Step 2 B Flashcards
1
Q
1 week old child’s mother complains that the child has a transient rash that has splotchy areas of erythema with a central clear pustule. Your microscopic examination of the liquid in the pustule reveals eosinophils.
A
Erythema toxicum - benign, self-limited condition of unknown etiology. Found in 50% of term newborns. 2-3cm erythematous macules; some have central yellow-white pustule. Exam of the fluid from these lesions demonstrates eosinophils. Rash waxes and wanes over the first days to weeks of life. No therapy indicated.
2
Q
Adolescent boy complains of splotchy red rash on the nape of his neck, discovered when he had his head shaved for football. Seems to become more prominent with exercise or emotion. Mom notes he has had it since infancy, but that it became invisible as hair grew. Similar rash on eyelids that resolved in the newborn period.
A
Salmon patches (aka nevus simplex or nevus flammeus) - flat vascular lesions that occur in the listed regions and appear more promiennt during crying. Facial lesions fade over the 1st few years of life. Lesions found over the nuchal and occipital areas often persist. No therapy indicated.
3
Q
African american newborn with scattered pustules full of a milky fluid. Upon examining pustules, they easily wipe away, revealing a small hyperpigmented macule.
A
Pustular melanosis - benign, self-limited disease of unknown etiology of the newborn period. More common in blacks than white. Found at birth, consist of 1-2mm pustules that result in a hyperpigmented lesion encircled by a collarette of scale upon rupture. Pustular stage of these lesions occurs during the 1st few days of life, with the hyperpigmented stage lasting for weeks to months. No therapy indicated.
4
Q
OB resident asks you to evaluate an area of a newborn’s scalp that seems to have no hair and is scaly and yellowish.
A
Sebaceous nevi (nevus of Jadassohn) - small, sharply edged lesions that occur most commonly on head and neck of infants. Yellow-orange in color and slightly elevated. Usually hairless. Malignant degeneration is possible, most commonly after adolescence.
5
Q
Newborn’s mother complains that her infant seems to have several very small raised white dots around his chain. The dots don’t wipe off with bathing, but they are also not erythematous.
A
Milia - fine, yellow/white 1-2mm firm raised lesions scattered over the face of the neonate. They are cysts that contain keratinized material. Commonly, these lesions resolve spontaneously without therapy. Epithelial cysts on the palate are called Epstein pearls. Milia should be distinguished from sebaceous gland hyperplasia, which manifests as smooth white/yellow papules, usually found on the infant’s nose; as maternal androgen levels drop, the hyperplasia resolves.
6
Q
Newborn’s father complains that his son has dandruff, with many waxy flakes of skin on the scalp. When he scrapes the lesions, hair often comes off with the flakes of skin. In addition, the baby has flaking of the eyebrows.
A
Seborrheic dermatitis- can begin anytime during life and frequently presents as cradle cap in the newborn period. Rash is commonly greasy, scaly, and erythematous and in smaller children involves the face, neck, axilla, and diaper area. In older children, the rash can be localized to scalp and intertriginous areas. Pruritus can be marked.
7
Q
3yoM awakes every night around 2:00AM screaming incoherently. Parents note he is agitated, seems awake but unresponsive, and goes back to sleep w/in a few minutes. No memory of episodes in the morning
A
Night terrors - non-REM phenomena seen less commonly than night mares (1-6% of all children). Can have evidence of autonomic arousal (tachycardia, sweating, tachypnea) and appear frightened/agitated.
8
Q
15mo toddler continues to wake up crying every night. Parents give nighttime bottle, rock her, and sing to her to help her go back to sleep. Parents are exhausted and ask you if she is having bad dreams.
A
Learned behavior
9
Q
Parents hear over their baby monitor that their 5yoF regularly calls out during the night. When parents check on her, she is sleeping comfortably and is in no apparent distress.
A
Somniloquy
10
Q
4yoM occasionally wakes in the middle of the night crying. When parents check on him, he seems visibly frightened and tells parents that Chihuahuas were chasing him.
A
Nightmares
11
Q
5yo child refuses to sleep in his bed, claiming there are monsters in his closet and that he has bad dreams. Parents allow him to sleep with them in their bed to avoid the otherwise inevitable screaming fit. Parents note that the child sleeps soundly, waking only at sunrise.
A
Learned behavior
12
Q
6yoM returns from playing all day in the snow with several erythematous, ulcerative lesions on his fingertips; he complains the lesions are painful and itchy
A
Chillblain - small ulcerated lesions on exposed areas such as ears and fingers. Lesions may last 1-2 weeks.
13
Q
Teen, just back from skiing trip, has blistering and peeling of several areas on her face; she reports the lesions started as firm, cold, white areas that felt stinging at the time and are now more sensitive than the surrounding skin.
A
Frostnip - small, firm, white, cold patches of skin in exposed area; treatment is rewarming the areas before they become numb
14
Q
9yoF presents during summer break with an area of erythematous, firm, and slightly swollen skin at the corner of her mouth and extending to her cheek. The area is not tender
A
Cold panniculitis - destruction of fat cells caused by exposure to cold weather or cold object; in this case, the child has “popsicle panniculitis”, which is usually a benign condition that self resolves.
15
Q
14yoM on mountain-climbing expedition in December becomes tired, clumsy, and begins to hallucinate. HR is 45bpm.
A
Hypothermia
16
Q
Skier recently rescued from a snowbank following an avalanche complains about his feet. Upon rescue they were whitish yellow and numb, but now they are blotchy and painful.
A
Frostbite - tissue is frozen and destroyed. There is initial stinging, followed by aching, culminating in numb areas. Once rewarmed, the area becomes red, blotchy, and painful.
17
Q
Megaloblastic anemia, growth failure, paresthesias, sensory defects, developmental regression, weakness, and fatigue
A
Vitamin B12 deficiency - can be seen in those ingesting a strict vegetarian diet or in a breast-fed baby whose mother has undiagnosed pernicious anemia or other cobalamin-malabsorption syndromes, or in a child with pernicious anemia. Neuro sx in a child include weakness, failure to thrive, irritability, fatigue, sensory defect delayed or loss of milestones, seizures, and neuropsych changes; hematologic changes include megaloblastic anemia
18
Q
Photophobia, blurred vision, burning and itching of eyes, poor growth, and cheilosis
A
Riboflavin deficiency - often occurs with deficiencies of other B-complex vitamins. Occurs bc of poor intake, reduced absorption in patients with biliary atresia or hepatitis, or poor absorption in those receiving probenecid, phenothiazine, or OCP’s signs and symptoms include cheilosis, glossitis, a variety of ocular problems (keratitis, conjunctivitis, and corneal vascularization), and seborrheic dermatitis.
19
Q
Megaloblastic anemia, glossitis, pharyngeal ulcers, and impaired immunity.
A
Folate deficiency - occurs w/ poor intake or absorption, high-demand diseases (i.e. sickle cell), and in inborn errors of metabolism. Can also be seen in conjunction with a variety of meds including high-dose NSAIDs, methotrexate, and phenytoin. Deficiency results in megaloblastic anemia, glossitis, pharyngeal ulcers, and impaired immunity.
20
Q
Irritability, convulsions, and hypochromic anemia
A
Vitamin B6 deficiency - can be due to poor absorption or as a result of vitamin inhibition dt drug ingestion (incl. INH, penicillamine, corticosteroids, and anticonvulsants). Seizures, peripheral neuritis, dermatitis, and microcytic anemia are commonly seen.
21
Q
Newborn infant noted to have microcephaly with sloping forehead, cutis aplasia on the scalp, micropthalmia, and cleft lip and palate. His echocardiogram demonstrates a complex heart lesion including atrial septal defect (ASD), ventricular septal defect (VSD) and dextrocardia.
A
Trisomy 13 - Failure to thrive, seizures, cleft lip and palate, micropthalmia, cutis aplasia of the scalp, congenital heart disease, and severe MR are seen. Advanced maternal age is commonly noted.
22
Q
17yoM with unusual gait, large mouth with tongue protrusion, microcephaly, seizures, hypopigmentation with blonde hair and pale blue eyes, unprovoked bursts of laughter.
A
Angelman syndrome - also called “happy puppet” syndrome bc of unusual gait and unprovoked outbursts of laughter. In some cases, it is caused by an interstitial deletion of chromosome 15q11-13; the deleted material always comes from the maternal side
23
Q
6wM small for his birth weight and had intrauterine growth retardation. Microcephalic, rounded face, hypertelorism, and epicanthal folds. Cry is high-pitched.
A
Cri du chat syndrome - - catlike cry assoc likely caused by abnormal laryngeal development; tends to resolve with time. Profound mental retardation, self-injury behavior, hypersensitivity to sound, and repetitive behaviors are less commonly seen. Deletion of the short arm of chromosome 5 is the etiology. 85% of cases are paternal in origin
24
Q
3d infant found at birth to have anal atresia and vertebral defects, VSD, TE fistula, absent left kidney, and shortened arms
A
VATER (or VACTERL) - association of commonly seen findings of unknown etiology: Vertebral defect Anal atresia Cardiac defects T-E Fistula Renal/Radial defect Limb abnormalities.
Intelligence is normal.
25
Afebrile, obese 14yoM has developed pain at the right knee and limp.
Slipped capital femoral epiphysis - onset frequently gradual; pain referred to the knee in 20% of cases can mask the pathology
26
6yoM developed a limp and has limited mobility of the hip. Denies pain and fever
Legg-Calve-Perthes disease - avascular necrosis or idiopathic osteonecrosis of the femoral head; cause unknown, boys 2-12yo most frequently affected. Sx include limp and pain in the anterior thigh, groin, or knee, although classic sx include a painless limp.
27
2yo refuses to walk, has fever, has significant pain with external rotation of the R leg, with ↑ WBC count
Septic arthritis of the hip
28
3yo refuses to walk, is afebrile, had an URI 1 week ago, has R hip pain with movement, and has normal WBC count
Transient synovitis is a disorder of unknown etiology, affecting children from 2-6yo. Usually presents with painful limp. WBC/ESR may be normal or slightly elevated.
29
Over the past several weeks, 2yoF has exhibited developmental regression, abnl sleep patterns, anorexia, irritability, and decreased activity. Sx have progressed to acute encephalopathy with vomiting, ataxia, and variable consciousness. Family has recently moved, and they are in the process of restoring the interior of their home.
Lead poisoning
Tx:
Symptomatic/extremely high levels (>70µg/dL) dimercaprol and calcium EDTA
Mild poisoning: IV calicum EDTA, or more likely oral dimercaptosuccinic acid
30
After a fight with her boyfriend, a 16yoF took "some pills". On exam, she is alert and complains of emesis, diaphoresis, malaise. LFTs, obtained at 12h post-ingestion, are elevated. Repeat levels at 24h show markedly elevated AST and ALT, along with abnormal coagulation studies and elevated bilirubin.
APAP poisoning.
N-acetylcysteine (NAC) is an effective tx fo APAP poisoning and acts as a glutathione substitute by binding directly to N-acetyl-p-benzoquinone imine, the cytotoxic metabolite of APAP. Ideally, it should be given w/in 8h of ingestion, after 36h it is probably ineffective.
31
What is the vitamin deficiency?
Beriberi (peripheral neuropathy, heart failure)
Wernicke-Korsakoff syndrome
B1 (thiamine
32
What is the vitamin deficiency?
Angular cheilosis, stomatitis, glossitis
Normocytic anemia
Seborrheic dermatitis
B2 (riboflavin)
33
What is the vitamin deficiency?
Pellagra (dermatitis, diarrhea, delusions/dementia, glossitis)
B3 (niacin)
34
What is the vitamin deficiency?
Cheilosis, stomatitis, glossitis
Irritability, confusion, depression
B6 (pyridoxine)
35
What is the vitamin deficiency?
Megaloblastic anemia
Neural tube defects (fetus)
B9 (folate, folic acid)
36
What is the vitamin deficiency?
Megaloblastic anemia
Neurologic deficits (confusion, paresthesias, ataxia)
B12 (cobalamin)
37
What is the vitamin deficiency?
Scurvy (punctate hemorrhage, gingivitis, corkscrew hair)
Vitamin C (ascorbic acid)
38
Recurrent/severe sinopulmonary infections w/ viruses and encapsulated bacteria with:
↓ or absent B-cells
↓ immunoglobulins
X-linked agammaglobulinemia (aka Bruton agammalgobulinemia)
39
Recurrent/severe sinopulmonary infections with viruses and encapsulated bacteria with:
Normal B cells
↓ Immunoglobulins
Common variable immunodeficiency
40
Focal or generalized seizures
Mental retardation
Port wine stain/nevus flammeus along territory of the trigeminal nerve (represents congenital unilateral cavernous hemangioma)
Hemianopia, hemiparesis, hemisensory disturbance, ipsilateral glaucoma .
Skull XR reveals gyriform intracranial calcifications that resemble a tramline.
Sturge-Weber syndrome
Tx: aimed at controlling seizures and reducing intraocular pressure.
Argon laser therapy is successful in removing skin lesions
41
Components of APGAR scores
Appearance: blue/pale -- pink w blue extremities -- completely pink
Pulse: absent -- 100
Grimace: None/flaccid -- grimace or noticeable reflex irritability -- active motion (sneeze, cough, pull away)
Activity: limp -- some flexion -- active motion
Respirations: absent -- weak cry (slow/irregular respirations) -- strong/vigorous cry
42
Congenital toxoplasmosis:
Triad of features (3)
Other features (8)
Triad: Chorioretinitis, hydrocephalus, intracranial calcifications
Others: Microcephaly, intellectual disability, deafness, seizures, spasticity, HSM, jaundice, thrombocytopenia
43
Sequelae of unrepaired atrial septal defect (5)
```
Right ventricular failure
CHF
Arrhythmias
Eisenmenger syndrome (R to L shunt)
Paradoxical embolus/stroke
```
44
Live virus vaccines (5)
| + 3 not used in US
```
MMR
Varicella
Herpes Zoster
Oral Polio
Intranasal influenza
```
Not in US: small pox, yellow fever, BCG
45
On average, what age do girls begin puberty?
10.5 yo
46
On average, what age do girls begin pubertal growth spurt?
12 yo
47
What is average age of menarche?
12.5 years old (0.5 years after pubertal growth spurt)
48
What tanner stage?
Breast bud with elevation of breast and papilla; areola enlarges
Sparse, long, slightly pigmented pubic hair
Tanner stage 2
Aveage 10.5yo
49
What tanner stage?
Enlargement of breasts
Darker, coarser, more curled pubic hair
Tanner stage 3
50
What tanner stage?
Areola and papilla form secondary mound above level of breast
Pubic hair adult in type, covers smaller area
Tanner stage 4
51
When would you expect the anterior fontanelle to close?
1% by 3 months
38% by 12 months
96% by 24 months
52
Causes of delayed closure of anterior fontanelle (5)
```
Down syndrome
Achondroplasia
Rickets
Congenital hypothyroid
Increased ICP
```
53
Infant with depressible occipital bone, soft like a ping pong bone
Craniotabes - sign of rickets
54
Timing and cause of physiologic jaundice
1st few days of life, resolves in 1-2w
Normal, mild hyperbilirubinemia
Newborns have ↑HCT compared to adults
Fetal RBCs have shorter half life
Caused by ↑ RBC turnover, ↑bilirubin production, and ↓bilirubin conjugation due to less UDP-glucouronyl transferase
55
Timing and cause of breast milk jaundice
4-14 days old, continues weeks to months
Breast milk promotes intestinal bilirubin absorption, causing hyperbilirubinemia
Diagnostic: improves when you switch to formula
56
Tetralogy of Fallot
1. Pulmonary valve stenosis → right ventricular outflow tract obstruction
2. Right ventricular hypertrophy
3. Ventricular septal defect
4. Overriding aorta
57
Intellectual disability PLUS:
Smooth philtrum
Thin vermillion border
Small palpebral fissures
Microcephaly
Fetal alcohol syndrome
58
Intellectual disability PLUS:
```
Flat facial profile
Slanted palpebral fissures
Small low-set ears
Excessive skin at nape of the neck
Single transverse palmar crease
Clinodactyly
Large space between first two toes
```
Down syndrome
59
Intellectual disability PLUS:
```
Long, narrow face
Prominent forehead and chin
Large ears
Macrocephaly
Macroorchidism
```
Fragile X syndrome
60
What is diagnosis, cause, and karyotype?
+ Breast development
Absent uterus and upper vagina/cryptorchid testes
Minimal/absent axillary and pubic hair
Diagnosis: Complete androgen insensitivity syndrome
Cause: X-linked mutation of androgen receptor
Karyotype: 46, XY
61
What is diagnosis, cause, and karyotype?
+ Breast development
Absent/rudimentary uterus and upper vagina
Normal ovaries
Normal axillary/pubic hair
Diagnosis: Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)
Cause: Hypoplastic or absent mullerian ductal system
Karyotype: 46, XX
62
What is diagnosis, cause, and karyotype?
Variable breast development
Normal uterus and vagina
Streak ovaries
Normal axillary and pubic hair
Diagnosis: Turner syndrome
Cause: Complete/partial absence of 1 X chromosome
Karyotype: 45, XO
63
Nephrotic syndrome
Normal histopathology
Most common cause in pre-adolescent children
Minimal change disease
Also has effacement of foot processes
Steroid therapy cause complete remission in >90% of children
64
Nephrotic syndrome
Crescent formation on histopathology
Most common cause in adults
Focal glomerulosclerosis
65
Nephrotic syndrome
thickened basement menbrane, subepithelial spikes
Second most common cause in adults
Membranous glomerulonephritis
66
How old is this child?
Fine motor: two-finger pincer grasp
Gross motor: walks w/o assistance, waves bye, climbs on furniture
Language: 2-3 words, "mam" and "dad"
Social: peek-a-boo, imitates actions
12 months
67
How old is this child?
Fine motor: builds tower of 6 cubes
Gross motor: walks up and down stairs, jumps, throws ball overhead
Language: 200 word vocab, 2 word phrases, 2 quarters (50%) of speech is intelligible
Social: 2 step commands, removes clothes
2 yo
68
How old is this child?
Fine motor: copies circle, uses utensils to feed self, stacks 9 blocks
Gross motor: climbs stairs with alternating feet, tricycle, kicks ball
Language: 3 word sentences, 3 quarters (75%) of speech intelligible, states 1st name
Social: washes/dries hands, helps with household tasks, group play
3yo
69
How old is this child?
Fine motor: copies cross, draws person, uses scissors, holds crayon with tripod grasp
Gross motor: hops on 1 foot without losing balance, jumps over objects
Language: counts to 10, tells stories, uses plurals and prepositions
Social: cooperative play, imaginary friends, imitates adult roles
4 yo
70
Neonatal respiratory distress
Tachypnea shortly after birth, resolves by day 2 of life
CXR with bilateral perihilar linear streaking
Transient tachypnea of the newborn
Inadequate alveolar fluid clearance at birth results in mild pulmonary edema
71
Neonatal respiratory distress
Severe respiratory distress and cyanosis after premature birth
CXR with diffuse, reticulogranular (ground-glass) appearance, air bronchograms, low lung volumes
Respiratory distress syndrome
Surfactant deficiency results in alveolar collapse and diffuse atelectasis
72
Neonatal respiratory distress
Tachypnea and severe cyanosis
CXR with clear lungs with decreased pulmonary vascularity
Persistent pulmonary hypertension
High pulmonary vascular resistance results in R to L shunting and hypoxia
73
Stridor in infant/child:
Most common from 6mo-6yo
"barky" cough, fever, rhinorrhea and congestion
Croup (laryngotracheobronchitis)
74
Stridor in infant/child:
Most severe at 4-8mo
Persistent stridor
Worsens when supine
Improves when prone
Laryngomalacia
75
Stridor in infant/child:
Acute onset
Moderate to severe respiratory distress
Foreign body aspiration
76
Newborn with scalp swelling limited to the surface of one cranial bone
Cephalohematoma -
```
Subperiosteal hemorrhage (always limited to 1 cranial bone)
No discoloration of overlying scalp, and swelling is usually not visible until several hours after birth because subperiosteal bleeding is a slow process
```
Most cases resorb spontaneously w/in 2w-3mo.
77
Newborn with diffuse swelling of scalp, extends across suture lines
Caput succedaneum
May be ecchymotic
Usually involves the portion of the head presenting during vertex delivery
78
Acquired causes of aplastic anemia (6)
```
Drugs (NSAIDs, sulfonamides, ect)
Toxic chemicals (benzene, glue, ect)
Idiopathic
Viral infections (HIV, EBV, ect)
Immune disorders
Thymoma
```
79
Aplastic anemia and progressive bone marrow failure
Short stature, microcephaly, abnormal thumbs, hypogonadism
Hypo/hyperpigmented areas, cafe au lait spots, large freckles
Strabismus, low-set ears, middle ear abnormalities (i.e. hemorrhage, incomplete development, chronic infections, deafness, ect)
Fanconi anemia
80
Clinical features of DiGeorge syndrome (5)
```
CATCH:
Cotruncal cardiac defects
Abnormal facies
Thymic aplasia/hypoplasia
Cleft palate
Hypocalcemia
```
Chromosome 22q11.2 deletion
Defective development of pharyngeal pouches
81
Newborn with:
Intrauterine growth restriction
Radiolucent bone disease
Hepatosplenomegaly
Thrombocytopenia
Purpuric skin lesions - "blueberry muffin rash"
Hyperbilirubinemia
Sensorineural deafness
Cataracts/glaucoma
Cardiac malformations: PDA/pulmonary artery stenosis
Neuro sequelae: intellectual disability/meningioencephalitis/behavior disorders
Congenital rubella
82
```
Brown, fibrous plaques on forehead
Ash leaf spots (hypopigmentation)
Shagreen patch (leathery, thickened skin on lower trunk)
Facial angiofibromas
Seizures
Intellectual disability
```
Tuberous sclerosis
83
Crigler-Najjar type I vs type II
Type I:
Jaundice appears in first few days, absent hepatic UDP-GT activity, serum bilirubin 20-50mg/dL → kernicterus, no effect with phenobarbital
Type II:
Jaundice presents in childhood or as young adult, markedly decreased activity of hepatic UDP-GT, serum bilirubin
84
Congenital defects associated with lithium use during pregnancy (4)
1. Ebstein anomaly: tricuspid leaflets displaced into RV, hypoplastic RV, tricuspid regurgitation or stenosis
2. Patent foramen ovale
3. ASD
4. Dilated RA with increased risk of SVT and WPW
Physical exam: wide, split S2, tricuspid regurgitation murmur
85
What glycogen storage disease?
Lactic acidosis, hyperlipidemia, hyperuricemia (gout)
Increased glycogen in liver, severe fasting hypoglycemia
Severe HSM, enlarged kidneys
Type I, Von Gierke
86
What glycogen storage disease?
Diaphragm weakness → respiratory failure
Type II, Pompe
87
What glycogen storage disease?
Hepatomegaly, hypoglycemia, hyperlipidemia
Normal kidneys, lactate, and uric acid
Type III, Cori
88
What glycogen storage disease?
Painful muscle cramps, myoglobinuria with strenuous exercise
Type V, McArdle
89
6-12 week old newborn:
```
Prolonged jaundice
Poor feeding
Lethargy
Hypotonia
Hoarse cry
Macroglossia
Umbilical hernia
Dry skin
Hypothermia
Constipation
Developmental delay
```
Congenital hypothyroidism (cretinism)
90
Average age for boys to begin puberty
11.5yo
91
Average age for boys to begin pubertal growth spurt
13.5-14yo
92
What tanner stage?
Testes and scrotum enlarge
Pubic hair: sparse, long, slightly pigmented
Tanner stage 2
93
What tanner stage?
Enlargement of penis (length first)
Pubic hair darker, coarser, more curly
Tanner stage 3
94
What tanner stage?
Penis grows in breadth, glans enlarges, testes enlarges, scrotum darkens
Pubic hair adult in type, over smaller area (adult hair extends to thighs)
Tanner stage 4
95
Neonate:
Small for gestational age, hepatosplenomegaly, petechiae/purpura, jaundice, microcephaly, seizures, intracranial calcifications, feeding difficulties, hydrocephaly, chorioretinitis, optic nerve atrophy, central vision loss, thrombocytopenia, hemolytic anemia, progressive hearing loss (unilateral)
In utero CMV infection
96
Palpable purpura w/o thrombocytopenia or coagulopathy
GI symptoms: Abdominal pain, vomiting, guiac + stool (50%), intussusception (3.5%)
Renal symptoms: hematuria, proteinuria, nephrotic syndrome (2%)
Transient, migratory arthritis/arthralgias
Henoch-Schonlein purpura -- most common systemic vasculitis of childhood
97
What type of immunodeficiency?
Congenital heart defect, hypocalcemia, recurrent infections
DiGeorge syndrome
98
What type of immunodeficiency?
Chronic mucocutaneous candidiasis, chronic diarrhea, failure to thrive
Severe combined immunodeficiency (SCID)
99
What type of immunodeficiency?
Poor smooth pursuit of eyes, elevated AFP after 8 months
Ataxia telangiectasia
100
What type of immunodeficiency?
Partial albinism, recurrent URIs, neuro disorders
Chediak-Higashi disease
101
```
Rash: sandpaper, erythematous and blanching, starts on trunk then becomes generalized. Spares palms and soles
Strawberry tongue
Beefy red pharynx
Cervical LAD
Desquamation of hands/feet
Fever and chills
```
Scarlet fever caused by S. pyogenes
102
Prodrome for 2-3 days: fever, malaise, anorexia, cough, coryza, conjunctivitis
Koplik spots on buccal mucosa
Day 5: erythematous maculopapular rash starting on head, extending to extremities. Lasts 4-5 days. Resolves from head down.
Measles (rubeola)
103
Sudden high fever for 3-4 days (>102 degrees)
Then rash starting on trunk, extending to extremities
Erythematous papules on soft palate and uvula
Mild cervical LAD
Edematous eyelids
Bulging anterior fontanelle
Roseola infantum
104
3yo
Recurrent pneumonia and skin abscessess
No color change on nitroblue tetrazolium test
Chronic granulomatous disease
Defective NADPH oxidase → inability to generate respiratory burst → impaired phagocytosis/killing by neutrophils
↑ susceptibility to catalase positive organisms (i.e. S. aureus, Aspergillus)
Nitroblue tetrazolium test: looks for NADPH activity. Normal = turns blue in presence of NADPH oxidase. Defective = stays yellow (or other color)
105
Cyanotic newborn
Single S2
+/- VSD murmur
CXR: "Egg on a string" heart - narrowed mediastinum
Transposition of the great vessels
106
Cyanotic newborn
Harsh pulmonic stenosis murmur
VSD murmur
CXR: "boot shaped" heart (RVH)
Tetralogy of fallot
107
Cyanotic newborn
Single S2
VSD murmur
CXR: minimal pulmonary blood flow
Tricuspid atresia
108
Cyanotic newborn
Single S2
Systolic ejection murmur (↑ flow through truncal valve)
CXR: ↑ pulmonary blood flow, edema
Truncus arteriosus
109
Cyanotic newborn
Severe cyanosis
Respiratory distress
CXR: Pulmonary edema, "snowman sign" (enlarged supracardiac veins and SVC)
Total anomalous pulmonary venous return with obstruction
110
Salter Harris Fracture type I
Slipped (SALTR mnemonic)
Fracture plane passes all the way through the growth plate, not involving the bone
Good prognosis
111
Salter Harris Fracture type II
Above (SALTR mnemonic)
Most common
Fracture passes across most of the growth plate and up through the metaphysis
112
Salter Harris Fracture type III
Lower (beLow) (SALTR mnemonic)
Fracture plane passes some distance along the growth plate and down through the epiphysis
Poorer prognosis as proliferative and reserve zones are interrupted
113
Salter Harris Fracture type IV
Through or Transverse or Together (SALTR mnemonic)
Intra-articular
Fracture plane passes directly through the metaphysis, growth plate, and down through the epiphysis
Poor prognosis as proliferative and reserve zones are interrupted
114
Salter Harris Fracture type V
Ruined or Rammed or cRushed (SALTR mnemonic)
Crushing type injury
Does not displace growth plate but damages it by direct compression
Worst prognosis
115
Generalized reabsorptive defect in PCT
Associated with ↑ excretion of nearly all amino acids, glucose, HCO3-, and PO4.
May result in metabolic acidosis (proximal renal tubular acidosis)
Fanconi syndrome
Cause include hereditary defects (i.e. Wilson disease, tyrosinemia, glycogen storage disease), ischemia, multiple myeloma, nephrotoxins/drugs (i.e. expired tetracyclines, tenofovir), lead poisoning
116
Reabsorptive defect in thick ascending loop of henle
Affects Na/K/2Cl cotransporter
→ hypokalemia, metabolic alkalosis, hypercalciuria
Bartter syndrome
Autosomal recessive
117
Reabsorptive defect of NaCl in distal convoluted tubule → hypokalemia, hypomagnesemia, metabolic alkalosis, hypocalcuria
Gitelman syndrome
Autosomal recessive
Less severe than Bartter syndrome
118
Gain of function mutation → ↑ Na reabsorption in collecting tubules (↑ activity of epithelial Na channel) → hypertension, hypokalemia, metabolic alkalosis, ↓aldosterone
Liddle syndrome
Tx: Amiloride
119
Follicular conjunctivitis and pannus (neovascularization) formation in the cornea.
Concurrent infection in nasopharynx → nasal discharge
Chlamydia trachomatis serotype A-C
Diagnosis by Giemsa stain examination of conjunctival scrapings
Tx: topical tetracycline or azithromycin
120
```
Quad screen:
↓ MSAFP
↓ β-hCG
↓ Estriol
Normal Inhibin A
```
Trisomy 18
121
```
Quad screen:
↓ MSAFP
↑ β-hCG
↓ Estriol
↑ Inhibin A
```
Trisomy 21
122
```
Quad screen:
↑ MSAFP
Normal β-hCG
Normal Estriol
Normal Inhibin A
```
Neural tube or abdominal wall defect
123
Prolonged/heavy menstrual period that maintains a normal menstrual cycle (21-35 days)
Diagnosis?
Potential causes?
Menorrhagia
Causes: coagulopathy (ITP, hemophilia, vWF), endometriosis, leiomyoma, neoplasm
124
Heavy/prolonged menstrual cycle AND occurs at irregular intervals
Menometrorrhagia
125
Uterine bleeding at irregular intervals, typically occuring between menstrual periods.
Diagnosis?
Potential causes?
Metrorrhagia
Causes: pathologic (leiomyoma, endometriosis, GU neoplasms) vs medicinal (OCP's - "breakthrough bleeding")
126
Biophysical profile parameters (5)
```
Fetal breathing
Fetal tone
Fetal movement
Amniotic fluid volume
Non-stress test
```
6 = equivocal, delivery should be considered if fetus is at term
127
Rhonchi
Low-pitched, continuous sounds often described as similar to a snoring sound.
Generated by narrowing of larger airways due to mucus from bronchitis, or narrowing from asthma/COPD.
Coughing should decrease/eliminate rhonchi if they are caused by secretions.
128
Wheezes
High-pitched whistling sound during breathing when air flows through a narrowed airway, most commonly heard in asthmatics
129
Crackles/Rales
Discontinuous sound heard more often during inhalation caused by airway opening.
Divided into dry or moist, with dryness being caused by disease processes such as fibrosis and the moistness/wetness being secondary to heart failure or pneumonia.
130
Tactile fremitus
Feeling for vibrations along posterior chest while pt is saying "ninety-nine".
Increased over areas of consolidation (i.e. lobar pneumonia) bc sound waves travel faster through liquid than air.
Decreased over pneumothorax - air is barrier to the sound waves
131
Egophony
Auscultating while patient says "EEEEEE"
If consolidation is present, high-frequency noises are preferentially transmitted across the abnormal lung tissue, causing the observer to hear an "AAAAA" through the chest (aka "E to A changes")
132
5 stages of change
Precontemplation - don't even consider changing, in denial
Contemplation - ambivalent about changing. Assess barriers as well as benefits of change
Preparation - experiment with small changes as determination increases
Action
Maintenance and relapse prevention - incorporating new behavior.
133
Definition of Metabolic Syndrome
Any 3 of the following 5:
1. Fasting plasma glucose >100 or on meds for hyperglycemia
2. BP >130/85 or on meds for HTN
3. Triglycerides >150 or on meds for hypertriglyceridemia
4. HDL 40" for men, >35" for women
134
5 A's of behavioral counseling
1. Assess patient's practices and risk factors
2. Advise pt to change
3. Agree with pt on goals
4. Assist pt in changing or addressing motivational barriers
5. Arrange follow-up, support and/or referral
135
ASCVD (atherosclerotic cardiovascular disease) statin benefit groups (4)
1. Current ASCVD
2. LDL >190
3. DM age 40-75yo
4. ASCVD risk >7.5%
136
Role of G6PD
G6PD generates NADPH needed to reduce glutathione.
Glutathione is needed to neutralize reactive oxygen species and hydrogen peroxide.
Without G6PD, RBCs are susceptible to oxidation
*** Heinz bodies - increased Hgb
137
What drugs provoke anemia with G6PD deficiency? (7)
Spleen Purges Nasty Inclusions From Damaged Cells:
```
Sulfa
Primaquine
Nitrofurantoin
INH
Fava beans
Dapsone
Chloroquine
```
138
Anti-dsDNA
SLE, especially active lupus nephritis
139
Anti-histone
Drug induced lupus
140
Anti-La/SSB
Sjogrens
141
Anti-smith
SLE
142
Anti-topoisomerase 1 aka Anti-Scl-70
Diffuse cutaneous systemic sclerosis aka Scleroderma
143
Anti-centromere
Limited cutaneous systemic sclerosis aka CREST scleroderma
```
C- Calcinosis cutis
R- Raynaud phenomenon
E- Esophageal dysmotility
S- Sclerodactyly
T- Telangiectasias
```
144
CREST scleroderma
AKA limited cutaneous systemic sclerosis
```
C- Calcinosis cutis
R- Raynaud phenomenon
E- Esophageal dysmotility
S- Sclerodactyly
T- Telangiectasias
```
145
Causes of anion gap metabolic acidosis
```
GOLDMARK
Glycols (ethylene and propylene)
Oxoproline
L-lactate
D-lactate
Methanol
Aspirin
Renal failure
Ketones
```
```
MUDPILES
Methanol
Uremia (renal failure)
DKA
Propylene glycol
Iron, INH
Lactic acidosis
Ethylene glycol
Salicylates
```
146
S and S of infective endocarditis
Fever, weakness, fatigue, anorexia
New regurgitation murmur (mitral vs tricuspid/IVDU)
New heart failure
Signs of septic emboli (splinter hemorrhages, Osler nodes "Ouch", janeway lesions, roth spots, focal neuro deficits/stroke, renal infarct/hematuria, splenic infarct)
Signs of systemic immune reaction (glomerulonephritis, arthritis)
147
Paraneoplastic syndromes associated with small cell lung cancer (3)
↑ADH → SIADH → hyponatremia
↑ACTH → ↑ cortisol → cushing syndrome
Lambert eaton myasthenic syndrome: Ab against presynaptic Ca channels at NMJ → muscle weakness that improves with use
148
Lambert-eaton myasthenic syndrome
Paraneoplastic syndrome associated with small cell lung cancer
Ab against presynaptic Ca channels at NMJ → muscle weakness that improves with use
149
Paraneoplastic syndome associated with squamous cell lung cancer
↑PTHrP → ↑ bone turnover and →↑ Ca reabsorption in the kidney → hypercalcemia
150
What antibodies are associated with celiac disease?
Anti-endomysial Ab - binds tissue transglutaminase
Anti-gliadin - binds to a component of gluten (lower predictive value, not often used)
151
What would an intestinal biopsy show in a patient with celiac disease?
Blunting of duodenal and jejunal villi
152
Types of shock (5)
```
Cardiogenic
Septic
Hypovolemic
Anaphylactic
Neurogenic
```
153
Mechanism and cause of:
Cardiogenic shock
Mechanism: Failure of myocardial pump
Cause: MI, arrhythmia, tamponade, PE, cardiac contusion
154
Mechanism and cause of:
Septic shock
Mechanism: peripheral vasodilation → ↓ total peripheral resistance
Cause: GN bacteria, DIC, endotoxins
155
Mechanism and cause of:
Hypovolemic shock
Mechanism: inadequate blood/plasma volume
Cause: hemorrhage, severe burns, trauma
156
Mechanism and cause of:
Anaphylactic shock
Mechanism: generalized hypersensitivity, Type I reaction, mast cell degranulation, vasodilation due to histamine
Cause: Allergic reaction
157
Mechanism and cause of:
Neurogenic shock
Mechanism: autonomic dysfunction → peripheral vasodilation and bradycardia
Cause: CNS/spinal injury
158
Following successful treatment of syphilis, what lab results would you expect to see?
FTA-ABS will be positive for life
RPR and VRDL will be negative after treatment.
159
Causes of acute pancreatitis? (12)
PANCREATITIS
```
hyperParathyroidism - hypercalcemia
* chronic Alcohol
Neoplasm - blocks ducts → backup of pancreatic juices
* Cholelithiasis
Rx's - RTI's, PI's, sulfa
ERCP
Abdominal surgery
* hyperTriglyceridemia
Infection (mumps)
Trauma
Idiopathic
Scorpion sting
```
* = most common
160
S and S of acute pancreatitis (5)
```
Epigastric pain radiating to the back
Nausea/vomiting
Sitophobia (fear of eating due to pain)
Cullen's sign - periumbilical ecchymosis
Grey Turner's sign - flank ecchymosis
```
161
What medications have the highest risk of causing drug-induced lupus? (5)
```
SHIPP
Sulfa, especially sulfalazine
Hydralazine
INH
Phenytoin
Procainamide
```
162
Tumors of MEN I
PPP
Parathyroid adenoma
Pancreatic tumor
Pituitary adenoma
(IIa is PPM, IIb is PMM)
163
Tumors of MEN IIa
PPM
Pheochromocytoma
Parathyroid hyperplasia
Medullary thyroid
(I is PPP, IIb is PMM)
164
Tumors of MEN IIb
PMM
Pheochromocytoma
Medullary thyroid
Mucosal neuromas
(I is PPP, IIa is PPM)
165
Definition of acute kidney injury
1 of 3:
↑Cr > 0.3 gm/dL w/in 48h
↑ Cr >50% w/in 7d
Urine output
166
According to the 2013 ACC/AHA guideline for treating hypercholesterolemia, what are the 4 major basic groups that benefit from the use of statins to prevent atherosclerotic cardiovascular disease (ASCVD)?
1. Clinical ASCVD - MI, ACS, angina, stroke/TIA, PVD, h/o revascularization procedures (angioplasty, stent, coronary bypass)
2. LDL > 190
3. DM and 40-75yo
4. 40-75yo with 10 year ASCVD risk >7.5%
167
What meds are identified as high-intensity statin therapy?
Atorvastatin 40-80mg
| Rosuvastatin 20-40mg
168
What pneumoconiosis is most closely associated with:
Shipbuilding, roofing, plumbing, brake mechanics
Asbestosis
169
What pneumoconiosis is most closely associated with:
foundries (casting metal), sandblasting, mining
Silicosis
170
What pneumoconiosis is most closely associated with:
exposure in the defense and aerospace industries
Beryllosis
171
```
Deep bone pain
Chest pain
New stroke onset
Painful swelling of hands/feet
Dyspnea
Priapism
```
Sickle cell crisis
172
Type I hypersensitivity reaction
Immediate
IgE mediated release of vasoactive mediators from mast cells and basophils
i.e. Anaphylaxis
173
Type II hypersensitivity reaction
IgG and IgM against CELLULAR antigens
i.e. Autoimmune hemolytic anemia
174
Type III hypersensitivity reaction
IgG and IgM against SOLUBLE antigens → immune complex deposition → activation of complement
i.e. SLE, RA
175
Type IV hypersensitivity reaction
T cell mediated
Delayed hypersensitivity
i.e. contact dermatitis, poison ivy
176
Common causes of cirrhosis (5)
```
Alcoholism
Chronic Hepatitis B/C
Chronic bile duct obstruction
Cholestasis
Hepatic parenchymal disease
```
177
Labs seen with cirrhosis (5)
```
↑LFTs: ALT, AST, GGT, Alk phos, bilirubin
↓ Albumin
Prolonged PT
Anemia
Thrombocytopenia
```
178
Vasculitis + bloody nasal discharge + hemoptysis + glomerulonephritis + positive c-ANCA
Granulomatosis with polyangiitis
aka Wegener's granulomatosis
179
Vasculitis + hepatitis B infection
Polyarteritis nodosa
180
Vasculitis + abdominal pain + arthralgias + glomerulonephritis + palpable purpura
Henoch schonlein purpura
181
Vasculitis + young asian woman + ↓ peripheral pulses
Takayasu arteritis
182
Vasculitis + asthma + eosinophilia + granuloma formation
Eosinophilic granulomatosis with polyangiitis
aka Churg strauss syndrome
183
Vasculitis commonly involving branches of the carotid artery
Temporal/giant cell arteritis
184
Vasculitis in child with fever, bilateral conjunctivitis and "strawberry tongue"
Kawasaki disease
185
Digit ischemia in young male smoker
Thromboangiitis obliterans
aka buergers disease
186
Symptoms of primary hyperparathyroidism
↑PTH → ↑ serum calcium
STONES - nephrolithiasis
BONES - osteopenia, osteitis fibrosa cystica, bone pain
ABDOMINAL GROANS - constipation, pancreatitis, PUD
PSYCHIATRIC OVERTONES - depression, psychosis, cognitive dysfunction, lethargy
187
What is osmotic demyelination syndrome aka central pontine myolysis
Rapid correction of hyponatremia → free Na inside brain cells moves outside → quick shrinkage of brain volume
Irreversible
Causes paralysis, confusion, obtundation, coma, LOCKED IN SYNDROME
188
Definition and treatment for severe hyperkalemia
K >6.5 with ECG changes (prolonged PR, short QT, wide QRS, peaked T waves)
1. Stabilize cardiac membranes to prevent arrhythmia - IV calcium gluconate or IV calcium chloride
2. Drive K out of serum into cells - Insulin + glucose, β-agonist (albuterol), sodium bicarbonate (alkalosis)
3. Remove K from body - hemodialysis, Kayexalate aka Sodium polystyrene sulfonate PO or enema (exchanges Na for K in the gut → excretion), Loop diuretics (↑ renal excretion)
189
Management for pheochromocytoma
1st: α blockers to ↓ peripheral vasoconstriction → ↓ BP
2nd: β blockers to ↓ tachycardia *** must be done after α blockade to prevent unopposed vasoconstriction and increased BP
3rd: surgical resection
190
General antiarrhythmic drug classes
NO βAD BOY KEEPS CLEAN
I - Na channel blcokers
II - β-blockers
III - K channel blockers
IV - Ca channel blockers
191
S and S of cushing syndrome
```
BAM CUSHINGOID
Buffalo hump
Amenorrhea
Moon facies
Crazy
Ulcers
Skin changes - acne, easy bruising, striae
HTN
Infection
Necrosis of femoral head
Glaucoma and cataracts
Osteoporosis
Immunosuppression
Diabetes
```
192
"Muddy brown" granular casts
Acute tubular necrosis
193
Renal disorder associated with HIV infection or heroin use
Focal segmental glomerulosclerosis
194
Anti-glomerular basement membrane antibodies
Goodpasture syndrome
195
Abnormal type IV collagen synthesis → hematuria and deafness
Hereditary nephritis aka Alport syndrome
196
Most common cause of nephrotic syndrome in children
Minimal change disease
197
Nephritic syndrome following pharyngitis or skin infection
Postinfectious glomerulonephritis
198
Gross hematuria following URI
IgA nephropathy - Berger disease
199
What malignant cell type is characteristic of Hodgkin Lymphoma?
Reed-sternberg cell
Malignant B cell
Large, bilobed nucleus, nucleoli, owl-eye appearance
200
Most common subtype of hodgkin lymphoma
Nodular sclerosis
201
B-symptoms
Low grade fever
Night sweats
Weight loss
202
In an HIV positive patient, what prophylactic abx should be started when the CD4 count is
TMP-SMX for PJP prophylaxis
203
In an HIV positive patient, what prophylactic ax should be started when the CD4 count is
TMP-SMX for PJP prophylaxis when CD4 is
204
Central vs Nephrogenic Diabetes insipidus
Central: impaired ADH secretion. Desmopressin → ↑ urine osmolality
Nephrogenic: inability to respond to ADH. Desmopression → no change in urine osmolality
205
Classic pentad for thrombotic thrombocytopenic purpura?
```
Hemolytic anemia
Uremia
Thrombocytopenia
Fever
Neuro changes: AMS, seizure, coma, death
```
206
Types of DMARDS (5)
```
Hydroxychloroquine
Sulfasalazine
Methotrexate
TNF α inhibitors
Anticytokines - anakinra, rituximab, abatacept
```
207
FENa calculation and interpretation
(Urine Na x Serum Cr) / (Urine Cr x Serum Na)
2% = intrinsic AKI
208
```
Bone/back pain
Pathologic fracture
Anemia
Hypercalcemia
Frequent infections
Renal failure
```
Peripheral blood smear: rouleaux formation
SPEP: monoclonal spike
UPEP: bence jone proteins
Imaging: "punched out" lytic lesions on long bones and skull
Multiple myeloma - malignant myoclonal proliferation of plasma cells
209
Anti-mitochondrial antibodies
primary biliary cirrhosis
210
Anti-smooth muscle antibodies
Type 1 autoimmune hepatitis
211
Anti-liver/kidney microsomal antibodies (ALKM-1)
Type 2 autoimmune hepatitis
212
Perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA)
Primary sclerosing cholangitis, churg strauss, microscopic polyangiitis
213
Recurrent sinus and pulmonary infections
| Anaphylaxis during transfusion
IgA deficiency - most common immunodeficiency
| Patients develop anti-IgA antibodies → anaphylaxis during transfuions
214
Risk factors for bladder cancer
Smoking (risk doesn't go back to normal until after 20 years of quitting)
Male sex
Aniline dyes
Radiation
Cyclophosphamide
Chronic Schistosoma haematobium infection (squamous cell)
215
Classic findings of dermatomyositis
Muscles: symmetric progressive proximal muscle weakness
Skin: malar rash, heliotrope rash, gottron's papules, mechanic's hands, shawl sign, V sign
216
Treatments for grave's disease
Hyperthyroidism due to autoimmune activation of TSH receptor
β-blockers for symptomatic control
Thionamides (PTU, methimazole) → ↓ production of thyroid hormone
Radioiodine ablation
Surgical resection
217
Criteria for acute rheumatic fever
2 major or 1 major + 2 minor:
Major: Joints (migratory polyarthritis), Pancarditis (epi/myo/endo), Nodules, Erythema marginatum, Syndenham chorea
Minor: arthralgias, fever, ↑ ESR/CRP, prolonged PR
218
Absolute indications for dialysis (5)
AEIOU:
Acidosis - significant, intractable metabolic acidosis
Electrolytes - severe persistent hyperK
Intoxications - methanol, ethylene glycol, lithium, aspirin
Overload - hypervolemia not managed by other means
Uremia (severe) - based on clinical presentation
219
DRESS syndrome
DRESS: drug reaction with eosinophilia and systemic symptoms
Drug-induced (2-6w after initiation) with extensive rash, fever, LAD, heme abnormalities, hepatitis, and involvement of 1+ internal organs.
220
Triad for hemolytic uremic syndrome (HUS)
Anemia
Thrombocytopenia
Acute renal failure
Also: schistocytes
221
Thrombotic thrombocytopenic purpura (TTP) vs hemolytic uremic syndrome (HUS)
Both: Fever, anemia, acute renal failure, thrombocytopenia
Both can present with ↑ LDH, indirect bili and schistocytes
TTP: + focal neurological deficits
HUS - presence of bloody diarrhea often precipitated by E. coli O157:H7 or shigella
222
Parkinsonian symptoms + autonomic insufficiency
Shy-drager syndrome
223
Medications for parkinsons (6)
1. Carbidopa-Levodopa (sinemet) - drug of choice, most efective - bad side effects and on-off phenomenon
2. Dopamine receptor agonists (bromocriptine, pramipexole)
3. MAO-B inhibitor → ↑ DA activity (selegiline)
4. Amantadine (antiviral)
5. Anticholinergic drugs (trihexyphenidyl and benztropine)
6. Amitriptyline - anticholinergic and antidepressant
224
Medication for alzheimers
Cholinesterase inhibitors - donepezil, rivastigmine, galantamine
225
Differential diagnosis of coma or stupor (7)
SMASHED
- Structural brain pathology - stroke/subdural/epidural, tumor, hydrocephalus, herniation, abscess
- Meningitis, Mental illness
- Alcohol, Acidosis
- Seizure, Substrate deficiency (thiamine)
- Hypercapnia, Hyperglycemia, Hyperthermia, Hyponatremia, Hypoglycemia, Hypoxia, Hypotension/cerebral Hypoperfusion, Hypothermia
- Endocrine causes (addisons, thyrotoxicosis, hypothyroid), encephalitis, encephalopathy (HTN/hepatic/uremic), extreme Ca/Mg/P disturbance
- Drugs (opiates, barbs, benzos, sedatives), dangerous compounds (carbon monoxide, cyanide, methanol)
226
Differential diagnosis for delirium
SMASHED (for coma) + P.DIMM.WIT
```
Postop state + pain meds
Dehydration/malnutrition
Infection
Medications/intoxications
Metals
Withdrawal states
Inflammation, fever
Trauma, burns
```
227
Duke's major and minor criteria
Major: sustained bacteremia, endocardial involvement
Minor: predisposing condition, fever, vascular phenomena, immune phenomena, + blood culture, + echo
228
Ranson's criteria at admission:
```
GA LAW
Glucose >200
Age >55
LDH >350
AST >250
WBC >16
```
229
Types of melanoma (4)
1. Superficial spreading - most common (70% of all cases), 1-20 years of radial growth followed by vertical growth.
2. Nodular sclerosing - 15-30% of all cases, aggressive vertical growth, poor prognosis
3. Lentigo maligna - 4-10%, 5-15 years radial growth phase, good prognosis
4. Acral lentiginous - 35-60% in African Americans, Asians, Hispanics, palms and soles of hands and feet and nail beds. Aggressive vertical growth phase, poor prognosis.
230
Location of hesselbach hernia
Under inguinal ligament, lateral to femoral vessels
231
Location of bochdalek hernia
Stomach herniation through posterior diaphragm
232
Locatino of morgagni hernia
Stomach herniation through anterior diaphragm
233
Location of indirect inguinal hernia
Lateral to inferior epigastric artery, females
Arises through the deep ring and enters inguinal canal, exits internal inguinal ring into scrotum.
Often congenital
234
Location of direct inguinal hernia
Medial to inferior epigastric artery, males
Directly protrudes through inguinal wall, exits through superficial inguinal ring
Less common, acquired
235
Prehn sign
Testicular pain that is not improved with elevation
Sign of testicular torsion
236
Subclavian steal syndrome
Occlusion of subclavian artery → UE claudication
Blood "stolen" from vertebral artery → retrograde flow through vertebral artery → vertebral-basilar ischemia → dizziness, ataxia, syncope
237
Differential diagnosis for anterior mediastinal mass (4)
```
FOUR T'S:
Thymoma
Teratoma
Thyroid neoplasm
Terrible lymphoma
```
