Rosh Flashcards
(162 cards)
1
Q
most appropriate first-line treatment for minor bleeding in patients with von Willebrand disease.
A
Desmopressin is the most appropriate first-line treatment for minor bleeding in patients with von Willebrand disease.
2
Q
lab findings in VOn Willebrand
A
Patients may present with an prolonged activated partial thromboplastin time (seen in patients with low factor VIII levels) but will have normal platelet levels and prothrombin time.
3
Q
In this cancer patient with a new diagnosis of DVT without other complicating factors the best treatment option is?
A
low molecular weight heparin therapy and discharge her to follow up with her primary doctor.
4
Q
An ECG with a small positive deflection buried in the end of the QRS complex?? Disease associated? Imaging?
A
epsilon wave, (terminal positive deflection in QRS) is characteristic for arrhythmogenic right ventricular cardiomyopathy (formerly called right ventricular dysplasia)
Cardiac MRI and place defibrillator
5
Q
Pemhigus? Disease of what?
Diagnosis?
tx?
A
Pemphigus is an autoimmune disorder characterized by bullae and blisters that develop from deposition of immunoglobulin G autoantibodies in the epithelial cell surface. Biopsy is required to make an official diagnosis. Treatment includes management of volume depletion and electrolyte disarray, typically in a burn unit
6
Q
Infantile SPasm Triad?
A
infantile spasms or West syndrome. Infantile spasms are defined by the triad of findings: (1) clusters of myoclonic seizures on awakening, (2) hypsarrhythmia pattern on EEG, and (3) developmental delay.
7
Q
HypoK EKG findings
A
Flattened or inverted T
U wave
8
Q
Numbers for compartment syndrome. TWO
A
- Direct compartment pressures over 30 mm Hg
- the difference of diastolic blood pressure compartment pressure (known as the delta pressure) less than 30 mm Hg are indicative of compartment syndrome, with the latter being more accurate.
9
Q
POst viral PNA?
A
Staph aureus
10
Q
bullous pemphigoid
Tx?
Etiology?
A
bullous pemphiGoid (igG). Bullous pemphigoid is a chronic bullous disease that involves IgG autoantibodies against the basement membrane (subepidermal).
Tx- doxy and wound care. If severe immunomodulators.
Nikolsky NEGATIVE
Age >60
11
Q
Most commo area of clavicle fractures
What vessels/nerve at risk with any clavicle fracture
A
Middle 1/3 (80%)
A careful neurovascular assessment should be performed since the subclavian vessels and brachial plexus run in close proximity to the clavicle
12
Q
BRUE??
What makes them low risk
A
Breief unexplained unexplained event.
Infants are considered low risk for having serious underlying pathology or recurrence of episodes if they meet all of the following criteria:
- age greater than 60 days
- gestational age ≥ 32 weeks and postconceptional age ≥ 45 weeks
- occurrence of only one BRUE
- duration of event less than one minute and no cardiopulmonary resuscitation was required by a trained professional.
13
Q
Erythema multiforme lesion looks like?
Associated with which two viruses
A
Erythema multiforme is characterized by a rash of “target lesions” that typically have a dark red center and are surrounded by a pale ring and sometimes another red outer ring.
HSV and Mycoplasma PNA
14
Q
Bacterial tracheitis
Which bugs? How does the kid good look? How
A
Bacterial Tracheitis
Patient will be 3–5 years old
Complaining of high fever, barky cough, stridor
Treat as airway emergency!
Comments: Patient will look like croup but toxic appearing
Most common staph aureus.
Borad IV ABx
15
Q
which typical asthma med should be avoided in prengancy
A
Acute asthma exacerbations should be treated in the ED as in any nonpregnant patient. Epinephrine may also cause uterine vasoconstriction and reduced fetal oxygenation.
16
Q
What is the most common cause of acute mesenteric ischemia?
A
Cardiac emboli to the superior mesenteric artery.
17
Q
What bacterial infection should be considered as the cause of flexor tenosynovitis in sexually active patients?
A
Answer: Disseminated gonorrhea.
18
Q
What is the role of dexamethasone in a child presenting with a high-risk for H. influenzae meningitis?
A
Answer: Treatment with dexamethasone has been shown to decrease hearing loss associated with H. influenzae meningitis in children.
19
Q
Presentation of neonatal seizures?
Dx of chose?
A
lip smacking, eye deviation, staring, rhythmic blinking, and bicycling movements.
Phenobarbital
20
Q
malrotation mid gut
Test? Finding?
When and age?
A
1 week of life- surgical emergency
The classic presentation is an infant with bilious vomiting. The child may initially appear well, but as gut ischemia occurs, abdominal pain, distention, hematochezia, and shock develop.
An upper GI study is the gold standard for diagnosis of malrotation with midgut volvulus, showing characteristic corkscrew appearance of the jejunum.
21
Q
Commonalities of Taco and Trali
Big difference
A
- Pulm edema, hypoxia in both
- Hypotension and FEver in TRALI
Hypertension in TACO
-
22
Q
What is the most common organism associated with bacterial tracheitis?
A
Staph Aureus
23
Q
Skiers thumb
MO injury?
tx?
What’s injuried?
A
Gamekeeper’s Thumb - Skier’s Thumb
Patient with a history of skiing
Complaining of pain, swelling, and tenderness on the ulnar side of the metacarpophalangeal joint of the thumb
Most commonly caused by the forceful radial abduction of the thumb
Treatment is thumb spica splint
24
Q
PArkland formula
A
4 mL x Patient’s kg x % BSA, giving half in the first eight hours and the remaining half in the next 16 hours
25
Cause of HyperCalcemia in Sarcoid
hypercalcemia (due to macrophage production of calcitriol),
26
What does positive pressure do in asthma (non invasive)
Noninvasive positive pressure ventilation applies a consistently positive airway pressure to increase laminar flow. This leads to airway stenting, elimination of dead space through alveolar recruitment, and an increase in tidal volumes and minute ventilation.
27
When do you use ACoagulation in superficial venous thrombosis
found to have thrombus within 5 cm to the deep venous system (e.g., near the saphenofemoral or saphenopopliteal junction) or an affected vein segment that is greater than 5 cm are at increased risk for thromboembolism and should be anticoagulated. Options for anticoagulation include rivaroxaban, low-molecular-weight heparin, or fondaparinux.
28
When do you give steroids in PJP
Patients with arterial partial pressure of oxygen less than 70 mm Hg or an alveolar-arterial gradient greater than 35 mm Hg should also be treated with corticosteroids
29
How do hematocrit levels change in hypothermic patients?
2% increase in hematocrit for every 1°C drop in temperature.
30
```
Ammonia:
Chlorine:
Hydrocarbons:
Hydrogen sulfide:
Nitrogen oxides:
Phosgene:
Pulmonary edema
```
Ammonia: cleaning product odor, fertilizers
Chlorine: swimming pool odor
Hydrocarbons: fuels
Hydrogen sulfide: rotten egg odor, cyanide like effect
Nitrogen oxides: combustion
Phosgene: hay odor, plastics/textiles
Pulmonary edema
31
Contraindications to LPs (5)
1. Infection over site
2. Fracture
3. Cardiopulm instability
4. Bleeding Diathesis
5. Increased intracranial pressure
32
5 parts of ottawa critrea
tenderness over the posterior lateral malleolus, tenderness over the posterior medial malleolus, tenderness over the navicular bone, tenderness over the base of the fifth metatarsal, and inability to bear weight for four steps
33
Flexion teardrop fracture
- Hyperflexion
- stable fracture of the antero-inferior aspect of the vertebral body that occurs due to hyper-flexion. . The vertebral body is divided into three columns: the anterior, middle, and posterior columns and unstable bc it fractures through all.
-
34
Jefferson Fracture
ABC
```
Axial load (diving, head on football)
Burst
C1 rfactrue
```
Unstable
Jefferson fracture is a burst fracture of the lateral masses of C1.
35
Ankle Arthrocentesis Location
medial to the tibialis anterior tendon and directed toward the anterior edge of the medial malleolus
36
Most common cause of SVC?
Clinical signs and symtoms
SVC via compression, infiltration, or thrombosis. The most common etiology of this disorder is squamous cell carcinoma of the lung, which causes 65% of all cases of SVC syndrome. Signs and symptoms are typically caused by venous hypertension in the head, neck, and chest. These include dyspnea, periorbital edema and facial swelling,
37
Lymphogrganulum
Population at risk?
- Initial presentation and timeline
- Secondary presentation
Lymphogranuloma Venereum
Primarily seen in men who have sex with other men
With a history of recent travel to tropical and subtropical areas of the world
Incubation period- 3-21 days Complaining of small, shallow painless genital ulcer
Secondary- 3-20 days after ulcers resolve- PE will show tender inguinal/femoral lymphadenopathy
Most commonly caused by Chlamydia trachomatis
Treatment is doxycycline
38
Carcinoid Syndrome
Symtoms?
Treatment?
Carcinoid Syndrome
Patient presents with skin flushing, wheezing, and diarrhea
Diagnosis is made by 24-hour excretion of 5-hydroxy-indoleacetic acid (5-HIAA) in the patient’s urine
Most commonly caused by carcinoid tumors (neuroendocrine tumors that secrete vasoactive material such as serotonin, histamine, catecholamine, prostaglandins, and peptides)
Octrotide
39
In submersion/drowning, The degree of pulmonary insult is ultimately determined by ?
the quantity of liquid aspirated.
40
7 steps of catching a baby
engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.
41
Infantile Spasm Triad?
Infantile spasms are defined by the triad of findings: (1) clusters of myoclonic seizures on awakening, (2) hypsarrhythmia pattern on electroencephalogram, and (3) developmental delay.
42
Septic thombophlebitis-other name?
Define?
triad?
Septic thrombophlebitis (i.e. Lemierre syndrome) is an infected clot of the jugular vein caused by local invasion from bacterial pharyngitis.
Traid- 1. ancedent pharyngitis
2. Fever not breaking with Abx
3. Septic pulm emboli
These patients are described as toxic in appearance with fever, anterior neck pain and stiffness, as well as possible respiratory distress from septic pulmonary emboli. Treatment is with admission for intravenous antibiotic therapy.
43
Indication of Left Main on EKG?
ST segment elevation in lead aVR greater than 1 mm or greater than the elevation seen in the ST segment of V1 should prompt concern for occlusion of the left main coronary artery
44
Most common cause of acute mesenteric isshemia
ost common cause of acute mesenteric ischemia is from arterial embolism that often originates from the left atrium, left ventricle, cardiac valves, or proximal aorta. Atrial fibrillation, especially if not on anticoagulation, places the patient at high risk for distal embolization.
45
How to treat bad pulm contusions
Exceptions
“Good lung” should be positioned down (good to ground) to improve V/Q matching and oxygenation
Exceptions: “bad lung” is in the dependent position (down) include massive hemoptysis (to prevent blood from filling the good lung), large pulmonary abscesses (to prevent pus from filling the good lung), and unilateral emphysema (to prevent hyperinflation)
46
Ethylene Glycol lab findings??
Markers of intoxication with ethylene glycol include high anion gap metabolic acidosis with an absence of significant lactate or ketone concentrations, and calcium oxalate formation leading to acute renal failure.
47
Mortality in myxedema coma is proportional to the severity of the patient’s ...?
Hypothermia
As with other causes of hypothyroidism, the TSH is typically high while T4 and T3 are low. Definitive therapy for patients with myxedema coma is with the administration of intravenous thyroxine.
48
What is the Star sign? Caused by?
classic “star sign” of hyperechoic blood in the basal cisterns, consistent with a subarachnoid hemorrhage. Most of these cases are caused by rupture of a cerebral aneurysm (75%). less commong cuases arteriovenous malformations (B), vertebral artery dissection (D)
49
L3 and L4 radiculopathy findings
Compression of L3 (A) results in weakness with hip flexion and adduction with decreased sensation of the anterior thigh. L4 (
B) radiculopathy presents with weakness with knee extension, and decreased sensation of the lateral thigh, anterior knee and medial leg
50
Most common complicatoin of HELLP
| Other complications?
Patients with HELLP syndrome are at risk for bleeding complications, including disseminated vascular coagulation (DIC), intracranial hemorrhage, placental abruption, and spontaneous hepatic or splenic hemorrhage. Hepatic hemorrhage can progress to hepatic rupture, which is associated with a maternal and fetal mortality rate of over 50%.
51
HgSS with hyphema- avoid which med group? Why?
However, carbonic anhydrase inhibitors are contraindicated in patients with sickle cell disease because the lower aqueous pH induces sickling of red blood cells, occludes the trabecular meshwork and leads to increased intraocular pressure
52
Which med in RIPE should be avoided in pregnancy?
pyrazinamide- tetargenic
53
Latent TB tx?
Latent TB, first line: Isoniazid with B6
54
Acute interstitial nephritis
Cause?
Presentation?
UA findings?
Acute interstitial nephritis (AIN), most often due to a hypersensitivity drug reaction, presents abruptly with signs and symptoms of acute kidney injury. Patients may have malaise, nausea and vomiting, and oliguria. Classic symptoms of rash, fever, and eosinophilia can be seen in cases due to drug reaction, although most patients do not have all three cardinal symptoms. Cases caused by nonsteroidal anti-inflammatory drugs are also less likely to present with classic symptoms compared with other agents. Urinalysis findings include pyuria, microscopic or gross hematuria, eosinophiluria, and mild proteinuria.
55
Severe DIsease? What is it? What test? Tx? Risk factors?
Sever Disease - Apophysitis Of The Calcaneus
Overuse injury in children + wearing cleats
Heel pain
(+) Calcaneal compression test
Manage with supportive care (ice, pain medication, reduced activity)
56
Cuff size formula estimate?
Formula: cuffed ETT size = (age/4) + 3.5 and uncuffed ETT size = (age/4) + 4.
57
Neuro deficit in lightening strike
Other indications of a lightning injury include keraunoparalysis, a temporary paralysis of the extremities which may appear blue, mottled and cold. Due to transient vascular spasm and sympathetic nervous system instability, this is more commonly seen in the lower extremities and often resolves in a few hours.
58
Shoulder Impingement Syndrome (SIS)
cause
test
tx
```
Shoulder Impingement Syndrome (SIS)
Repetitive motion
Neer/Hawkins-Kennedy tests
Ice, rest, pain control, PT referral
Orthopedic evaluation
```
59
Indications for CT before LP
- AMS
- Hx of intracranial mass
- Immunocompromised
- Focal deficits
- New onset seizre the week prior
60
Failure to capture?
Spikes ut no QRS after
Failure to capture can range from complete absence of pacemaker activity to pacemaker spikes being seen but not resulting in depolarization of the myocardium. Complete absence of activity can be due to battery depletion, fracture of the pacemaker lead (which is uncommon with today’s technology) or disconnection of the lead from the generator. Intermittent failure to capture is commonly due to lead displacement and is most likely to happen within the first month of placement.
61
IgG autoantibodies against the desmosomes
IgG autoantibodies against the desmosomes (C) is an example of type II or cytotoxic hypersensitivity reactions and is the mechanism by which pemphigus vulgaris occurs.
62
IgG autoantibodies against the basement membrane (subepidermal)
Bullous pemphigoid is a chronic bullous disease that involves IgG autoantibodies against the basement membrane (subepidermal)
63
CI TO handling splenic infarcts non-op?
Realtive CI?
Contraindications to nonoperative management include persistent hemodynamic instability, generalized peritonitis, inability to follow clinically with serial abdominal examinations (due to lack of resources or altered mental status), high-grade splenic injury (grade IV or higher), or need for operative management of other intra-abdominal injuries.
Another relative contraindication would be age > 55 years as these patients are at higher risk for failure of nonoperative management, including embolization.
64
SBP labs?
Labs will show PMNs > 250/µL, WBC > 1,000/µL, pH < 7.34
65
HOw long for gtube to mature? How to manage if it fals out before?
Patients who have inadvertently removed their tubes before four weeks postprocedure should be admitted to the hospital for intravenous antibiotics and monitoring for signs of peritonitis.
66
What tets is most reliable for achiles rupture
The calf squeeze test, or Thompson test, is the most reliable indicator of an achilles tendon rupture with a sensitivity of 96%.
Remember ambulation and flexion require a bunch of muscles
67
Raynauds tx?
long-acting dihydropyridine calcium channel blockers, such as nifedipine and amlodipine, are the recommended first-line therapy for the disease
68
Indications for HD in lithium OD
lithium level is greater than 5 mEq/L, when the lithium level is greater than 4 mEq/L in the setting of renal insufficiency, and in patients who present with altered mental status, seizures or life-threatening complications regardless of their lithium level.
69
Heptarenal syndrome labs?
Hepatorenal syndrome presents with an increasing serum creatinine with minimal proteinuria and low sodium excretion in the setting of acute or chronic liver disease. Oliguria is typically present.
70
```
Hydroflouric Acid?
What industry?
Presentation?
Labs derangement?
Tx?
```
Hydrofluoric Acid
Glass etchers, rust removal, metal cleaner
Dermal exposure: blue-gray burn, pain out of proportion to exam if not treated will escar
Hypomagnesemia, hypocalcemia
Hypocalcemia → dysrhythmias
Rx: irrigation, calcium gluconate
Alkaline burn → liquefactive necrosis
71
```
MAC
Mycobacterium avium complex (MAC)
HIV patients with CD4 < ?
Symtoms?
Diagnosis is confirmed by??
Treat with ?
HIV patients with CD4 < 50/mm3: consider prophylaxis
CD4 < 50/mm3 prophy?
```
Labs?
Mycobacterium avium complex (MAC)
HIV patients with CD4 < 50/mm3
Fever, diarrhea, weight loss, anemia
Diagnosis is confirmed with AFB and culture
Treat with clarithromycin and ethambutol for at least 12 months (+/− rifampin or rifabutin)
HIV patients with CD4 < 50/mm3: consider prophylaxis
CD4 < 50/mm3: azithromycin or clarithromycin
Anemia, Leukopeina
72
Toxic Mega Colon diagnosis critrea
Radioraphic evidence but one of the following
1. Tachy >120
2. Fever >38
3. Leukopenia > 10.5
4. Anemia
73
Cholangiocarcinoma prognosis?
The main risk factor is??
Obstruction of the bile duct causes symptoms such as ?
Cholangiocarcinoma is a rare cancer of the bile duct with an overall poor prognosis. The main risk factor is primary sclerosing cholangitis. Obstruction of the bile duct causes symptoms such as jaundice, dark urine, pale stools, and pruritus.
74
what blood test tells the severity of placental abruption?
Fibrinogen levels correlate best with the severity of bleeding, with initial levels of ≤ 200 mg/dL having a 100% positive predictive value for severe hemorrhage
75
Most common cause and locatin of Ulcer
The most common cause of upper gastrointestinal (GI) bleeding is an ulcer in the upper GI tract with duodenal ulcers being most common. Sixty to eighty percent of all ulcers are caused by infection with H. pylor
76
Sceloderma renal crisis
Scleroderma renal crisis is a sudden, life-threatening form of renal disease that occurs in the initial years of the disease. It is characterized by acute onset of oliguric renal failure, moderate to marked hypertension (although 10% are normotensive), microangiopathic anemia, and mild thrombocytopenia.
77
EKG findgins in RBBB
he ECG in a RBBB will show a wide S wave in lead I and a RSR’ pattern in lead V1.
Remember this just means the ventricles are depolorzing in seqence instead of at the same time. The Right ven is blocked"
78
How to fix a nurse maid elbow?
Hyperpronation method: apply pressure to the radial head and hyperpronating the forearm
Supination-flexion method: supinate and fully flex the elbow while applying pressure to the radial head and pulling with gentle traction
79
Antidote for mag toxicity?
Fist sign of mag toxicity?
antidote for magnesium sulfate toxicity is calcium gluconate, which should be administered intravenously at a dose of 1.5-3 grams over 5 minutes. The first sign of magnesium sulfate toxicity is hyporeflexia (loss of deep tendon reflexes) and occurs at serum concentrations between 4–8 mEq/L. At serum concentrations > 10 mEq/L, patients can develop respiratory depression. Patients being treated with high dose magnesium sulfate should be monitored closely for loss of deep tendon reflexes as this is the first sign of toxicity.
80
HIstamine poisoning? What fish? What symtoms? tx?
Histamine Food Poisoning
Dark-fleshed, peppery-tasting fish
Tuna, mahi mahi, mackerel
Histidine decarboxylase converts histidine to histamine
Anxiety, flushing, headache, palpitations, vomiting
Antihistamines
81
ACA findings?
Anterior cerebral artery: frontal lobe dysfunction, apraxia, contralateral paralysis (lower > upper), flat affect, abulia (taking a long time to complete an act)
82
MCA findings?
Middle cerebral artery: contralateral paralysis (upper > lower), aphasia
83
Menierres triad?
Cause?
Tx?
Ménière Disease- 1. Episodic vertigo >20 mins
2. Senso hearing loss
3. Tinnitus/feeling of full ear
Patient presents with episodic low-frequency hearing loss, tinnitus with aural (ear) fullness, and vertigo lasting 1–8 hours
Diagnosis is made clinically
Most commonly caused by too much inner ear endolymph and increased pressure within the inner ear
Treatment is low-salt diet, diuretics (HCTZ + triamterene)
84
Tx of litium od?
Fluids and whole bowel irrigation (polly glycol)
HD if >5, >4 with CKD or any neuro symtoms
85
Encephalitis vs meningitis
Encephalitis and meningitis manifest with similar symptoms, especially early in the infection. The classic meningitis triad is fever, headache, and altered mental status, while altered mental status plus focal neurologic deficit is more descriptive of encephalitis
86
Epsilon wave?
An epsilon wave is a small positive deflection at the end of the QRS complex that is the most specific finding for arrhythmogenic right ventricular dysplasia.
87
Romberg positive with eyes closed- where is problem?
Classically, a positive Romberg test with the eyes closed points towards a vestibule-labyrinth (inner ear), proprioception (dorsal columns) such as tabes dorsalis, or peripheral nerve sensory abnormality such as chronic inflammatory demyelinating polyradiculopathy (chronic form of Guillain-Barre’ syndrome).
88
Most common bug to cause lung abscess? 2/2 to ?
Lung abscesses are often polymicrobial infections with strictly or facultatively anaerobic bacteria the predominant organisms found. The most common anaerobic organisms include Peptostreptococcus, Prevotella, Bacteroides and Fusobacterium spp.
Often 2/2 to aspiration
89
Indications for iron overdose tx with deferoxamine
Patients with a iron level > 500 mcg/dL, regardless of symptoms, should receive deferoxamine. Other indications for deferoxamine include signs of systemic toxicity including intractable vomiting or diarrhea, shock, severe altered mental status, and an elevated anion gap metabolic acidosis.
90
Complicated malaria presents how?
what vrsion is deadliest?
Tx?
Complicated disease can present with hepatosplenomegaly, icterus, jaundice, respiratory failure due to acute respiratory distress syndrome, renal failure, profound hypoglycemia, hemolytic anemia, coma, seizures, or altered mental status.
P. falciparum is the deadliest and is known to cause complicated malaria (severe organ system damage), as in the patient in this clinical scenario. P. falciparum is also endemic to sub-Saharan Africa and is known to exhibit resistance to chloroquine.
These patients should be treated with intravenous artesunate.
91
Primary CNS lyphome associated with?
CT findings?
Tx?
Focal neurologic deficits are not typically seen. The appearance of primary CNS lymphoma on CT of the head with IV contrast is of hyperdense or isodense round, solidly enhancing lesions with sharp borders. Only 1–2 lesions are typically present and periventricular lesions are most commonly seen.
Primary CNS lymphoma has a poor prognosis with a median survival of < 1 month.
Treatment of primary CNS lymphoma consists of whole brain irradiation, corticosteroids, and chemotherapy typically utilizing both methotrexate and zidovudine.
92
Clues to suggest bacterial over viral diarrhea
high voume bloody diarrhea
Abdominal pain (significant)
Fever >40
Onset/length (if longer than 1 week likely
93
Tx of infected tragus piercing?
Perichondritis- infected of connective tissue surronding the cartilaginous tissue. Often pseudomonas- tx with cipro
94
Labs in wilson disease
low copper
low ceruplasmin
increased urine copper
95
Faget sign?
Faget Sign
Fever
Bradycardia
Pulse-temperature dissociation
Typhus, typhoid, Legionella, and Mycoplasma
96
EKG findings for anuersym?
On ECG, the tracing concerning for left anterior wall aneurysm is described as QS waves with persistent ST elevation in leads V2–V4.
```
Persistent ST elevation > 2 weeks following MI
Precordial leads
Q or QS waves
T waves small relative to QRS
Reciprocal changes absent
```
2-3 weeks after MI
97
Most common contaminants?
Bacillus species, coagulase-negative Staphylococcus species, Propionibacterium species and viridans streptococci.
98
Findings suggestive of positive blood culture being a contaminant
ypical organisms of the skin flora are isolated (e.g., coagulase-negative Staphylococcus), when only one of two cultures are positive or when growth first occurs after 72 hours of incubation.
99
Mitral regurg murmurs?
Acute: unique, harsh, midsystolic murmur best heard at apex that radiates to the base rather than the axilla
Chronic: blowing holosystolic murmur best heard at apex with radiation to axilla
100
CML
Mostly seenn in aduts
Philadelphia chromosome
Basophilia on smear
Good progognosis
Chronic Myelogenous Leukemia (CML)
Patient will be 30–60 years old
Most patients asymptomatic when diagnosed
PE will show splenomegaly
Labs will show Philadelphia chromosome t(9;22) (BCR-ABL) and low leukocyte alkaline phosphatase (LAP)
Treatment is allogenic HSCT (curative), imatinib
Phase determined by blast percentage
101
ALL
74% affect B celllprecursor
| Most common childhood leukemia
102
CLL
Smudge cell
Poor prognosis
Old pll
103
What drugs can be cleared with HD?
amanita mushrooms, barbiturates, ethylene glycol, isoniazid, lithium, metformin, methanol, salicylates, and theophylline, carbamazapine
wont clear if they are too big, bound to protein, or distribute too much
104
Options for Abx for cellulitis without constitional symtoms that need MRSA coverage
1) amoxicillin and minocycline, 2) amoxicillin and doxycycline, 3) trimethoprim-sulfamethoxazole, and 4) clindamycin.
105
Most common congenital malformation of the GI tract
Meckels
106
Inferior shoulder dislocation
Etiology?
How is the arm positioned?
Tx? and how to reduce?
Artery/nerve often injuried?
Inferior Shoulder Dislocation
Arm raised, inability to adduct arm
Rotator cuff detachment
Brachial plexus, axillary artery often injured
107
Formula for hypotension in a child 1-10?
IN a neonate?
less than 1yo>
The American Heart Association and Pediatric Advanced Life Support guidelines define hypotension in children aged 1 to 10 years as a systolic blood pressure less than 70 + (2 x age in years)
neonate <60
<1= < 70
108
What is the most common cause of death in serotonin syndrome?
Answer: Hyperthermia
109
MOA of fos/pheynytoin
MOA of Keppra
Fosphenytoin is preferred to phenytoin due to fewer side effects and faster infusion rates. Both prolong the refractory period of voltage-gated sodium channels.
Levetiracetam inhibits presynaptic calcium channels, limiting neurotransmitter release.
110
Iron Toxicity
Inquire about number of vomiting episodes
Patients with ??? more prone
Patients without vomiting in the first x hrs willl??
\Lab findings?
```
Stages
1 (< 6 hrs):
2 (6–24 hrs):
3 (12–24 hrs):
4 (24–96 hrs):
5 (3–6 wks):
```
Whole bowel irrigation for large acute ingestion
Chelating agents: indications?
ron Toxicity
Inquire about number of vomiting episodes
Patients with myelodysplasia, sickle cell, thalassemia more prone
Patients without vomiting in the first 6 hours after exposure will not have major toxicity
GI necrosis, hemorrhage
Uncoupling of oxidative phosphorylation → anaerobic metabolism
Anion gap metabolic acidosis
Stages
1 (< 6 hrs): GI Sx
2 (6–24 hrs): GI Sx improve
3 (12–24 hrs): coma, shock, seizures
4 (24–96 hrs): hepatic failure, hypoglycemia, coagulopathy
5 (3–6 wks): GI Sx, pyloric scarring, obstruction
AXR: most pills radiopaque
Whole bowel irrigation for large acute ingestion
Chelating agents: deferasirox, deferoxamine, deferiprone
Indications: serum Fe level > 500 mcg/dL or severe signs and symptoms (such as metabolic acidosis, repetitive vomiting, toxic appearance, lethargy, hypotension, or signs of shock)
111
Indications for hyperbaric chamber for carboxyhemoglobin?
Hyperbaric oxygen is indicated for those with evidence of end-organ damage regardless of carboxyhemoglobin level, those with loss of consciousness, seizures, coma, focal neurologic deficits or blindness, those with evidence of myocardial ischemia or life-threatening dysrhythmia, persistent symptoms despite treatment, or a carboxyhemoglobin level >25% in nonpregnant patients or >15% in pregnant patients.
112
Esysipelas
Part of skin invovled?
Presentatoin?
Most likely bug?
Tx?
Erysipelas
It typically involves the upper dermis, superficial lymphatics and the superficial subcutaneous tissue.
Patient presents with malaise, fever, chills, or nausea
PE will show intense and deeply erythematous, sharply demarcated elevated shiny patch
Most commonly caused by Streptococcus pyogenes infection (group A beta strep)
Treatment
Infections with systemic compromise: parenteral cefazolin, ceftriaxone, or flucloxacillin
Mild infections: oral amoxicillin or cephalexin
113
Fusion or capture beats seen in??
VT
114
LeFort Frctures?
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Le Fort Fracture
I: transverse fracture separating maxilla from pterygoid and nasal septum
II: maxilla and palate fractured
III: craniofacial dissociation
II and III: CSF rhinorrhea
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115
Hydrofluoric Acid
Source?
RIsk untreated?
Treatment?
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Hydrofluoric Acid
Glass etchers, rust removal, metal cleaner
Dermal exposure: blue-gray burn, pain out of proportion to exam
Hypomagnesemia, hypocalcemia
Hypocalcemia → dysrhythmias
Rx: irrigation, calcium gluconate
Alkaline burn → liquefactive necrosis
Acidic burn → coagulative necrosis
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116
Tumor Lysis syndrome?
When?
Labs?
Tx?
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Tumor Lysis Syndrome
1–5 days after chemotherapy
Hematologic malignancy
Hyperuricemia
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
IVF, correct electrolyte abnormalities, dialysis (in severe cases)
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117
Tx options for PID inpt?
cefotetan and doxycycline
clindamycin and gentamicin
ampicillin-sulbactam with doxycycline.
118
Who gets prophy for Pertussis?
Azithromycin 500 mg in a single dose on day one, followed by 250 mg daily for four additional days is the regimen of choice.
Close contacts within 3 days Postexposure prophylaxis is indicated even for close contacts who have already received Tdap vaccination given the high rate of conversion in this group.
119
CIs to Succ?
succinylcholine is contraindicated include:
burns > 1-5 days old involving > 10% BSA
crush injuries > 5 days old
denervation injuries (stroke, spinal cord) > 5 days old until 6 months post-injury
neuromuscular diseases; and intra-abdominal sepsis > 5 days until resolution.
120
What disease needs higher dose of rocc/succ?
Myasthnia Gravis
121
Risk factors for development of preeclampsia are??
Risk factors for development of preeclampsia include nulliparity, age < 18 years or > 40 years, twin or multi-order gestations, obesity, those with a first-degree relative with pregnancy-induced hypertension, and preexisting conditions
122
Hereditary angioedema
inheritance pattern?
Triggers?
Tx?
Angioedema
ADominnant
Patient presents with swelling of the tongue, face, and neck in the absence of hives
Most common causes : Idiopathic or minor trauma
Drug-induced: ACE inhibitors (most common)
Hereditary: C1 esterase inhibitor deficiency
Treatment is airway management
Hereditary: C1 esterase inhibitor replacement or FFP
123
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Ehrlichiosis and Anaplasmosis
Vector: ?
Presentation?
Labs show??
Treatment?
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Ehrlichiosis and Anaplasmosis
Vector: ticks, avoid tick bites and remove ticks from body
Febrile illness, headache, myalgia, rash, chills
Labs show leukopenia, thrombocytopenia
Test whole blood PCR, do not delay treatment
Treatment: doxycycline
124
Herpangina
symtoms?
Describe lesion?
Tx?
PAINFUL and back of mouth
Herpangina is characterized by sudden onset of high-grade fever, sore throat, dysphagia, and lesions in the posterior pharynx. Characteristic lesions, present on the anterior tonsillar pillars, soft palate, uvula, tonsils, posterior pharyngeal wall, and, occasionally, the posterior buccal surfaces, appear as discrete vesicles and ulcers surrounded by erythematous rings t
125
which tubo=ovarian abscesses need drainage? (4)
Most TOAs resolve with antibiotic administration alone. Indications for surgical drainage include
ruptured abscess, sepsis, abscess larger than 9 cm, and patients who fail to improve after 48–72 hours of antibiotics.
126
Transfusion complications?
Transfusion Complications
Massive transfusion: coagulopathy, hypothermia, hypocalcemia
Febrile reaction: most common complication, fever or chills
Hemolytic reaction: ABO incompatibility, immediate fever or chills, HA
Rx: stop transfusion, IVF, diuretics
Allergic reaction: urticaria or hives
TRALI: like ARDS
Rx: stop transfusion
Delayed reaction: 3–4 weeks after transfusion, decreased Hgb
GVHD: immunocompromise, rash, pancytopenia, increased LFTs
Prevention: irradiated blood products in immunocompromised
127
Ways to minimize post LP headache?
Preventive measures: small-caliber needle, blunt needle (whitcre) stylet replacement before needle removal
128
Most common inherited disorder of bilirubin?
Mutation?
What bili is high?
How to treat?
Gilbert Syndrome
UGY1A1 gene
UNconjugated bili is high bc they lack glucoronsytransferase (which turns bili into conjugated)
Triggers including fasting, hemolysis, physical exertion, stress, menses
Usually asytomatic jaundice
129
EKG in Posterior stemi (3)
horizontal ST depression in V1–V4, prominent R waves, and tall, upright T waves. I
n this setting, posterior ECG leads can be performed by placing V4–V6 just inferior to the scapula and repeating the ECG with leads now denoted as V7–V9. If there is 0.5 mm of ST elevation in the posterior leads, then the patient has an ECG concerning for a posterior STEMI
130
Most common risk factor for endometerosis?
Others?
Cesarean section is the most significant risk factor.
Multiple gestation, younger maternal age, prolonged labor (>12 hrs) and rupture of membranes >24 hours, and use of intrauterine monitoring during labor all also increase the risk of endometritis.
131
Risk factos?
Exam?
Tx? Add what for GBS?
Postpartum Endometritis
Patient will be postpartum, early-onset disease < 48 hours after delivery (C-section more common)
Fever, abdominal pain, foul-smelling lochia
PE will show uterine tenderness
Labs will show leukocytosis
Most common postpartum infection
Treatment is clindamycin + gentamicin
GBS colonized: add ampicillin or use ampicillin-sulbactam
132
Xa reversal?
** only for major bleeding?
Increases bleeding risk
Prothrombin complex concentrates (PCC) are used to stop severe bleeding
Andexanet, coagulation factor Xa (recombinant), is first FDA-approved reversal agent
133
?? the reversal agent of choice for dabigatran
Idarucizumab (C) is the reversal agent of choice for dabigatran
134
Pemphigus Vulgaris tx?
Age?
Presentation?
Pemphigus Vulgaris
Patient will be 40–60 years old
Painful flaccid bullae on mucosal surfaces
PE will show flaccid blisters that extend with lateral pressure (Nikolsky sign positive) involving mucous membranes
Diagnosis is made by biopsy
Most common cause is autoimmune
Treatment is high-dose steroids
135
SIDS risk factors?
| Protective factors?
Sudden Unexpected Infant Death (SUID)
Peak incidence: 1–2 months old
Risk factors: maternal smoking or drug use, prone sleeping position
Recommendations: supine sleeping, pacifiers, breastfeeding
136
Tamponade findings on US?
Echocardiography
Diastolic collapse of RA (highly sensitive and specific)
Early diastolic collapse of RV (less sensitive but very specific)
137
Tricuspid Regurgitation
Causes: tricuspid ring stretching > pulmonary HTN, endocarditis, rheumatic heart disease
Pansystolic murmur at left (or right) sternal border
Tricuspid Regurgitation
Causes: tricuspid ring stretching > pulmonary HTN, endocarditis, rheumatic heart disease
Pansystolic murmur at left (or right) sternal border LOUDER DURING INSPIRATION (Diffefrent than mitral regurg)
138
Clinical interventions that improve mortality in patients with COPD are
Clinical interventions that improve mortality in patients with COPD are long-term oxygen therapy and smoking cessation.
139
Dominant terminal R wave in lead aVR associated with OD of??
widening of the QRS complex. Another hallmark finding of TCA toxicity on ECG is a dominant terminal R wave in lead aVR.
140
Impetigo is a ?? most commonly seen in children. ??? is the most common cause of impetigo, though group ??are implicated in some cases.
Impetigo is a superficial skin infection most commonly seen in children. Staphylococcus aureus is the most common cause of impetigo, though group A streptococci (GAS) are implicated in some cases.
141
Low risk occupational exposure
1. Blood onto intact skin
2. Contact with urine, feces, salive
3. Bite with donor blood
142
High Risk occupational exposure
1. Hollow needle with blood visvibe
2. Deep bite with donor blood on wound
3. Large amount of blood on mucosa or non intact skin
143
Moderate Risk exposure
1. needle stick with solid needle or hallow needle with no bllood
2. Small amount o fblood onto mucosa
3. Superficial bite with donor blood
144
Perichondritis IS?
Presents as?
Risk factors are ?
Tx is?
ENT follow-up
Perichondritis
Infection of connective tissue of the ear
Risk factors include trauma, burns, skin breakdown, piercing
Consider I&D, obtain wound culture
Antipseudomonal antibiotics
Clinical features include a swollen, warm, tender, and erythematous auricle, which may include the ear lobule. Pain with deflection of the auricle is also commonly noted. This is often associated with a fever, and the tympanic membrane is typically unaffected.
ENT follow-up
145
?? are the most common benign bone tumor.
Osteochondromas are the most common benign bone tumor.
146
OSteochondoromas
Where?
Finding on xray
Tx?
Osteochondromas are the most common benign bone tumor. Many lesions are asymptomatic and incidentally found on radiographs. Some may present with a painless mass while others may develop mechanical symptoms, such as a catching sensation.
On X-ray osteochondromas appear as a sessile or pedunculated outgrowth along the surface of bone. T
hey are most often seen in the distal femur, proximal tibia, proximal femur, and proximal humerus. Treatment most often is observation, however, osteochondromas may be surgically resected if symptomatic.
147
Thoracotomy indications (3)?
Thoracotomy indications: initial chest tube output of > 20 mL/kg (or 1,500 mL) or subsequent output of > 200 mL/hour or Persistent bleeding at a rate greater than 7 mL/kg/hr following chest tube placement
148
How to estimate gestational age on exam?
As a general rule, the uterine fundus reaches the level of the umbilicus around 20 weeks and increases approximately 1 cm each week thereafter (until the fetal head engages in the pelvis at term).
149
Lab findings in Rocky Mountain?
thrombocytopenia and hyponatremia
150
Lowest spot for thoracentesis?
| How much below the dullness do you enter?
The needle should be inserted at least one interspace below the top of the effusion in the midscapular or posterior axillary line.
However, the lowest level at which a thoracentesis should be performed is the eighth posterior intercostal space
151
Vitreous Detachment
Risk factors?
US findings?
Tx?
Risk factors for vitreous detachment include trauma, ocular surgery, and myopia, which is associated with > 50% of non-traumatic detachments. Symptoms include cobweb-like floaters from the vitreoretinal separation, as well as pinpoint flashes of light resulting from mechanical depolarization of retinal axons secondary to the vitreous tugging on the retina.
152
US findings of retinal vs vitreous detachment?
Ultrasound findings of both vitreous and retinal detachments demonstrate a serpiginous structure within the globe that can often be differentiated by involvement of the optic nerve. Vitreous detachment can cross over the optic nerve, while retinal detachment will never cross the optic nerve since it is made of nerve fibers, which converge into the optic nerve.
153
is the most common degenerative disease of the motor neuron system.
Presents as?
Amyotrophic lateral sclerosis (ALS) is the most common degenerative disease of the motor neuron system. Patients with ALS demonstrate asymmetrical distal weakness without sensory findings and bowel/bladder intact
Anterior horn
154
HD indications for ASA toxicity?
```
Hemodialysis indications
Level > 100 mg/dL
Coma
Rising levels despite alkalinization
Kidney failure
Pulmonary edema
Altered mental status
Clinical deteriorationn
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155
Scorpion
Temperature revgeral
disconjugate gaze
Fascicullations
156
Brown Recluse
Papule to necrotic blister
157
Black WIdow
Local Papule w/ Halo
Muscle Fasciculations
Abdominal Pain
Diaphoresis
158
Pit Viper
Trianguat Head
Local Swelling and oozing with coagulopathy
159
Eastern Coral
Muscle Paralysis
160
Intestinal Malrotation
PE
AXR:
Upper GI series:
Diagnosis is made by
Treatment is
Intestinal Malrotation
Patient will be a child within the first year of life
Sudden onset of bilious vomiting
PE will show hemodynamic instability and abdominal distension
AXR: double bubble sign
Upper GI series: corkscrew sign
Diagnosis is made by upper GI series and confirmed by observing failure of the duodenal-jejunal junction to cross midline
Treatment is surgical (Ladd procedure)
161
De Winter
EKG?
```
de Winter Syndrome
Acute LAD occlusion
Upsloping ST elevation in aVR
ST segment depression in the precordial lead with tall, positive, symmetric T waves
STEMI equivalent
Consult cardiology
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162
CN + CO exposure tx?
CN + CO exposure: hydroxocobalamin, sodium thiosulfate (second line)
