer 33

PAO2 = FiO2 * (713) - (PaCO2/0.8) PaO2 = from ABG. Elevated A-a, if > (Pt age/4 + 4). Causes of ⬆︎ A-a gradient: Anything that impairs gas exchange. Diffusion (CHF or Pneumo), VQ miss match (PE), R->L shunt. Norm A-a gradient: ⬇︎ FiO2, hypoventilation.

Answer 34

Hemorrhagic = Subarachnoid or intracerebral. Intracerebral hemorrhage: Acute focal neurologic signs, worse over mins-hours. As it expands, get elevated ICP (headache (h/a) , V, AMS. Risk factor HTN. Subarachnoid hemorrhage: Severe h/a, hx of LOC, n/v.

Answer 35

Abrupt focal neurologic deficits, no h/a, no LOC. hx of TIA. | Tx: <3-4.5 hrs: Alteplase >4hrs: ASA (Asprin).

Answer 36

1.Hypertonic saline. It will draw out water from edematous brain tissue. 2.Elevate head of the bed. 3.Craniectomy. No mannitol.

Answer 37

ST depression in V1 and V2

Answer 38

Hepatically cleared, so CYP450 alterators. S/E: Nephrotoxic (cause vasoconstriction, leads to an AKI acutely), HTN (from the vasoconstriction of the kidney), Neurotoxic, Glc intolerance, infection, Gingival hypertrophy & hirsutism & GI problems. Tx: adjust the cyclosporine or tacrolimus dose.

Answer 39

Same as cyclosporine, but no hirsutism or gum hypertrophy. Hepatically cleared, so CYP450 alterators. S/E: Nephrotoxic (cause vasoconstriction, leads to an AKI acutely), HTN (from the vasoconstriction of the kidney), Neurotoxic, Glc intolerance, infection

Answer 40

Epigastric pain, worse when eating. Eastern Asia, Andean part of south America. Diets rich in salt-preserved foods. Mets to liver.

Answer 41

<1 month: Bacterial infections or from the hospitalization. 1-6 months: Opportunistic infections. From being on high dose steroids. >6 months. Community acquired things at higher rates.

Answer 42

Early diastolic murmur, decrescendo. bounding pulses = water hammer (hammers bound). Pulsus bisferiens (biphasic pulse) = 2 strong systolic pulses. From increased stroke volume causes abrupt rise is systolic bp. Widened pulse pressure. Best heard on R. Sternal border = Aortic root disease/dilation (turbulent flow in aortic root). Best heard L. Sternal border 3&4 ICS = valvular disease (like IE, or prosthetic valve dysfunction or bicuspid valve mcc developed countries).

Answer 43

Organophosphate = inhibit acetylcholinesterase. Too much Ach and get massive parasympathetic symptoms. Also used as a chemical weapon (sarin gas). Colorless, tasteless, fruity odor Dx if needed: RBC Achesterase activity levels. Or just give Atropine and see if resolves. Tx: ABCs, Atropine immediately (competitive inhibitor at the muscarinic receptor) + clothing removal (absorbed through the skin). Tx later: Pralidoxime (works at both muscarinic and nicotinic receptors, reverses the neurotoxicity and reactivates cholinesterase activity). Only give Pralidoxime after Atropine.

Answer 44

From forcible pulling or twisting an extremity. Red flag for child abuse. Next step: Skeletal survey for additional Fx. Various stages of healing. Look for retinal hemorrhages. Report to CPS.

Answer 45

GM+ve filamentous rods, weakly acid fast. | Tx: TMP-SMX.

Answer 46

Can aortic aneurysm. Steroids before Bx. Can't afford to be wrong. If eyes involved, admit with high dose pulse steroids. methylprednisolone 500 - 1000mg daily.

Answer 47

CYP 450 enzyme inhibitors: | Stops liver enzymes from metabolizing the drug (breaking it down. The drug stays more and has more effects).

Answer 48

CYP 450 enzyme inducers: | Break it down faster. Drug clears faster.

Answer 49

Watch and wait.

Answer 50

Tx: 1. Topical ciprofloxacin (fluoroquinolone) if adult & ok for kids if uncomplicated infection. Piperacillin or ceftazidime.

Answer 51

1. BB 2. Non-DHP CCB Verapamil, disopyramide. (prolong diastole and decrease myocardial contractility, lets the heart fill more).

Answer 52

>3cm at renal arteries

Answer 53

Ab for Ash Receptor. Therefore Tx is Achesterase inhibitors. Pyridostigmine

Answer 54

Family of colon cancers. mt DNA mismatch repair gene. screening colonoscopy. High risk **endometrial carcinoma**. Endometrial Bx from 30s. **Risk ovarian cancer**. Prophylactic hysterectomy & BSO at 40 or after kids.

Answer 55

(Echi the dog, treat with albendazole). Hydatid cysts. Dog tapeworm in rural and developing countries. Sheep farming. Humans get from eating food or water with dog feces. Eggs hatch in SI go to liver and get multiple cysts. Asymptomatic for years, illness when cysts large or rupture. Eggshell calcifications on CT. Dx: U/S (showing smooth, round cyst)+ Serology for Echinococcus IgGs. Tx: small cysts (<5cm) Albendazole, large cysts percutaneous drainage or surgery. (Echinococcus = cysts (multiple)).

Answer 56

Severe Hypovolemic HyperNa: Tx = 0.9% Saline, once normal volume status, switch to 0.45%. Less severe Hypovolemic: Tx = 5% Dextrose in 0.45% Saline.

Answer 57

Often from HTN. Decussate 2X, ipsilateral symptoms. Ipsilateral hemiataxia of trunk if in the vermis. Ipsilateral hemiataxia of limbs if in the cerebellar hemispheres.

Answer 58

Before Methotrexate, test for Hep B, Hep C, TB. No Methotrexate if prego or want to get preg. No Methotrexate if liver or kidney problem, causes hepatotoxicity (avoid alcohol). Do regular CBCs and LFTs. Methotrexate: Anti-Folate immunosuppressant.

Answer 59

damage of the dorsal column

Answer 60

SAAG = Serum albumin - Peritoneal fluid albumin. (blood should have higher album) >1.1 = Portal HTN: (LFTs albumin 3.1- paracentisis albumin 1.1 = 2.0) Tx: Furosemide & spironolactone & Na Restriction. Get a cell count and diff to r/o SBP. <1.1 = Non-portal HTN: (=peritoneal fluid has a lot of albumin). Causes are malignancy (persistently bloody fluid, mcc Hepatocellular carcinoma, 2. Mets from ovaries or prostate. Get Alpha-fetoprotein & cytologic analysis), pancreatitis (pancreas has proteins in it, serosanguinous), nephrotic syndrome (loosing), TB (fever, night sweats, yellow coloured).

Answer 61

(hyperdense fluid collection with irregular margins).

Answer 62

South West develop CAP (community acquired pneumonia) >1 week. Arthralgias and erythema nodosum. CXR: Unilateral infiltrate w/ ipsilateral hilar LAD (lymphadenopathy). Bx: spherules with endospores. Dx: Serology testing. Tx: If severe or risk factors (HIV, DBM, immunocompromised) = ketoconazole or fluconazole. If not severe, supportive.

Answer 63

Single blue inclusions on Wright stain in an RBC. Spleen usually would have cleared these nuclear remnants. Therefore conditions with functional asplenia (Eg. Sickle cell) or splenectomy.

Answer 64

G6PD deficiency or thalassemia. Hb getting oxidized and precipitating as denatured. Bite cell, Heinz body (the rigid precipitate) geet’s phagocytosed out

Answer 65

=schistocyte MAHA: 4 things DIC, HUS, TTP, Prosthetic valve

Answer 66

From ribosomal precipitations, blue granules in the cytoplasm of RBCs. Nonspecific. Thalassemias, lead poisoning.

Answer 67

hard exudates, AV nicking, flame, sliver wiring

Answer 68

microaneurysms

Answer 69

High LAP score, fever, no basophilia, late myeloid cells (metamyelocytes & bands).

Answer 70

40-59, >30% blasts = AML. | 40-59, <30% blasts = CML.

Answer 71

Lymphoblasts (lack peroxidase +ve granules). PAS +ve. TdT +ve (pre B & pre T lymphoblasts).

Answer 72

Middle age (40-59) WBC >100000, basophils, neutrophil precursors. Low leukocyte alkaline phosphatase score, large spleen. Lots PMNs. (Early myeoloid cells (promyelocytes & myelocytes). BCR-ABL fusion chromo 22 (Translocation 9-22), this causes tyrosine kinase to be constantly on. Tx: Tyrosine kinase inhibitors (imatinib).

Answer 73

Lymphadenopathy, hepatosplenomegaly. Needs PCP prophylaxis. Treat only the symptomatic. Predominate lymphocytes. Dx: lymphocytosis, mature lymphocytes, smudge cells, flow cytometry. Tx: Rituximab, monoclonal Ab for CD20 Antigen on B lymphocytes.

Answer 74

Heme pigment injury. From a clerical error (mismatched blood). <1hr, fever, chills, pain at the IV site, hypotension (from cytokine release), hemoglobinuria (dark urine), flank pain. Get an intravascular hemolysis (RBCs getting destroyed). Leads to Hb build up in the kidney, renal tubular cell injury and acute renal failure. Dx: Direct coombs test showing Ab coated RBCs. Tx: 1. Stop transfusion 2. IV normal saline (prevents kidney injury or DIC progression

Answer 75

Within weeks Donor T cells Rash, fever, GI symptoms, pancytopenia (low cell counts).

Answer 76

Get chronic CO2 retention (makes acid). kidney compensates and keeps HCO3. stopping the HCO3/Cl exchanger. By increasing HCO3-, you decrease Cl-.

Answer 77

increase in echoes from pathologic changes in tissue density.

Answer 78

Big toe extends up and small toes fan out.

Answer 79

bilateral lymph nodes, 1 ulcer Painless secondary, involves the palms and soles 1. Penicillin IM. 2. Doxycycline if Penicillin allergy

Answer 80

Chlamydia trachomatis. Painless, singular ulcer. Then get +lymph node, tender. Tx: Doxycycline.

Answer 81

H.Ducreyi. Painful ulcer, singular large 1-2cm. gray/yellow exudate. +ve lymph node (pusy node), tender. Developing country, rare in US. Dx: gram stain (GM negative rods) & clinical. Tx: Azithromycin or Ceftriaxone.

Answer 82

SLE + Scleroderma + Polymositis. Anti-U1 ribonucleoprotein (RNP).

Answer 83

3.0-4.5 = normal

Answer 84

NSAIDS, beta-lactams, PPIs.

Answer 85

1. Broad spec ABX 2. Bolus the shit 3. Pressors.

Answer 86

Start on Insulin.

Answer 87

Constipation

Answer 88

Young person. H/A, tachycardia, sweating/hot flashes, anxiety. Catecholamines (epi, nore, dopamine) inhibit insulin secretion, leads to hyperglycemia (Remember stress response leads to gluconeogenesis).

Answer 89

3Ps (MEN gene problem) Pituitary adenoma: prolactin, GH, ACTH, vision prob. Primary HyperPTH: mltp adenoma or hyperplasia, HyperCa (Bone breaking down to release the Ca, Kidney stones, polyuria). Depression, poor sleep. Can cause HTN from increased renin secretion. Pancreatic tumor: Gastrinoma or Insulinoma.

Answer 90

(RET proto-oncogene) Medullary thyroid cancer (calcitonin, parafollicular C cells). Pheochromocytoma. Parathyroid hyperplasia.

Answer 91

Medullary thyroid cancer (calcitonin). Pheochromocytoma. Mucosal neuromas/marfanoid habitus. If Pt has medullary thyroid cancer, check for ret gene before you do the thyroid surgery. Might have a pheochromocytoma undiagnosed and go into crisis.

Answer 92

>1500ml or >200ml/hr for 2 hours.

Answer 93

Loud first heart sound (opening snap = early diastolic sound). The murmur itself, if the stenosis is mild, late diastolic. As the stenosis progresses, mid-diastolic. Often a young person with rheumatic heart disease. (atrial myxoma, the valve itself is healthy and therefore has no opening snap)

Answer 94

Metoprolol succinate, carvedilol, bisoprolol.

Answer 95

Leads to vasoconstriction

Answer 96

statins & colchicine (Gout) are direct myotoxins. Get Rhabdo. CPK >1000U/L

Answer 97

TAG >150 mg/dL, increased cardiovascular risk LDL >190 mg/dL >40yo with diabetes >7.5% History of CVD If high risk or has

Answer 98

Insulin secretagogues. Inhibits ATP-sensitive K channels on pancreatic beta-cells. Causes L-type Ca channels to open, similar to sulfonylureas. Taken with meals, rapid onset and short duration of action. Good for controlling postprandial glucose levels. Good for patients that occasionaly have large meals or irregular dietary schedules. Metabolized in the liver, good for patients with chronic kidney disease. Won’t lead to hypoglycemia. (Sulfonylureas have a longer duration of action and risk of causing fasting hypoglycemia).

Answer 99

Goal BP >60yo <150/90mmHg. Add Rx if systolic >150 or diastolic >90. Goal BP <60yo with CKD or DBM, <140/90. Add Rx if systolic >140 or diastolic >90. Treatment choice: If you’re black: Thiazide diuretic or CCB (alone or in combo). ACEI/ARB not first-line. If you’re not black: Thiazide diuretic, ACEI, ARB or CCB. Alone or in combo. If you’re not black & have CKD: ACEI or ARB (they are renal protective, they activate the RAAS system causing a decreased GRF by decreasing aldosterone). BB are unfavorable in DM Pts, they affect insulin sensitivity.

Answer 100

more common in older men

Answer 101

Pancreatitis (mc).

Answer 102

causes fatigue, constipation & depression. | causes a nephrogenic diabetes insipidus. This is why the Tx of HyperCa is IV 0.9% hydration, they will be hypovolemic.

Answer 103

shallow breathing causes poor recruitment of the lung bases. hypoxia which stimulates increased respiratory rate (tachypnea). Causes low pCO2. Get low pCO2 & low O2.

Answer 104

based on how clean the wound is. Clean wounds, worry about skin flora. 1st & 2nd Gen Cephalosporins. If penicillin allergic (cephalosporins are structurally similar) Tx: Vancomycin or clindamycin.

Answer 105

MC benign liver tumor. Triphasic CT shows centripetal enhancement (enhancement moving from periphery to center). No central scar. Found incidentally.

Answer 106

Benign liver tumor. R lobe of liver. Women on estrogen OCPs or pregnant women. No centripetal enhancement on triphasic CT. No central scar present. Elevated alk phos & GGT from compressing the biliary system. Normal LFTs. Do not Bx, risk of bleeding. Dx: Ab u/s showing a solid mass (solitary hyperechoic lesion, well demarcated). Tx: Surgical excision. Complication: Rupture leading to shock or malignant transformation.

Answer 107

MC benign nonvascular liver lesion. Usually asymptomatic and incidental. central stellate scar Fills on arterial phase of CT. Most <5cm, solitary lesion. Well-circumscribed, hyperdense lesion. From hyperplastic response to hyperperfusion from a large artery at the center of the lesion (aberrant congenital artery). Dx: Triphasic, helical CT scan. Tx: Nothing, doesn’t grow. Don’t have to d/c OCPs.

Answer 108

Take Fe with Vitamin C. because, Fe is best absorbed in acidic environment. Fe if best on a empty stomach. Get constipation. Fe must be continuous for several months to replenish stores.

Answer 109

congenital mobile cecum. Needs emergent laparotomy & resection of volvulized segment (right colectomy)

Answer 110

Chronic constipation leads to colonic dysmotility redundantly in the sigmoid colon inverted U or coffee bean shaped flexible sigmoidoscopy endoscopic reduction of the twisted

Answer 111

cecum and ascending colon Electrolyte imbalance can precipitate Bowel rest/NPO & colonic decompression

Answer 112

Intermittent: <2days/wk symptoms or SABA use; <2x/month nighttime. awakenings. Tx: SABA: Albuterol, Pirbuterol. Mild Persistent: >2days/wk not daily SABA; 3-4x/month nighttime. Tx: low dose inhaled steroid. Moderate: Daily; >1x/wk at night. Tx: LABA salmeterol or formoterol. Severe: every day; 4-7x/wk at night. Tx: Oral prednisone. Or others. If Pt has no symptoms for 3 months, consider a step down therapy. Bronchodilator response is >12% in FEV1

Answer 113

>3.5 g/dL / 24hr, hypoalbuminemia, edema, hyperlipidemia and lipiduria. Hypercoaguable (from losing antithrombin3, protein C & S imbalance), most common is renal vein thrombosis. Primary glomerular: membranous, Focal segmental, minimal change. Secondary: DBM, amyloidosis

Answer 114

If the child is <10, don’t do a Bx. | Tx. Emperic Prednisone-Corticosteroids.

Answer 115

Focal segmental: MC nephrotic adults, teens & blacks. HIV, Heroin, Obese. Membranous: 2nd MC nephrotic, solid cancers. Hep B (unvaccinated Pt, immigrant, HBsAg and HBeAg, negative anti-HBsAg Ab). MC to get renal vein thrombosis. HBeAg or antibody deposits in the glomeruli. Minimal change: MCC kids <6yo, NSAIDS or lymphomas (Hodgkin) adults.

Answer 116

PaO2 <55mmHg or SaO2 <88% on room air (55LB Plugs Offenses, 88 the wide receiver Score on Offense). If RHF, start O2 a little earlier.

Answer 117

antimetabolite chemo drugs s/e: BMS, get a BX

Answer 118

Pulmonary fibrosis. Get PFTs.

Answer 119

S/E: Hyper K, via inhibitors Na channels in collecting duct.

Answer 120

S/E prolong QT and cholestasis

Answer 121

⬆︎ AFP & bHCG.

Answer 122

⬆︎ BHCG, norm AFP.

Answer 123

Cellulitis of submandibular (under mouth) space from dental infections in the mandibular molar. Spreads from the teeth root to the sublingual space. Polymicrobial. Displaces the tongue posteriorly. May lead to an acute airway obstruction. Neck described as “woody” or “brawny”. Next step: Secure the airway. Dx: CT of neck. Tx: IV ABX (ampicillin-sulbactam, clindamycin).

Answer 124

SE = SD/√N. | 95% CI of mean = mean +- 1.96 *SE.

Answer 125

Disease status Positive Negative Exposure positive: a b Exposure negative: c d Odds and Probability are similar for rare diseases

Answer 126

+ve disease -ve disease Positive test TP FP PPV Negative test FN TN NPV Sensitivity specificity PPV = (TP/ (TP+FP)) if move cut-off point left, both TP & FP will increase. Therefore PPV will decrease. (use the alcohol example). NPV = (TN/ (TN+FN)) PPV = what are the chances the person actually has the disease if the test is positive. NPV = what are the chances the person does not have the disease given the negative test result. high pretest prob (belongs to high risk group) of having a disease, will have low NPV

Answer 127

NNH= 1/AR. | AR: a/(a+b) – c/(c+d).

Answer 128

NNT=1/ARR (absolute risk reduction). ARR of 4% = 0.04. NNT=1/0.04. ARR= Control Event rate – Experimental Event rate. (Drug reduces the rate from 50 to 30%, ARR = 0.5-0.3 =0.2.

Answer 129

(When they take a study and ask you to compare it to a whole population). The excess risk in a population that can be explained by exposure to a particular risk factor. ARP=(risk exposed - risk unexposed)/risk exposed. ARP=(RR-1)/RR.

Answer 130

Muddy brown casts: ATN, hypovol shock. BUN/Cr <20:1. Broad casts: Chronic renal failure. RBC casts: glomerular disease or vasculitis. WBC casts: pyelonephritis, acute interstitial nephritis (AIN). Fatty casts: Nephrotic syndrome.

Answer 131

No Doxy, give Amoxicillin

Answer 132

At 28-32 weeks and up to 72hrs of delivery. | High titers means immunized.

Answer 133

If has CKD or is unstable, to a transesophageol echo

Answer 134

Aspiration pneumonia: Foul smelling sputum, poor dentition. Think gram negative anerobes. Tx: Clindamycin, Augmentin (Amox-Clavulanate), Metronidazole + Amoxicillin, Carbapenem. Anareobes make beta-lactamase inhibitors.

Answer 135

if <3cm fluid, IV ABX. if >3cm, CT guided percutaneous drainage. if 5th day not better, surgical drainage and debridement.

Answer 136

HBsAg: surface antigen, first evidence of infection. HBeAg: marker of viral infection & replication (can you infect someone). IgM anti-HBcAg: Ab to core antigen.

Answer 137

Acute HepB

Answer 138

Early phase

Answer 139

Window phase

Answer 140

Chronic carrier

Answer 141

Chronic activated

Answer 142

Vaccinated

Answer 143

IgG (anti-HBc), Anti-HBs. (vaccinated are anti-has and not anti-HBc, because the vaccine only had pieces HBsAg parts, it didn’t have the virus parts).

Answer 144

Bisphosphonates

Answer 145

Myelodepression

Answer 146

won’t have hemarthrosis or tons of swelling

Answer 147

>3cm = anneurysm Risk of rupture >5.5cm

Answer 148

PAD at the bifurcation of the aorta

Answer 149

ACEI to inhibit RAAS

Answer 150

Auto Dominant. Telangiectasia, recurrent epistaxis, widespread AV malformations. Chronic disease, so clubbing. Telangiectasia can lead to AVMs, subject to high-pressure flows and risk of hemorrhagic stroke in a child.

Answer 151

Will be bilateral. PaO2/FiO2 <300 mmHg. Risk factors infection, trauma (24-48hrs after), massive transfusion. ARDS = Noncardiogenic pulmonary edema. Leads to leakage of bloody and proteinaceous fluid into the alveoli. Alveoli will collapse due to a loss of surfactant. Leads to impaired v/q and decrease lung compliance (less stretchy). Leads to PAH from hypoxic vasoconstriction. PaO2 decreases meaning you need more FiO2. PaO2/FiO2 is decreased. PCWP in normal. Tx: Mechanical ventilation with low TV ventilation to prevent overdistending the alveoli and causing a barotrauma (pneumothorax). Tx: keep O2 >88% or PaO2 55-80. By increasing PEEP (15-20), not by inc FiO2.

Answer 152

Measure of air flow from the ventilator

Answer 153

Measure of compliance, the ability to expand.

Answer 154

Problem is host Donor T cells and the patient's MHC.

Answer 155

Host T lymphocytes acting on the donor organ. Acute rejection is the first 6 months. The organ will show signs of decreased function and tenderness. Dx: Biopsy showing Tcell infiltration. Tx: High dose IV steroids and adjust the dose of their immunosuppression meds.

Answer 156

MVP mcc of Mitral Regurge in the US.

Answer 157

prominent V waves (persistent RA pressure). Holosystolic murmur L lower sternal boarder. 90% are secondary causes

Answer 158

Cardiac Tamponade (pressure on the pericardial sac, LV and RV have to compete), severe asthma or COPD

Answer 159

Choriocarcinoma (B-hCG really high, really high), teratoma & yolk sac tumors (AFP).

Answer 160

An ovarian germ cell tumor. From cells that differentiate into fetal yolk sac and GI tract. Makes Alpha-fetoprotein

Answer 161

No Doxy, Amoxicillin Erythema Migrans is the rash.

Answer 162

North eastern part of USA. Tick bite. Intravascular hemolysis & anemia. Dx: Blood smear for the Maltese cross. Tx: 7-10 days of atovaquone + azithromycin or quinine + clindamycin (severe disease).

Answer 163

Tx if symptoms <2x/wk: Lifestyle changes weight loss, elevate head of the bed & histamine 2 recepto antagonists Famotidine, Ranitidine. Tx if severe or frequent symptoms: PPI = esomeprazole, omeprazole, pantoprazole for 8 weeks.

Answer 164

Common in Pts that have immunosuppression (DM or >50yo) and vascular disease. U/s is less sensitive, hard to see air-filled structures. Tx: Emergent cholecystectomy & broad spectrum parenteral ABX (piperacillin-tazobactam).

Answer 165

Protozoan (No eosinophilia) cause colitis or liver, brain illness to people who live or travel to developing countries. From the consumption of contaminated food and water. Get a liver abscess (U/S: single, subcapsular, low-density lesion in R lobe (more portal blood supply)). Protozoa enter the colon, they spread to the liver via the portal supply. Some get Dysentery (bloody stools with mucus & Ab pain). Don’t drain the abscess. Prolonged diarrhea 2-3wks, that progresses to colitis (tenderness and bloody diarrhea). (No eosinophils). Dx: Serology of stool E Histolytic antigen by PCR or enzyme immoassay. Tx: 1. Metronidazole (for the abscess) & 2. Intraluminal ABX (paromomycin) to stop the intestinal colonization. Dx: Stool ova & parasites. (Giardia and prolonged diarrhea that is watery and has fat malabsorption, greasy smelly stools). (Echinococcus has cysts, cysts need surgical drainage. Entamoeba causes an abcess and that needs ABX). Echinococcus = Tape worm = cysts.

Answer 166

FEV1 & DLCO. Want greater than 40%.

Answer 167

LDH is high. Can not be cultured, needs a special stain by bronchoalveolar lavage or sputum. Tx: TMP-SMX + steroids if PaO2 <70 or A-a gradient >35 on room air(decreases mortality). 2nd line Dapsone + TMP or Primaquine + clindamycin. 3rd line Atovaqone.

Answer 168

CBF (cerebral blood flow) increase in brain , if CO2 is increased, send more blood to the brain

Answer 169

Risk of pneumothorax. Meconium plugs the airway and prevents proper alveolar expansion leading to rupture

Answer 170

Coxsackievirus causes pericarditis and myocarditis.

Answer 171

1. Topical retinoids or benzoyl peroxide 2. Topical ABX erythromycin 3. PO ABX tetracycline

Answer 172

Dx: Clinical during the cough. Lymphocytosis is a clue. PCR if need to confirm Tx: Emperic Macrolide Macrolide to all close contacts for 3 weeks. regardless of immunity status, vaccination can wane. <1month old: Azithromycin for 5 days (erythromycin has risk of pyloric stenosis in neonates). >1month old: Any macrolide (erythromycin, azithromycin). Hospitalize if <3 months old, risk of apnea. Respiratory isolation first 5 days of abx tx. Prevented by: 5 doses of DTaP as a kid + Tdap booster at 11-12yo.

Answer 173

WAGR: Wilms, Aniridia, GU problems, Retardation & Beckwith-Wiedemann. Mets to lungs. WAGR syndrome = 11p deletion syndrome. Dx: 1. Ab u/s 2. CT or MRI to confirm 3. Pathology. Tx: surgery & chemo/radiation. Good survival rates.

Answer 174

**Live vaccine** 2 doses, age 1 & age 4. Postexposure prophylaxis for a child >1yo exposed in last five days, give the live vaccine. If cannot receive live vaccine (neonate, immunocompromised, pregnant women), give varicella Ig (passive immunity). Effective for baby if mom got chicken pox 5 days before to 2 days after delivery. Varicella is largely contagious via respiratory droplets, highly contagious. 2 weeks after exposure, Varicella has a prodrome of fever and malaise 24hrs before the rash. The vesicular rash will be in different stages. Breakthrough virus is possible, (Eg. Question will give a 3yo, that hasn’t received the second dose of VZV vaccine).

Answer 175

Vertbral, Anal Atresia, Cardiac, Tracheoesophageal fistula, Renal, Limb (Vacteral is anal atresia, charge is choanal atresia, missing eye piece and ear problems).(charge syndrome nose (choanal) is above the anus, c is before v).

Answer 176

``` C oloboma (missing eye part) H eart defects A treasia choanes R etardation of growth/development G enito-urinary anomalies E ar abnormalities. ``` **a bunch of things don’t develop** Genetic testing if suspect CHARGE syndrome. Do an echo and renal u/s. (if choanal atresia, make sure to investigate for charge syndrome

Answer 177

Strep pneumo, H influenza.

Answer 178

Dx: Karyotype & methylation studies. Then in-situ hybridization. Then microsatellite probes. Tx: Obesity related, screen for OSA & DM.

Answer 179

Alteration of chromosome 11p15 (has the gene for IGF2, monitor for hypoglycemia). Risk for tumors like Wilms tumor and hepatoblastoma. Next step: Abdominal u/s & AFP every 3 months birth to 4 yo. Renal u/s every 3 months age 4-8yo.

Answer 180

For Wiskott-Aldrich and SCID.

Answer 181

Abnormal B-cell differentiation. Problems with IgG and IgA, IgM or both. Respiratory infections with encapsulated bugs (strep & Haemophilus). Get giardia. Get failure to thrive and chronic respiratory problems (asthma or bronchiectasis). Increased risk of autoimmune disease and malignancies. Presents later in age, teenager. B cells normal (total lymphocytes (lymphocytes) – t cell lymphocytes (CD4 + CD8)= b cell lymphocytes). Low Igs. Tx: Avoid infections, there IV Ig infusions (replace what they don’t have).

Answer 182

Low IgG and normal Ab response to vaccines. Has a prolonged physiologic response. Seen after 6 months, when mom’s Abs wane. Asymptomatic or develop recurrent infections (otitis media, resp infections). Has asthma, eczema and food allergies. Normal WBC count. Dx: Low IgG levels. Tx: Self-resolves. (X-linked agamma, Bruton. All Igs low, no Ig response to vaccines, low WBCs).

Answer 183

Ampicillin & gentamicin (because caused by GBS and want it broad spectrum). For >1month empiric ABX is 3rd gen cephalosporin + vanco

Answer 184

Age 3-5yo. Intellectual disability & severe seizures. EEG shows slow spike wave pattern.

Answer 185

Cardiovascular manifestations, bicuspid aortic valve, aortic root dilation, aortic coarctation and HTN. These increase the risk of aortic dissection

Answer 186

Glu to valine Tx: Empiric Ceftriaxone (for Salmonella, GM-ve) and oxacillin or Vanco (for Staph A.) Pseudomonas is not encapsulated.

Answer 187

Infantile Seizure, Adenoma sebaceous (bumps on face). Skin involvement has hypopigmented macules, angiofibromas, shagreen patches or forehead plaques. Autosomal dominant (family hx). Neurocutaneous d/o or de novo mutation in TS complex genes (seizures). Leads to benign tumors (hamartomas) in the brain, skin and other organs. Eg. Brain hamartomas are subependymal nodules (giant cell tumor). High association with cardiac rhabdomyoma, get an Echo. The mass typically regresses after infancy. Mt in TSC1 or TSC2 gene. Management: Serial skin and exams. Tumor surveillance. Neuropsych evals.

Answer 188

Generalized seizures, mental retardation, port wine stain aka nevus flammeus (along trigeminal nerve 1st or 2nd branch, represents cavernous hemangioma aka capillary malformation). Gyriform intracranial calcification look like a tramline (leptomeningeal angiomatosis). Can also lead to vision problems if it hits the occipital lobe. Can get glaucoma. Dx: MRI with contrast to see the intracranial vascular malformation. Tx: Control the seizures and decrease intraocular pressure.

Answer 189

Airborne respiratory droplets (daycare, waiting rooms). cough, coryza (runny nose), conjunctivitis, maculopapular rash spares soles (the rash can coaless & darken, blanching → nonblanching). Then a high fever (>105), cervical lymphadenopathy. NO arthritis. Koplik spots (pathognomonic, small white lesions back mouth/buccal mucosa). Vitamin A reduces morbidity and mortality for Pts with measles by promoting Ab cells and regeneration of epithelial cells (gut, lungs and eyes). So if Pt if vitA def or if Pt is hospitalized (severe measles), make sure you replace Vit A. Dx: PCR showing rise in Abs. Tx: Supportive care. Pts who are … Measles vaccine is 2 doses (1 & 4 yo).

Answer 190

Milder disease, (3 day measles) Rash face to feet maculopapular (fine pink rash), the rash doesn’t darken. Posterior auricular, suboccipital, posterior cervical lymphadenopathy. Arthralgia (measles does not have arthralgias). Arthralgia & Arthritis is in teens and adults, can persist months after the rash. Long term complication: Subacute sclerosing panencephalitis (dementia). Symptoms 2-3 weeks after inhaling respiratory droplets. Some Pts have petechial or erythematous papules on the soft palate, Forchheimer spots. (No cough, choryza or high fever in Rubella). Tx: Supportive. Congenital Rubella (at birth): Hearing loss, cataracts, PDA (machine-like murmur). Prevented: Immunize at 1 & 4y.o.

Answer 191

Exanthema subtile, 6th disease. (Human Herpes Virus) HHV6. Maculopapular rash after the fever resolves.

Answer 192

Fever, rash & HypoNa Travel Fever plus rash distal (palms/soles & wrist/ankles & initially maculopapular) → centripetally. Headache. Low platelets & hypoNa from ADH response to hypovolemia from vascular injury. Transmitted via the bite of a tick infected with Rickettsia, a bacteria that causes vascular injury. Prevalent during the summer in the eastern and southeast US. Grassy or wooded areas. Tx/Next step: Empiric Doxycycline. To confirm Dx with serology. Doxy will prevent disease progression and mortality.

Answer 193

Benign capillary bed tumor. Rapidly grows in the first year of life, the spontaneously regresses during childhood. Tx: BB Propranolol for complicated ones (Eg. on eye lid), it causes vasoconstriction or the vessels.

Answer 194

excessive sucking hyperactive reflexes jittery baby. less severe than opiate withdrawal

Answer 195

X-linked (boys). Catalase positive (S.Aureus, Aspergillus, serratia m, cepacia). GCD disease gets abscesses, lung and skin. Recurrent bacterial & fungal infections. Neutrophil problem for oxidative burst. Problem with NADPH oxidase. Have decreased superoxide anions. Phagocytes can’t oxidize anything and granulomas form. Dx: Dihydrohodamine 123 or Nitroblue tetrazolium test (oxidative burst testing of neutrophils). Tx: Infection prevention. Need antimicrobial & antifungal prophylaxis with TMP-SMX. INF gamma injections also help. (Strep pyogenes is catalase-negative. CGD is not left shifted).

Answer 196

intussusception Butt and legs. Joint pain knees and ankles. IgA immune-mediated vasculitis in kid after prev mild illness (URI). Ab pain and palpable purpura, arthralgia, renal disease (hematuria), scrotal pain. Normal platelet count. If Renal B/x, will see IgA in mesangium. Tx: NSAIDS

Answer 197

Houses before 1978 confirm with venous lead. Tx if screening lead levels >45: Chelate with Dimercaptosuccinic acid (succimer) & remove from house. Tx if >70: Use EDTA. D before E

Answer 198

MCC in kids <20yo get Staph Aureus. Anticipate resistance with IV vancomycin MCC >20yo: Pseudomonas (more resistant bacteria), come from all the abx exposure and their poor lung function. Strep pneumo rarely causes pneumo in CF Pts (but MCC in healthy).

Answer 199

Respiratory distress in a full-term baby. CXR: Bilateral perihilar linear streaking.

Answer 200

Histiocytes (macrophages in tissue) CNS (get central diabetes insipidus, polyuria and hyperNa). Dx: Biopsy. Tx: Curettage or chemo.

Answer 201

Suspect in any neonate (28 days) vomiting bile. Duodenum ends up in R. abdomen. Bowel ischemia and perforation are complications. If shock or signs of ischemia, do emergency laparotomy. Dx: 1. X-ray to r/u perforation, duodenal atresia or distal obstruction. Contrast upper GI series (barium swallow) to locate obstruction. Show ligament of trietz on R side of abdomen = malrotation. Contrast in a corkscrew patter = volvulus. Tx: 1. Stop enteral feeds, NG decompression and IV fluids. 2. Surgery (volvulus gets reduced. If malrotation, Ladds procedure is done).

Answer 202

= analogue of ADH. Often used to treat central diabetes insipidus (missing ADH in brain). It is also used to released vWF and treats heavy menstrual bleeding with vWbrand disease. Desmopressin S/e: Hyponatremia from excess ADH stimulation (like an SIADH) (HypoNa, high urine osmolality, high urineNa (from increased natriuretic peptide release), euvolemia (no edema or JVD)). Next step: Serum electrolytes.

Answer 203

H.flu type b, non-vaccinated. But Other H.flu strains, Strep and S.Aureus can also cause it (need vanco abx) Fever, dysphagia, drooling, distress, hot potato voice, respiratory distress. Life threatening. Fast onset (hours), without notable prodrome. PE: hyperextended neck, tripod position (leaned forward, hyperextended neck) = sign of impending respiratory problem. Risk of obstruction. TX: 1. Endotracheal incubation in a controlled setting (ER, OR). If it fails, tracheotomy. 2. Broad spec ***Ceftriaxone (H. Influ & Strep) & Vancomycin (MRSA). Prophylaxis rifampin for all family members to protect anyone exposed. Don’t need Dx, if clinical suspicion is high, would delay treatment.

Answer 204

Barky the croupy seal. Parainfluenza. Steeple sign on CXR. Bark seal like cough, inspiratory stridor, improves on leaning forward, fever. No drooling. Gradual onset (days). TX: 1. Dexamethasone (steroid) for mild cases to decrease the edema. 2. Nebulized racemic epi if stridor at rest. If all of that fails or if impending respiratory failure (AMS, poor breathing effort), then intubate (neb epi before intubating). No drooling. Nebulized epinepherine: Constricts mucosal arterioles in the upper airway leads to decreased edema & reduced secretions. Observe the Pt for 4 more hours. (Steroid, Racemic Epi, Intubate).

Answer 205

*Floppy larynx tissues* collapsing on inspiration. Causes inspiratory stridor (mcc). Worse when lying down. Prone position improves, because the tongue moves forward anteriorly (less obstruction). Exacerbated with feeding or URI. 4-8 months y.o. Crying and feeding make the stridor worse because of increased airflow. Some Pts will also have GERD. Dx: Flexible fiberoptic laryngoscopy. Showing omega shaped epiglottis & supraglotic structures collapsing when breathe in. Tx: spontaneously resolves by 18 months. If FTT (failure to thrive), surgery consult.

Answer 206

Idiopathic avascular necrosis of femoral capital epiphysis. Age 4-10. Gradual onset. But pain for >1month. X-ray can be negative. As progresses, internal rotation & abduction of hip joint limited. Proximal thigh atrophy. Antalgic gait. Pain can be referred to the thigh or knee. Boys. Dx: Repeat X-rays (may be normal at first). Tx: splinting or surgery. Refrain from weight bearing activities. Keep the femoral head in the acetabulum.

Answer 207

Fat teen (not always, or accelerated growth, tall and thin teen). Hip or knee pain (referred pain). If not fixed, risk of avascular necrosis. Superior displacement of the proximal femur. Hypothyroid Pts too (normally TH allows for ossification of the growth plate). If a Pt gets SCFE at an early age, likely to develop bilaterally. Limited internal rotation. Dx: Frog leg lateral X-ray. Look at both hips. Tx: surgical pinning femoral head.

Answer 208

Ca gluconate to stabilize the cell.

Answer 209

are unilocular adnexal masses with homogeneous low level/internal echoes (blood) or ground glass appearance

Answer 210

Likely from uterus endometrial proliferation. Dx: CBC, Pelvic U/S. if >45yo: +Endometrial Bx. if <45yo: First try combo OCPs (will build up and shed the lining). Then do an endometrial Bx. If <45yo + Obese or + Tamoxifen: +Endometrial biopsy. Ultimate Tx once r/o cancer: Endometrial ablation.

Answer 211

>40 y.o, history of pelvic surgery. Sudden urge to void, then immediate loss of urine. Involuntary detrusor muscle spasms (overactive bladder). Detrusor over activity. Do a UA and post void residual first. Tx:1. bladder training (resisting the urge) increases bladder capacity, kegels. 2. Oxybutynin (antimuscarinic) to relax the detrusor and spasms. (oxybutynin, parasympathetic causes peeing, so antimuscarinic will decrease parasympathetics, and calm the overactive bladder).

Answer 212

``` Neurogenic bladder (Eg. From Diabetes Mellitus) From diminished contractility of the bladder detrusor. Sx: Incomplete emptying & persistent involuntary dribbling (even at night). Path: Impaired detrusor contractility or bladder outlet obstruction. PVR (>150ml ♀ >50ml ♂) Tx: Peeing = parasympathetics, give cholinergics (bethanecol). “Bethan, call your bladder and tell it to pee”. If severe, intermittent catheterization. ```

Answer 213

(Add penicillin if unknown GBS). Contractions <37 wks, cervical dilation &/or effacement. Risk factors multiple gestations, hx of preterm delivery, hx cervical surgery. If <34 weeks: tocolytics (indomethacin, nifedipine) to postpone delivery + corticosteroids (betamethasone). If <32 weeks: tocolytics + corticosteroids + Mg Sulfate (week tocolytic & fetal neuroprotection, worried if deliver will have cerebral palsy).

Answer 214

Chronic inflammatory postmenopausal women (can be premenopausal girl too – from low estrogen). Can coexist with autoimmune conditions. Itchy and painful. Vulva thinning Porcelain-white polygonal patches. Cigarette paper like. Scratching can lead to scaring (thickened white vulvar plaques). Involves perianal region, figure 8. The labia minora and clitoral hood can eventually become atrophied which leads to atrophy of the vagina opening. It is premalignant, can lead to vulvar squamous cell carcinoma. The vagina (inside vestibule) itself will not be involved. Dx: Vulvar punch biopsy to r/u malignancy (since it can become malignant). Tx: High potency topical corticosteroids (clobetasol) (stop the chronic inflammation). Only once a day or skin atrophy, discoloration and striae. If refractory to treatment, get a biopsy, might be cancer. Dx for kids: clinical no Bx needed. Tx for kids: Give steroids. LPlanus has a propensity to involve the mucous membranes including the mouth and vagina which are rarely affected in LSclerosis vs. Lichen simplex chronicus is leathery skin from scratching.

Answer 215

Complicated means Ab resistant, treatment failure, DM, CKD, pregnant, immunocompromised, hospital acquired, result of procedure or catheter. Dx: Needs a urine culture prior. Tx: Fluroquinolones 5-14 days (no if preg) or IV broad spec like Ceftriaxone.

Answer 216

Needs Urine culture before. Stable: Tx: oral fluoroquinolone (ciprofloxacin, levofloxacin). Unstable or pregnant: IV ceftriaxone & inpatient. Once afebrile for 24-48hrs & symptom improvement, switch to PO ABX.

Answer 217

Urease producing bacterium, the cause is Proteus mirabilis or Klebsiella pneumonia. Urease splits urea into ammonia and CO2. Ammonia becomes ammonium (alkalinizes the urine). High pH in urine stops phosphate from being soluble. You develop struvite stones (Mg, ammonium & phosphate) aka, Staghorn calculus. The stones are big so you get reoccurring UTI. Tx: ABX & stone removal (the stone can harbor bacteria).

Answer 218

Pulmonary injury (fever, cough, lung opacities on CXR). Short term get hypersensitivity pneumonitis (wet basilar crackles). Long term get interstitial lung disease.

Answer 219

Syncytiotrophoblast cells of the placenta making LDH & Beta-hCG. LDH secreting germ cell tumor. Solid adnexal mass. No precocious puberty (estrogen controls this and estrogen is normal).

Answer 220

Estrogen secreting sex cord stromal tumors. Large complex ovarian mass. Postmenopausal women, rare prepuberty. Secretes estrogen (breast tender, postmenopausal bleeding, precocious puberty (too much estrogen)), endometrial hyperplasia (from too much estrogen) and mass effect (abdominal distension). Granulosa cells convert testosterone to estradiol via aromatase. They also secrete inhibin (inhibits FSH). Next step: Endometrial biopsy, surgical staging. Tx: Surgery. Unilateral Salpingo-oophorectomy. Reoccurence: Monitor inhibin levels. Tx if also developed endometrial cancer: Hysterectomy and bilateral salpingo-oophorectomy.

Answer 221

Ovarian germ cell tumor. Young women. Secretes alpha-fetoprotein & hCG.

Answer 222

Complex appearance (cystic & solid), abnormal internal features (irregular, thickened septations or papillary projections.

Answer 223

contraception only good for 3 month. Inhibits GNRH. S/E: weight gain and breast tenderness. First r/o pregnancy s/e: bleeding/spotting in first 6 months. No period after 1 year. Tx: estrogen supplementation 7-14 days.

Answer 224

Urine protein/creatinine ratio (>0.3) or 24hr collection for total protein (>300mg).

Answer 225

risk factors: Cocaine & HTN. Abruptio placentae complications: For mom: hypovolemic shock or DIC from tissue factors running out. For kid: hypoxia, preterm delivery (not getting enough blood). Give IV fluids, left lateral decubitus to get uterus off of aorta and ivc (will increase Cardiac output).

Answer 226

1. Contraceptives, progestin-releasing IUD. | 2. If no improvement, Hysterectomy & histological stain to confirm dx.

Answer 227

stimulates medullary respiratory center. Lowers CO2 IM progesterone. Progesterone keeps the uterus quiet and protects against amniotic rupture. Tx: of Preterm labour Progesterone causes vasodilation. Progesterone causes constipation (diarrhea in pregnancy is not normal).

Answer 228

Normal pregnancy, BP 5-10mmHg lower from vasodilation in the first trimester. Back to normal by the 3rd trimester

Answer 229

Cardiotoxicity, get an ECHO, check EF. HER2 Positive breast carcinoma (Her titties...).

Answer 230

S/E: mcc hot flashes (Tamoxifen inhibits estrogen in the CNS, thermoregulation), venous thromboembolism (increases protein C resistance). (don’t pick CAD)

Answer 231

For postmenopausal osteoporosis. Estrogen agonist on bone & mild antagonist in breast (protective effect against breast cancer). S/E: contraindicated in venous thromboembolism (PE or DVT) people. (anything with estrogen agonist potential).

Answer 232

When born: hepatosplenomegaly, skin lesions (diffuse maculopapular rash involves hands and soles, may desquamate), rhinitis, Abnormal long bone Xray, Blueberry muffin spots (from extramedullary hematopoiesis). Later: keratitis, Hutchinson teeth, saddle nose, cns probs.

Answer 233

Too much oxytocin leads to tachysystole (rapid) of uterus and tetany (long prolonged) of uterus. Oxytocin is also similar structure to ADH, can cause Hyponatremia (seizures). Tx: Hypertonic fluids, counters the ADH. Contraindication to oxytocin: prior classical c/s, risk of uterine rupture.

Answer 234

>5 contractions/10 mins. When the uterus is contracting, the vessels are compressed and blood isn’t delivered to the vessels. Can lead to late decelerations.

Answer 235

No vaginal bleeding, cervix closed, no fetal cardiac activity or empty sac. Dead fetus still inside (failure to detect heart beat & not growing).

Answer 236

Cervical dilation and fetal parts at the cervical os. Before 20 weeks gestation. Has painful uttering cramping. (Before 20 weeks, it is likely cervical insufficiency).

Answer 237

(After done breastfeeding). Benign milk retention cyst, few weeks to months after she stops breast feeding. From dried deposited proteins in the lactiferous duct, blocks and causes milk accumulation. Smooth, mobile, fluid filled mass, nontender, up to 5 cm. Dx: U/S. Tx: asymptomatic, do nothing. Symptomatic, needle aspiration, ice pads, supportive bra.

Answer 238

From ductal carcinoma, eczematous nipple changes (flaking, crusting skin). Includes areola. Bloody nipple discharge.

Answer 239

Mass infiltrates the duct and the tissue. You will feel a breast mass, have bleeding from the duct & have lymph adenopathy.

Answer 240

show increased Doppler flow (blood vessels) around the pregnancy = ring of fire. Tx if stable: Methotrexate.

Answer 241

Hematocrit >65%. From excessive transfusion (delayed umbilical cord clamping, twin-twin transfusion), intrauterine hypoxia (placenta problems like DM, HTN, preeclampsia, smoking), or from genetic conditions. Often asymptomatic besides plethoric appearance. Increased viscosity can lead to increased RBC mass, leads to hypoglycemia and hypocalcemia from decreased cellular uptake. Tx: Hydration with oral feeds or glucose-containing fluids (this will decrease the viscosity).

Answer 242

good for 5 yrs IUDs make a physical barrier by thickening cervical mucus and impairing implantation.

Answer 243

Likely GBS, give penicillin or Amox. 2nd line 1st gen cephalosporin (Cefazolin)

Answer 244

GM +ve cocci in clusters

Answer 245

GM +ve cocci in pairs and short chains

Answer 246

, get a 24hr urine collection to get a baseline of proteinuria. If nephrotic range, risk for thromboembolism (losing protein c & s) and needs anticoagulation during pregnancy.

Answer 247

``` Gardnerella (anaerobic bacteria), fishy (bad odor, amine odor), thin gray white. Wet mount with clue cells. Clue cells = epithelial cell coated with bacteria cells. Positive KOH test. pH >4.5. No vaginal inflammation (itching, redness). From an imbalance in vaginal flora, lactobacilli colonization decreases. Leads to an increased pH and overgrowth of anaerobic bacteria. Increased incidence in women having sex with women, douching and smoking. Tx: Oral Metronidazole or clindamycin. No matter if pregnant. No alcohol (disulfiram like reaction with metronidazole). ```

Answer 248

Odor, thin, frothy, yellow green discharge. Elevated pH >4.5. Friable macular cervical lesions (strawberry cervix), postcoital bleeding. Vagina will be inflammed (red and itchy). Dx: Wet mount showing motile, flagellated, ovoid protozoa. Lots of PMNs. Tx: Metronidazole both partners (even if asymptomatic). No sex for 1 week. No alcohol (disulfiram like reaction with metronidazole).

Answer 249

From unopposed estrogen. MCC obesity, from peripheral conversion of androgens to estrogens in adipose. Without treatment can progress to cancer. If desires future kids, initial management is with progestin (Progestin IUD), this will counteract estrogen’s effects and promote differentiation of tissue. F/u with repeat endometrial Bx every 3 months. If progresses to cancer, do hysterectomy.

Answer 250

Tobacco. It metabolizes estrogen in the liver. Progesterone stops that proliferation caused by estrogen. Having kids.

Answer 251

Toxoplasm gondii. From undercooked or cured meat or cat feces contact. Multiple ring lesions parenchymal on MRI with CD4 count <100. Symptomatic babies have macrocephaly, hydrocephalus and lesions in the ventricles and basal ganglia (diffuse intracerebral calcifications). We don’t test for toxo in the USA, only after a Pt has symptoms. Can experience chorioretinitis in adulthood from reactivation on the infection. Dx: Toxo IgM or IgA in serology. Tx = Sulfadiazine + Pyrimethiamine (TMP variation) + Folate for 1 year.

Answer 252

Mom had a mono like illness in pregnancy. Primary contact with infected bodily fluids (saliva and urine) or vertical transmission (placental transfer). Common in kids 1-4yo, in day care or preschool (reason why pregnant women get it). Infant with growth restriction, hepatosplenomegaly, jaundice, and petechiae (low platelets). Transplacentally transmitted. Mom with nonspecific febrile illness. Most common congenital infection. 90% babies asymptomatic. For symptomatics, periventricular calcifications (punctate calcifications around the ventricular margin) and microcephaly small head. Both may get neudevelopmental abnormalities later. MCC of nonhereditary sensorineural hearing loss in kids. Dx: CMV PCR or urine or saliva. Tx: Antiviral (valganciclovir, ganciclovir) to prevent progressive hearing loss. (CMV is periventricular calcifications & normal head & hearing loss vs. Toxo is diffuse calcifications & big head).

Answer 253

Tx: anticholinesterase.

Answer 254

Pathology is a loss of Ach neurons 1.Tx: Donepezil (for all stages of Alz), rivastigmine and galantamine = Anticholinesterase. Tx: Memantine (for moderate-severe dementia). NMDA receptor antagonist.

Answer 255

If liver disease, you want a benzo that doesn’t create metabolites and doesn’t use phase 1 cytochrome P450. This is Lorazepam, Oxazepam and Temazepam.

Answer 256

Goal directed actions, family history, worse on finger-nose. Bilateral, but might be asymmetric, one side worse than the other. An action tremor Tx if tremor-related disability/problems at work: 1st line. Propranolol (reduces tremor by blocking peripheral adrenergic receptors on muscle fibers). Contraindicated if asthma or COPD. 2nd line. Primidone, central acting anticonvulsant.

Answer 257

Tx: Habit reversal training. If no work or school problems, 1. Antipsychotics (block dopamine) or Anti-dopamine meds. 2. Alpha2 agonists (clonidine, guanfacine). f/u comorbid ADHD or OCD

Answer 258

NMS Neuroleptic Malignant syndrome: From Dopamine D2 receptor antagonism (low dopamine). Tx: D/C the med & Dantrolene (muscle relaxant) or Bromocriptine or Amantadine (dopamine agonist). (bros do dope, need to raise the dopamine levels back up).

Answer 259

``` Serotonin syndrome: Serotonin med (SNRIs, Tamadol included) or MAO-I (phenelzine). ``` Tx: D/C all serotonin meds, supportive care. Prevention: Wait 2 weeks of d/c’ing a SSRI before adding MAOI. Fluoxetine, wait 5 weeks, because it has long half-life.

Answer 260

Paroxetine

Answer 261

Center on the nonexistence of self or parts of self, others, or the world. A person with this type of delusion may have the false belief that the world is ending.

Answer 262

Specific delusion mostly in Schizo Pts. Pt believes a person has been replaced with an exact double that can act in every way like the original. “My sister is an imposter”.

Answer 263

Hepatotoxicity & thrombocytopenia

Answer 264

Abscess on u/s.

Answer 265

hydration, alkalinization of urine with Potassium citrate and low-purine diet. Alkalinization will solubilize the uric acid.

Answer 266

Hydrochlorothiazide (reasorb Ca).

Answer 267

Na restriction diet. Increased Na intake enhances Ca excretion (HyperCalciuria).

Answer 268

Posterior wall MI

Answer 269

Atelectasis (Mucus plug) Decreased breath sound (lungs can’t move). Decreased Tactile fremitus (lungs can’t move). Dullness to percussion (No air in lungs). Mediastinal shift towards the bad side. (white out lung).

Answer 270

Chikungunya: Mosquito-borne viral illness by the Aedes mosquito, endemic from West Africa. Tx: supportive (virus).

Answer 271

If an upper lobes, Think CF. Recurrent cycle of bronchial thickening and dilation. Leads to permanent destruction of airways. Comes from recurrent bacterial infection. Accumulation of bacteria causes increased release of neutrophils, which brings more Elastase. Pseudomonas. MCC pediatric hemoptasis. Kartagener can lead to bronchiectasis.

Answer 272

Emphysema in lower lobes.

Answer 273

Vomiting leads to hypovolemia. Hypovolemia stimulates aldosterone. Aldosterone leads to low H. Get alkalosis. Tx: IV fluids and K. IV fluids will lead to decrease in aldosterone secretion.

Answer 274

ACEi with 24hrs of MI.

Answer 275

> 50y.o. >1month pain neck, shoulders, hips. Morning stiffness, limited range of motion (ROM), aching. ESR >40. The muscles have no actual weakness though. Inflammatory d/o of proximal joints, bursae and tendons. Dx: ESR or CRP (if elevated, Tx the Pt). Or Give 20mg Prednisone and see if symptoms go away. Tx: low dose glucocorticoids Prednisone 20mg daily (helps the inflammation).

Answer 276

ESR fine. Tender neck muscles.

Answer 277

Factor 2a (Thrombin) inhibitors

Answer 278

Factor 10a inhibitors

Answer 279

Doxycycline

Answer 280

If low cortisol, get increased ADH and get hyponatremia.

Answer 281

Gram-ve rod. CAP, GI (liver, diarrhea) and Neuro prob (ataxia). Old man near water (hotels, air conditioning and cruises). *HypoNa*. Causes a very high fever >102. Primarily intracellular. Dx: Urinary antigen testing. Tx: Macrolides (azithro, erythromycin) or Fluroquinolones (levo, ciprofloxacin). They achieve high intracellular concentrations.

Answer 282

Life threatening. Pentad: low platelets, MAHA, kidney prob, neuro changes (h/a, confusion, coma, stroke), fever. Ab to ADAMTS13 eats it up. Can’t cleave vWF off endothelial surface anymore. vWF accumulates and traps platelets. Makes a thrombi and shears RBCs. Leads to MAHA and end organ damage of kidneys or CNS. Normal PT. Dx: Peripheral smear, clinical & labs. Tx: Plasma exchange emergently (removes the autoAb & reups the ADAMTS13). If no plasma exchange, mortality rate 90%.

Answer 283

disease can cause primary adrenal deficiency (eosinophilia)

Answer 284

From loss of gastric secretions (vomiting or NG suction). They get volume depleted so their ECF shrinks. Shrinked ECF will stimulate mineralocorticoid levels (stimulates RAAS). Get ⬆︎ in NaCl reabsorbing (Cl will go the same direction as Na), Urine therefore has low Cl <20. Low Cl will lead to impaired HCO3 excretion. Get ⬆︎ in H & K secretion and metabolic alkalosis. Tx: give IV saline, it will fix the ECF and this will fix the Cl and metabolic alkalosis problems.

Answer 285

Have high urine Cl >20. Their ECF is expanded in Hyperaldosterone, cushing, excessive black liquorice. Or Euvolemic in Bartter & Gitelman. Giving Saline won’t fix the metabolic alkalosis.

Answer 286

``` Confusion. Urea >20. Respirations >30. BP <90/60. Age >65. 0: low mortality, OutPt. 1-2: intermediate, InPt. 3-4: ICU. ```

Answer 287

Fluoroquinolone (-floxacin) or Beta-lactam + macrolide (ceftriaxone + azithromycin). Covers both typicals and atypicals.

Answer 288

Worsens HTN

Answer 289

PCV13 infants and young children. PCV13 vaccine all adults >65, PPSV23 later. PPSV23 alone if <65 with chronic med issues (heart & lung disease, DBM, smoking, chronic liver disease). Then after 65, give PCV13 then PPSV23. If person has chronic med condition leading to ⬆︎ risk of pneumonia (Heart, lung disease, DBM, smoking, chronic liver disease), they get PPSV23 first, then PCV13 & PPSV23 at 65 y.o. PPSV23: Capsular material from 23 serotypes known to cause pneumonia. Only proteins can activate proteins, polysaccharides can’t. So the vaccine has a T cell independent B cell response. It is less effective in young children and the elderly, reason given later. PCV13: Capsular polysaccharides from 13 serotypes covalently linked to inactivated diphtheria toxin protein. Causes a T cell dependent B cell response (stronger response).

Answer 290

primary prophylaxis against MAC with azithromycin or clarithromycin.

Answer 291

Have long, sharp teeth. Can reach soft tissue structures (nerves & tendons). Need ABX prophylaxis. Pasteurella (GM -ve cocco)& anerobes. Tx: Amoxicillin/Calvulanate (anaerobes with calvulanate

Answer 292

Physostigmine (cholinesterase inhibitor, keeps Ach around longer).

Answer 293

If high risk of malignancy (>2cm, >60, smoker or quit <5yr ago), surgically resect.

Answer 294

Spinal cord ends L1-L2. Conus medullaris (part of spinal cord): Sudden onset, perianal anesthesia, symmetric motor weakness, hyperreflexia, early onset GU probs. Would get upper motor neuron injury only (because part of cord). ``` Cauda equina (peripheral NS parts) : L2-L5, S1-S5 Radicular pain, saddle anesthesia, asymmetric motor weakness, hyporeflexia (because part of PNS), late onset GU probs. Radiculopathy = nerves not working well. ```

Answer 295

Lose patellar reflex. Sensation loss of the anteromedial thigh and medial shin. Weakness of hip flexion, hip adduction, knee extension.

Answer 296

Sensation loss of the lateral shin and dorsum of the foot. Weakness of foot dorsiflexion & inversion, foot eversion, toe extension.

Answer 297

Lose Achilles. Sensation loss of posterior calf, sole and lateral foot. Weakness of hip extension and foot plantarflexion.

Answer 298

Sesation loss of the perineum. Weakness of urinary or fecal incontinence and sexual dysfunction.

Answer 299

Fetal vitamin K deficiency. Cleft abnormalities.

Answer 300

Longer PR interval & same length. From delayed impulse from atria to the ventricles. PR >0.20 sec (5 small boxes). Tx: Not a prob, at worst patient needs O2, fluid, Atropine to fix it.

Answer 301

More P waves than Q. P waves can hide. PR interval varies. Problem. Complete failure of impulse to go from the atria to the ventricles. You see a regular rhythm that has p waves before, after and buried in QRS complexes. If untreated, can lead to ventricular arrhythmias or asystole. Pt with a history of heart disease. Tx: Atropine won’t help (Atropine works on Vagus nerve and SA node only. Problem is in bottom of the heart). Dangerous. Tx: Temporary Cardiac Pacing while you work up the cause (MI, increased vagal tone, hyperK, drug like Beta Blocker, CCB). Permenant pacemaker is placed if no identifiable cause.

Answer 302

Have persistent ST elevations, new deep Q waves in leads of the previous MI.

Answer 303

family history. ⬆︎ extravascular hemolysis ⬆︎ MCHConcentration (from cell membrane loss & dehydration). Dx: Eosin-5-maleimide binding test (flow cytometry) or with acidified glycerol lysis test (osmotic fragility). Negative Coobs test. Increased risk of bilirubin gallstone formation. Tx: supportive (folic acid, transfuse if Hb low). Splenectomy if becomes severe.

Answer 304

Hereditary spherocytosis: +ve family history, negative coombs. AIHA (Autoimmune): No family history, positive coombs.

Answer 305

Cofactor for K and Ca. (If Pt had refractory K or refractory Ca).

Answer 306

UMN or pyramidal/corticospinal tract disease. Weakness in the supinator muscles causes unopposed pronations

Answer 307

= proprioception (reason why they start swaying). | B12 prob, tabes dorsalis (syphilis).

Answer 308

Impaired adaptation to darkness. Can progress to night blindness. Dry everything (skin, cornea, conjunctiva).

Answer 309

Cheilosis, glossitis, Seborrheic dermatitis groin, pharyngitis, edema/erythema of mouth. NormalIy, in almost all food sources, therefore anorexic or malabsorption Pts.

Answer 310

Pellagra, diarrhea, PHOTOSENSITVE dermatitis (like a sunburn, becomes hyperpigmented and thickened), dementia/depression (from neuron degeneration), death. From only eating corn or cereal or a bowel disease problem (Crohn) or anorexia or alcoholism. 4Ds. Also made from tryptophan (carcinoid syndrome have a depletion of tryptophan. Hartnup disease, problem tryptophan absorption). Prolonged INH can also trigger a decrease in tryptophan.

Answer 311

macrocytic anemia & peripheral neuropathy (shuffling gait).

Answer 312

2 days - 1 week. New MR. New holosystolic/mid-to-late systolic murmur apex, right after an MI. inferior wall MI No palpable thrill (not an RV problem) backs up to the atria and lungs and leads to pulmonary edema & CHF. LV compliance is not increased because this is an acute change.

Answer 313

up to 1 week. After an LAD or RCA MI. New holosystolic murmur (left sternal border with a thrill). Palpable thrill. Biventricular failure (JVD + lung bibasilar crackles). Shock sudden onset hypotension = cardiogenic shock. Increased O2 level in RA and RV = step up.

Answer 314

Hyperphosphatemia (phosphate in tumor cells is 3x>normal cells. Phosphate binds calcium, forms calcium-phosphate stones.

Answer 315

Hepatotoxicity & peripheral neuropathy B6 def if DBM.

Answer 316

Tricuspid regurgitation & R sided heart failure.

Answer 317

Acute-onset, unilateral facial paralysis. HSV reactivation is the MCC. Upper face involve (a stroke would only have the lower face). Inflammation, edema and degeneration of the myelin sheath. Tx: Glucocorticoids will decrease inflammation.

Answer 318

upwards dislocation

Answer 319

Do things with their butts, downward dislocation

Answer 320

Bladder scan. Then put a foley catheter If still not relieved, try a fluid bolus.

Answer 321

Can’t see, can’t pee, can’t climb a tree. Often have tendon pain & enthesitis (tendon pain). PMS & negative gram stain (sterile analysis). 1-4 weeks after enteric or chlamydia. Tx: NSAIDS.

Answer 322

Eg. if elevation in 1,aVL, V2-V6, would have reciprocal ST-segment depression in 2, 3, aVF. You can have a STEMI without biomarker elevated early (troponin). Next step: Coronary reperfusion (cardiac cath)/ PCI – percutaneous coronary intervention, O2, Big ASA (325mg) chewed to enter the bloodstream quick, platelet P2Y12 receptor blocker (clopidogrel, ticagrelor), nitroglycerin, BB and anticoagulation (Heparin). PCI within 12 hrs of symptom onset and within 90 mins door to balloon of a capable facility/ within 120 minutes door of a non-PCI capable facility. PCI > fibrinolytics (TPA). After the cardiac cath, would go to the ICU. (Before you answer cardia cath, check the amount of time).

Answer 323

Non-ST elevation myocardial infarction (=Troponin rises in 6-12 hours). EKG signs of ischemia = anterior precordial T-wave inversion. Tx for Unstable Angina & NSTEMI: Relief ischemic pain, maintain hemodynamic stability, prevent recurrent ischemia and thrombi. Give antiplatelet agents, ASA & clopidogrel (P2y12 receptor blocker = clopidogrel, prasugrel, ticagrelor), ASA and ticagrelor. = Dual antiplatelet. Give anticoagulant therapy, unfractionated heparin, enoxaparin, bivalirudin to prevent additional plaque thrombosis or recurrent coronary thrombosis. Give beta blockers, metoprolol, atenolol to reduce myocardial O2 demand (by slowing the heart rate down) and reduce the risk of ventricular arrhythmia. Give Nitrates/Nitroglycerin to reduce myocardial O2 demand and relieve ischemic pain. Give High-intensity statins, atorvastatin, rosuvastatin, to stabilize atherosclerotic plaques and lower risk of coronary syndrome. (Exercise testing is only for patients with stable angina, not an NSTEMI or unstable angina. If Pt has what you think is an MI, don’t stress test them). (TPA is used for STEMI only and only when cardiac cath/percutaneous intervention is not possible).

Answer 324

only for patients with stable angina, not an NSTEMI or unstable angina

Answer 325

Tx: 1. Beta blockers 2nd line. Non-DHP CCB (verapamil, diltiazem), same action as BB, but for people with BB contraindication (bradycardia, asthma). 3rd line are long-acting nitrates (isosorbide mononitrate

Answer 326

Low risk: Asymptomatic people of all ages. Atypical chest pain women <50yo. If low risk and her EKG was fine: No additional testing. Intermediate risk: Atypical angina men all ages. Atypical angina women =>50yo. Typical angina women 30-50yo. If intermediate risk: Stress test (exercise EKG, myocardial perfusion imaging). High risk: Typical angina men >=40yo. Typical angina women >=60yo. If high risk, evaluate for CAD with coronary angiography (cardiac cath) and start on CAD therapy.

Answer 327

Classical: 1. Typical location, quality and duration. 2. worse by exercise or emotional stress. 3. Relieved by rest or nitroglycerin. Atypical angina: 2 of the 3. Nonanginal: <2 of the 3.

Answer 328

Up to 3cm. Step 1: compare x-ray. If no old CXR available, do a CT (gives more detail about the nodule). Stable size and appearance for 2-3 yrs, low malignancy & reassure, no further workup. If ground glass lesions, higher malignancy risk, get yearly assessment. Unstable or new lesion, further assess for malignancy. <0.8cm w/ smooth margins, less likely malignant. >2cm w/ irregular or speculated margins, likely malignant. >60 or smoker, likely malignant. Need a CT to further assess all of this. If CT thinks malignant, bx then surgically excise. If less likely malignant, serial CT 2-3 yrs.

Answer 329

Normal: WBC 0-5cells/mm3 Glc 40-70mg/dL Protein <40mg/dL. Bacterial: WBC >1000 Glc <40 Protein >250. TB: WBC 5-1000 Glc <10 (***) Protein >250. Viral: WBC 10-500 (smaller) Glc 40-70 (norm) Protein <150 (smaller). (Bacteria eat up glc. TB is a bacteria. Both bacteria & virus made from protein).

Answer 330

(mimics sarcoidosis, lung problem, immunosuppressed). Endemic mycosis. Ohio and Mississippi river valleys, the midwest. Soil contaminated with bat or bird droppings. Chicken coops, farm buildings, bird roots, caves. Dry cough CXR: hilar lymphadenopathy with focal, reticulonodular or miliary infiltrates. Rarely causes disease in immunocopetent Pts. If immunocompromised, cause disseminated histoplasmosis. Dx: Urine or Serum Histoplasma Ag Immunoassay (fungal cultures take too long). Some have granulomas with narrow based budding yeasts. Tx: self resolves, if severe disseminated, IV amphotericin B (fungicidal, needed for disseminated histoplasmosis) for 2 weeks, then oral itraconazole (fungistatic) for 1year maintenance Tx. Also after 2 weeks of Tx, start HARRT.

Answer 331

(lung & skin problem (ulcerated skin & lytic bone), yeast). Mississippi valley. (wisconsin, great lakes, ohio river). mild to mod lung infection. Hematogenous spread to skin. Also hits, bone & prostate making lytic lesions. Skin is nodular lesion w/ violaceous hue, can become a micro abscess or ulcerations. Affects immunocompetent and incompetent Pts (Histo is mostly incompentent). Dx: Broad-based budding yeast on sputum culture. Tx: Itraconazole or amphotericin B.

Answer 332

(Actin, Actors use their mouths → mouth infection, Shawn Pen is an actor) GM+ve rod anarobic. Abscesses in head and neck, form sinus tracts. Granular yellow pus, draining sulphur granules. Following dental procedure. Tx: penicillin. If allergic, clindamycin (gram positive & anaerobes)

Answer 333

: (Not the cardia, effects the lung, like TB) GM+ve rod aerobic. Weakly acid fast. Subacute pneumonia. Mimics TB. Tx: TMP-SMX.

Answer 334

Chronic hyperglycemia causes dilation of the renal afferent arterioles and constricts the efferent arterioles. Leads to ⬆︎ GFR and microalbuminuria. Best cure is control BP (140/90 or 130/80). ACEI & ARBs.

Answer 335

GM+ve anaerobic. ABX resistant spores are ingested and convert to functional bacilli in the colon. Produce exotoxins, enterotxin A & cytotoxin B. They penetrate colonic epithelial cells, you get apoptosis & loss of tight junctions. Watery diarrhea. Risk factors: recent ABX, >65yo, Gastric acid suppression (PPI).

Answer 336

Large linear

Answer 337

vesicles and round/ovoid ulcers in esophagus

Answer 338

Yellow or white fluffy or granular retinal lesions near retinal vessels

Answer 339

MC: Candida especially if thrush. Tx: Fluconazole. 2nd MC: CMV. CD4 count <50. linear ulcers. Intranuclear and intracytoplasmic inclusions. Tx. Ganciclovir (active form, thymidine kinase not needed). CMV esophagitis would have severe odynophagia, without dysphagia or thrush. 3rdMC: HSV (Herpes) esophagitis. Has circular or ovoid or volcano vesicular ulcerations. Tx. Acyclovir. Eosinophilic intranuclear inclusions. Both CMV & HSV have severe odynophagia.

Answer 340

Decreases the production of sex hormone-binding globulin. Leads to constant high estrone. Leads to problems with the GnRH pulses. Leads to high LH and an LH/FSH imbalance. Leads to lack of LH surge, anovulation and abnormal uterine bleeding. Tx: Weight loss and combo OCP.

Answer 341

Blistering: Tx: prevent bacterial superinfection with topical silver sulfadiazine or mupirocin.

Answer 342

Opioids suppress GNRH and LH

Answer 343

⬆︎ Aldosterone. Leads to ⬇︎ FE Na (<1% fraction excreted Na in urine, more Na reabsorbed). Urea is also reabsorbed in hypotension. If Pt is taking a diuretic, use FeUrea instead (<35%).

Answer 344

Pleural protein/Serum prt: >0.5. Pleural LDH/Serum LDH >0.6. Upper limit normal LDH >2/3: 90*2/3=60. Glc <60 for complicated parapneumonic effusion (bacteria eating up plc), malignancy, TB or R.Arthritis. pH<7.2 in empyema. (pleural fluid should have absolutely no proteins in it, the smaller number 0.5). Normal pleural fluid pH 7.6. Transudate: 7.4-7.55. Exudate 7.30-7.45. pH <7.3 is from bacteria or tumor. TB – exudative, elevated adenosine deaminase. Cancer is an exudate with high LDH. For a stable minor parapneumonic effusion (minimal layering of L lateral decubitus film), Tx: PO ABX. Moderate or large effusion, Tx: u/s & drainage (Chest tube or VATS). Complicated parapneumonic effusions require drainage & ABX. Exudates are from ⬆︎ permeability of the pleural or capillary membranes or disruption of thoracic lymphatic drainage. If Pt has markers of inflammation, it will cause increased cytokines. Cytokines will lead to increased permeability of cells from the vasculature to pericapillary space. Chylothorax: Chyle composed of T cell lymphocytes, Igs, chylomicrons containing TAGs. Only malignancy & trauma can cause. Disruption of lymphatic drainage causes chylothorax.

Answer 345

After asthma attack, Pt with muscle weakness & difficulty lifting arms, or arrhythmia, or EKG abnormality. Causes K shift into cell. Via, activation Na/K ATPase, activation Na/K/2Cl cotransporter. And by stimulation of Insulin, which will cause intracellular shift.

Answer 346

Old man on cruise, hyponatremia, atypical pneumonia, GI & neurologic symptoms. Gram -ve, intracellular (poorly stains). Tx: fluoroquinolone (Cipro) or macrolide.

Answer 347

3rd world, MC = Rheumatic disease. 1st world, MC =Bicuspid valve(L side &middle age) or root dilatation (R side). In old ppl, Bicuspid valve = aortic stenosis

Answer 348

CT angio, looking at thoracic vessels

Answer 349

CT ab with contrast looking at spleen (solid organ)

Answer 350

If hemostable, FAST if neg, get CT Ab. If AMS, CT directly. Try repair before removal. If remove, encapsulated vaccinations

Answer 351

Single blue inclusions on Wright stain in an RBC. Spleen usually would have cleared these nuclear remnants. Therefore conditions with functional asplenia (Eg. Sickle cell) or splenectomy. Howell & Jolly are part of band called the reminants. Punk rockers spleen removed.

Answer 352

G6PD deficiency or thalassemia. Hb getting oxidized and precipitating as denatured. (Cap of the ketchup Heinz bottle). Bite cell: When a Heinz body (the rigid precipitate) gets phagocytosed out. G6PD deficiency or thalassemia.

Answer 353

Schistocytes means: MAHA (DIC, HUS & TTP) or prosthetic valve.

Answer 354

From ribosomal precipitations, blue granules in the cytoplasm of RBCs. Nonspecific. Thalassemias, lead poisoning.

Answer 355

A response to hypoxia or tumor. Secondary erythrocytosis (high number of immature RBCs).

Answer 356

Get imaging to r/o Osteomyelitis. Polymicrobial.

Answer 357

Diffuse lymphadenopathy (Supraclavicular, epitrochlear and mediastinal), fever, night sweats. Non-Hodgkin Lymphoma. HIV Pts. Reactivation of latent oncogenic viruses. AIDS defining malignancies are invasive cervical carcinoma (HPV), Kaposi sarcoma (HSV8), CNS lymphoma (EBV) and Non-hodgkin lymphoma (from reactivation of EBV in B lymphocytes). Dx: Excisional lymph node Bx.

Answer 358

White men. Chronic malabsorptive diarrhea, protein-losing enteropathy, migratory non-deforming arthritis. Infection GM+ve bacillus tropheryma whippelii. Migratory polyarthropathy & valvular involvement. Lymphadenopathy. Skin hyperpigmentation. Dx: Bx showing PAS+ve macrophages in lamina propria

Answer 359

destroys MLF (medial longitudinal fascicles). Called internuclear ophthalmoplegia

Answer 360

Sudden, worst headache of my life = severe h/a). Causes spontaneous or triggered by physical exertion. Risk factors are smoking, HTN, PCKD Auto Dominant. Can have meningismus from blood irritating the meningies. Symptoms to rapidly progress. Nausea, vomiting, brief LOC, photophobia. Often has a prodromal headache that represented a sentinel bleed. Dx: 1. Non-contrast CT showing blood in the basal cistern and cerebral sulci. 2. LP. CT head can miss low-volume bleeds. If still considering, get an LP to confirm. Elevated opening pressure and increased RBCs, xanthochromia (yellow CSF, from Hb breakdown). RBC will stay in the LP with serial collection tubes. Tx: clipping the aneurysm. (Meningitis would not have a dramatic onset and doesn’t progress as rapidly as SAH. Meningitis Pts have a high fever and appear ill). (HSV encephalitis would have an elevated WBC count on CSF)

Answer 361

Internal capsule. From HTN, DBM, Hyperlipidemia and smoking. Path: Microatheroma formation & lipohyalinosis in small vessels causing thrombotic occlusions. Causes pure motor hemiparesis, (cortico signs are absent aka, no sudden worst headache).

Answer 362

Nicotine replacement (decreases withdrawl) varenicline (nicotinic aCh partial agonist, decreases cravings. No give is cardiac problems) Bupropion (avoid if bulimia or seizure).

Answer 363

monosaccharides. Absorbed without being degraded by pancreatic enzymes or brush border enzymes. If normal person: [ ] in urine and venous is high (close to what you gave). If celiac (no absorb): [ ] in urine and venous is low (i.e. not absorbed). If panc prob: [ ] in urine is high (it was absorbed independant).

Answer 364

5-HT serotonin receptor agonist decreases brain inflammation and CGRP release

Answer 365

1. Acetaminophen & limit exposure to light and sound. 2. Add a low-potency opioid (acetaminophen-codeine), antimetic (promethazine). Don’t give potent opioids, it can can cause GI symptoms. Avoid Ergotamine in pregnancy, risk of uterine contractions and vasoconstriction & fetal anomalies. Avoid triptans in pregnancy, risk of growth restriction. No NSAIDS in first trimester, risk of miscarriage; 3rd trimester risk of PDA closure.

Answer 366

Prophylaxis if frequent (>4 per month), long lasting or disabling (ER visits). Prophylaxis: Topiramate, beta blocker (propranolol), amitriptyline. Prophylaxis if pregnant: 1. Beta Blocker – Propranolol or Metoprolol, safest profile, give lowest dose possible. Prolonged doses of BB, lead to low BP and risk of growth restriction from decreased placental perfusion. 2. CCB Verapamil. Avoid Topiramate, cause fetal anomalies avoid.

Answer 367

All pressures are low (RA, PCWP both=preload). SVR (after load) is high Mixed venous O2 is low.

Answer 368

Example from an MI. R Atrial & PCWP (L.A) pressures are high. CVP is high (pressure in the veins). Cardiac index is low. SVR is high. (reflex from ⬇︎ CO leading to ⬇ BP). MvO2 low (the low tissue perfusion signal to tissues to extract more oxygen).

Answer 369

RA, RCWP are normal or decreased. Capillary leakage, ⬆︎ permeability. CVP is low. Cardiac index is high. (due to ⬇︎ SVR, reflex). SVR is low (leads to ⬇︎ afterload). Peripheral vasodilation. MvO2 is high. Circulation moving too fast (HR up). (All arteries dilate and heart starts working super fast).

Answer 370

Distributive shock: Anaphylactic, Neurogenic, Septic Shock. | Obstructive shock: Large PE, Tampanod, Tension Pneumo

Answer 371

can cause kidney damage (crystalizes in urine leads to obstruction). Causing a renal tubular obstruction. Tx & prevention: hydration and adjust dose.

Answer 372

Distensibility = compliance. COPD, lungs are more compliant from alveolar damage.

Answer 373

BNP >400 pg/ml = CHF. BNP <100 pg/ml

Answer 374

Hyponatremia in Pts with CHF parallels the severity of heart failure and is a predictor of the outcomes. CHF will activate renin, leads to NORE, leads to ADH release, overall leads to increased aldosterone, leads to HypoNa via free water retention and dilutional hyponatremia (From both Aldo & ADH). HypoNa leads to reduced K excretion, leads to hyperK

Answer 375

Tx longterm, after stable: ACE inhibitor (s/e hyperK) + BB (sustained-release metoprolol succinate, bisoprolol, carvedilol). If can’t take ACEi, Tx: hydralazine & oral nitrate. Really low EF Tx: Dobutamine. Activates B1 leads to increased cAMP & Ca Channel activation. Leads to increased ionotropic & chronotropic. But only use if the Pt has end-organ dysfunction resulting from the hypoperfusion, s/e: risk of arrhythmia and it increases myocardium demand.

Answer 376

Tx: D-penicillamine, trientine = Cu chelators, Zinc for maintenance tx (interfares with absorption). Liver transplant if fulminant liver failure or cirrhosis.

Answer 377

Cysteine stones Family history, . +ve urinary cyanide nitroprusside test. Problem with cysteine amino acid transport and dibasic amino acids. Leads to decreased reabsorption and they stay in urine, poor solubility.

Answer 378

X on the back of an envelope oxalate = ethylene glycol = antifreeze acute renal failure is a complication.

Answer 379

Bradycardia, hypotension and hypoglycemia. Cardiogenic shock (cold and clammy hands), bronchospasms, AMS and seizures. BB are competitive antagonists for endogenous catecholamines, prevents the liver glucose production and glycogen breakdown. Symptoms within 6 hrs of ingestion. If the heart rate gets too low, you can get a AV block. Beta blockers also cause wheezing/bronchospasm from beta 2 blockade. Tx: 1. ABCs, correct the hypotension and hypoglycemia. 2. IV fluids, atropine 3. IV glucagon if profound hypotension. (increase cAMP) (Temporary pacing won’t work here, it fails to capture) (Don’t use dobutamine, will cause vasodilation and worsen hypotension).

Answer 380

Alpha-2 agonists. Similar to an opiod overdose, bradycardia, pinpoint pupils, AMS.

Answer 381

From viral myocarditis (coxsackie, adeno, parvo B19).

Answer 382

Subclinical hypothyroidism has increased risk of statin myopathy. So check TSH before starting a statin

Answer 383

Fibroblast dysfunction. Scleroderma renal crisis will show schistocytes and low platelets. For systemic sclerosis renal crisis: Tx: ACEI, they have increased RAAS. Connective tissue thickening, from fibroblast dysfunction. Skins signs are hands and feet with edema and thinkened skin. Has HTN from renal involvement

Answer 384

AutoAb against platelet membrane antigens. Petechial rash. Platelets will be a variable size on peripheral smear. Post URTI (viral) or immunization, supportive care. Labs: isolated low platelets <100K and megakaryocytes (large platelets on smear). Due to IgG autoAbs for the platelet membrane. Petechiae, ecchymoses and mucosal bleeding (heavy period, nose bleed). Dx: Diagnosis of exclusion, work up the coagulation tests (PT, PTT, Fibrinogen) Kid Tx: 1. Supportive first if only cutaneous symptoms (petechiae), resolves in 3 months. 2. IV Ig’s or steroids (glucocorticoids) or anti-D Ig if person starts mucosal bleeding. 3. If still persists, spleenectomy (removes source of destruction). Adults Tx: IV Ig’s or glucocorticoids or anti-D immune globulin (for Rh positive cases).

Answer 385

Take the leukocyte # * % of neutrophils from the differential. Eg.: WBC count of 5000 & Neutrophils 20% = Absolute neutrophil count of 1000 Worry about with myelosuppression drugs (hydroxyurea). Risk for bacterial infections due to absent or blunted neutrophil mediated inflammatory response. Medical emergency. Tx: Blood and urine cultures. Then immediate IV broad spec ABX (need anti-pseudomonal beta lactam agent). Eg. Cefepime, Meropenem, Pip-Tazo.

Answer 386

synthetic cannabinoids (Dronabinol).

Answer 387

Weight loss is from systemic inflammation. Tx: Progesterone analogues (Megestrol acetate or medroxyprogesterone acetate) or corticosteroids. Synthetic cannabinoids won’t work. Progesterone analogues preferred, less side effects.

Answer 388

Detect increases in BP by stimulating an increase in parasympathetic vagal tone to slow the heart rate and cause vasodilation and decrease BP. In old men with atherosclerotic disease, the carotid sinus becomes oversensitive, get an exaggerated vagal response (>3 sec ventricular pause and >50mm Hg drop in systolic BP). Causes syncope or presyncope, from blood not going to the brain. Triggered by tactile stimulus (shaving, rubbing a shirt collar or turning head). Dx: Carotid massage which produces the exaggerated vagal response, on a tilt table so the patient doesn’t fall. Tx: Permanent pacemaker.

Answer 389

High voltage QRS complexes, lateral ST depression, Lateral T wave inversion.

Answer 390

A wave = R atrial contraction followed by tricuspid valve closure. C wave = R ventricle contraction against a closed tricuspid. X decent = R atria pressures decreasing, after RV contraction. V wave = Peak R atrial filling right before reopening of tricuspid. normal Canon A wave Cannon A waves caused by surge in jugular venous pressure due to R atrial contraction against a closed tricuspid. Happens with any arrhythmia involving AV dissociation (like ventricular tachycardia where the ventricle dissociates from the atria; complete AV block; frequent PVC). Prominent V wave = Tricuspid regurge. RA filling still with regurge, during systole. No x wave.

Answer 391

P.E: (sinus tachycardia). | S1Q3T3. Prominent S in lead 1, Q in lead 3, inverted T in lead 3.

Answer 392

Rate control with beta blocker or Non-DHP CCB (Verapamil, Diltiazem) for asymptomatic or mildly symptomatic Pt age >65 (because rhythm meds have lots of side-effects). Rhythm control (antiarrhythmic drugs or electrophysiologic procedure), if rate control didn’t work, Pt has heart failure or is a young person.

Answer 393

Can lead to tachycardia-mediated cardiomyopath

Answer 394

If score = 1: Antithrombic Tx with ASA or oral anticoagulant (Rivaroxaban, apixaban, dabigatran) (preferred over ASA). If score >=2: Warfarin or PO anticoagulant (rivaroxaban, apixaban, dabigatran).

Answer 395

>.5s QT interval normal: <440ms in males & <460ms in females. HypoCa, HypoMg, HypoK, Meds, Inherited diseases. High risk for syncope & arrhythmias. Can lead to torsades or polymorphic ventricular tachycardia. Tx: Beta blockers Class 2. If symptomatic with lightheaded, palpitations or syncope, beta-blocker + pacemaker. Avoid vigorous exercise & meds that prolong QT interval. Avoid Satolol (it is class 3) Avoid class 3 anti-arrythmics (Satolol, Dofetilide), that can prolong the QT further leading to Torsades

Answer 396

1 big box is 200ms or 0.2second Prolonged QT>0.5s or 500ms.

Answer 397

HR <60, Regular. Check the PR interval 0.12-0.2, normal. Check QRS normal duration <0.12 and QRS shape. Bradycardia is normal in young adults, athletes and old people when they sleep. Symptomatic means has fatigue, dizzy, light-headed, hypotension, syncope, angina or CHF. Tx: 1. First remove reversible causes & IV Atropine. 2. If still persists, IV epinephrine or dopamine or transcutaneous pacing (pacemaker). (Atropine is an antimuscarinic/anticholinergic, stops the heart’s parasympathetics/slowing). (Not Adenosine, Adenosine blocks conduction at the AV node. Used for SVT. It would worsen bradycardia).

Answer 398

Regular, narrow complex tachycardia (QRS <120ms), HR >100. Tachycardia from above the bundle of His. Palpatations, dizziness, lightheaded, SOB, diaphoresis, chest pain, presyncope or syncope. Young patient. Comes from 2 conduction pathways, slow and fast in the AV node. The slow and fast pathways create a looped circuit. Tx if hemodynamically stable: 1. Find the type of SVT using vagal maneuvers (carotid massage, valsalva, cold-water immersion, eyeball pressure. They increase the parasympathetic tone in the heart and slows the conduction in the AV node, the gives enough time to increase the AV node refractory period and stop the extra reentrant pathway) or IV Adenosine. Adenosine slows AV node conduction interrupts reentry pathway. Carotid sinus massage, slows SA & AV node activity. This allows to unmask any hidden P waves. Tx if unstable (hypotension & poor perfusion/cold extremities): Synchonized cardioversion. (Amiodarone is used for stable wide QRS complex tachycardia like ventricular tachycardia, or to treat A.Fib).

Answer 399

Peaked T waves, then Short QT, QRS widening & sine wave with ventricular fibrillation tx: IV Ca gluconate or IV CaCl to stabilize the sarcoplasma

Answer 400

Broad flat T waves, U wave, S.T depression and premature ventricular beats

Answer 401

rhythm on monitor but no pulse or BP in a cardiac arrest patient. Next step: CPR & vasopressor (epinephrine 1mg every 3-5mins) while you find what is wrong. This would keep perfusion to the brain and heart. Not a shockable rhythm, so defibrillation or synchronized cardioversion would not work. (Defibrillation is for V.Fib of V.Tach with no pulse) (Synchronized cardioversion is for symptomatic monomorphic VT that didn’t respond to antiarrhythmics, unstable A.Fib with RVR with a pulse).

Answer 402

can be caused by HypoK or HypoMg, first thing is get a BMP & get digoxin levels. (Spironolactone might help stop the hypoK, but you first need to identify the problem).

Answer 403

Short PR, delta wave, ST& Twave abnormalities. WPW is from an accessory AV pathway (bundle of kent). You bypass the normal AV node, instead the conduction goes straight from the atria to the ventricles. Most are asymptomatic. If there is retrograde conduction ventricles to the atria, can lead to re-entrant SVT or A.Fib leading to RVR. The EKG would show, short PR interval <0.12s, delta wave, QRS interval widening which can lead to a wide QRS >0.12s. Avoid things that slow the heart. Develop paroxysmal SVT from an excessory pathway. Sudden death can happen if WPW is untreated. The goal is to control the ventricular response. Tx: IV Procainamide or ibutilide if stable (rhythm control with an anti-arrhythmic drug). Tx if unstable: Electrical synchronized cardioversion.

Answer 404

Saw-toothed F waves. The atrial rate is usually around 300/min. The ventricle can be regular or irregular. Comes from a reentrant circuit from the R atrium. Risk factors are similar to a fib (CAD, HTN, CHF). Frequently following cardiac surgery. Risk for arterial thromboembolism. So use CHA2DS2VASC. Tx: Chronic anticoagulation (Rivaroxaban, apixaban). Add rate control if the rate is too high (Metoprolol, Verapamil). Doesn’t need rhythm control, it can precipate RVR. Definitive Tx: Radiofrequency ablation of the reentrant circuit or electric cardioversion. Both of them have a risk of thromboembolic events and need weeks of anticoagulation before the procedure.

Answer 405

Tdap, for Adults one time dose instead of Td if unknown status. DTaP: 2, 4 & 6 months. 15-18 months. 4-6 years. Contraindications: Anaphylaxis or an unstable neurologic d/o or encephalopathy developing w/in 1 week o the vaccine. If so, give diphtheria & tetanus toxoids & avaid pertussis. If no vaccination in the last 5yrs and Pt is punctured, revaccinate. For revaccination, if the Adult hasn’t had Tdap, just a single dose of Tdap now. (Tetanus Ig is only used for symptomatic tetanus (spasms) or if the wound is contaminated or if they didn’t get the full series as a kid or if they are unsure about their vaccination status). Tdap recommended because it prevents fetal pertussis. It is safe during every trimester but given during 3rd trimester, so they you will give passive immunity to the baby. Vaccine given even if mom had before pregnancy. If didn’t get during preg, get immediate postpartum

Answer 406

Adherent gray, pharyngeal pseudomembrane (white plaques). From aerobic bacterium Corynebacterium diphtheria.

Answer 407

Inhibits GABA, Glycine release.

Answer 408

Inhibits AcH release presynaptic. | Descending paralysis symmetrical

Answer 409

1. Febrile non hemolytic: Contaminating WBC and cytokines remain in the packed RBCs (1-6hrs, cytokines cause fever & chills). Prevented by reducing the WBCs (will also decrease the transition of CMV & HLA alloimmunization). 2. Hemolytic: Heme pigment injury. From a clerical error (mismatched blood). <1hr, fever, chills, pain at the IV site, hypotension (from cytokine release), hemoglobinuria (dark urine), flank pain. Get an intravascular hemolysis (RBCs getting destroyed). Leads to Hb build up in the kidney, renal tubular cell injury and acute renal failure. Dx: Direct coombs test showing Ab coated RBCs. Tx: 1. Stop transfusion 2. IV normal saline (prevents kidney injury or DIC progression). 3. Anaphylactic (mins to secs, wheezing, IgA def, have a rash or angioedema, respiratory distress). Prevented by washing the RBC to remove plasma (plasma houses IgA). Tx: Epinepherine. 4. TACO (Transfusion associated circulatory overload): RBC vol intracellular. From a large volume of blood transfused rapidly. Pts with renal or cardiac d/o at risk. Pts with chronic anemia. S3, HTN (from all overloaded fluid), Resp distress. Tx: Diuresis with IV furosemide. 5. TRALI (Transfusion related acute lung injury aka blood transfusion related pulmonary capillary damage): PMNs (neutrophilis) to lung, priming, anti-WBC Abs will damage lung microvasculature triggering inflammation and pulmonary edema (bilateral crackles, acute dyspnea, hypoxia). Hypotension. CXR causes bilateral pulmonary infiltrates. Tx: D/c transfusion & respiratory support (might need a ventilator). 50% Pts die.

Answer 410

Name Onset Cause Features Anaphylactic seconds to mins Recipient anti-IgA Abs Shock, low BP, Wheezing, Resp distress, Edema. Rash. (no fever). Acute hemolytic <1hr ABO incompatible/clerical Fever, flank pain (from the kidney injury resulting from the massive hemolysis leading to Hb in blood, Hb damages), pee blood (from the hemolysis). DIC (bleeding from the tube site) & positive Coombs.Next step: repeat type & cross. Tx: Stop transfusion, IV fluids. Febrile nonhemolytic (MC) 1-6hrs Cytokines accum stored blood Fever & chills. TRALI <6hrs Donor anti-WBC Abs Resp distress, non cardiogenic pulmonary edema, bilateral pulmonary infiltrates. Potentially fatal. Tx: Respiratory support. ``` Delayed hemolytic days to weeks More Ab response Asymptomatic, labs showing hemolytic anemia, positive coombs & new Abs. Often had a previous exposure to a Foreign Ab (pregnancy, prior tansfusion, sickle cell). Memory Ab bind donor RBCs, causes extravascular hemolysis. Fatigue, dyspnea, jaundice, low-grade fever, hemolysis (elevated indirect bili, LDH, retic count, decreased haptoglobin). Tx: Supportive. Prevention: review previous Abs and extensive cross matching. ``` Graft vs. Host Within weeks Donor T cells Rash, fever, GI symptoms, pancytopenia (low cell counts).

Answer 411

Tx: Ursodexycholic acid (to decrease bile acid levels), frequent antepartum monitoring (NSTs weekly) and delivery at 37 wks.

Answer 412

Delay cholecystectomy until postpartum.

Answer 413

neonate will get passive & active immunization when born = Hep B iG & HBV vaccine within 12 hours of birth. Step 2, then check baby for serologic markers. Hep B not passed in breast milk.

Answer 414

blindness, neurocognitive disability, constant seizures.

Answer 415

Normal: Should be high, hypercoaguable in pregnancy. Normal Fibrinogen levels = D.I.C

Answer 416

``` Neonatal opiate (methadone or heroin or prescription drugs) withdrawal: Increased IUGR, sudden infant death. Rest of symptoms are in the first few days of life. First 48hrs for heroin withdrawal. Presents at 48hrs-4weeks for methadone withdrawal. Neuro signs: Irritable, Increased wakefulness, High-pitched crying, seizures, frequent yawning, sneezing, hyperactive deep tendon reflexes, mottling (blotchy marbling/blotching of skin). GI signs: Diarrhea, Vomiting, Nasal stuffiness, poor weight gain, dehydration, constant or un-coordinating sucking. Tx: Symptomatic care, swaddling. Low stimulation environment. Small frequent feeds. ```

Answer 417

Add 7 days and subtract 3 months.

Answer 418

Recurrent UTIs risk of renal scarring from the inflammation in the renal system. Bacteria getting back to the kidneys causes inflammation. Can lead to renal scarring. Dx: voiding cystourethrogram – shows retrograde flow of urine (aka a dilated ureter). Tx: ABX prophylaxis (will prevent recurring UTIs).

Answer 419

Tx: NSAIDS and/or combined estrogen + progestin O.C.Ps. OCPs work by causing atrophy of endometrial tissue. Leads to reduced pain Tx if adnexal mass or infertility or OCPs no work: laparoscopic evaluation (cystectomy). Symptoms will return unless estrogen stimulation is permanently suppressed. Definitive Tx: hysterectomy & oophorectomy after completing childbearing. Asymptomatic or incidental Tx: Reassurance and observation.

Answer 420

(2nd mc cancer, skin =1 2nd mc cancer death, lung=1 women) 1 in 8 risk for women in the US. Risk increases with age & estrogen exposure (obesity, no kids, prolonged HRT). Alcohol consumption has a dose-dependent causal effect on breast cancer. TNM stage is most important. ER & PR+ are good prognostic features. High Her-2/neu oncogene is the worst prognostic factor (her = hurts the worst). Young person with aggressive cancer, likely has an inherited genetic mutation (BRCA) (BRCA cancer before 50yo). Active BRCA2 cancers are estrogen sensitive, don’t give them hormone sensitive contraceptives. Screening mammography at >50 yo. Breastfeeding and exercise (lowers estrogen in adipose) are protective.

Answer 421

it means they have AIDS

Answer 422

Postpartum hemorrhage (uterus and vagina extra dilated and hold a lot of blood) & perineal lacerations. Fetal complications: Age-related placental changes (infarction, calcifications) leads to uteroplacental insufficiency. Blood will start shunting from the kidneys to the brain. Leads to Oligohydramnios (pocket <2cm or AFI <5cm). Next step: NST and AFI evaluation. If any uteroplacental insufficiency (late decel, oligo (kidney shunting blood to the brain instead)). Immediate delivery, induce.

Answer 423

T3 is the active form. T4 converts to T3. T3 has a short half-life. If Pt is taking T3 when pregnant, switch the patient to T4, it has a long half-life.

Answer 424

``` NST: reactive or not. Amniotic fluid: Single pocket >2*1cm or Amniotic fluid index (AFI) >5cm. Fetal movement: >3 general body. Fetal tone: >1 flexion/extension. Breathing: >1 breath for >30 sec ``` 6/10 equivocal, repeat in 24hrs 4/10 deliver now

Answer 425

Hypotension. They put a local anesthetic into epidural space at L2-L5 blocking nerves. HypoTN when sympathetic nerve fibers for vascular tone are blocked. Get vasodilation & pooling. Hypotension can lead to decreased placental perfusion & get fetal acidosis. Prevention: IV fluid volume expansion prior. Tx: Left uterine displacement by lying Pt on L.Side, this will ⬆︎ Venous return (moves uterus off of the IVC, IVC is on the right side).

Answer 426

S/e of instead of injecting anesthetic (Buvicane) to the epidural space, they inject it into the epidural vasculature. Block inhibitory neural pathways and causes CNS overactivity (tachycardia, HTN). Risk for cardiovascular collapse. Tx: Stop the drug + Benzo for seizure control.

Answer 427

Either a gush of fluid, or a prolonged sense of wetness. Evaluate keeping baby in vs. delivering cost/benefit. if >34 wks, deliver. Complications now outweighs benefit of keeping in. if <34 wks with signs of infection (mom fever or fetal tachycardia), deliver If unknown GBS status or is positive, just give prophylactic Penicillin now. (normally, would have checked GBS at 36 wks). In patient, prophylactic ABX, corticosteroids (Betamethasone for lung maturity), fetal surveillance NSTs & u/s. If <32wks, add Mg Sulfate for neuro protection.

Answer 428

Preeclampsia. Hyperthyroidism (mimics TSH). Mets to the lungs.

Answer 429

Uncomplicated cystitis and healthy: Treat without urine culture (low risk of failure). Tx: TMP-SMX 3 days, nitrofurantoin 5 days (no if CRE problem), Fosfomycin 1 dose. Fluoroquinolone if sulfa allergy or resistant. Urine culture if treatment fails

Answer 430

Complicated means Ab resistant, treatment failure, DM, CKD, pregnant, immunocompromised, hospital acquired, result of procedure or catheter. Dx: Needs a urine culture prior. Tx: Fluroquinolones 5-14 days (no if preg) or IV broad spec like Ceftriaxone

Answer 431

Needs Urine culture before. Stable: Tx: oral fluoroquinolone (ciprofloxacin, levofloxacin). Unstable or pregnant: IV ceftriaxone & inpatient. Once afebrile for 24-48hrs & symptom improvement, switch to PO ABX.

Answer 432

Painless to mom, minimal vaginal bleeding. But fetal HR affected (it is the baby’s vessels that are bleeding). Needs 3rd trimester inpatient management with c/s at 34-35wks. Fetal hypotension leads to FHR abnormalities (brady (FHR <100 or sinusoidal = fetal anemia). If mom has ROM or contractions, it can rupture the vessels. Even a little blood loss is damaging to baby. Medical emergency. Risk factors IVF & placenta previa. Vs. Placenta previa is maternal blood loss therefore heavy persistent bleeding. Next step if ROM – rupture of membrane: Emergent c/s.

Answer 433

If Pt already has abnormal uterine bleeding (Eg. Bleeding between periods). Active breast cancer: Many breast cancers are progesterone sensitive. Active STD.

Answer 434

Hallucinations, HTN, tachycardia, hyperthermia, tremors, diaphoresis 24 hours after last drink. Often seen in people that now have a supervised monitoring (hospitalized, group home admission). Seizures (first sign of withdrawal), visual (featuring insects or animals)-auditory-tactile hallucinosis 12-48 hours later (They will ask exact timeline, not more than 2 days). Delirium tremors: 48-96hrs later (4-8days). Disorientation & global confusion. Hallucination, fever, autonomic hyperactivity. Life threatening. If severe, can lead to seizures. Moderate - severe withdrawal Tx: Benzo. Alcohol is an agonist of GABA, CNS depressant. Benzo (Lorazepam) inhibit GABA and counter the effects. Benzos will activate GABA A receptor, stops the excitation and replaces alcohol’s effects. Prefer a long acting Benzo, like Chlordiazepoxide. If refractory to benzo, use barbiturate. Also replace electrolytes and fluids. If liver disease, you want a benzo that doesn’t create metabolites and doesn’t use phase 1 cytochrome P450. This is Lorazepam, Oxazepam and Temazepam. Alcoholics get a new homeostasis therefore reduced consumption result in rebound CNS overexcitation. Chlordiazepoxide & Diazepam have long half-lives and risk buildup and toxicity

Answer 435

Traumatic event. Lasts >3days to <1month. Nightmares, dissociation and avoidance of reminders of the event. At risk for developing PTSD, so you have to treat it. Tx: Trauma-focused CBT (explaining and normalizing the stress response, exposure, cognitive restructuring. It decreases the progression to PTSD.

Answer 436

Tx Acute meds: 2nd gen antipsychotics (quetiapine, lurasidone), lamotrigine. 1. Lithium 2. Valproate 3. Lamotrigine 4. Quetiapine Avoid antidepressants, hey can precipitate the mania. If pregnant, switch to Lamotrigine for maintenance Rx. Valproate is teratogenic and causes neural tube defects. Agitated in ED: Benzos to calm down.

Answer 437

Tx: Avoid antidepressant monotherapy, it can induce mania. 2nd generation antipsychotics quetiapine and lurasidone. Or Lamotrigine, lithium, valproate and combination of olanzapine and fluoxetine. (1st generation antipsychotics cause E.P.S from its potent D2 antagonism).

Answer 438

BMP, CBC, Thyroid function test, Urine tox screen, syphilis screen.

Answer 439

Bipolar 2 and they get catonia or psychosis, it becomes bipolar 1

Answer 440

Intentional, desire to play the sick role. | Increased risk for MDD & Alcohol/Substance abuse. So monitor for both.

Answer 441

Tx: Aromatase inhibitors Anastrazole, letrozole. S/E osteoporosis (from low estrogen), get a dexa. Or Tx: Tamoxifen. s/e venous thrombosis.

Answer 442

Full uterine prolapse. Previous hysterectomy is a risk factor for a previous pelvic prolapse. Tx: Weight loss, pelvic floor muscle exercises and vaginal pessary placement (holds the uterus in place) or surgical repair.

Answer 443

No Bx, you might spread it.

Answer 444

teratoma that makes thyroid hormone

Answer 445

Fetal malposition (too much room for baby to move), umbilical cord prolapse, preterm labor (overextending the uterus making it stimulate contractions), preterm premature rupture of membranes (more pressure on the membrane), postpartum uterine atony (uterus too expanded to contract down). Can also lead to maternal dyspnea. Mom lungs compressed by enlarged uterus.

Answer 446

>5 contractions/10 mins. When the uterus is contracting, the vessels are compressed and blood isn’t delivered to the vessels. Can lead to late decelerations. Tx: Maternal repositioning, d/c uterotonic agents (oxytocin), or add tocolytic until it resolves.

Answer 447

(Endometrial cells, >45yo, next, endometrial Bx). (Atypical glandular, next, colposcopy, curettage & Bx). (Intraepithelial lesion, next, colposcopy & loop electrosurgical excision). (Can’t visualize junction, next, curettage).

Answer 448

Methimazole (Methimazole is teratogenic in the first trimester). *verified2020

Answer 449

Unilateral bloody discharge w/o breast mass. Benign. From a single dilated papilloma inside of a duct, therefore not palpable. Dx: Normal mammography & physical exam.

Answer 450

Synthetic prostaglandin, causes uterine contractions and expulsion of retained products of conception. Slow onset of action. Used to help spontaneous abortions. Or used for cervical ripening.

Answer 451

If woman infertile, irregular menses and high free Testosterone, has PCOS. Testosterone converts to Estrone in adipose (reason why weight loss is a treatment). High Estrone changes the pulse of GNRH release. Instead, you get an LH/FSH imbalance, which leads to no LH surge. No LH surge leads to, Anovulation. Prolactin and Testosterone are mildly elevated. High Estrone means the Pt would have bleeding after a Progesterone withdrawal test. PCOS has a risk factor to develop uterine cancer (from unopposed estrogen). Tx: 1. weight loss. 2nd line clomiphene citrate (selective estrogen modulator, inhibits estrogen receptors in the hypothalamus, allows the hypothalamus to restore the pulsatile GNRH and induces ovulation). High Estrogen, Normal FSH, Elevated GNRH. (testosterone is high, ovaries fail to mature) Have decreased progesterone secretion from the chronic anovulation. This means Estrogen goes unopposed and risk for endometrial cancer. If testosterone gets high too, to the point of virulization (deep voice, male pattern baldness), rule out an additional cancer. Tx: Some form of progesterone related OCP.

Answer 452

Theca Lutein cysts can develop as a result of hydatidiform mole, they are bilateral multiloculated ovarian cyts. They develop because of the extra betaHcg, and will go away once betaHcg declines

Answer 453

… (Therefore, Dopamine activates GNRH). If taking Dopamine antagonist, will have secondary amenorrhea.

Answer 454

Suggest aneuploidy. 15 wks: Do confirming karyotyping via amniocentesis (if declines, do cell-free fetal DNA test). 10-13 wks: CVS – Chorionic villus sampling.

Answer 455

Instead of 2 alpha and 2 gamma chains (HbF), have reduced or absent alpha chains made. Depends of the number of genes affected. If minor, has mild anemia. If both parents have the “cis” (aa/- -) gene, the baby can end up with a loss of all 4 alpha-globin genes (- -/- -) and have no globin chain. Instead forms gamma homotetramers (Hb Barts). Has extremely high affinity for O2 and does not release it to tissues. Cause high output cardiac failure. This leads to hydrops fetalis and intrauterine demise.

Answer 456

Tx: cephalexin, amoxicillin-clavulanate or nitrofurantoin. Mcc: Ecoli Repeat U.Culture after ABX completion (called “test of cure”). (important to make sure cleared, 1/3 patients don’t clear). If still persistent on repeat culture, do daily antibiotic suppression. risk factor for acute pyelonephritis (bacteria ascending up a dilated ureter). Also a risk factor for preterm labor (bacteria enzymes cause increased contractions), fetal tachycardia & low birth weight. Risk for ARDS.

Answer 457

High risk breast cancer before 50 & ovarian cancer at any age. Recommend prophylactic BSO after childbearing is complete. (“boobs” have an O, not an E. Risk of ovarian cancer, do not pick endometrial cancer).

Answer 458

5-14 days later. Mild eyelid swelling, watery or mucopurulent discharge. Untreated get corneal scarring. Tx: Oral Erythromycin or Azithromycin.

Answer 459

<7days. Purulent discharge. If not treated, risk of corneal ulceration, scarring and blindness. Dx: Thayer-Marting agar culture (GM intracellular diplococci). Prophylaxis: Topical erythromycin baby’s eyes & screening mom <25yo or risk factors. Tx: 1 dose IM Cefotaxime (3rd gen cephalosporin).

Answer 460

Previous C/S is not a contraindication. Contraindications are: ruptured membranes, hyperextended fetal head, fetal/uterine abnormalities, non-reassuring fetal monitoring and oligohydramnios. Have to get an NST because it can cause fetal distress.

Answer 461

Tx of CIN 3: Cold knife conization (scalpel) or loop electrosurgical excision procedure (electrocautery). Take out the transformation zone, it can progress to cancer (squamous cell cervical carcinoma). Diagnostic and curative. Complications: cervical stenosis (because strictures or scars can form). Stenosis can cause menstrual problems or infertility. Another complication: is cervical incompetence (too open) or preterm Labor. Tx of invasive carcinoma: Hysterectomy, radiation and chemo (depending on the disease stage).

Answer 462

Dx: symptom diary for 2 cycles. Tx: SSRI Qdaily or during the luteal phase. Or give OCPs to stop ovulation.

Answer 463

Mid cycle pain (10-14 days after last period). From rupture of the follicle releasing the egg & some blood during ovulation. Blood irritating the peritoneum. Unilateral (LLQ or RLQ) and lasts <1 day. Tx: Reassurance & a good H&P to r/o something more severe.

Answer 464

Submucosal bleed the most Dx: 1. Transvaginal U/S. Sonohysterography (saline infusion u/s) improves sensitivity of Dx submucous fibroids (enhances endometrial lining) to confirm. Tx: OCPs, levonorgestrel IUD. Myomectomy if fail conservative and don’t want hysterectomy. Hysterectomy is definitive Tx. Tx if causing recurrent pregnancy loss (>3 consecutive): Hysteroscopic Myomectomy. Tx if wants to get pregnant: Myomectomy (OCPs would not stop the risk of fibroids complications).

Answer 465

From decreased estrogen and progesterone postpartum. normal.

Answer 466

Baby blues

Answer 467

TX: 1st line: intrapartum Penicillins or Ampicillin … 2nd line: If penicillin allergic, Cefazolin (1st generation cephalosporin). Also given if unknown GBS status, mom intrapartum fever (means has a potential intraamniotic infection), rupture of membranes >18 hours, deliver <37wks (baby poor immune system). Or if GBS +ve during pregnancy or previous child, they don’t need screening, just treat. If Pt has GBS bacteriuria or GBS UTI in this pregnancy or previous child with neonatal sepsis. They are all high GBS colonizer states. Don’t bother screening, and just give prophylaxis with intrapartum Penicillin or Amox.

Answer 468

Can also cause late-onset >7days infection, from horizontal transmission from a household member. Mom intrapartum ABX would not prevent late onset development. Age 4-5wks, meningitis or a focal infection (cellulitis, osteomyelitis). Cellulitis-adenitis is an inflammation and induration of the face and/or submandibular area Dx: Blood, urine, CSF cultures. GM positive cocci in pairs and short chains. Next step: Emperic ABX. Tx: Penicillin G. (S.Aureus is Gram-positive cocci in clusters, not in pairs and chains)

Answer 469

Get a non-contrast CT of FND. Risk of stroke from platelet aggregation. Tx of preeclampsia: IV Labetalol (don’t give if Pulse <60, will lower it more), IV Hydralazine or Oral Nifedipine (don’t give if vomiting). Prompt delivery of baby.

Answer 470

give low dose ASA (DM, chronic HTN, previous preeclampsia, multiple gestations) first trimester. ASA will prevent platelet aggregation & prevent placental ischemia. Start before 16wks.

Answer 471

hemolysis, ⬆︎ LFT, low Platelets. A severe type of preeclampsia (ie has HTN). cause is abnormal placentation, trigger systemic inflammation & activation of coag cascade. Platelets rapidly consumed, MAHA. bad for liver, get hepatocellular necrosis and liver swelling. Tx: deliver.

Answer 472

3rd trimester. From microvesicular fatty infiltration of hepatocytes from abnormal fetal fatty acid metabolism. Causes hepatic inflammation leads to acute RUQ pain and mildly elevated LFTs. Causes fulminant liver failure, seen as hypoglycemia (low glucose (no glycogen to glucose)), hyperbilirubinemia, thrombocytopenia (platelets <100,000) and possibly DIC. Can cause multiorgan failure and fetal demise. Tx: Immediate delivery. (HELLP does not have hyperbilirubinemia or liver failure, HELLP has HTN).

Answer 473

Get a 24hr urine collection to get a baseline of proteinuria. If nephrotic range, risk for thromboembolism (losing protein c & s) and needs anticoagulation during pregnancy.

Answer 474

Concern of cancer, risk increases with age and BMI. Do a Pap test for cervical cancer, regardless of when the last one was. Get a transvaginal u/s. If endometrial thickness >4mm = abnormal, get an endometrial Bx (Gold Standard). Pap + Transvaginal u/s or Pap + Endometrial Bx (gold standard).

Answer 475

decrease the risk of ovarian and endometrial cancer. Ovarian, by chronic ovulation suppression. Endometrial, because progesterone suppresses prolif

Answer 476

More common to have a retained placenta if a still birth. Makes you fell the baby less.

Answer 477

Get labs at baseline, 3months and 1yr. Get even more if DBM or gained 5% of Initial weight.

Answer 478

(after you come up, you must come down) Depression, fatigue, hypersomnia, increased dreaming, hyperphagia (eat with decreased sympathetics), impaired concentration and intense drug craving.

Answer 479

Leads to hyperactivity of the HPA axis. This results in increased cortisol levels. Neurocytotoxic levels of hypercortisolemia may play a role in MDD pathology. This is also why stress & trauma lead to increased risk of depression. MDD also has decreased hippocampal & frontal lobe volumes & changes in sleep architecture. REM sleep latency (the time to go straight to REM) & slow-wave sleep (aka deep sleep) are both decreased. REM duration and density is increased. The biggest risk factor for future occurrence of MDD is a previous episode. Low 5-HIAA (5-Hydroxyindoleacetic acid) in CSF is associated with suicidal behavior. 5-HIAA is a metabolite of serotonin, means there is dysfunction in the serotonin metabolism (controls mood and behavior, SSRIs increase Serotonin levels). Tx in teens: Psychotherapy and if severe add Fluoxetine. If >=2 MDD occurrences, or <18yo, or persistent depressive symptoms or comorbid psych d/o, the Pt needs maintenance treatment (1-3yrs). If >=3 episodes, severe episodes (suicide attempts), chronic episodes >2yrs, ongoing psychosocial stressors, treatment is indefinite. If just one episode of MDD, continue Rx for 6 months, then taper to discontinue. SSRI adequate trial is >4-6 weeks. Don’t change the dose before then, even though patient might not think it is working. If persistent depression after 6 weeks, switch to a different class, rather than adding another agent.

Answer 480

Psychotic symptoms during a depressive episode. The psychotic symptom is mood congruent with the depression. Tx: Combined antidepressant and antipsychotic or electroconvulsive therapy.

Answer 481

In body fat and half-life of 10 to 13 days. urine tests for cannabinoids remain positive: -7 to 10 days in a casual cannabis user. -2 to 4 weeks in a heavy user. -Months in a chronic heavy user.

Answer 482

Projection: Attributing one’s own feelings to others. Acting out: Expressing unacceptable feelings through actions.

Answer 483

Limb shortening, bowing and gross motor delay. Big heads (macrocephaly).

Answer 484

Autosomal recessive. Deficiency in Galactose 1 phosphate uridylyltransferase (GALT). Problem metabolizing galactose in breast milk & cow’s milk formula into glucose. Vomiting, jaundice and hepatomegaly. Will be a recently born baby. Cataracts in 1/3 of patients, from accumulated galactitol (galactose by-product) in the lens. Galactose can not be reduced to glucose. Pt will have low Glc. Excessive galactose can impair WBC function, risk for E.Coli sepsis. Can accumulate in RBCs and lead to hemolytic anemia. Dx: measure nonglc urine reducing substances. No GALT activity in RBCs. Tx: Galactose-free diet, soy formula. (Rubella would have microcephaly & heart defects (PDA)).

Answer 485

Non-progressive motor dysfunction, abnormal tone, movement and development. Premature babies having brain injury (prone to brain bleeds). Dx by age 2yo. Have hypertonia & hyperreflexia (spasticity) of lower extremities. Feet point down and in = equinovarus deformity (club foot). Tx: Prevent contractures from developing.

Answer 486

Macrocytic anemia, Triphalangeal thumbs (finger instead of a thumb) craniofacial anomalies (cleft palate, webbed neck). Defect in erythroid progenitor cells, leads to apoptosis of RBCs. Only RBCs are low (platelets & WBC normal). Tx: Corticosteroids or transfusion if refractory.

Answer 487

Oligo Amniotic fluid index <5 cm or single deepest pocket <2cm. Poly AFI single deepest pocket >8 cm (MVP = maximum vertical pocket). AFI >24 cm

Answer 488

Autistic features, sleep problems. Mutation in MECP2 gene X-linked. Breathing abnormalities are common, alternating hyperventilation and hypoventilation or apnea. As gets older, develops seizures.

Answer 489

Dx: Get the CT or MRI (more sensitive). Next step is aggressive Treatment. Tx: IV ABX for Staph & S.Pyo (Eg. Vanco). Expand for Pseudomonas if recent ABX use. Drainage via tympanostomy for mild cases, mastoidectomy for severe infection.

Answer 490

Lamellated periosteal reaction. Cortical layering.

Answer 491

Postinfectious from viral illness. Symptoms 1-3 weeks after infection and resolve within 2 weeks. Staggering gait, intention tremor and nystagmus = cerebellum.

Answer 492

Next step: PA & lateral x-ray. If not visible on x-ray, CT scan. If high-risk features (sharp object in stomach or esophagus or proximal duodenum; respiratory compromise; esophageal obstruction signs (drooling); a battery (halo sign = double ring, electrical and chemical injury risk, corrosion risk); >2 magnets (can entrap the bowel segment loops)), next step: Endoscopic removal. If no high-risk features, next step: Serial x-ray. If not transiting, next step Endoscopic removal.

Answer 493

Neonates (<28days) - 3months: Group B Strep. <2yo: Neisseria. 3-10 y.o: 1. S.pneumo, 2. Neisseria. Empiric Tx: Certriaxone & Vanco, Penicillins also work.

Answer 494

MCC of short stature and pubertal delay in teens. Normal birth weight & height. Between 6 months to 3 yrs, drops growth percentiles. Stays around 5 to 10th percentile. Puberty and adolescent growth spurts eventually occur. Will reach normal adult height. Bone age will be slightly delayed. If kid comes in, schedule a follow up, they tend to go on to be normal. Normal birth --> 6m to 3yrs drops off 5-10th percentile --> Puberty back to normal

Answer 495

``` Appearance: all blue/pale blue extremity, pink body all pink Pulse: none <100/min >100/min Grimace: none grimace/whimper cough, cry, sneeze Activity: limp some flexion spontaneous Respiratory: absent slow weak cry reg good cry ``` APGAR <7, needs further evaluation & resuscitation. check pulse Ox and give PEEP. If HR <60, chest compressions.

Answer 496

(with a skin opening) or tuft or hair: | Next step: Lumbar u/s to look for neural tube defect. If u/s abnormal, do MRI (confirms a spine problem).

Answer 497

<4 months b/l u/s. >4 months x-ray

Answer 498

Group A streptococcus - Pyogenes infection. Joints (migratory arthritis, polyarthritis). O (carditis = friction rub, prolonged PR interval, diffuse ST elevations). Nodules (sub cutaneous). Erythema marginatum (red circles, raised edges). Sydenham chorea (continuous rapid, irregular jerks). Cause MRegurge, later MS. From group A strep (pyogenies). From an untreated strep pharyngitis. 2 major or 1 major + 2 minor or chorea or carditis present. Elevated ESR & CRP. Prevented: Penicillin Tx of strep pharyngitis. Tx: IM Benzathine Penicillin G. Prophylaxis with IM Benzatine Penicillin G every 4 wks to prevent recurrence of Group A Step making their heart disease worse (Once see Rheumatic Heart Disease).

Answer 499

ASD (wide fixed splitting of S2), transverse palmar crease, upward slanted palpebral fissure, depressed nasal bridge, furrowed tongue (trenches in it), short neck, hypotonia at birth, low birth weight, intestinal atresia, Atlantoaxial instability (laxity of posterior transverse ligament, will compress the spinal cord). Associated with hirschsprung (squirt sign, failure of neural crest migration, can not relax), duodenal atresia. Early onset Alzheimer. Increased risk of Acute Myeloid Leukemia (A.M.L). Associated with Hypothyroidism. Associated with complete atrioventricular septal defect (endocardial cushion defect, gets heart failure; fixed split S2 = ASD; systolic ejection murmur, holosystolic murmur = VSD). Brushfield spots = white spots on the iris

Answer 500

VSD (holosystolic murmur, left sternal border), closed fists, rocker bottom feet (king Edward sits on a rocker thrown), small jaw (micrognathia), low ears, prominent occiput, intellectual disability. Overlapping fingers, no creases. Second most common trisomy. From meiotic nondisjunction within maternal oocytes. Dx: Prenatal u/s & karyotype to confirm. Tx: Die in first year from heart failure CHD or respiratory failure.

Answer 501

VSD, Cutis aplasia (absent epidermis over skull), small eyes, holoposencephaly, omphalocele, polydactyl, cleft palate (midline defects).

Answer 502

VSD, Cutis aplasia (absent epidermis over skull), small eyes, holoposencephaly, omphalocele, poldactyl, cleft palate (midline defects).

Answer 503

Tachypnea, cyanosis, no murmur, single S2. Presents a few days after birth when the ductus arteriosus closes. (Transposition appears at birth).

Answer 504

Cyanosis first 24hrs, single S2 (now the Aorta is in front of the pulmonary artery and you can’t hear the pulmonary artery), narrow mediastinum (egg on a string on X-ray). From moms with DBM (not gestational, essential DM causes heart problems). From DiGeorge. Heart rotates at 8 wks. Will present right at birth if there is not enough blood mixing via the PDA, ASD or VSD. Next step: 1. Prostaglandins to keep ductus arteriosus open (indomethacin ends the PDA, prostas keep it open). 2. Get an Echo.

Answer 505

Retinitis Pigmentosa Tx Omega 3 FA to slow progression.

Answer 506

Infertility is due to testicular fibrosis and seminiferous tube digenesis. Elevated LH & FSH. Puberty would be delayed (from the low testosterone). Tall males, with intellectual disability, gynecomastia and small testicles. Because testosterone is reduced, increased gonadotropins causes expression of aromatase, increased conversion of testosterone to estradiol and elevated estrogen/androgen ratio. These patients are at an increased risk of male breast cancer (invasive ductal carcinoma, hormone receptor-positive).

Answer 507

D/c enteral feed and broad spec ABX

Answer 508

By 4 months, Moro and grasp reflexes disappear. Also they stop sticking out their tongues. Babinski stays until 2yo.

Answer 509

S.Aureus or Group A beta (Pyogenes). Golden-yellow/honey-colored crust papules. Important to wash hands. Complication of Strep skin infection is poststrep glomerulonephritis. Can also happen secondary to skin trauma (varicella, herpes, scabies, eczema), increased risk of bacterial invasion. Tx if localized, non-bullous: Topical mupirocin (it stops the spread to others). Tx if extensive bullous or widespread non-bullous: Oral cephalexin, dicloxacillin or clindamycin.

Answer 510

Caused by S.Aureus, makes exfoliative toxin that breaks cell adhesions. Bullae with yellow fluid and crusting overlying sites of ruptured bullae. From a superficial bacterial infection of the epidermis, from breaks in the skin. Tender and pruritic. The lesions rupture leaving behind a collarette of scale (collar or necklace) in the periphery of the lesion. If it ruptures, can lead to the honey-colored coating. Dx: Clinical. Tx: PO ABX Cephalexin. Strep pyogenes only causes nonbullous impetigo

Answer 511

(has cataplexy): has low CSF levels of orexin-A/hypocretin-1. Decreased sleep latency & REM onset. Wakes up refreshed. Hypnogogic = going to sleep. Dx: Sleep study. Tx: Modafinil non-amphetamine is best. 2nd line: amphetamines and methamphetamine.

Answer 512

Buproprion, phenylephrine & BB (atenolol & propranolol) may give

Answer 513

Takes 6wks, continue for 4-9month. SSRI: Fluoxetine. (kids & teens). CNS s/e: insomnia, headache Sertraline (Breastfeeding, undetectable in breast milk) (es)Citalopram. SNRI: Venlafaxine. Duloxetine. Nore&Dop RI: Bupropion (no weight gain, smoking cessation), no give for Bulimia or Seizure disorder. Bulimia because those patients have electrolyte disorders which can precipitate a seizure. Stimulatory & can help with weight loss. Also good to add as a second agent to augment SSRI’s effects. Atypical: Mirtazapine. S/e: sedating, fatigue & weight gain. TCA: -triptyline MAOI: Phenelzine, Tranylcypromine Other: Trazodone

Answer 514

1st gen: Haloperidol. Fluphenazine. Block D2 of Dopamine. 2nd gen: Risperidone. High prolonged QTC effects. Onlanzapine (s/e: sedation, metabolic effects, weight gain, dyslipidemia, ⬆︎ Glc, diabetes) for all antipsychotic meds. Aripiprazole: low metabolic syndrome. Quetiapine. Ziprasidone: Low metabolic syndrome. Lurasidone: Block 2A & D2 for less extrapyramidal side effects. All 2nd gen cause QTC prolongation, get a 12 lead EKG before and after. 3rd Gen: Clozapine. s/e:Agranulocytosis.

Answer 515

Short acting, therefore massive withdrawal symptoms after 24hrs. Seizures, tremors, anxiety, perceptual disturbances, psychosis. Is like an alcoholic withdrawal. From abrupt d/c without a taper. Anxiety, insomnia, tremor, agitation. Psychosis and seizures, life-threatening. Shorter-acting benzos Alprazolam & Lorazepam have earlier and more severe symptoms. Tx: Benzo taper over months with a longer half-life benzo Diazepam. (SSRI withdrawal is anxiety & depressive exacerbations).

Answer 516

⬆︎ risk of adverse effects. Elderly metabolize benzos more slowly more likely to experience confusion and increased risk of falls. Dementia is a risk. Another adverse effect is paradoxical agitation (within an 1hr of administration). Tx: d/c the Benzo with a taper. Switch to an SSRI or SNRI.

Answer 517

Tx: leg massage, heating pads, exercise. Fe if had low Fe. Tx: Dopamine-agonists (pramipexole or ropinirole). S/E can cause psychosis

Answer 518

<26/30 means a problem. | 26 or more is normal.

Answer 519

Metoclopramide, prochlorperazine and promethazine. | Can all cause E.P.S. Metoclopramide is a prokinetic agent (cause people to eat).

Answer 520

Next step, dry and stimulate the infant. Next step, skin-to-skin contact (underdeveloped thermoregulatory center & risk of hypothermia), also helps initiate breastfeeding. Next step, Vitamin K, Hepatitis B Vaccine, Erythromycin eye ointment. Next step, Newborn screenings: metabolic/genetic disorders, hyperbilirubinemia, hearing, Pre ductal (right arm) & post ductal (either leg) pulse ox (CHD) & hypoglycemia. Positve CHD screening: >3% difference in upper & lower, get an Echo.

Answer 521

Outpouching of laryngeal mucosa protrudes through the thyroid membrane. Enlarges with Valsalva (filling with air). Acquired version in glassblowers or trumpet players from the repeated oropharyngeal pressure.

Answer 522

Kids with lateral, cystic neck mass. Embryologic structure, made of paired arches separated by clefts that form many face and neck structures. Abnormalities often from the 2nd branchial arch, therefore often forms between the internal and external carotid arteries, anterior to the sternocleidomastoid & inferior to the mandible. Often only detected when it becomes infected after a URI. Can even go on to form a sinus tract or drain fluid. Tx: Resection.

Answer 523

Midline neck mass. Moves superiorly with swallowing. Often detected after a U.R.I. leads to it getting infected, leads to it being red and tender. From a defect in the ducts that formed the thyroid failing to atrophy (epithelial remnants). The tract connects to the base of the tongue, reason moves when stick out tongue or swallow. Dx: *Do a thyroid imaging before removing, the cyst might be the only source of thyroid hormone.* Tx: Surgically remove because risk of recurrent infection.

Answer 524

Poly microbial. Life threatening. 6 months to 6yo. Normal vertebral body space is smaller than the anterior next space (prevertebral space). Get a CT with contrast to confirm

Answer 525

Dystrophin is a plasma membrane protein in muscle fibers. Without it, muscle fibers will degrade. Dx: 1. CK level (r/o myopathy). 2. genetic testing deletion of dystrophin gene which destroys amino acid coding sequence. Bx: muscles replaced with fat & fibrosis. Dx: Echo and EKG to screen for dilated cardiomyopathy and conduction abnormalities (fibrosis leads to muscle heart failure). Pts die by age 30 from respiratory or heart problems.

Answer 526

Auto dominant. Teen or adult onset. Trinucleotide CTG repeat expansion of dystrophia myotonica protein kinase (DMPK) gene. Severity depends on # of repeats. Myotonia (delayed muscle relaxation), unable release hands from handshake (first sign). Skeletal muscle weakness (face and hand). Dysphagia, risk of aspiration. Cardiac muscle, conduction anomalies or arrhythmia. Testicular atrophy/infertility. Cognitive and behavioral manifestations. Excessive daytime sleepiness. Dx: Genetic testing. Tx: Symptomatic care. Die 45-55yo from heart or respiratory failure. (Myasthenia gravis has fluctuating, not permanent weakness. Myotonia doesn’t happen).

Answer 527

Auto dominant. Teen or adult onset. Trinucleotide CTG repeat expansion of dystrophia myotonica protein kinase (DMPK) gene. Severity depends on # of repeats. Myotonia (delayed muscle relaxation), unable release hands from handshake (first sign). Skeletal muscle weakness (face and hand). Dysphagia, risk of aspiration. Cardiac muscle, conduction anomalies or arrhythmia. Testicular atrophy/infertility. Cognitive and behavioral manifestations. Excessive daytime sleepiness. Dx: Genetic testing. Tx: Symptomatic care. Die 45-55yo from heart or respiratory failure. (Myasthenia gravis has fluctuating, not permanent weakness. Myotonia doesn’t happen).

Answer 528

Herpangina, summer/early fall. grey vesicles on tonsillar pillars and posterior oropharynx can progress to fibrin-coated ulcers. Posterior pharynx only. Self resolves. (Herpes involves the anterior pharynx). Coxsackievirus causes pericarditis and myocarditis. Tx: Supportive (virus) – hydration & analgesia.

Answer 529

Painful ulcers. Lasts a few days and then the mucosa returns to normal

Answer 530

Talipes equinovarus & adduction of forefoot. More in males. They can still walk, and stand. Differs from metatarsus adductus because this will be a rigid and upward deformity of the forefoot and hindfoot. Tx: stretching, manipulation serial plaster casts. Have to start treating ASAP or problem with gait. Surgery before 1y.o if no results

Answer 531

S/e of Erythromycin (macrolide) Forceful vomiting = projectile vomiting, non bilious = pyloric stenosis. Age 3-5 weeks, first born. Pts on macrolides or formula-fed infants (slower gastric emptying times, pass more volume in less time, puts more burden on the stomach). Forceful vomiting, then extreme hunger. Olive shaped mass. The abdomen won’t be distended because not a lot of air passes through. Dx: Abdominal u/s. Tx: Pyloromyotomy

Answer 532

A phosphatase uses water to remove a phosphate, hydrolyzing a substrate). Glycogen storage disease. No glycogen to glc. Glycogen accumulated in liver, kidneys and intestinal mucosa. Presents at 3-4 months. Pt with hypoglycaemia (seizures), lactic acidosis (buildup in liver), hyperuricemia & hyperlipidemia. Doll-like face, round cheek. protuberant abdomen from hepatomegaly. The spleen is not affected.

Answer 533

Glucocerebrosidase enzyme deficiency. Glucocerebroside accumulate in macrophages of the liver, spleen and bone marrow (causes anemia & thrombocytopenia). MC lysosomal storage disease. Causes bone pain (accumulate in the bones) and cytopenia (low cell counts). Hepatosplenomegaly is present. Sugars will be fine. Cause failure to thrive and delayed puberty.

Answer 534

Can’t break down fatty acid chains. Hypoketotic (low ketones) hypoglycemia (low glucose) during fasting states (Eg. Illness).

Answer 535

<2 y.o. Neural crest origin (precursor for sympathetic chain and adrenal medulla). Tumours of adrenal (abdominal mass) or paravertebral sympathetic chain line (Horner’s syndrome, anhidrosis, facial flushing). Firm, nodular. Calcifications and hemorrhages on X-ray & CT. Makes HVA and VMA. Dopamine converts to HVA & Nore/epi converts to VMA. Can have periorbital ecchymoses (raccoon eyes) from orbital mets obstructing blood flow. Can have a paraneoplastic finding of opsoclonus-myoclonus syndrome. Mass crossing the midline, symptomatic

Answer 536

Metastatic to lungs. Incidental (asymptomatic) unilateral abdominal swelling 2-5 y.o. MCC Renal malignancy kids. From metanephros (precursor of kidney parenchyma). HTN from renin secretion & compression of renal vasculature. Associated with other syndromes. WAGR: Wilms, Aniridia, GU problems, Retardation & Beckwith-Wiedemann. Mets to lungs. WAGR syndrome = 11p deletion syndrome. Dx: 1. Ab u/s 2. CT or MRI to confirm 3. Pathology. Tx: surgery & chemo/radiation. Good survival rates

Answer 537

Can loose up to 7% of birth weight in first 5 days. Excreting the excess uterine fluid. Loose more if breastfeed. Regain the weight by 10-14days. After 1st week, >6 wet diapers/day. <1 week, #wet diapers=#number of days.

Answer 538

Subperiosteal hemorrhage. On the surface of one cranial bone. Resorb spontaneously weeks-months. Rarely might need phototherapy from the caused hyperbilirubinemia. It is firm (periosteum contains it).

Answer 539

Diffuse, ecchimotica swelling of the scalp, above the periosteum. Might cross midline and suture lines (because above periosteum). It is boggy.

Answer 540

Telescoped bowel palpable as a cylinder or sausage. Target sign on U/S. <2y.o, after a viral illness or GI illness. Leads to hypertrophy of Peyer patches in the terminal ileum. Causes the telescoping. Risk factors are prematurity, low BP and CHD. Inconsolable crying with legs drawn to the abdomen and periods of normal activity. **Henoch-Schonlein purpura can lead to it**. Ileocecal junction is most common location (RLQ), terminal ileum goes into the colon. Inflammation can push it to be palpated in RUQ. If intussusception in an older child or repeated bouts or atypical location (not at ileocecal junction), think of a lead point cause = intestinal abnormality, like Meckel diverticulum (anemia or rectal bleeding history), next step, do a Meckel scan = 99m technetium pertechnetae. Dx: 1. u/s guided Air or saline enema Tx: Air or saline enema. Might need surgery. X-ray shows a crescent sign:

Answer 541

Holosystolic L lower sternal border. Exertion (crying, feeding, hyperventilation) will lead to ⬆︎ PVR from the Pulmonary obstruction. As result, more shunting R to L. Knee to chest will cut femoral arteries. Get ⬆︎ Systemic vascular resistance and decrease R to L shunting.

Answer 542

Can lead to cortical laminar necrosis causing neuro damage or chance for recurrent seizures. Tx: IV or rectal Benzos. Prevention: Loading dose of phenytoin. Don’t do head CT until seizing controlled.

Answer 543

All children <2y.o with first febrile UTI should undergo a renal and bladder U/S to evaluate any anatomical abnormalities that might predispose. Important because at risk for complications. Needs 1-2 wks of ABX. Get U/S after improved fever and symptoms subside, to r/o structural anomaly. (Positive nitrites = Enterobacteria. Positive leukocyte esterase = Made by WBCs). If symptoms do not decrease with abx, Do a renal ultrasound right away to r/o a renal abscess. If culture grows non-E.Coli bacteria or if recurrent UTI >2x or if CKD or if abnormal u/s, do a voiding urethrogram. If Reno ultrasound shows hydronephrosis or Scarring, do a voiding urethrogram. Dx: Urine culture . Tx: empiric ABX (3rd gen cephalosporin (cefixime) in kids, can’t give cipro), empiric ABX are needed to prevent permanent renal complications. If symptoms persist after 48hrs, likely has a renal infection, get a renal & bladder u/s & broaden the ABX. ``` Recurrent UTIs (>2x) in a kid, think of a urologic abnormality and make sure to get a voiding cystourethrogram (check for vesicoureteral reflux) after treating the current UTI. If the urethrogram shows high grade reflux, will need daily PO prophylactic ABX. ```

Answer 544

Chronic inflammation leads to increase in cytokines. Increased cytokines leads to increased hepcidin production. Hepcidin will inhibit Fe absorption and release.

Answer 545

(Single S2 + harsh crescendo-decrescendo Systolic murmur) Tet spell = cyanotic during feeding. Harsh, systolic ejection murmur L upper sternal border (crescendo-decrescendo)= pulmonary stenosis. Single S2 = normal aortic & inaudible pulmonary components. RV outflow tract obstruction (pulmonary stenosis)→ increase pulmonary vascular resistance. RVH. Overriding aorta. VSD. When pulmonary vascular resistance > systemic resistance, get a R → L shunt. Acute Tx: knee-chest (to increase vascular resistance & reduce R→L shunting) + inhaled O2 (stimulate pulmonary vasodilation & systemic vasoconstriction. Send RV blood to pulm artery instead of the aorta.

Answer 546

1. Hemolytic anemia 2. Low platelets 3. AKI (Cre). MCC E.Coli O157:H7, Shiga toxin less common. MAHA, Intravascular hemolysis. Platelet microthrombi shear the RBCs (anemia) and leads to MAHA. Shiga toxin leads to endothelial damage (in the renal glomeruli) Vascular injury led to platelets thrombi forming. Tx: supportive IV fluids, improves in 2-3wks. Some need dialysis for the A.K.I.

Answer 547

surgical mask until 24hrs of ABX on board.

Answer 548

Deletion of dad’s copy 15q11-q13. Hypogonadism (small balls) and almond shaped eyes. Dx: Karyotype & methylation studies. Then in-situ hybridization. Then microsatellite probes. Tx: Obesity related, screen for OSA & DM.

Answer 549

Strep pneumo, H influenza.

Answer 550

Claw hand. Supinated forearm, wrist extended, hyperextended MCPs, flexed DIPs, PIPs. From C8 & T1 nerve damage.Bad prognosis if has Horner’s. Tx: gentle massage. If no progress by 3-6 months, surgery.

Answer 551

Waiters tip, internally rotated, elbow extended, flexed wrist, fingers flexed. Injury to C5C6C7. Decreased or absent Moro reflex. Grasp reflex is fine. Tx: gentle massage & physio to prevent contractors. Most recover by 3 months. If no recovery, surgery by 3-6 months.

Answer 552

Term babies have enough iron stores for 6 months. After 6 months, dietary intake becomes the most important source.

Answer 553

be isolated or part of the VACTERL d/o (Vertebral, Anal, Cardiac, TracheoEsophageal, Renal, Limb defects) Bowels distended with air. Air from lungs getting into the fistula. Goes to stomach and bowels. Next step: Attempt NG tube placement. If it doesn’t pass, you have confirmed. CXR can confirm.

Answer 554

All cells get trapped in the spleen (RBCs, Platelets, WBCs). Spleen can hold a lot of blood. Leads to hypovolemic shock (lots of RBCs getting trapped in the spleen). Leads to low platelets & increased reticulocytes (normocytic anemia). Acute Tx: IV fluids. Packed RBC transfusion to give volume an correct anemia. Don’t give too many transfusions because, after the crisis, RBCs will come out of the spleen and risk of hyperviscosity.

Answer 555

Give Fe until age 1

Answer 556

In kids, from a hematogenous spread. **MCC Staph Aureus**. Seeds in rich vascularized metaphyses of long bones (Eg. Femur, Tibia). Risk factors are sickle cell disease and immunodeficiency. Fever + localized bony inflammation (point tenderness and swelling) + avoids using the limb. Dx: CBC, ESR, CRP, blood cultures and x-rays. MRI. Gold standard Dx: Bone Bx and/or culture. Tx: IV antistaph Aureus ABX.

Answer 557

Due to functional asplenia, risk factors are encapsulated bacteria (strep pneu (mcc), H. Influenzae (rare if vaccinated) and N. Meningitis. Prevented with vaccination with pneumoccal conjugate and polysacc & meningococcal conjugate vaccine. Prevented with prophylactic penicillin (because strep mcc) until age 5. (Staph causes osteomyelitis, not sepsis).

Answer 558

Specific gravity: <1.006 = dilute urine. Inability for the kidneys to concentrate urine (low specific gravity). Common in patients with sickle cell disease or sickle cell trait. Sickle cells in the vasa recta Prevent proper urine concentrating abilities. Sodium is normal, because they still have proper ADH. Will have nocturia and polyuria despite fluid restriction. Tx: if sickle cell trait, none. Tx: if sickle cell disease: RBC transfusions will improve RBC function and there decrease sickling in the kidneys.

Answer 559

Elite athlete noisy breathing after exercise. Throat tightness. Asthma Tx no effect. Inspiratory stridor during exercise (asthma has expiratory wheezing). Instead of vocal cords opening (abducting) during inspiration, now they adduct and block the larynx. Triggered by smells, exercise or stress. Dx: Laryngoscopy showing vocal cords adducting. Tx: 1. Encourage the patient to sniff or pant. It activates the posterior cricoarytenoid which abducts the cords. Or NIPPV. Try not to intubate these patients. Longterm Tx: Education and speech-language therapy.

Answer 560

Inspiratory Stridor: Obstruction at level of the larynx or superior to it. Expiratory Stridor: Obstruction inferior to the larynx. Biphasic stridor: Obstruction at the trachea. (vascular rings).

Answer 561

Premi babies, RDS. Haziness & decreased lung volumes. Does not improve with surfactant and mechanical ventilation. From repeated injury to neonatal lungs (prolonged mechanical ventilation, prolonged O2 and inflammation). Resolves over 2-4 months or develops P.A.H.

Answer 562

Risk for RDS, prematurity <28 weeks & low birth weight, C-section without labor, maternal diabetes. Insulin, inhibits cortisol and block sphingomyelin, inhibits surfactant. unable to reduce surface tension (risk of pneumothorax). RDS on X-ray: Diffuse reticulogranular appearance (ground glass). RDS on Physical Exam: Grunting to ⬆︎ end-expiratory press. Nasal flaring to decrease nasal airway resistance. Rib retractions to pull in the compliant chest wall. Hypoxia and cyanosis. Prevented: Maternal antenatal glucocorticoids. Tx: CPAP (forces alveoli open). Intubate and mechanically ventilate if severe.

Answer 563

Adult: Fever and then viral arthritis.

Answer 564

Tx: 1. Cover with sterile saline dressing and plastic wrap (minimize heat and fluid loss). 2. Nasogastric tube (to decompress the stomach) 3. Single stage closure.

Answer 565

Can be from prenatal pills (High Fe content). GI symptoms, green diarrhea. Hemorrhagic, because Fe is caustic to GI tract. Hypovolemic shock. Lactic acidosis (gapped metabolic acidosis (Na-Cl-HCO3), H+ production), bowel obstruction. Fe in the belly looks radiopaque on X-ray. Fe does damage by free radical production and lipid per oxidation. Dx: Serum Fe levels. Tx: 1. Aggressive volume resuscitation. 2. Deferoxamine (chelating agent, binds Fe for renal excretion.

Answer 566

Day 2-4 of life. more RBC turnover fetal RBCs, shorter life span; decreased hepatic bilirubin clearance (UGT levels not at adult capacity, less conjugation to make it soluble) enterohepatic recycling is increase (less gut bacteria means less bili to urobili and fecal extraction, so you reuptake bili). Asians have decreased UGT. Tx: frequent feeding will promote gut colonization and fecal excretion. Can add phototherapy.

Answer 567

not feeding enough, red crystals (mild dehydration), not enough wet diapers. From slower transit and elimination of bili. From increased beta-glucuronidase in breast milk, it later deconjugates intestinal bilirubin. (if not feeding enough, not pooping enough and the Billirubin for their fetalHb is not being excreted. Peak in first 2 weeks in life). Indirect bili. Prevented by: >10-20mins/side every 2-3hrs.

Answer 568

If baby not dehydrated. Allergic to the breast milk. High B-glucuronidase in breast milk which will deconjugate bili.

Answer 569

Bili >20mg/dl get phototherapy. Exchange transfusion for >25mg/dl.

Answer 570

First X-ray (r/o perforation) then water soluble contrast enema to Dx level of obstruction. Meconium ileum (microcolon = underused colon), problem is at the terminal ileum. Tx: hyperosmolar enema to dissolve the meconium (gastrografin). If no work, surgery.

Answer 571

Vasculitis medium arteries. young kid <5yo. Conjunctivitis (non-purulent), Fever, Lymphadenopathy. Muccocutaneous inflammation (red/crack lips, strawberry tongue, red mouth, generalized polymorphous rash). Extremity changes edema, erythema. The vasculitis causes a prolonged inflammation, leads to a prolonged fever. Resolves within 2 weeks. Risk of coronary artery aneurysm. Get a baseline Echo and repeat 6-8 wks. Also risk for thrombosis (clots) in the dilated artery. Tx: ASA – Asprin & IV IgG started within 10 days of fever to decrease the risk of aneurysm. ASA prevents thrombis and lowers inflammation.

Answer 572

Problem if no menstruate by 15 yo and rest of development has been normal. Precocious puberty before 8. For girls, breast develops first. Then pubic hair. Then menses (around Tanner stage 4). 6 months before menarche, girls get a growth spurt. Once breasts develop, menarche will start in 2-2.5yrs.

Answer 573

Excess estrogen leads to premature epiphyseal fusion & advanced bone age

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