Step 2 Missing Knowledge Flashcards

Question

Preterm infants vaccination schedule

Answer 1

Given according to chronological age rather than age corrected for gestation

Answer 2

Uterine fatigue from prolonged, induced, or precipitous labor Intraamniotic infection Uterine overdistension (multiple gestation, fetal macrosomia, polyhydramnios) Retained placenta Grand multiparity Operative vaginal delivery

Answer 3

Standard dose at 28 weeks gest After delivery or procedures, Kleihauer-Betke test performed to determine whether higher dose needed due to increased risk of fetal blood cells entering maternal circ

Answer 4

Common, seen more in pts taking dopamine agonists (e.g. ropirinole, pramipexole) than those treated with carbidopa-levodopa. Psychotic sx treated with antiparkinson med dose reduction and/or addition of LOW potency antipsychotic (quetiapine, pimavanserine)

Answer 5

Rapidly progressive cellulitis of submandibular and sublingual spaces Airway obstruction can occur due to displacement of tongue posteriorly

Answer 6

Due to transection of nerve fibers Form over several weeks - months following injury/amputation FOCAL tenderness, altered local sensation Pain with local pressure that can complicate fittings for amputational prosthetics Injection of local anesthetic can provide transient pain relief and confirm dx Mx: excision of neuroma

Answer 7

Rfs for preterm delivery: Prior spont preterm delivery (main rf) Tobacco use, multiple gest, prior cervical surgery (e.g. cold knife conization for CIN) No prior preterm delivery: TV US cervical length measurement at 16-24 weeks gest to assess risk for preterm delivery (if short cervix identified, <= 2.5cm on USS, high risk for preterm, so offered vag progesterone (prevent uterine contractions)) Prior preterm delivery: ... w/ Painful contractions = prior preterm labor: Tx = progesterone ... w/o painful contractions = cervical insufficiency: Tx = prophylactic cerclage

Answer 8

Small fiber: pos sx: pain, paresthesia, allodynia Large fiber: neg sx: numbness, loss of proprioception and pos sense, diminished ankle reflexes

Answer 9

CXR to assess for complications (e.g. parapneumonic effusion, abscess, necrotising pneumonia)

Answer 10

CT preferred test for screening Indications: high-energy mechanism of injury or any one of following: neuro deficit spinal tenderness altered mental status intox distracting injury N.B: presence of single vertebral # in pt w blunt trauma indication to image ENTIRE SPINE (CT scan)

Answer 11

B12 def due to alterations in ca homeostasis, leading to impaired absorp of b12 in terminal ileum May have isolated neuro findings (paraesthesias, sensory ataxia, neuropsych changes) w/o megaloblastic anaemia

Answer 12

Late-night salivary cortisol assay, 24-hour urine free cortisol and/or low dose overnight dex suppression test NOT early morning cortisol!

Answer 13

Placement of pts in knee-chest pos during hypercyanotic spell causes kinking of femoral arteries, increasing SVR so reduces R to L shunting through VSD so increases PBF and improves hypoxaemia

Answer 14

(Multiple motor tics and at least one vocal tic) Habit reversal training Pharmocotherapy: ANTIPSYCHOTICS, dopamine depleters, or alpha adrenergic receptor agonists

Answer 15

Severe coughing paroxysms can increase intraalveolar pressure and cause air to leak into subcut tissues (subcut emphysema) resulting in SPM CXR to confirm dx and rule out pneumothorax

Answer 16

Met ac (acute/chronic): Winter's formula: expected PaCO2 = (1.5 x HCO3-) + 8 +/- 2 Met alk (acute/chronic): ~7 increase in PaCO2 per 10 increase in HCO3- Resp ac (chronic only): ~ 4 increase in HCO3- per 10 increase in PaCO2 Resp alk (chronic only): ~ 4 decrease in HCO3- per 10 decrease in PaCO2

Answer 17

Distinguished by viral URTI by presence of severe, persistent or worsening sx (cough, nasal discharge) Tx = oral abx

Answer 18

Imaging: CT abdo/pelvis if nonpregnant/adult; USS +/- MRI if pregnant/child If nonperforated appendicitis visualised: Abx & appendectomy <= 12 hrs If perforated appendicitis: Abx & bowel rest; contained abscess: PCD; diffuse contamination: I&D with appendectomy

Answer 19

Localised pain and tenderness over medial tibial condyle Assoc w overuse Rfs: obesity, DM, knee OA and angular deformity of knee Dx clinical but Xray can exclude concurrent OA Mx: quads strengthening exercises and NSAIDs (N.B: same mx as for PF syndrome) CF PF syndrome: more common in Females; anterior (rather than medial) pain worsened by squatting, climbing stairs, prolonged sitting

Answer 20

Suspect if pt from endemic region (southeastern and south central US) w/ hx of tick bite, febrile illness w/ systemic sx, leukopenia and/or thrombocytopenia, and elevated aminotransferases. Rash uncommon Tx = doxycycline

Answer 21

Common postgastrectomy complication GI sx (nausea, diarrhoea, abdo cramps) Vasomotor sx (palpitations, diaphoresis) Tx: dietary mod (avoid simple sugars etc), improves over time

Answer 22

Early resp insufficiency may manifest as orthopnea and appear similar to OSA (daytime fatigue, early morning headaches) NIPPV prolongs survival and improves QofL

Answer 23

Assoc w/ ACEi, thiazide diuretics, beta blockers, hydroxychloroquine Idiopathic LP: wrists and ankles Drug-induced LP: more diffuse Tx = topical high-potency glucocorticoids (e.g. betamethasone) and discontinue suspected med

Answer 24

3 phases to ensure eradication and prevent disease relapse 1. induction with amphotericin B and flucytosine for 2 weeks 2. consolidation with high-dose oral FLUCONAZOLE for 8 weeks 3. maintenance with low-dose oral FLUCONAZOLE until CD4 count recovers to >100 for >3mo on ART N.B: ART initiation delayed for approx 2 weeks after tx for Cryptococcus due to risk of life-threatening CNS complications from immune reconstitution syndrome

Answer 25

NOROVIRUS Assoc w outbreaks on cruise ships and schools etc Vomiting, watery diarrhoea, abdo pain 1-2d after exposure Supportive tx CF Basillus cereus and Staph aureus: vom 6 hours after eating contaminated food

Answer 26

Very good at ruling out heart failure (ie very sensitive) if under 100 Caveat: can be falsely low in pts w heart failure and OBESITY (BNP undergoes increased clearance by fat cells)

Answer 27

Tx = as needed beta blockers or benzos Avoid benzos in pts with personal OR family history of SUBSTANCE USE DISORDER or when cog and sedative side effects could impair performance CF social anxiety disorder (generalised): SSRI/SNRI

Answer 28

Peaked T waves -> loss of P waves -> widened QRS -> SINE WAVE PATTERN -> asystole

Answer 29

Rapidly progressive cutaneous disorder seen in immunocompromised pts w P aeruginosa bacteraemia/sepsis Lesions begin as painless red macules, quickly progress to pustules/bullae and then form punched out gangrenous ulcers Pts usually febrile and ill Tx: Blood cultures and empiric IV Abx

Answer 30

Simple renal cysts mostly benign and do not require any investigations Malignant renal mass: multilocular mass, irregular walls, thickened septa and contrast enhancement

Answer 31

Women over 40 w CHRONIC PELVIC PAIN (CF fibroids), dysmenorrhoea and heavy menstrual bleeding SYMMETRICALLY enlarged uterus (CF fibroids), boggy, globular and tender

Answer 32

Caused by compression of nerve root due to disk herniation or spondylosis Neck pain, shoulder/arm pain, paraesthesia and diminished reflexes Improvement of radicular sx when hand placed over head dx and tx

Answer 33

Ecchymosis, petechiae, poor wound healing, perifollicular hemorrhage, coiled hairs and gingivitis Platelet count, PT, PTT normal

Answer 34

Gastric fundus migrates into thoracic cavity Large defects can result in herniation of surrounding stomach and intraabdo organs Sx: N&V, POSTPRANDIAL FULLNESS, dysphagia, epigastric pain, chest pain Chest imaging: retrocardiac air-fluid level within thoracic cavity (can also be seen in sliding hernias) Dx confirmed with barium swallow/upper endoscopy Mx: surgery (medical antireflux for sliding hernia)

Answer 35

Urinalysis to evaluate for HM and infection PSA in sx pts to assess risk for prostate ca unless life expectancy under 10 years

Answer 36

Letrozole N.B: cyclic progesterone for endometrial protection but does not induce ovulation

Answer 37

Gonorrhoea and Chlamydia due to high rate of asx infection and risk of long term sequelae (infertility) NAAT used N.B: cervical ca screening begins at age 21 w cervical cytology (Pap smear) But routine HPV testing not performed for those under 30 cos most HPV infections transient and spont clear in this age group

Answer 38

Erythematous, tender, warm lymph node Fever, fluctuance Periodontal disease or dental caries: ANAEROBES m/c organisms (e.g. Prevotella) Unilateral = bacterial Bilateral = viral (acute adeno, subacute chronic EBV CMV)

Answer 39

Hard signs (require immediate surgery): Distal limb ischaemia Absent distal pulse Active bleeding or rapidly expanding haematoma Bruit or thrill at site of injury Soft signs (require further imaging e.g. CT angio): Diminished distal pulses Unexplained hypotension Stable haematoma Documented haemorrhage at time of injury Assoc neuro deficit

Answer 40

Less than 1 USS: Hyperechoic liver (fatty infiltration)

Answer 41

Polycythaemia: chronic Hypoxia EPO Hypoglycaemia: low nutrients, low plasma glucose, low insulin Hypothermia: shunting blood to vital organs, decrease subcut fat, increase heat loss Hypocalcaemia: Placental dysfunction less ca transfer to fetus Perinatal asphyxia and meconium aspiration

Answer 42

Impaired memory and attention/concentration PERSONALITY, MOOD and BEHAVIOUR CHANGES Motor sx (ataxia, slowed mvts) Varies in severity from asx to dementia Rfs: long-standing HIV disease, age >= 50, CD4 < 200 MRI: DIFFUSE brain atrophy, ventricular enlargement and increased white matter intensity CF PML: sx: focal cortical involvement (e.g. motor deficits, ataxia, vision abnormalities); MRI well delineated ASYMMETRIC white matter lesions N.B: primary CNS lymphoma: CD4 <100, focal neurological deficits, neuropsychiatric symptoms (e.g., personality changes), and headaches Tx: Combination chemotherapy with high-dose METHOTREXATE (after a brain biopsy has been obtained). Radiotherapy if the patient has a poor functional status and for patients with intraorbital or spinal cord lesions. NOT SURGERY In patients with HIV-related PCNSL, administering antiretroviral therapy concurrently with definitive cancer treatment is essential for facilitating immune reconstitution.

Answer 43

Hepatocellular pattern of liver injury (raised AST/ALT, normal ALP and bili) High levels of auto antibodies, leading to elevated serum globulins and GAMMA GAP (total protein - albumin >= 4) Pos serology (anti smooth etc) and hypergammaglobulinaemia confirms dx

Answer 44

Activating effects (e.g. anxiety, insomnia) possible EARLY side effects of SSRI but improve with time Pts w anxiety more sensitive to these effects so benefit from temp dose reduction or starting off at a lower dose

Answer 45

Hearing (repeated ear infections can cause conductive hearing loss, which can be confused with some behavioural disorders of childhood)

Answer 46

Cavernous sinus thrombosis (facial/ophthalmic venous system is valveless) CN 3, 4, 5 and 6 deficits Severe headache, binocular palsies, bilateral periorbital oedema (impaired venous flow in orbital veins), hypo/hyperesthesia in V1/V2 distribution, vomiting (ICH), papilloedema CF brain abscess: raised ICP from brain abscess -> brain herniation not bilateral periorbital oedema

Answer 47

Both early diastolic Valve disease: left sternal border Aortic root disease: right sternal border

Answer 48

Facial nerve palsy Other extrapulm manifestations: cutaneous (papules, nodules, plaques, erythema nodosum), opthal (ant/post uveitis, keratoconjunctivitis sicca), neuro (FNP, central DI, hypogonadotropic hypogonadism), cardio (AV block, dilated/restrictive cardiomyopathy), GI (HSM, asx LFT abnormalities) Plus: hyperca, peri lymphadenopathy, parotid gland swelling, polyarthritis*, constitutional sx (fever*, malaise) * Lofgren syndrome

Answer 49

Complication of cardiac surgery Separation of bony edges of sternum Mild pain or sensation of chest wall instability and 'clicking' w chest mvt Palpable rocking or clicking of sternum confirms dx Mx: URGENT surgical exploration & repair

Answer 50

Hypercoag disorder Recurrent and migratory superficial thrombophlebitis at UNUSUAL SITES (arm, chest area) Assoc w pancreatic ca (also stomach/lung/prostate ca)

Answer 51

Spiro with furosemide Etoh abstinence, SODIUM RESTRICTION Avoid ACEi, ARB, NSAID

Answer 52

Educate pts on range of reactions to trauma (physical, emotional): NORMALISING Trauma-focused CBT beneficial for pts w severe and persistent sx N.B: do not initially refer for individual psychotherapy as pt unlikely to be compliant

Answer 53

See pt JOINTLY AS A TEAM to provide clear and consistent info and minimise tendency for splitting to impact tx

Answer 54

Hct > 65% in term neonates Rfs: excessive transfusion (delayed UC clamping, T2T transfusion syndrome), intrauterine hypoxia (uteroplacental insufficiency e.g. smoking, mat DM) and genetic conditions (e.g. trisomy 21) High blood viscosity limits organ perfusion and can cause resp distress, hypoglycemia and poor feeding

Answer 55

INTIMATE PARTNER VIOLENCE (higher risk due to increased emotional, physical and financial stressors)

Answer 56

Beta blockers: propranolol Anticonvulsants: primidone (given if beta blockers contraindicated e.g. asthma etc)

Answer 57

FACTITIOUS DIARRHOEA Investigations: stool osmolality (hypoosmolar = addition of dilute fluid; hyperosmolar = addition of conc fluid e.g. urine), stool electrolytes (elevated Mg or phosph = use of saline osmotic laxatives), stool osmotic gap (osmotic laxatives = high osmotic gap diarrhoea)

Answer 58

<6mo: monitor for spont descent >= 6 mo: refer for orchiopexy (perform at age 1 to reduce risk of test torsion, infertility and ca). Imaging not indicated prior to referral

Answer 59

Rfs = birth weight > 4kg, shoulder dystocia, vacuum delivery Mx = reassurance and gentle handling (self-limiting); place affected arm in long sleeve garment & pin sleeve to chest w elbow flexed to 90 degrees to decrease pain

Answer 60

Excessive intake of CALCIUM & ABSORBABLE ALKALI (usually in form of CALCIUM CARBONATE ANTACIDS) Renal vasoconstriction and decreased GFR Renal loss of sodium and water, reabsorp of bicarb Triad: HYPERCALCAEMIA, AKI, MET ALKALOSIS Rfs: CKD, thiazide use, NSAID, ACEi Suppressed serum PTH, hypophosphataemia (intestinal binding of phosph by caco3), hypomagnasaemia (decreased renal absorp of mag)

Answer 61

Porphyria cutanea tarda Assoc w HEP C and warrants screening

Answer 62

Ingestion of cat feces or UNDERCOOKED MEAT from animals infected with TG N.B: diffuse intracranial calcifications of newborn seen (periventricular c in cong CMV infection which is spread by saliva Also TG: macrocephaly/microcephaly; seizures. Serology/PCR CMV: microcephaly; SNHL. Urine/saliva PCR

Answer 63

24-28 wks: Hb/Hct; Ab screen if RhD neg; 1hr 50g GCT (initial prenatal visit screening if high risk for T2DM) 36-38wks: GBS rectovag culture (not earlier even if GBS in prior preg)

Answer 64

CHOANAL Failure to pass catheter through nares into oropharynx dx CF TEF w EA: coughing and choking w feeds and resp distress

Answer 65

RAISED IOP -> OAG OAG: insidious loss of PERIPHERAL VISION steroid-induced OAG: central blurriness due to corneal oedema

Answer 66

Lack of fetal descent after >= 4hrs in a primi with epidural (>=3hrs w/o) and >=3hrs in multigravida with epidural (>=2hrs w/o) Mx: operative vaginal delivery (e.g. VACUUM-ASSISTED) Other indications for op vag delivery: mat exhaustion, fetal distress and mat conditions in which Valsava not recommended (e.g. HOCM)

Answer 67

Screening HEAD USS Preterm babies increased risk of developing ICH due to presence of germinal matrix (friable, highly vasc area in brain). N.B: ICH can be asx therefore must screen ALL preterm babies

Answer 68

Amphetamine like properties Severe agitation, combativeness, psychosis, delirium, myoclonus, seizures Tachy, increased BP Effects of intox may take up to a week to subside (CF other stimulants/hallucinogens which have much shorter duration of effect)

Answer 69

Seen in PREPUBERTAL GIRLS w LOW ESTROGEN production Inflam from poor hygiene, infection, irritation, trauma also contributes Partial adhesions asx no tx needed Top estrogen first line for sx lesions

Answer 70

Occurs in women >60 Water diarrhoea during periods of FASTING and/or at NIGHT Colonoscopy: normal appearing mucosa Biopsy: mononuclear infiltrate within lamina propria, subepithelial collagen band Rfs: concurrent autoimmune diseases, cigarette smoking, NSAID use

Answer 71

Exquisitely painful swelling (firm, erythematous) of parotid glands Exacerbated by chewing/palpation Trismus, systemic findings (fever, chills) Elevated serum amylase w/o pancreatitis Rfs: ELDERLY, DEHYDRATION, POSTSURGICAL Decreased oral intake (NPO periop) Meds (anticholinergics) Obsrtuction (calculi, neoplasm) Mx: USS or CT scan (ductal obstruction, abscess) Hydration, oral hygiene Abx Massage Sialogogues

Answer 72

Samter triad: Asthma Chronic rhinosinusitis with nasal polyps NSAID-induced resp reactions (worsening sx after NSAIDs) COX inhibitors result in imbalanced production of leukotrienes over prostaglandins

Answer 73

Severe uncontrolled inflam in CD can lead to fibrotic stricture of small bowel w SBO Smoking and young age (under 30) at dx increases risk Bilious emesis, severe abdo pain and inability to pass flatus and/or stool Tx= surgery to remove strictured portion of small bowel

Answer 74

Suggests very high androgen levels due to androgen-producing neoplasm Elevated DHEAS seen in androgen-producing adrenal tumours: Raised DHEAS, T; low LH CF: PCOS (not as rapidly progressing): normal/raised DHEAS, T; high LH

Answer 75

CASE-CONTROL

Answer 76

Proliferation of colonic or oral bacterial in SB Rfs: anatomic abnormalities (strictures, ILEOCECAL RESECTION or other surgeries, SB diverticulosis) motility disorders (DM, scleroderma, opioid use) immunodef (IgA def) chronic pancreatitis gastric hypochrlorhydria, PPI use Bloating, flatulence Chronic watery diarrhoea Poss malabosption Low B12 (bacteria consump), raised folate (bacterial synthesis) Dx: CARBOHYDRATE BREATH TESTING (lactulose or glucose -> hydrogen production by bacteria fermenting carb earlier than normal) Gold standard (but invasive): endoscopy w jejunal aspirate/culture Tx: oral Abx (rifaximin, cipro, doxy)

Answer 77

Calcium and vit D supplementation CALCITRIOL (1,25D) preferred because it does not need PTH-mediated renal conversion to active form (ie renal 1 alpha hydroxylase dependent on PTH to convert 25 to 1,25D) HypoPTH = iatrogen in adults, autoimmune in children

Answer 78

Look out for OGI w high velocity injury mechanism OGI signs: visible entry wound, globe deformity, irregularly shaped pupil In absence of OGI (CI to use of fluorescein/topical agents), further corneal assessment should be performed via FLUORESCEIN STAINING N.B: penlight test (pupils, foreign body) and visual acuity before fluorescein staining Fluorescein concentrates on BASEMENT MEMBRANE exposed by coreneal epithelial defect Localised uptake: corneal abrasion Uptake followed by CLEARING IN WATERFALL PATTERN = FULL THICKNESS CORNEAL LACERATION with OGI (caused by washout from leaking aqueous humour) -> IMMEDIATE OPHTHALM CONSULT

Answer 79

Weakening of linea alba between rectus abdominis muscles Nontender abdo bulge in PREGNANT/POSTPARTUM pts Conservative mx reassurance

Answer 80

PYLORIC STRICTURE Confirm dx with UGI endoscopy; tx = surgery

Answer 81

Rfs: Severe trauma/recent surgery Prolonged fasting/TPN Critical illness (sepsis, ICU, mech vent) Fever, leucocytosis, RUQ pain +/- raised LFTs Abdo USS HIDA/CT if needed Tx: Enteric Abx coverage Cholecystostomy for initial drainage Consider cholecystectomy once stable

Answer 82

Usually benign, caused by WITHDRAWAL OF MATERNAL HORMONES Pathophys: fetal endometrial proliferation from mat estrogen followed by endometrial sloughing after delivery from mat progesterone withdrawal Light, self-limited vag bleeding +/- additional signs of maternal estrogen exposure: phys leukorrhoea, labial swelling, breast hypertrophy +/- galactorrhoea Reassure pt Resolves on its own within few days

Answer 83

Initial stabilisation If covering large TBSA, aggressive fluid resusc URETHRAL CATHETERISATION ASAP to monitor UO (delay can lead to oedema that obstructs visualisation and catheterisation of urethra) N.B: sharp surgical debridement for full thickness burns only performed 72 HOURS AFTER when burns fully demarcated (e.g. partial thickness may progress to full thickness during that time)

Answer 84

VISIONAL ABNORMALITIES most prominent in prepubertal children (CF headaches in obese women) Papilloedema leading to blurry vision and ENLARGED PHYSIOLOGIC BLIND SPOT (no rods/cones over area of optic nerve) CN VI esp affected in children (diplopia and impaired eye abduction)

Answer 85

JVP waveform: right atrial haemodynamics throughout cardiac cycle Cannon A waves: intermittent, prominent A waves caused by surge in JVP that occurs due to RA contraction against closed tricuspid valve Indicative of cardiac arrhythmia involving ATRIOVENTRICULAR DISSOCIATION (VT, complete AV block) N.B: ACxVy (A = RA contraction; C = RV contraction; V = peak of RA filling) Absent A wave = AF Prominent V wave & absent x descent = tricuspid regurg Flattened y descent = cardiac tamponade

Answer 86

Acute: activity mod, NSAIDs, ice Chronic: eccentric calf-strengthening resistance exercises

Answer 87

N/V, hyperventilation, HYPERTHERMIA (from HAGMA. leading to impaired aerobic resp so LACTIC ACIDOSIS (because gluconeogenesis impaired) and hyperthermia (byproducts of energy production)) ALTERED MENTAL STATUS

Answer 88

Rfs: Retained POC from: elective abortion w nonsterile technique missed or incomplete abortion (rare) Fever, chills, abdo pain Sanguinopurulent malodorous vag discharge Boggy, tender uterus; dilated cervix Pelvic USS: retained POC; thick endometrial stripe Mx: IV fluids Broad spectrum Abx SUCTION CURRETAGE for uterine evacuation to remove nidus of infection (Hysterectomy if pelvic abscess or condition does not improve after suction curretage and 48hrs of abx)

Answer 89

ARDS Aspirated liquid causes hypoxemia and can wash out pulm surfactant leading to ARDS ARDS can develop INSIDIOUSLY so CARDIOPULM MONITORING required for at least 8 hours in all pts with a draining event, even if asx

Answer 90

Based on expected human behaviours to reduce errors The most effective type involves PHYSICAL CHANGES that facilitate safe action w/o human effort and eliminate poss of error e.g. epidural solution bags incompatible with peripheral IV catheters Less effective HFE designs incorporate physical design changes but have a greater reliance on human effort (e.g. visual cues on bags)

Answer 91

Uterine fundus inverts and prolapses through cervix or vag after delivery Firm, rounded mass protruding through cervix or vag Likely occurs due to excessive fundal pressure and TRACTION ON UC prior to placental sep -> cord avulsion Fundus no longer palpable transabd Severe abdo pain and heavy vag bleeding w poss hemorrhagic shock Mx: discontinuation of uterotonics (e.g. oxy) and IMMEDIATE MANUAL REPLACEMENT OF UTERUS to prevent exsanguination If unsuccessful, uterine relaxants and laparotomy

Answer 92

Mild: nausea, flushing, headache, hyporeflexia Mod: areflexia, hypocalcaemia, somnolence Severe: resp paralysis, cardiac arrest Common rf: renal insuff (as mag excreted by kidneys) Tx: stop mag Give IV calcium gluconate bolus N.B: MgSO4 given to prevent eclamptic seizures and also for fetal neuroprotection at under 32 weeks gest (decrease risk for cerebral palsy)

Answer 93

MVP Occurs due to myxomatous degen of mitral valve leaflets and chordae causing mid-systolic click followed by mid-late systolic murmur

Answer 94

Aka painful bladder syndrome Pain exacerbated by bladder filling and relieved by voiding May also have dyspareunia and urinary frequency/urgency More common in women; assoc w psych and pain disorders (e.g. fibromyalgia)

Answer 95

Period of normal dvp followed by regression of speech, loss of purposeful hand use (e.g. twisting fingers), stereotypical mvts, gait disturbance DECELERATION IN HEAD GROWTH (microcephaly), BREATHING ABNORMALITIES (alt hyper/hypoventilation esp during periods of heightened emotion), autistic behaviours and seizures

Answer 96

>= 1.1 indicates PORTAL HTN (cirrhosis, HF) ↑ Protein levels (> 2.5 g/dL) Right heart failure Early Budd-Chiari syndrome ↓ Protein levels (< 2.5 g/dL) Cirrhosis Severe liver metastases Late Budd-Chiari syndrome <1.1 indicates no portal HTN (malignancy, TB, nephrotic syndome, pancreatitis) ↑ Protein levels (> 2.5 g/dL) Peritoneal carcinomatosis Pancreatitis Tuberculosis Chylous ascites (not secondary to cirrhosis) ↓ Protein levels (< 2.5 g/dL) Nephrotic syndrome Severe malnutrition

Answer 97

Characterised according to location Anterior: thymoma, lymphoma, germ cell tumours, thyroid tissue (ectopic, substernal goiter) Middle: lymphadenopathy (sarcoid, lung ca), lymphoma, benign cyst masses (pericardial cysts, BRONCHOGENIC CYST*), vasc masses, oes tumours Posterior: neurogenic tumours (schwannoma, neurofibroma), meningocele, spinal masses (metastases), lymphoma *arise from anomalous budding of foregut infancy/adulthood: may become sx with chest discomfort and recurrent coughing/frequent resp infections CT chest w IV to confirm

Answer 98

More common in OBESE children Early activation of adrenal androgens Precocious dvp of pubic and axillary hair, acne and body odour in child with normal bone age CF CAH: advanced bone age due to much higher levels of androgens

Answer 99

Food borne pathogen (eg contaminated beef) causes inflammatory diarrhoea Stools initially watery then become bloody Most pts AFEBRILE (if fever, consider other pathogens)

Answer 100

Late decelerations on non-stress test OLIGOHYDRAMNIOS on USS (single deepest pocket <2cm) because blood shunted from kidney (which produces amniotic fluid) to brain Late (>= 41wks) or post-term (>= 42wks) preg plus one of above: IMMEDIATE DELIVERY due to risk of intrauterine fetal demise If reactive non-stress test and/or vertex pos -> induction of labour If abnormal fetal heart rate tracings (e.g. late decelerations) or fetal malpresentation (e.g. breech) -> C section N.B: amnioinfusion done if variable decelerations (which occur 2 to oligohydramnios from ROM and subsequent cord compression)

Answer 101

Performed for preg at risk for fetal hypoxemia, acidemia and/or demise or for decreased fetal mvts Reactive vs non reactive Reactive: Baseline of 110 to 160/min Mod variability (6-25/min) >= 2 accelerations in 20 mins, each peaking >=15/min above baseline and lasting >= 15sec Nonreactive: Does not meet criteria for reactive Concerning for fetal hypoxemia and acidemia M/c cause of nonreactive is benign: QUIET FETAL SLEEP CYCLE (lasts <= 40min) Therefore nonreactive nonstress test extended (40-120min) to ensure that fetal activity outside of sleep noted

Answer 102

Increases risk of upper extremity DVT Risk highest in hosp pts, esp those w malignancy or hypercoag state Arm swelling, erythema and pain Dx: DUPLEX USS Tx: 3 mo anticoag

Answer 103

Complicated: bacterial invasion of pleural space, requires drainage w chest tube in addition to abx Pos pleural fluid gram stain/culture dx of complicated effusion and require CHEST TUBE placement Pleural fluid characteristics: pH <7.2, glucose <60, wbcs >50,000, LDH >1000 CF uncomplicated is sterile invasion of pleural space and opp figures to above. Only require abx

Answer 104

Usually results from direct extension of an adjacent infection (OM, sinusitis, dental infection) VIRIDANS STREP & STAPH AUREUS 2 m/c isolated organisms Headache, fever, focal neuro deficit, seizure Brain imaging (CT/MRI): single ring-enhancing lesion with central necrosis CF Rhizopus causes nectroic and highly destructive lesions and occur in pts w DM or severe immunocompromise

Answer 105

Worsening abdo pain, unstable vital signs or signs of infection 7-10d after onset of acute necrotising pancreatitis CT ABDO: gas within pancreatic necrotic collection

Answer 106

Variable Comb of headache, increased ICP, seizures and/or focal deficits N.B: venous sinuses' dual anatomic function: CSF drainage and cerebral venous blood return So raised ICP signs/sx, impeded blood return leading to venous stroke/hemorrhage Dx clinical and prothrombotic rfs (e.g. OCP use) often present Brain MRI w MR venography dx Tx anticoag w heparin (continue even if hemorrhage as risk of worsening hemorrhage low) CF ICH: focal neuro signs not present

Answer 107

Fever, dysphagia, muffled voice and pain w neck extension Lateral neck soft tissue X ray: WIDENED PREVERTEBRAL SPACE Mx: airway protection, IV abx, +/- surgical drainage

Answer 108

Immune med destruction of spinal cord Often post infectious (molecular mimicry) Bilateral motor weakness, early flaccid (LMN) then late spastic (UMN) Bilateral sensory dysf (ALL modalities CF infarction of ant spinal artery: vib and proprioception spared, loss of pain and temp sensation below present) DISTINCT SENSORY LEVEL Aut dysf (bladder/bowel) MRI spine: no compressive lesion, T2 hyperintensity LP: raised WBCs, raised IgG index Tx: high dose IV glucocorticoids Plasmapheresis N.B: GBS aka acute inflam demyelinating polyneuropathy: no UMN signs and no distinct sensory level N.B. 2: presentations of MS include: transverse myelitis, INO, optic neuritis and cerebellar dysfunction. These initial presentations may not be disseminated in time.

Answer 109

MA (m/c congenital foot deformity): medial deviation of forefoot, neutral position of hindfoot, flexible pos typical. Tx: REASSURANCE Clubfoot: medial/upward deviation of forefoot & hindfoot, hyperplantar flexion of foot, rigid pos typical (congenital clubfoot). Tx: SERIAL MANIPULATION & CASTING; surgery for refractory cases

Answer 110

Acute, diffuse, noninflam hair loss Triggered by stressful event, e.g. weight loss, preg, major illness/surgery, or psych trauma Widespread thinning of hair but scalp and hair shafts normal Self-lim disorder, takes up to 1 year to resolve

Answer 111

HEMORRHAGIC until proven otherwise Tx: TUBE THORACOSTOMY EMERGENT THORACOTOMY for extreme bleeding incl: Initial bloody output >1500ml Persistent hemorrhage or continuous blood transfusion to maintain HD stability

Answer 112

M/c cause of abnormal haemostasis (easy bruising, nonpalpable purpura) PT and PTT normal; PLT count normal or slightly low Pathophys: uraemia -> elevated urea -> arginine (substrate for urea production) and its precursors shunted to diff pathway -> increased NO -> inhibit primary hemostasis via decreased PLT adhesion, activation and aggregation

Answer 113

Type of CONVERSION DISORDER Assoc w: Prolonged LOC e.g. 20 mins vs 1-2 min in syncope Absence of objective findings (e.g. pallow, sweating, abnormal vital signs) Pt's awareness of sx during syncopal episode e.g. felt head throbbing while on floor

Answer 114

INCENTIVE SPIROMETRY Deep breathing exercises N.B: prophylactic abx prior to surgery only given to pts w preexisting lung condition

Answer 115

All research involving human participants require IRB approval If using secondary data (e.g. medical charts) and limited risk to participants, informed consent NOT needed

Answer 116

Normal (CF Down's) Long face, prominent chin and forehead, protruding ears, joint hypermobility and macrocephaly Assoc dvp delays and ADHD common

Answer 117

HE: hyperthermia (<= 40C) assoc w weakness, dizziness, profuse sweating, headache and/or nausea NORMAL MENTATION (CF EHS) Mx: cooling (e.g. cold water shower) and oral hydration w salt-containing fluids

Answer 118

Lab error characterised by PLT aggregation in vitro Peripheral smear: large clumps of PLTs No further investigations needed

Answer 119

OBSERVATION & REEXAMINATION after completion of full menstrual cycle (e.g. 6 weeks) as oes sensitive and size/tenderness change w menses If enlarging after 6 weeks then eval w breast USS If static at 6 weeks, continue to follow up every 6-12 months for 1-2 years to evaluate for tumour growth and exclude malignancy/phyllodes tumour

Answer 120

PaO2 <= 55 or SaO2 <=88% RA PaO2 <=59 or SaO2 <=89% in pts w cor pulmonale, evidence of RH strain or Hct > 55%

Answer 121

Inadequate clearance of beta 2 microglobulin despite dialysis Prevalence increases w age and dialysis duration Predilection for OSTEOARTICULAR structures presenting as: SCAPULOHUMERAL PERIARTHRITIS (shoulder pain/hypertrophy) carpal tunnel syndrome bone cysts

Answer 122

PaO2 <= 70 Alveolar-arterial grad >= 35 or Pulse ox < 92% on RA to reduce risk of resp decompensation

Answer 123

BILIARY CYST (dilation of biliary tree, most commonly involves CBD) Asx: incidental finding on imaging Sx: RUQ pain, jaundice and/or RUQ mass Acute complications: pancreatitis, cholangitis and stone formation Why increase risk of pancreatitis? Due to abnormally long pancreatobiliary junction so predisposes to obstruction, leading to reflux of pancreatic fluid as well as cholestasis (conj hyperbili)

Answer 124

BRONCHIAL CARCINOID tumours Arise in prox airway, causing airway obstruction (dyspnea, wheezing, postobstructive pneumonia) or hemoptysis CT scan w contrast: avidly enhancing (hypervasc) mass w an endobronchial component CF small cell: bulky hilar and mediastinal mass squamous cell: central cavitation (heterogeneous density) due to tumour necrosis

Answer 125

CONGENITAL HYPOTHYROIDISM Constipation, large fontanelle (delayed bony maturation), hypotonia and poor feeding or growth

Answer 126

Following dental/resp tract procedures: VIRIDANS STREP (e.g. Strep sanguinis, mitis, mutans, milleri). Causes late-onset IE of prosthetic valve (>1 year after valve placement). CF staph epidermidis causes early-onset IE of prosthetic valve (<1 year after valve placement) Manipulation of infected areas of GI/GU tract: ENTEROCOCCUS Following skin/soft tissue infection or in IVDU: STAPH AUREUS (acute) or coag neg Staph (STAPH EPIDERMIDIS)

Answer 127

Nighttime snoring and GASPING FOR AIR Caused by ADENOTONSILLAR HYPERTROPHY (CF obesity in adults) Open mouth breathing during day (nasal obstruction secondary to adenoid hypertrophy) Tx: tonsillectomy and adenoidectomy

Answer 128

Verbal at home but refuse to speak in specific social settings e.g. school Considered an anxiety disorder and should be tx early to prevent long-term educational and social impairment CBT w graded exposure to social situations, family therapy or SSRI

Answer 129

Placed in internal jugular vein (using USS) or subclavian vein (anatomic landmark) CVC tip ideal placement is in lower SVC Tip placement in smaller veins -> VENOUS PERFORATION Inappropriate tip placement -> PNEUMOTHORAX or myocardial perf leading to PERICARDIAL TAMPONADE ARTERIAL PUNCTURE (e.g. subclavian) also risk esp if done without USS PORTABLE CXR should be performed immediately post insertion (except if completely uncomplicated insertion)

Answer 130

Obliterative endarteritis and submucosal fibrosis Leading to ANORECTAL STICTURE formation, reduced rectal compliance, constipation and fecal intolerance Chronic tissue hypoxia -> neovasc and telangiectasia -> hemorrhage

Answer 131

M/c due to ATHEROSCLEROTIC DISEASE Results in transient ischaemia of regions supplied by VB system (brainstem, cerebellum, occipital lobes) when cerebral perfusion is further reduced (e.g. standing up) Dizziness/vertigo, brainstem sx (diplopia, dysarthria) and bilateral motor and/or sensory sx CT angio head/neck dx

Answer 132

Establish adequate patent airway Maintain adequate ventilation and gas exchange Ensure HD stability Place pt w bleeding lung in dependent pos (lateral pos) BRONCHOSCOPY to identify site and attempt early therapeutic intervention Surgery if ongoing unilateral bleeding despite initial bronchoscopy and/or pulm artery embolisation N.B: massive hemoptysis = >600ml of blood over 24 hr period or bleeding rate > 100ml/hr

Answer 133

2-6cm prox to insertion of tendon on calcaneus CF sc calcaneus bursitis: at calcaneal prominence (Achilles tendon insertion site)

Answer 134

Precipitating factors: infection or surgery preg or childbirth tapering of immunosuppressive meds meds (aminoglycosides, beta blocker) Increased generalised and oropharyngeal weakness resp insufficiency/dyspnea INTUBATION for deteriorating resp status PLASMAPHARESIS or IVIG as well as CORTICOSTEROIDS N.B: do NOT increase pyridostigmine dose as it is an cholinomimetic so causes increased secretions, worsening resp status

Answer 135

SVT Distinct P waves with >= 3 different P wave morphologies, atrial rate > 100/min and irregular rhythm Precipitated by acute resp illness in pts w underlying lung disease Tx: correct underlying inciting disturbance

Answer 136

BMI >= 40 or BMI >= 35 and additional weight-related comorbidity Weight loss med indicated for pts w BMI >= 30 or those w BMI 25-29.9 and weight related complications Both interventions may be pursued concurrently

Answer 137

Large and prone to recurrence Acute mx w pericardiocentesis Prevention of reaccumulation, either by PERICARDIAL WINDOW or PROLONGED CATHETER DRAINAGE

Answer 138

Removal with small forceps as close to skin surface as possible Pull firmly upwards without twisting N.B: body of tick should not be squeezed or crushed as this can expel secretions into the wound and increase transmission risk If deer tick attached for >= 36 hours, prophylactic single dose of DOXY within 3d of tick removal CF abx prophylaxis not effective for anaplasmosis and babesiosis

Answer 139

Intentional and repeated fire setting with no obvious motive Pts have fascination with fire and deliberately start fires to reduce tension and feel pleasure or relief

Answer 140

Abx use, CYTOTOXIC CHEMO, recent hospitalisations, advanced age (>65) Stool PCR dx C diff: watery diarrhoea, abdo cramps, nausea, fever, LEUKOCYTOSIS

Answer 141

Rfs: advanced cirrhosis w portal HTN Acute liver failure, severe alcoholic hepatitis Patho: splanchnic vasodilation (from release of vasodilators e.g. NO) -> renal hypoperfusion -> RAAS activation -> overwhelming renal vasoconstriction -> AKI Precipitants: GI bleed, infection (e.g. SBP) N.B: SBP tx = cefotaxime; prophylaxis = fluoroquinolones Dx: bland urinalysis (no red cells, casts or protein) very low urine Na (<10) exclusion of other causes of AKI NO IMPROVEMENT W TRIAL OF VOL EXPANSION Tx: albumin + splanchnic vasoconstrictors (terlipressin, norepi, or midodrine + octreotide) liver transplantation curative N.B: cirrhosis (not advanced): release of prostaglandins -> vasodilation -> ascites and ADH release -> H20 retention -> hyponatraemia; hypokalaemia as well due to vomiting/diarrhoea/diuretic use

Answer 142

FANCONI ANEMIA Defective DNA repair impairs normal HSCT production and predisposes to malignancy (e.g. leukaemia) Pancytopenia, short stature, HYPOPLASTIC THUMBS, ABNORMAL SKIN PIGMENTATION

Answer 143

Encephalopathy and myoclonus, relieve on discontinuation Other causes of myoclonus: Physiologic (sleep transitions, hiccups) Infectious/metabolic (meningitis, liver failure) Neurodegenerative disease (Parkinson's, CJD) Seizure disorder Med side effects (serotonergics, anticonvulsants)

Answer 144

Follicular miniaturisation Men: effect of DHT on genetically suspectible follicles Women: isolated/idiopathic (most cases) or due to hyperandrogenism (e.g. PCOS) Men: vertex, frontal hairline, temporal areas Women: vertex, frontal scalp (spares hairline) Tx men: oral finasteride, top minoxidil Women: top minoxidil

Answer 145

Hypergonadotropic hypogonadism (primary ovarian insufficiency)

Answer 146

HEAD OF BED ELEVATION AT 30-45 degrees Suction of subglottic secretions Min of pt transport Limited use of gastric acid inhibitors (to reduce burden of microorganisms in gastric secretions)

Answer 147

Acute cholangitis: infection of extrahepatic biliary system, occurs due to biliary obstruction (bile stone, ca, STRICTURE e.g. PSC)

Answer 148

Due to inadequate dietary intake (e.g. NPO), intestinal malabsorption and hepatocellular disease An acutely ill pt with underlying liver disease can become vit K def in 7-10d Labs: prolonged PT followed by prolonged PTT CF DIC: prolonged PT, PTT but low platelets, low fibrinogen, raised D dimer etc

Answer 149

Lean: identification and removal of inefficiency and waste in a CURRENT workflow (CF failure modes and effects analysis: prospective so identifies POTENTIAL errors) Six Sigma: near elimination of defects through STATISTICALLY DRIVEN process improvement Model for improvement: incremental cycles of planning, piloting, assessing and refining intervention to achieve goal (PDSA cycle) Change management: engaging personnel to adopt innovation & implement organisational changes

Answer 150

Central retinal artery occlusion Central retinal vein occlusion Retinal detachment: floaters, photopsia, progressive visual field defect; funds w vitreous hemorrhage and marked elevation of retina; surgical correction Vitreous hemorrhage: hazy vision +- red hue or vision loss, floaters/shadows; PROLIFERATIVE DIABETIC RETINOPATHY rf; decreased/absent red reflex, RBCs/floating debris in vitreous, obscured view of fundus; bed rest, HOB elevation (30-45 deg), photocoag/vitrectomy in some cases

Answer 151

Aromatase deficiency CF CAH: classic type (21 alpha hydroxylase def): ambiguous ext genitalia at birth, normal female internal repro organs, hyponatremia; non-classic type: later in life: primary amenorrhoea and virilisation at puberty but normal genitalia at birth

Answer 152

M/c in young women (median age 21) Assoc w OVARIAN TERATOMA

Answer 153

Due to combination of EXCESSIVE FLUID INTAKE and NONOSMOTICALLY MEDIATED RELEASE OF INAPPROPRIATELY HIGH LEVELS OF ADH In severe cases, pts may experience seizures, profound confusion and even death Other nonosmotic causes of ADH release: nausea, pain, physical or emotional stress, hypotension, hypovol, hypoxia, hypoglycaemia N.B: high altitude cerebral edema is rare and accompanied with severe headache and concomitant pulm oed

Answer 154

Carribean, central/South America, Africa, Asia Aedes mosquito Incubation: 3-7d HIGH FEVER, SEVERE POLYARTHRALGIA Headache, conjunctivitis, myalgia, MP diffuse rash (CF SLE sun-exposed eg malar) Lymphopenia, thrombocytopenia, transaminitis (like Ehrilichiosis) Supportive care Chronic arthralgia frequently occurs (MTX may be needed)

Answer 155

Low energy, impaired concentration, hypersomnia and weight gain As it has MILD STIMULANT PROPERTIES Can also be used for SMOKING CESSATION

Answer 156

Absolute CIs: amniotic fluid leak cervical insufficiency multiple gestation placental abruption or previa premature labor preeclampsia/GHTN severe heart or lung disease

Answer 157

BPP= Nonstress test plus USS measuring: amniotic fluid vol fetal breathing mvt fetal mvt fetal tone 2 points per cat if normal, 0 if abnormal. normal = 8 or 10 N.B: if NST is abnormal (< 2 accelerations / recurrent variable/late decelerations) indicative of either fetal sleep cycle (benign cause) or fetal hypoxia/acidemia. Further eval w BPP Contraction stress test (FHR monitoring during contractions) used to assess fetal wellbeing if BPP equivocal (6/10) . Abnormal if late decelerations w >50% contractions Umbilical artery doppler USS used to monitor FGR (est FW < 10th centile)

Answer 158

Reassurance w BREATHING RETRAINING (abdo diaphragmatic breathing) If not improving, small dose of benzo e.g. lorazepam breathing into paper bag NOT recommended as can cause hypoxia

Answer 159

ALKALINISATION of urine (POTASSIUM CITRATE) Reduction of uric acid production (low-purine diet, allopurinol) N.B: thiazide diuretics decrease uric acid secretion but can lower urine pH so making uric acid stones more likely to form

Answer 160

FOOSH w post displacement of distal humerus fragment Ant displaced prox humerus fragment can entrap BRACHIAL ARTERY & MEDIAN NERVE which pass anterior to the humerus N.B: ulnar nerve injury from supracondylar fracture from FLEXED elbow (not hyperextended)

Answer 161

Mucous hypersecretion (dark-coloured sputum) leading to formation of MUCOUS PLUG in airways Leading to ATELECTASIS N.B: trach dev away from affected side if large pleural effusion/TP

Answer 162

DIASTOLIC & CONTINUOUS usually due to pathological cause so require TTE CF midsystolic murmurs in young asx pts usually benign no need for echo

Answer 163

Sig withdrawal sx Incl risk for GENERALISED SEIZURES & CONFUSION Also tremours, anxiety, perceptual disturbances, psychosis

Answer 164

Non-IgE mediated reaction to a protein (typically COW'S MILK/SOY) BLOODY STOOLS in well-appearing infants (m/c age 1-4 weeks)

Answer 165

UTERINE OVERDISTENSION (twin gest, severe polyhydramnios) because sudden loss of amniotic fluid leads to uterine decompression causing placental hemorrhage and separation Rigid, tender uterus and uterine irritability (high-frequency contractions) because bleeding increases intrauterine pressure Other rfs: HTN, pre-eclampsia, cocaine, tobacco, abdo trauma, prior placental abruption

Answer 166

Increase bicarb reabsorption (in prox tubule: carbonic anhydrase enzyme) and H+ excretion Increased bicarb reabsorp causes increased Cl- excretion (in collecting duct) (to maintain total body electronegative balance) Most of excreted H+ in form of NH4+ or H2PO4- (Resp compensation w hyperventilation is main compensation for primary met ac)

Answer 167

FEVER, MP RASH, AKI (+/- arthralgias) Pyruia, HM, white cell casts Eosinophilia, urinary eosinophils Drugs: penicillins, TMP-SMX, NSAIDS, cephalosporins

Answer 168

BILIARY CYST (Biliary atresia = absent or abnormal GB)

Answer 169

Cross-sectional Biased in favour of longer-lasting and milder conditions as cross-sectional is a snapshot so misses out acute and more severe conditions CF ecological fallacy is when you are analysing country-level data and then making inferences on individuals

Answer 170

CENTRAL CORD SYNDROME (esp if elderly pts have cervical spondylosis) Loss of pain and temp sensation (decussating fibers of spinothalamic tract) in upper extremities and disproportionate upper extremity weakness (with larger lesions affecting lateral corticospinal tracts) Another classic (altho slowly progressive) cause of CCS is syringomyelia

Answer 171

Small-vessel vasculitis that causes PALPABLE PURPURA (CF TTP nonpalpable petechial rash), GLOMERULONEPHRITIS, ARTHRALGIAS & PERI NEUROPATHY Labs: cryoglobins, RHEUMATOID FACTOR (due to IgM binding to Fc region of IgG). Immune complexes activate complement so HYPOCOMPLEMENTEMIA and deposit in small vessels of organs causing the vasculitis CHRONIC HEP C m/c cause, check serologies in all cases

Answer 172

Mild, irregular contractions that cause no cervical change and ultimately resolve without intervention Discharge home w labour precautions

Answer 173

PIPERACILLIN-TAZOBACTAM (due to high risk for secondary bacterial infection w aerobic/anaerobic pathogens) while awaiting cholecystectomy

Answer 174

Language disorder: persistent difficulties in acquisition and use of language due to deficits in comprehension and/or production Specific learning disorder: requires use of standardised achievement testing to dx but language disorder is a rf for SLD

Answer 175

Groin pain on weight bearing Pain on hip ABDUCTION & INT ROTATION No erythema, swelling or point tenderness NORMAL WBC NORMAL ESR & CRP CRESCENT SIGN seen in advanced stage (X ray may be normal initially) MRI most sensitive modality

Answer 176

Pathologic: Holosystolic (could be VSD)/diastolic Harsh Grade >= 3 intensity Intensity persists w Valsalva & standing Loud, fixed or single S2 Hepatomegaly ECG & ECHO Benign: Early or midsystolic Musical or vib Grade 1-2 intensity Decreases or disappears w Valsalva & standing (N.B: venous hum is benign but increases w standing) Normal S1 & S2 REASSURANCE

Answer 177

Rfs: Male, age >50, FHx DM Tobacco and alcohol MANUAL WORK (e.g. gardening) Thickening of palmar fascia at 3rd, 4th & 5th digits Discrete FIBROTIC NODULES & CORDS along flexor tendons near distal palmar crease Gradual decrease in extension of digits Mod of hand tools Needle aponeurotomy Intralesional glucocorticoid injection Surgery for contractures or advanced disease

Answer 178

No empyema/lung abscess: treat for CAP (ie pen tolerant: amox/co-amox (if higher risk) & macrolide/doxy; if pen allergic: cephalosporin & macrolide/doxy; if cephalosporin intolerant: fluoroquinolone) Empyema/lung abscess present: extend coverage to include ANAEROBES (AMPICILLIN-SULBACTAM)

Answer 179

E.g. combined effects of etoh & benzos Benzo OD on its own: altered mental status, ataxia, slurred speech When VITAL SIGN DERANGEMENT OR RESP DEPRESSION seen, CO-INGESTION with other sedative-hypnotics or CNS depressants should be considered

Answer 180

Benign bony growth (exostosis) on midline suture of hard palate Congenital or dvp later in life Chronic and asx Surgery if mass becomes sx, interefers w speech/eating/denture fitting etc

Answer 181

Depends on condition of valve (prosthetic or native) and prior hx of IVDU Native: VANCO Once organisms identified on blood cultures than abx can be changed accordingly

Answer 182

Observation for most lesions PROPRANOLO for high risk e.g. Large, facial, segmental, rapidly growing Periorbital Hepatic Subglottic

Answer 183

DM (diabetic neuropathy) Long standing HIV infection Uraemia Meds (FLUOROQUINOLONES, METRONIDAZOLE) Chemo (cisplatin, paclitaxel) Toxicity (alcohol abuse, heavy metal exposure)

Answer 184

Ensure that methods used to achieve a worthwhile goal are necessary, appropriate and not excessive

Answer 185

First few months of life as hyperpigmented patches w an INCREASED DENSITY OF HAIR FOLLICLES CF nevus simplex (eyelids, neck, fade w time) and flammeus (port wine stains, does not fade with time, unilateral on face) are flat, blanchable and erythematous vasc birthmarks

Answer 186

Etiology: Recurrent idiopathic or viral pericarditis Cardiac surgery or radiation therapy Tuberculous pericarditis Fatigue, dyspnoea on exertion Peripheral oedema, ascites, hepatic congestion Pericardial knock in early diastole JVD w positive Kussmaul sign and prominent y descent ECG: low voltage QRS complexes CXR/CT: PERICARDIAL CALCIFICATION Echo: BIATRIAL ENLARGEMENT, NORMAL ventricular wall thickness and cavity size CF cardiac amyloidosis: ventricular Wall thickness present and no calcified pericardium

Answer 187

Asx condition Normal decrease in Hb with a nadir at age 2-3 mo Normocytic anaemia with low to normal retic count Transient downregulation of EPO due to increased tissue oxygenation after birth Anaemia resolves with increased erythropoietin drive after age 3 mo

Answer 188

Cryotherapy w liquid nitrogen Curettage Topical therapy (cantharidin, podophyllotoxin)

Answer 189

Non-stress tests beginning from 3rd trimester due to increased risk for stillbirth

Answer 190

Life-threatening form of acute cholecystitis Fever, RUQ pain, N/V Crepitus in abdo wall adjacent to GB Rfs: DM, vasc compromise, immunosuppression Air-fluid levels in GB, GASS IN GB WALL Cultures w gas-forming Clostridioides, E coli Unconj hyperbili, mildly elevated aminotransferases (CF acute cholecystitis: raised ALP, conj bili) Emergency cholecystectomy Broad spectrum abx w Clostriodes coverage (tazosin)

Answer 191

Alveolar consolidation causes V/Q mismatch from localised intrapulm shunting Pneumonia down -> increased perfusion of poorly ventilated region -> increased V/Q mismatch and worsened hypoxaemia Pneumonia up -> decreased perfusion of poorly ventilated region -> decreased V/Q mismatch and improved hypoxaemia

Answer 192

Administer early in ratio of 1:1:1 (FFP/packed red cells/platelets) to reduce coagulopathy (major mortality in trauma pts)

Answer 193

Clinical features of SLE, SS, RA and polymyositis that appear sequentially Important manifestations: Raynauds, swelling of fingers and hands, inflam arthritis and myositis AUTOANTIBODIES for U1 RIBONUCLEOPROTEIN

Answer 194

Usually curable w chemo and radiation Risk of death sig elevated in those getting treatment compared to age-matched pop For first 8-10 years, most deaths due to HL relapse; thereafter most due to second malignancy and cardiovascular disease

Answer 195

Causes: renal impairment, increased mag intake Neuromuscular: low reflexes, paralysis, weakness, resp failure CVS: hypotension, brady, conduction defects Electrolyte: hypoca Discontinue mag meds IV fluids +- loop diuretics IV ca for NM and CVS sx HD in severe renal impairment

Answer 196

Left: pulm oed, S3 & S4 ischaemic changes in ant, lateral or inf leads increased LV and RV preload increased SVR Mx: fluid restriction (due to pulm oed), preload and afterload reduction, reperfusion therapy Right: clear lungs & JVD, marked hypotension atypical epigastric pain, nausea, no SOB inf ischaemic changes, ST elevation in V4R*, bradyarrhythmias (due to RCA occlusion so infarct to SAN/AVN) increased RV preload, decreased LV preload increased SVR Mx: *RV involvement eval w right-sided precordial ECG, fluid resuscitation, avoid preload reduction, reperfusion therapy N.B: cardiogenic shock: dobutamine/norepinephrine/ dopamine

Answer 197

e.g. endometrioma may be on ovary UNILOCULAR, HYPOECHOIC adnexal mass on USS CF tuboovarian abscess: complex multicystic adnexal mass w enhancing rims

Answer 198

IVC FILTER

Answer 199

Prolonged PTT that fails to correct w MIXING TEST (combination w normal plasma) Most pts w these autoantibodies are asx but can go on to develop APS CF VWD: mixing test would correct PTT

Answer 200

ENTEROCOCCI esp Enterococcus faecalis

Answer 201

Provide clinical assessment and early intervention for hosp pts at high risk for clinical deterioration Can support primary care teams and reduce in-hosp mortality rates

Answer 202

Rfs: Eldery (age >60) DM Aural irrigation (cerumen removal) Micro: PSEUDOMONAS AEURIGINOSA Severe, unremitting ear pain (WORSE AT NIGHT & WITH CHEWING) Deficits of lower CNs (VII, IX, X) GRANULATION TISSUE in ext aud canal Elevated ESR IV cipro +- surgical debridement

Answer 203

IMMEDIATE COLPOSCOPY (even in preg pts) and biopsy of cervical abnormalities due to high risk of progression to cervical ca Colposcopy identifies cervix under magnification and uses acetic acid to contrast and identify abnormal (ACETO-WHITE CHANGES) from normal cells, abnormal vessels (feature of high-grade) also become visible Inadequate colposcopy -> endocervical curettage (invasive and deferred during preg due to high risk of miscarriage and preterm delivery) Cervical biopsy performed during preg if high-risk lesion HPV co-testing used if atypical squamous cell of undetermined sig and low-grade intraepi lesion N.B: women >= 35 with ATYPICAL GLANDULAR CELLS on Pap test -> endometrial biopsy (in addition to colposcopy) as AGC can be caused by either cervical or endometrial ca Endometrial biopsy if AGC and under 35 years of age but rfs for endometrial ca (obesity, anovulation) N.B2: if atypical squamous cells or pos cytology/HPV then perform reflex triage testing (ie HPV testing if cytology pos or cytology testing if HPV pos)

Answer 204

Direct myotox: statins, fibrates, colchicine, ethanol, cocaine Vasoconstrictive ischaemia: cocaine, amphetamines Prolonged immobilisation (compressive ischaemia): ethanol, benzos, opiates

Answer 205

BENZOS for BP and anxiety ASPIRIN for inhibition of cocaine-induced PLT aggregation Nitroglycerin & Ca channel blockers for vasoconstrictive pain Immediate cardiac cath if indicated (STEMI) Caution with: fibrinolysis (increase risk for ICH), beta blockers (increase risk for coronary vasoconstriction)

Answer 206

Aetiology: preceding resp illness (90% viral) Cough for >5d to 3 weeks (+- purulent sputum) Absent systemic findings (fever/chills) Wheezing or rhonchi, chest wall tenderness Clinical dx, CXR only when pneumonia suspected Symptomatic tx (NSAIDs/bronchodilators) Abx NOT recommended

Answer 207

Unknown GBS status and any of the following rfs for vertical transmission: Rupture of membranes for >= 18 hours Intrapartum fever Fetal prematurity (<37 weeks gest)

Answer 208

Hemisection of spinal cord Ipsilateral hemiparesis and diminished proprioception, vib sensation and light touch at the level of the spinal cord injury and below Contralateral diminished pain and temp sensation 1-2 LEVELS DISTAL TO THE CORD INJURY & BELOW

Answer 209

Episodic, inappropriate closing (adduction) of vocal cords during inspiration Resulting in laryngeal obstruction and inspiratory stridor (CF exp wheezing in asthma, exp stridor in tracheomalacia) Throat tightness and impaired inspiration Triggers: strong smells, stress or exercise Laryngoscopy dx (vocal cord adduction during inspiration) Acute episodes tx: ask pt to SNIFF/PANT or NIV Long-term mx: education and therapy w speech-language pathologist Can present in ELITE ATHLETES & often mimics exercise-induced asthma

Answer 210

Binds to sulfhydryl groups Disrupts cellular respiration and gluconeogenesis Sources: pesticides/insecticides, contaminated water (esp from wells), pressure-treated wood (e.g. used in outdoor fences) Acute: garlic breath, vomiting, watery diarrhoea, QTc prolongation, severe: PANCYTOPENIA, HEPATITIS Chronic: hypo-hyperpigmentation, hyperkeratosis, stocking-glove neuropathy, Mees lines (horizontal striation of fingernails) Dx: urine arsenic levels Tx: DIMERCAPROL (British anti-Lewisite) DMSA (succimer)

Answer 211

YES UNIVERSAL at FIRST prenatal visit 3rd trimester and delivery (if high risk)

Answer 212

Superficial pallor and anaesthesia Blistering, eschar formation Deep tissue necrosis and mummification Mx: RAPID REWARMING IN WATER BATH 37-39C Analgesia & wound care ANGIOGRAPHY/T99M SCAN to assess for thrombosis if rewarming unsuccessful, if thrombosis present then... ...Thrombolysis in severe, limb-threatening cases

Answer 213

Nonselective phosphodiesterase inhibitor, causes bronchodilation, used in COPD Tox from decreased clearance of drug eg CYP450 inhibitors CNS (tremour, seizure), CVS (tachyarrhythmia, hypotension) & GI (vom) sx

Answer 214

Amenorrhoea at age <40 Hypoestrogenic sx (hot flashes) Raised FSH Low estrogen (hence no withdrawal bleed after progesterone withdrawal test) Major causes: Idiopathic Turner syndrome FRAGILE X SYNDROME (FMRI PREMUTATION leading to accelerated follicle depletion) Autoimmune oophoritis Anticancer drugs Pelvic radiation Galactosemia N.B: levonorgestrel IUD can cause amenorrhoea by thinning endometrium; copper IUD causes heavy bleeding; both FSH normal

Answer 215

YES! Represents form of creative play, aiding in dvp of social and emotional competence, as well as providing comfort in times of distress

Answer 216

No as this is caused by nontyphoid subtype Self-limited infection Supportive mx N.B: abx tx paradoxically assoc w EXTENDED TIME OF ASX CARRIAGE (due to disruption of gut microbiota which normally prevents it from colonising) If higher risk of invasive disease, then abx warranted (extremes of age, immunocompromised, SCD, CV or sig joint disease, severe disease requiring hosp) CF typhoidal requires abx due to serious complications (intestinal perforation, encephalopathy)

Answer 217

Wound care: copious irrigation w saline Debridement of dead tissue Secondary intention healing Imaging: radiographer if # or foreign body suspected Infection mx: CO-AMOX if wound infected or high risk for infection: PUNCTURE WOUND (e.g. cat bite) Involvement of face, hand/foot, joint, genitalia Immunocompromised Primary closure (cosmetic reasons or involvement of deep MSK or vasc structures) TETANUS prophylaxis if incompletely vaccinated or last dose >= 5 years ago Rabies prophylaxis if high-risk animal cannot be quarantined/observed N.B: oral flora of cats includes PASTEURELLA MULTOCIDA and anaerobes

Answer 218

Growth failure, easy fatigability and heart failure Holosystolic murmur loudest at left lower sternal border and an APICAL DIASTOLIC RUMBLE due to increased blood flow across mitral valve

Answer 219

Age < 2: RBUS followed by VCUG if abnormal Age >= 2: observation alone Recurrent febrile UTIs: RBUS and VCUG

Answer 220

MAGNETIC GAIT: slow, wide-based steps as if feet stuck to ground N.B: UMN signs may also occur in addition to triad Dx confirmed w improved sx w large-vol LP (Miller Fisher test), MRI scan VP shunting tx N.B: secondary causes of NPH include SAH, meningitis, trauma causing scarring and destruction of arachnoid granulations

Answer 221

FOOT IMAGING (X ray, MRI) for all DFU that are: deep (exposed bone) long-standing (> 7-14d) large (>=2 cm) raised ESR/CRP adjacent soft tissue infection

Answer 222

ASPIRATION OF BLOOD from corpus cavernosa Intracavernous injection of PHENYLEPHRINE

Answer 223

Mechanical ventilation: 1. Lung protection: limit alveolar distending vol (VT 6) & pressure (Pplat <=30) 2. Ventilation: tolerate permissive hypercapnia (raised PaCO2 & decreased pH acceptable) to avoid excessive VT 3. Oxygenation: set lowest feasible FiO2 (SpO2 92-96%) to avoid O2 tox 4. Increasing the PEEP: to distend the alveoli (thereby increasing alveolar ventilation as well as decreasing the work of breathing) and increase oxygen diffusion into the pulmonary capillaries. Patients with severe ARDS often require higher levels of PEEP to help recruit alveoli and improve gas exchange. Supportive care: 1. Treat underlying cause 2. Prevent iatrogenic harm: NEGATIVE FLUID BALANCE (due to increased vasc permeability), timely extubation (minimise sedation) 3. +/- corticosteroids in mod-severe early cases N.B: Prone positioning is technically difficult and is usually only pursued after alternative interventions to stabilize the patient's oxygenation have been attempted.

Answer 224

Hx: Personal/FHx of MIGRAINES Episodes have an identifiable trigger (infection, stress) Sx: Stereotypical vomiting episodes, self-limited lasting 1-2d Between episodes: usually asx, regular intervals (2-4wks)

Answer 225

Lateral curvature of spine without known aetiology in child >= 10 Forward bend test: asymmetric thoracic or lumbar prominence X RAY SPINE to determine degree of scoliosis and assess skeletal maturity Most curves mild: monitor every 6mo Thoracolumbar spinal brace if child has growth potential remaining and Cobb angle >= 30 degrees Surgical fixation for severe curvature (>= 40-50 degrees)

Answer 226

QUOTIDIAN FEVER for >= 2 weeks FIXED ARTHRITIS for >= 6 weeks PINK MACULAR RASH that WORSENS DURING FEVER (CF acute RF: transient and migratory rash) Leukocytosis, thrombocytosis, elevated ESR and anaemia CF poly/oligoarticular JIA not assoc w fever/rash

Answer 227

Postnasal drip, GORD, asthma m/c causes Cough following URTI: ORAL 1ST GEN ANTIHISTAMINE (chlorphenamine) or comb antihistamine-decongestant (brompheniramine and pseudoephedrine) Cough following rhinitis: intranasal glucocorticoids If pts do not respond after 2-3 weeks, further investigation needed (e.g. sinus imaging, high res CT chest, PFTs) or empiric therapy for suspected cause e.g. GORD, asthma etc

Answer 228

Coronary artery aneurysms Also increased risk of ventricular dysfunction due to LYMPHOCYTIC MYOCARDITIS, esp in infants HF sx (diaphoresis with feeds) and signs (hepatomegaly, pulm oed, S3 gallop)

Answer 229

Caused by intestinal epithelial damage (e.g. gastroenteritis, coeliac) Leads to carb (ie lactose) malabsorption and TRANSIENT sx of diarrhoea, crampy abdo pain and bloating CF milk protein induced proctocolitis: non-IgE mediated reaction causing bloody, mucoid stools in early infancy

Answer 230

Rfs: collagen defects uterine abnormalities cervical conisation obstetric injury Clinical features: >= 2 prior painless, 2nd trimester losses OR painless cervical dilation in current preg OR 2nd trimester cervical length <= 2.5cm plus a prior preterm delivery Mx: CERCLAGE placement performed in 1st trimester if hx of cervical insufficiency Suture removed at term to allow vag delivery

Answer 231

Interruption of blood flow to anterior spinal artery Leading to anterior spinal artery ischaemia particularly in lower thoracic levels Acute bladder paralysis, lower extremity paresis, crude touch/pain sensation loss and diminished reflexes initially Vibration and deep touch sensation preserved because post columns receive blood supply from intact posterior spinal arteries

Answer 232

Common in pts w advanced AIDS Signs of elevated ICP Elevated ICP can compress 6th cranial nerve resulting in diplopia and lateral gaze palsy

Answer 233

Secondary cause: HIV infection Strep pharyngitis (guttate psoriasis) Meds (systemic glucocorticoid withdrawal, antimalarials, lithium, beta blocker)

Answer 234

Women <45: normal finding, not reported Postmenopausal: abnormal finding, may indicate ENDOMETRIAL HYPERPLASIA/CA due to shedding so needs to be investigated with endometrial biopsy!

Answer 235

Criteria: pH > 7.25 Adequate ox (Pa)2 >= 60) on minimal support (FiO2<= 40 and PEEP <= 5) Intact resp effort and sufficient mental awareness to support airway If meet criteria, pt undergoes SPONTANEOUS BREATHING TRIAL (remain intubated but vent support turned off for around 1-2 hrs) Also during SBT, RSBI can be calculated and if >105 indicates breathing rapidly and shallow so not ready for extubation N.B: tidal vol 6-8 is a good level to prevent barotrauma from ventilator

Answer 236

Oes: PROLONGED (>1hr) Occurrence at REST in younger pts w/o multiple cardiac rfs

Answer 237

Tall P waves (RA enlargement) and left axis deviation (left sided vol overload) on ECG Decreased pulm markings on CXR (hypoplasia of RV and pulm outflow tract) Reason: Tricuspid atresia -> pulm stenosis due to lack of development of pulm valve/artery) ASD and VSD present to allow mixing of blood

Answer 238

Resolves spont within a week of dvp Assoc w recurrent illness which can become less frequent over time Antivirals used to decrease sx duration and number of recurrences

Answer 239

Aeitiology: Penetrating trauma Fall w object in mouth (toothbrush, pencil) Neck manipulation (yoga, sports) Gradual onset hemiplegia Aphasia Neck pain Thunderclap headache CT or MR angio

Answer 240

CMV: periventricular haemorrhages and hydrocephalus ex vacuo (due to parenchymal blood loss); SNHL TG: parenchymal haemorrhages and obstructive hydrocephalus; chorioretinitis Rubella: cataracts, SNHL Syphilis: osteoarticular destruction (Hutchinson teeth, saddle nose)

Answer 241

Patchy, nonscarring hair loss Exclamation point hairs may be seen Autoimmune TOPICAL/INTRALESIONAL CORTICOSTEROIDS (e.g. triamcinolone) Extensive hair loss: oral Janus kinase inhibitor (baricitinib) or topical immunotherapy Recurring course common, most pts have regrowth over time CF trichotillomania: irregular patches w broken hairs of varying lengths

Answer 242

Female, HLA DRB1 Environmental factors (e.g. Western hemisphere) LOW VIT D LEVELS EBV

Answer 243

BONE AGE N.B. abdo/pelvic USS if Peripheral precocious puberty but first need to do bone age Eval followed by basal LH levels and GnRH stim test to confirm peripheral

Answer 244

AMIODARONE, verapamil, quinidine, propafenone can lead to dig tox in pt on a stable dig regimen DECREASE DIG DOSE by 25-50% when initiating amiodarone, close monitoring of dig levels

Answer 245

SHIGELLA High fever, abdo cramping, mucoid and/or bloody diarrhoea (may be watery initially)

Answer 246

Intimal layer tear or vaso vasorum bleed -> intramural haematoma -> coronary artery occlusion Women <55 Rfs: POSTPARTUM, multiparty, CTD (esp fibromuscular dysplasia) Similar chest pain sx to MI, elevated trop Dx: coronary angio (dissection plane w/o atherosclerosis) Tx: conservative (beta blockers, aspirin) PCI CABG

Answer 247

Early: Anastomotic leak (sepsis) Bowel ischaemia (diffuse abdo pain) Late: Anastomotic stricture (dysphagia, bowel obstruction) Marginal ulcer (abdo pain, bleeding, perianastomotic perforation) Cholelithiasis, cholecystitis (RUQ pain, N.B: rapid weight loss after surgery -> altered bile composition (cholesterol supersaturation), GB stasis (lower CCK release as duodenum bypassed) -> gallstones) Dumping syndrome (diarrhoea, crampy abdo pain, vasomotor) Stomach (anastomotic) stenosis caused by progressive narrowing of GJ anastomosis leading to obstruction of gastric pouch outflow Occurs within 1st YEAR of surgery Progressive sx of nausea, postprandial vomiting, GO reflux and dysphagia Dx and tx OGD to visualise anastomosis and open narrowing CF Dumping syndrome: sx above but also hypotension, tachycardia, diaphoresis, light-headedness, syncope CF anastomotic leak from either GJ/JJ: WEEK after sx; fever, abdo pain, tachypnoea, tachycardia; ORAL CONTRAST-ENHANCED ABDO CT followed by URGENT SURGICAL REPAIR if leak indicated (OGD CI as can worsen leak and cause frank perforation) CF marginal ulcer at GJ anastomosis: several months after surgery; nausea, abdo pain, signs of bleeding; OGD

Answer 248

Cardioversion if HISS Antiarrhythmics e.g. IV PROCAINAMIDE or ibutilide N.B: AVN blockers e.g. beta blockers, ca channel blockers, dig and adenosine should be avoided as they cause increased conduction through the accessory pathway

Answer 249

Spontaneous abortion Benign causes (cervical polyp) to life threatening (ectopic, septic abortion) Speculum and pelvic USS indicated N.b: acute cervicitis is a cause (mucopurulent endocervical discharge) Empiric abx therapy indicated: usually Cef and doxy but doxy CI in pregnancy so cef and azithro Untx can ascend the uterus and cause obstetric/fetal complications so test of cure needed after

Answer 250

UC ENTANGLEMENT because foetuses move around each other in uterus Can lead to hypoxia and foetal demise Cord entanglement is spontaneous and unpredictable and labour increases the risk due to constant agitation from uterine contractions Therefore, mo-mo twins require close antenatal foetal surveillance and elective C section prior to onset of labour (if in labour, emergent C section)

Answer 251

Excessive daytime sleepiness, cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis Tx: sleep hygiene, naps, avoidance of alcohol and drugs that cause drowsiness MODAFINIL to decrease daytime somnolence

Answer 252

Common cause of acute, unilateral lower abdo pain in repro-age woman USS: THIN-WALLED ovarian cyst with PELVIC FREE FLUID Haem stable patients managed with observation and reassurance CF h unstable pts who may have continuous bleeding require surgery

Answer 253

Neck pain, odynophagia and fever following penetrating trauma to posterior pharynx Infection within retropharyngeal space can drain into superior mediastinum (with spread to carotid sheath, resulting in thrombosis of IJV* and deficits in CN 9, 10, 11 & 12) Extension through alar fascia into 'danger space' can transmit infection into posterior mediastinum (potential space between pericardium and vertebral column) and result in ACUTE NECROTISING MEDIASTINITIS: dx with CXR: WIDENED MEDIASTINUM (all pts w retropharyngeal abscess require CXR therefore) Tx for ANM: urgent surgery *Lemierre syndrome caused by oropharyngeal infection (tonsillitis/pharyngitis) that leads to local invasion of lateral pharyngeal wall and infection of neurovascular bundle, especially IJV. Thrombosis of IJV allows septic embolisation to different sites. FUSOBACTERIUM NECROPHORUM most frequent bacterial cause of LS

Answer 254

STAPH AUREUS & PSEUDOMONAS (warm, moist environment) osteomyelitis N.B: bone changes consistent w osteomyelitis take >= 2 weeks to form Tx: IV abx (cipro and tazosin) and surgical debridement

Answer 255

Aetiology: severe neuro injury (e.g. cardiac arrest) causing prolonged cerebral hypoxia Comatose pt Appears within 72hr of injury Myoclonus Generalised, symmetric EEG Antiepileptic meds

Answer 256

Obstipation No air in the rectum on AXR NG tube insertion for gastric decompression followed by EMERGENCY LAPAROTOMY due to high risk of bowel ischaemia, perforation CF partial SBO: conservative mx only

Answer 257

Tamsulosin (alpha blocker) given to cause ureteral smooth muscle relaxation and facilitate stone removal <5mm: small - mx expectantly 5-10mm: medium - tamsulosin >10mm: surgery

Answer 258

Increased TBG: Estrogens & estrogenic meds Acute hepatitis Decreased TBG: Androgenic hormones High-dose glucocorticoids/hypercortisolism HypoproteinaN.B2:emia (nephrotic syndrome. starvation) Chronic liver disease N.B: if TBG conc increased, more TBG binds to thyroid hormone so thyroid hormone production increases to maintain euthyroid state (so total T4 high, free T4 normal) N.B2: salicylates, furosemide and heparin displace T4 from its binding hormones so leads to decreased thyroid hormone production...

Answer 259

INTRA-ABDO ABSCESS: fever and abdo sx return several days after abdo op e.g. subphrenic abscess: RUQ pain, leucocytosis, fever, pulm manifestations

Answer 260

HYPOCALCAEMIA in infants of diabetic mothers due to mat hypomag (caused by osmotic diuresis)

Answer 261

Unresorbed bile acids spill into colon, resulting in mucosal irritation - Bile acid enters terminal ileum too rapidly & overwhelms resorptive capacity (e.g. post cholesytectomy) - Ileal disease impairs absorptive capacity (e.g. CD, abdo radiation damage) Secretory diarrhoea (fasting diarrhoea, nocturnal episodes) Bloating. abdo cramps Unremarkable serum and stool studies Tx: BILE-ACID BINDING RESINS (cholesyramine, colestipol) CF budesonide for microscopic colitis (women, triggered by meds e.g. PPI, NSAIDs)

Answer 262

LV apical hypokinesis, basilar hyperkinesis -> balloon shape on echo (octopus trap)

Answer 263

Impulse control disorder characterised by inability to resist impulse to steal objects of low monetary value or not needed for personal use Rare, seen in adolescene CBT tx

Answer 264

Haemolytic anaemia, cytopaenias, and HYPERCOAG STATE (intraabdo or cerebral venous thrombosis)

Answer 265

TRIHEXPHENIDYL (anticholinergic) Used in YOUNGER pts where tremour is primary concern CF propranolol and primidone for ET

Answer 266

Raised (perfrom USS of foetal anatomy): Open neural tube defects (anencephaly, open spina bifida) Ventral wall defects (omphalocele, gastroschisis) Multiple gestation Lowered: Aneuploidies (trisomy 18 & 21)

Answer 267

Normally cervix should dilate >= 1cm every 2 hours Protraction: cervical change slower than expected, +/- inadequate contractions; tx = OXYTOCIN Arrest: no cervical change >=4 hours with adequate contractions / no cervical change >=6 hours with inadequate contractions; tx = C SECTION

Answer 268

>= 2 prior painless, 2nd trimester losses Painless cervical dilation Mild sx, no pain or contractions and a dilated cervix (bulging and prolapsing membranes) Rfs: Collagen defects Uterine abnormalities Cervical conisation Obstetric injury Mx: Cerclage placement

Answer 269

Focal, unilateral and/or monomorphic wheeze Focal area of diminished breath sounds Xray: HYPERINFLATION of AFFECTED side +- mediastinal shift towards unaffected side Atelectasis if complete obstruction +- foreign body (however most radiolucent so difficult to see) CF pneumothorax: no wheezing, xray: air without lung markings and ipsilateral lung collapse not hyperinflation

Answer 270

Initially normal or mildly elevated due to lack of insulin and hyperosmolality causing increased EC shift of K+ But TOTAL BODY K+ DEFICIT present as osmotic diuresis develops (causing loss of water, sodium, pot, phos)

Answer 271

Small, pruritic, erythematous papules LINEAR PATTERN on exposed areas (breakfast, lunch, dinner), each w a haemorrhagic central punctum Mx: supportive, bug eradication

Answer 272

Centor criteria: 0 - 1 present: no testing/tx for strep infection 2 - 3 present: rapid strep antigen test -> pen/amox if pos 4 present: rapid strep antigen test or empiric pen/amox

Answer 273

Discoid lupus: scaly, erythematous plaques leading to atrophy, hypopigmentation and scarring PCT: lesions form fragile blisters and erosions rather than scaly plaques; individual lesions triggered by minor trauma Both affect sun-exposed areas N.B: PCT tx: phlebotomy, hydroxychloroquine, deferoxamine; sun protection and avoidance of ppt factors (e.g. exogenous oestrogen)

Answer 274

Subacute fever, vomiting, headache, lethargy Cranial nerve palsy Stroke Imaging: BASILAR MENINGEAL ENHANCEMENT & hydrocephalus CSF: WBC 100-500, mildly increased protein, low glucose, increased ADA NAAT or AFB CSF smear

Answer 275

Subacute fever, vomiting, headache, lethargy Cranial nerve palsy Stroke Imaging: BASILAR MENINGEAL ENHANCEMENT & hydrocephalus CSF: WBC 100-500, mildly increased protein, low glucose, increased ADA NAAT or AFB CSF smear

Answer 276

Indicates infection w gram neg bacterium e.g. Kingella kingae 3rd gen ceph needed e.g. ceftriazone

Answer 277

Variant of GBS Characterised by OPTHALMOPLEGIA, ataxia and areflexia Strength preserved Assoc w anti-GQ1b antibody

Answer 278

Potential complication of neuraxial anaesthesia (e.g epidural block) LP, or spinal surgery More common in older adults taking ANTITHROMBOTIC MEDS Slowly progressive motor and sensory dysfunction and localised back pain Bowel and bladder dysfunction potentially URGENT MRI & NEUROSURG DECOMP

Answer 279

MAGENSIUM SULPHATE (so in pts with preeclampsia w MG give valproate instead) fluoroquinolones, aminoglycosides NM blocking agents CNS depressants muscle relaxants ca channel blockers beta blockers opioids statins

Answer 280

Due to extreme unconjugated bilirubinemia Unbound bilirubin crosses BBB Chronic disease (kernicterus) results in hyperkinetic mvts (chorea, dystonia), sensorineural hearing loss and gaze abnormalities

Answer 281

Most cases (AFI >= 24) are idiopathic and asx Pts at term gest with mild, asx poly expectantly mx CF pts w severe or sx poly at preterm gest increased risk for obstetric complications (e.g. preterm labour, PPROM); amniocentesis for these pts

Answer 282

Common and benign childhood condition Cyanotic vs pallid subtypes Cyanotic: triggered by vigorous crying; apnoea & cyanosis -> LOC; rapid return to baseline Pallid: triggered by minor trauma, pain or fear; brady, pale, diaphoretic, limp -> LOC; brief (<5min) confusion/sleepiness CF seizure which is prolonged (>5min) post-ictal confusion BHS: dx clinical, no further ix; assoc w IDA so screening important

Answer 283

Bilateral scrotal USS: solid hypoechoic lesion = seminoma; cystic area and calcifications = NSGCT Serum tumour markers: beta hCG, AFP & LDH elevated in NSGCT RADICAL INGUINAL ORCHIECTOMY to confirm dx histologically and definitive tx

Answer 284

Typically indicates foetal met ac However, OPIOIDS and other meds can cause minimal variability due to foetal CNS depression

Answer 285

Congenital CMV infection Most infected infants are asx (don't have classic SGA, microcephaly, jaundice, HSM) Hearing loss can be at onset or DELAYED until later in childhood; one or both ears can be affected Sx infants tx to prevent progressive hearing loss; asx individuals w isolated SNHL not tx

Answer 286

Prolonged exposure to dopamine blocking agents UPREGULATION & SUPERSENSITIVITY of dopamine receptors Abnormal invol mvts of mouth, tongue, trunk and extremities Can first appear during tx or following antipsych dose ruduction/discont

Answer 287

Receptive anal intercourse Direct spread from vag Mucopuruluent anal discharge +/- rectal bleeding Tenesmus, constipation Pruritus, rectal pain, rectal fullness NAAT of rectal swab Cef + doxy (Chalmydia coverage)

Answer 288

Can occur following cardiac surgery Fever, chest pain, leukocyotsis and mediastinal widening on CXR Tx: drainage, surgical debridement, prolonged abx N.B: AF commonly occurs within a few days of CABG and is self-lim usually; rate control (beta blockers/amiodarone); anticoag +/- cardioversion if AF lasts >24hr after CABG

Answer 289

Present <24hr after blunt thoracic trauma Tachypnoea, tachycardia, hypoxia Rales/decreased breath sounds CT scan (most sensitive) or CXR with patchy alveolar infiltrate NOT CONFINED BY ANATOMIC BORDERS (ie nonlobular) CF ARDS alveolar infiltrates bilateral and do not manifest until 24-48hr after traumatic injury Tx: pain control Pulm hygiene (incentive spiro, chest PT) Supplemental oxygen and vent support

Answer 290

Progressive, PAINLESS muscle weakness involving prox muscles Results from direct catabolic effects of cortisol on skeletal muscle that lead to MUSCLE ATROPHY CK and ESR NORMAL (as no direct damage to myocytes and no inflam)

Answer 291

Rfs: Haem malignancy Infection (CMV, EBV, malaria) Inflam disease (SLE, pancreatitis) Splenic congestion (cirrhosis, preg) Meds (anticoagulation, G-CSF) Diffuse or LUQ pain, peritonitis Referred left shoulder pain (Kehr sign) HD instability Dx: acute anaemia due to intraperitoneal haemorrhage; intraperitoneal free fluid on imaging Tx: catheter-based angioembolisation (stable pts) Emergency splenectomy (unstable pts)

Answer 292

Common Pt factors: increasing age and male (prostate enlargement) Type of surgery: HERNIA REPAIR, joint arthroplasty or anorectal ops Anaesthetic factors: prolonged an duration, excessive fluid admin, use of meds (opioids, anticholinergics) N.B: in addition to suprapubic pain etc, pts may be hypertensive, tachy due to symp stimualtion (distended bladder noxious stimulus) Dx: PORTABLE BLADDER USS (BLADDER SCAN) if POUR present (>600ml on USS), URINARY CATHETERISATION

Answer 293

Benign: Pituitary adenoma (m/c) Craniopharyngioma (N.B: in children AND adults) Meningioma Pituicytoma (low-grade glioma) Malignant: Primary (GCT, chordoma, lymphoma) Metastatic (breast, lung)

Answer 294

Early: hyperdynamic CVS occurring in response to peripheral vasodilation with capillary leak and intravasc hypovol Leading to an increase in SV, HR and PP resulting in BOUNDING PERIPHERAL PULSES N.B: severe hypodynamic phase: cool and clammy extremities due to shunting of blood to vital organs; decreased CO and increased SVR

Answer 295

Erythematous papules and pustules lim to face and scalp around 3 WEEKS of age Used to be called neonatal acne Mx: daily cleansing w GENTLE SOAP & WATER; self-res w/o scarring

Answer 296

Wrist: hamate #, compression from bike handlebar: numbness in medial 1.5 fingers plus intrinsic hand weakness "clumsiness" Elbow: similar sx plus numbness in HYPOTHENAR EMINENCE and MEDIAL DORSUM OF HAND, DECREASED GRIP STRENGTH and WEAKER WRIST FLEXION Compression can occur at epicondylar groove (repeated leaning on elbow e.g. on car windowsill) or cubital tunnel (repeated or prolonged flexion of elbow e.g. cell phone use) N.B: pts w ESRD receiving HD at risk for ulnar injury due to pos during HD sessions plus chronic uraemia causing gen muscle wasting and loss of sc soft tissue

Answer 297

Design stage: Matching Restriction Randomisation Analysis stage: Stratified analysis Statistical modelling

Answer 298

Hypoxaemic resp failure (leading to coma/seizures) Obstructive shock (leading to pulm oedema and CVS collapse) DIC Supportive care: intubation w mechanical ventilation, vasopressors, massive transfusion

Answer 299

UPPER GI SERIES to eval for midgut volvulus Dx: abnormally located LIGAMENT OF TREITZ on RIGHT SIDE of abdomen (malrotation) and a DUODENAL CORKSCREW or bird's beak appearance (volvulus)

Answer 300

Rfs: Local cellulitis, abrasions or pentrating trauma Bursal instrumentation/injection, prior bursal inflammation Immunocompromised Painful, localised bursal swelling w erythema and warmth +/- fever, chills, myalgia Dx aspiration of bursal fluid Consider xray (for suspected fracture, foreign body, osteomyelitis) Systemic abx Drainage in select cases

Answer 301

Early onset (<3mo post surgery): Staph aureus, gram neg rods, anaerobes; acute pain, wound infection or breakdown, fever Delayed onset (3-12 mo): Coag-neg staph (e.g. epidermidis), Pribionibacterium species, Enterococci; chronic joint pain, implant loosening, sinus tract formation Late onset (>12mo): Staph aureus, gram neg rods, beta haemolytic strep; acute sx in previously asx joint, recent infection at distal site (e.g. UTI)

Answer 302

Rare complication of head trauma or barotrauma Leakage of endolymph from semicircular canals and cochlea into surrounding tissues Progressive SNHL Episodic vertigo w nystagmus triggered by changes in pressure in inner ear (e.g. VALSALVA/elevation changes causing extra endolymph loss) Limit activities causing increased inner ear pressure ENT referral

Answer 303

DISCORDANCE between urinalysis and urine microscopy Myoglobinuria due to rhabdo leads to pos blood on urinalysis (myoglobin degradation -> haeme) in absence of rbcs on urine microscopy

Answer 304

TBI can damage cortical areas responsible for inhibiting lower sympathetic centres Disrupted inhibition -> PSH: rapid onsets of tachy, hypertension and tachypnoea often accompanied by fever and diaphoresis These episodes triggered by external stimuli (bathing, repositioning)

Answer 305

Pts more likely to have acute vasoocclusive pain episodes (e.g. abdo pain) due to increased met demands and hypercoag state Also at increased risk for preeclampsia and its sequelae incl. placental abruption, FGR and preterm delivery Therefore more frequent prenatal visits, baseline 24-hr urine collection and protein level testing, and low-dose aspirin for pre-eclampsia prophylaxis

Answer 306

Can present similarly with RLQ pain, fever and leukocytosis PROFUSE WATERY/MUCOID DIARRHOEA highly suggestive of infectious ileocecitis M/C causes are YERSINIA & CAMP JEJUNI N.B: Yersinia: consumption of contaminated food, most commonly RAW PORK. Additional sources of disease transmission include unpasteurized dairy, unfiltered water, and food contaminated with pet feces. The incubation period is typically 4–6 days, after which patients develop inflammatory diarrhea, nausea, low-grade fever, and, in some cases, right lower quadrant tenderness that may mimic appendicitis (pseudoappendicitis). N.B: unwashed veg -> Shigella dysenteriae (2d incubation period)

Answer 307

Primarily developing world Resp droplets/nine banded armadillo Low infectivity Macular, anaesthetic skin lesions w raised borders Nodular, painful nearby nerves w loss of sensory/motor function FULL-THICKNESS BIOPSY of skin lesion (active edege) Non culturable Paucibacillary: DAPSONE + RIFAMPIN Multibacillary: ... plus CLOFAZIMINE

Answer 308

Primary: LOBAR INFILTRATE (due to unchecked prolif) and sig IPSILATERAL HILAR LYMPHADENOPATHY, compression of RML and pleural effusions also may occur Reactivation: CAVITARY INFILTRATE

Answer 309

Inability to void >= 6 hours post vag delivery (or >=6 hours after catheter removal post C section) Dribbling of urine from overflow incontinence URETHRAL CATHETERISATION dx and tx (as decompresses bladder) Postvoid residual vol >= 150 ml dx

Answer 310

Autonomic dysreflexia Noxious stimulus (urinary retenion, constipation, pressure ulcer etc) below lesion stimulates symp activity but no counterbalance parasymp activity Above lesion: parasymp intact causing brady and vasodilation (facial flushing) Below lesion: unreg symp response -> hypertension

Answer 311

Structure fires (e.g. combustion of plastics) Occupational exposure (e.g. mining) Cyanide-containing meds (e.g. SODIUM NITROPRUSSIDE - used for HTN emergency) Can cause HAGMA with raised lactic acid (inhibits ox phosph and forces anaerobic respiration)

Answer 312

Age-related eye disorder resulting from DECREASED ELASTICITY OF LENS So cannot accomodate easily so harder to read objects close up

Answer 313

Suspect in any pt w hx of malignancy who develops back pain w motor and sensory abnormalities Bowel and bladder dysf late signs IV GLUCOCORTICOIDS first then MRI spine

Answer 314

Common cause of stroke in young patients Can occur spont (rfs) or after mild trauma or illness Partial Horner syndrome (ptosis and miosis w/o anhidrosis), unilateral headache and neck pain and cerebral ischaemia (TIA, stroke)

Answer 315

FLUOROQUINOLONES - increase collagen degradation, assoc w Achilles tendon rupture, retinal detachment and aortic aneurysm rupture or rfs for aortic aneurysm (ED, Marfan's, CVD)

Answer 316

Encephalopathy, abdo pain/vom, HAGMA OPTIC NEURITIS common complication that distinguishes methanol ingestion from other toxic alcohol ingestions (e.g. ethylene glycol which would present with AKI, flank pain due to calcium oxalate stones)

Answer 317

Iron: given to pre-term neonates exclusively breastfeeding from birth and continued until 1 year (Also mat iron def and early initiation of cow's milk before age 12 mo increases risk of IDA in neonates) Vit D: given to all neonates exclusively breastfeeding from birth

Answer 318

Mech vent with low tidal volume ventilation Reduces alveolar overdistension of remaining open alveoli (functional "baby lung") Prone pos also decreases mortality by homogenising ventilation throughout lungs (by distributing ventilation from ventral to dorsal (dependent) lung regions where majority of alveoli located)

Answer 319

INTERNAL VALIDITY (ability of research design to provide evidence of causal relationship between treatment and outcome) so increases as study becomes more tightly controlled CF external v CF external v: describes generalisability so increases as study becomes more like real world CF internal v

Answer 320

Acute onset of severe liver injury (raised aminotransferases) w encephalopathy and impaired synthetic function (INR >= 1.5) in a pt w/o cirrhosis or underlying liver disease

Answer 321

AMPICILLIN-SULBACTAM, imipinem, meropenem Alt: clindamycin N.B: metro not indicated as useful against only obligate anaerobes (whereas lung abscess contains obligate and facultative anaerobes)

Answer 322

Distal, symmetric polyneuropathy beginning with numbness/tingling/pain in feet and progresses proximally Older pts with long-standing, poorly controlled HIV at greatest risk Antiretrovirals decrease risk of progression GABAPENTIN first line for sx mx

Answer 323

Premature arrest of pulm dvp Alveolar hypoplasia with decreased septation Impaired vasculogenesis Premature infant w continued supplemental oxygen requirement >= 28d from birth Mild: diffuse hazy infiltrates, low/normal lung volumes Severe: fibrocystic changes, hyperinflation Supportive tx (oxygen, nutrition, fluid restriction/diuretics) Complications: pulmonary artery HTN CVD (HTN) Recurrent respiration infections

Answer 324

PRAZOSIN (in addition to SSRI/SNRI)

Answer 325

Inspiratory stridor (due to dynamic collapse of supraglottic tissues (epiglottis, arytenoids ie extrathoracic airway) on inspiration) Stridor increases in periods of increased airflow (crying, feeding) CF biphasic stridor heard in subglottic stenosis (subglottic airway less flexible than supraglottic so min change in inspiration vs exp therefore biphasic) CF expiratory stridor heard in tracheomalacia (collapsable intrathoracic airway) as increase intra thoracic pressure during expiration narrows intrathoracic trachea

Answer 326

Rare infection caused by gram neg bacilli Burkholderia pseudomallei Endemic to Thailand, Malaysia, Singapore and Northern Australia Transmitted when contaminated soil or water gets inoculated in sc tissue Those w DM at risk of severe disease Bipolar staining w safety pin appearance Fulminant pneumonia, cutaneous ulcers/abscesses (purple coloured lesions) and organ abscesses (spleen, liver, kidney, prostate) Tx: ceftazidime or a carbapenem followed by TMP-SMX

Answer 327

May occur due to uterine artery injury, leading to massive blood loss and HD instability despite minimal abdo pain (due to retroperitoneal space being large) and no obv source of bleeding HD unstable and retroperitoneal haematoma -> EMERGENCY LAPAROTOMY N.B: suspect if post C-section delivery w haemorrhagic shock and no signs of uterine atony (uterine atony: enlarged boggy uterus and heavy vag bleeding)

Answer 328

CEREBRAL AMYLOID ANGIOPATHY Assoc w Alzheimer's dementia, occurs due to beta amyloid deposition in walls of small and medium cerebral arteries leading to increased fragility of vessels Often involves occipital and parietal lobes, usually sparing ventricles and deep brain structures (CF hypertensive haemorrhage) N.B: AVM rupture most common cause of ICH in children

Answer 329

Oral DOXY or IV/IM CEFTRIAXONE for all stages of syphilis EXCEPT NEUROSYPHILIS (who require pen desensitisation followed by pen) All pts w syphilis require nontreponemal titres at time of tx (e.g. RPR) and again 6-12 mo to ensure adequate response (4-fold drop)

Answer 330

Compression of post tibial nerve under flexor retinaculum in medial ankle Trauma Overuse injury Inflamm disorder Burning pain, numbness, paraesthesia Medial ankle, heel, sole, toes Dx: clinical presentation, nerve conduction studies Tx: activity mod, orthotics, NSAIDs/corticosteroid injection, surgical release (refractory cases)

Answer 331

6 months: genu varum 2 years: straight legs 4 years: genu valgum >7 years: straight legs Physiologic genu varum features: symmetric bowing normal stature no leg length discrepancy no lateral thrust when walking

Answer 332

Monosaccharide absorbed in prox small intestine w/o degradation by pancreatic or brush border enzymes Pts w small intestinal mucosal disease will have impaired absorption of D-xylose Pts w malabsorption due to enzyme deficiencies will have normal absorption of D-xylose N.B: false-pos D-xylose test (low urinary D-xylose despite normal mucosal absorption) seen in: Delayed gastric emptying Impaired glomerular filtration SIBO (bacterial fermentation of D-xylose before it can be absorbed); SIBO tx w rifaximin

Answer 333

M/c from abdo surgery But also seen in Retroperitoneal/abdo haemorrhage, intraabdo inflam (e.g. pancreatitis), intestinal ischaemia, electrolyte abnormalities Dilated, gas filled loops of bowel w NO TRANSITION POINT

Answer 334

Risks: Tampon use, nasal packing, SURGICAL/POSTPARTUM WOUND INFECTION Exotoxin release acting as superantigens Fever > 38.9 Hypotension Diffuse macular rash involving palms & soles Desquamation 1-3 wks after disease onset Vom, diarrhoea Altered mentation w/o focal neuro signs Tx: supportive therapy, removal of foreign body, abx (VANCO, CEFEPIME, CLINDAMYCIN)

Answer 335

Rapid rise in bili despite phototherapy or levels > 25 or sx BIND (e.g. lethargy, change in tone) N.B: low albumin increases risk of BIND as less to bind w bili N.B. 2: IVIG for severe haemolytic disease of newborn due to Rh incompatibility

Answer 336

Marked discontinuity in identity & loss of personal agency w fragmentation into >= 2 DISTINCT PERSONALITY STATES Assoc w severe childhood trauma/abuse Tx: long-term psychotherapy

Answer 337

PSGN: Antistreptolysin O antibodies MPGN: Serum cryoglobulins Lupus nephritis: ANA, anti-dsDNA Endocarditis-assoc GN: pos blood cultures N.B: PSGN causes renal-lim disease so hypocomplementaemic glomerulonephritis assoc w systemic vasculitis usually due to MPGN or lupus nephritis

Answer 338

Reassuring: soft, mobile, <2cm; localised; absent systemic sx Worrisome: firm or hard, immobile, >2cm; generalised or supraclavicular; systemic sx present

Answer 339

ENTERAL NUTRITION Multiple benefits (reduction in infection, maintenance of gut integrity) when initiated early (<= 48hr) TPN only used for those w CI to EN (e.g. intestinal discontinuity, prolonged ileus)

Answer 340

Bleeding, haematoma (within 12hrs - localised or w retroperitoneal extension), arterial dissection, acute thrombosis, pseudoaneurysm, AV fistula formation Retroperitoneal haematoma: sudden HD instability, ipsilateral flank or back pain CT scan of abdo and pelvis/abdo USS Supportive, bed rest, intensive monitoring., IVF and/or blood transfusion

Answer 341

Common after whiplash-type injuries in older adults w underlying cervical spondylosis Damage to central cervical spinal cord causes upper extremity motor, sensory and reflex abnormalities Sacral (bowel/bladder) and lower extremity function generally preserved (due to central location of lesion and lateral spinal tracts therefore spared) MRI of cervical spine w/o contrast initial dx test (to determine extent of injury, may also perform non contrast CT cervical spine) Cervical myelogram dx and shows persistent cord compression but ordered second line as invasive Tx: glucocorticoids and/or surgery

Answer 342

Wilms tumour and hepatoblastoma so abdo USS and AFP every 3 mo and renal USS every 3 mo N.B: BWS: fetal macrosomia, rapid growth until late childhood, omphalocele or umbilical hernia, macroglossia, hemihyperplasia; caused by dysregulation of imprinted gene on Chr 11p15

Answer 343

ATYPICAL ANTIPSYCHOTICS (e.g. quetiapine) due to anticholinergic and antihistaminergic effects which reduce ability to form food bolus and increase aspiration risk Also acid suppressants, sedatives, immunomodulatory agents

Answer 344

Chromium: impaired glucose control in diabetics Copper: brittle hair, skin depigmentation, neuro dysf (ataxia, peripheral neuropathy) similar to SCD, anaemia, osteoporosis, oedema Iron: microcytic anaemia Selenium: thyroid dysf, cardiomyopathy, immune dysf Zinc: alopecia, pustular skin rash (perioral region & extremities), hypogonadism, poor wound healing, impaired taste, immune dysf

Answer 345

Hyperkalaemia due to blockage of ENaC so K+ does not move into lumen of collecting tubule Also increase in serum creatinine as inhibits renal tubular creatinine secretion, but GFR unchanged

Answer 346

Antepartum: Testing of HIV viral load monthly until undetectable, then every 3 mo CD4 count every 3 mo Resistance testing if not previously performed Initiation or continuation of HAART IMMEDIATELY! Avoidance of amniocentesis if viral load detectable Intrapartum: Avoidance of artificial ROM, foetal scalp electrode, operative vag delivery Viral load <= 50: ART + vag delivery Viral load > 50 to <= 1000: ART +/- zidovudine + vag delivery Viral load > 1000: ART + zidovudine + C section

Answer 347

1-3: subclavian vessels, brachial plexus, mediastinal vessels (e.g. aorta) 3-6: CVS 9-12: intraabdo: liver (right), spleen (left), kidney (post ribs 11 & 12) any level: pulm

Answer 348

Retained POC: heavy bleeding, +/- uterine atony, boggy or firm uterus, secondary to intraamniotic infection (causing inflam and adherence of tissues); pelvic USS, D&C Placental site subinvolution: heavy bleeding, uterine atony; uterotonics (oxytocin, methylergonovine*, carboprost**) Postpartum endometritis: fever, uterine tenderness, purulent lochia; broad spectrum IV abx (clind & gent) N.B: retained placenta causes immediate PPH w uterine atony (boggy, enlarged uterus); rfs = extreme PRETERM DELIVERY, retained placenta in prior delivery, uterine abnormality, placenta accreta spectrum, intraamniotic infection, intrauterine foetal demise; mx= downward traction of cord and oxytocin; manual placental extraction, D&C *CI in pts w hypertension as it is a potent vasoconstrictor ** CI in pts w asthma as causes bronchospasm

Answer 349

Suspect bacterial gastroenteritis in pt w bloody or mucoid diarrhoea Tx supportive, with close follow-up in well-appearing children Empiric abx NOT recommended primarily due to increased risk of HUS assoc w STEC

Answer 350

Young pts with recent influenza Causes rapidly progressive, necrotising pneumonia w high fever, productive cough (often w haemoptysis), leukopaenia and multilobar cavitary infiltrates Admission to ICU w broad spectrum abx, either vanco or linezolid CF Strep pneumo m/c cause of influenza-related bacterial pneumonia but rare in young individuals and less likely to cause cavitary infiltrates

Answer 351

Nomal stool osmotic gap = 50-125 Secretory diarrhoea: watery diarrhoea ocurring even during fasting or sleep. Can be caused by toxins (e.g. Vibrio cholerae), hormones (e.g. VIPoma), congenital disorders of ion transport (e.g. CF), or unabsorbed bile acids (e.g. due to postsurgical changes). Low stool osmotic gap (<50) Osmotic diarrhoea: polyethylene glycol, sorbitol, lactose which inhibits water resorption and results in high SOG (>125). Occurs after ingestion of causative substance (e.g. milk in pt w lactose intolerance) and does not occur during fasting

Answer 352

BAT can compress upper abdomen against vertebral column and injure pancreas Persistent abdo discomfort or nausea, increasing amylase, of peripancreatic fluid collection CF liver/spleen injury can cause free fluid on abdo USS but would be picked up on CT abdo/pelvis if sig bleeding

Answer 353

OLIGOHYDRAMNIOS (due to decreased prostaglandins so foetal vasoconstriction so decreased RBF) and premature closure of ductal arteriosus

Answer 354

RAI can raise titers of TRAB and worsen opth Glucocorticoids and antithyroid drugs can be used to minimise effects of RAI

Answer 355

Myopia caused by increased axial length of the eye or corneal protrusion Retinal detachment Macular degeneration Due to stretching and thinning of sclera, choroid and retina

Answer 356

Clinical signs may overlap with post-burn hypermetabolic response Burn wound sepsis signs: Temp <36.5 or >39 Vital sign changes incl tachy Evolving lab abnormalities (leukocytosis/penia, thrombocytopenia) Organ hypoperfusion and/or dysfunction e.g. oliguria or NEW-ONSET ENTERAL FEEDING INTOLERANCE (e.g. high gastric residual vol) after a period of tolerance, reflecting splanchnic hypoperfusion leading to GI hypomotility and ileus

Answer 357

Amoxicillin N.B: Lyme disease during preg does not cause harm to foetus but still tx w amox (Azithro reserved if intolerant to doxy and amox)

Answer 358

Biphasic reaction due to nicotine action at ACh receptors: Stimulatory phase: hypertension, tachy, seizures, myoclonus Inhibitory phase: hypotension, brady, coma Muscarinic sx: DUMBELLS Tx: primarily supportive Decontamination if transdermal exposure (e.g. green tobacco sickness from tobacco leaves) Benzos for seizures Atropine for sx brady and muscarinic sx

Answer 359

At risk for PVT that leads to syncope or SCD, esp during periods of rapid heart rate and high symp activity Beta blockers (esp nonselective e.g. propranolol, nadalol) dampen symp activity and shorten QT interval AT HIGH HEART RATES (prolong QT at slow heart rates) to reduce risk of these complications N.B: do not give sotalol as it is also a potassium channel blocker (AIDS) and do not give 1A as it has some K+ channel blocking properties too

Answer 360

Transvenous lead placement through tricuspid valve -> severe tricuspid regurgitation due to direct leaflet damage or inadequate leaflet coaptation Suspect if R HF following those procedures

Answer 361

Coxsackievirus A (causes HFM disease) vs HSV1 3-10 years vs 6mo - 5 years Late summer/early fall vs No seasonality Fever & pharyngitis; grey vesicles/ulcers on POSTERIOR oropharynx vs fever & pharyngitis; clusters of vesicles/ulcers on ANTERIOR oral mucosa & lips; erythematous & oedematous gingiva Supportive vs oral acyclovir

Answer 362

TRANSABDO USS to confirm foetal presentation and determine safest route of delivery N.B: where no palpable presenting foetal part, transabdo USS must be performed before amniotomy to avoid UC prolapse in pts w funic presentation (also amniotomy good for induction of labour but not helpful once labour begun)

Answer 363

Increased automacity of myocardial conduction and/or increased vagal tone Atrial tachy w AV block involves both of these mechanisms and is the answer

Answer 364

Nasal septal perforation secondary to septal haematoma

Answer 365

PT rupture: high-riding patella w a palpable defect at inferior pole QT rupture: low-riding patella, palpable defect superior to patella

Answer 366

Haematogenous or direct intrathoracic spread Rfs: immunosuppression, HD, recent thoracic surgery/trauma Organisms: Staph aureus (m/c), Strep pneumo, Salmonella, Candida Severely ill on acute presentation Fevers, chills, chest pain (pleuritic/non-pleuritic) Can be rapidly fatal ECG: tachy, diffuse ST elevation. +/- low-voltage QRS complexes CXR: enlarged cardiac silhouette and clear lung fields Echo: pericardial effusion Cytology: turbid fluid w increased WBCs (neutrophilia), increased protein. low glucose IV abx + pericardial drainage (pericardiocentesis dx and tx)

Answer 367

Disease PREVALENCE As disease prevalence increases, PPV increases and NPV decreases N.B: sensitivity/specificity are intrinsic test parameters that are not changed by disease prevalence.

Answer 368

Rfs: Pelvic radiation TAMOXIFEN use Postmenopausal patients Abnormal/PMB bleeding Pelvic pain or pressure Uterine mass USS +- additional imaging Endometrial biopsy Histopath of surgical specimen Tx: hysterectomy, +- adjuvant chemo/radiation

Answer 369

Aetiology: Increased intraabdo pressure causing organ dysfunction Rfs: massive fluid resusc, major intraabdo surgery/pathology Tense, distended abdo Increased vent requirements (diaphragmatic elevation, increased intrathoracic pressure) Increased CVP (venous compression but decreased venous return and cardiac preload) Hypotension, tachycardia Decreased urine output (decreased intraabdo organ perfusion) Mx: Temporising measures: Avoid over resusc w fluids Decrease intraabdo vol (NG tube) Increase abdo wall compliance (sedation) Def mx: surgical decompression

Answer 370

Present <24hr after blunt thoracic trauma Tachypnoea, tachycardia, hypoxia Rales or decreased breath sounds CT scan (most sensitive) or CXR (may be normal) w PATCHY ALVEOLAR INFILTRATE not restricted by anatomic borders (IRREGULAR) N.B: alveolar oedema can be exacerbated by subsequent fluid resusc efforts -> CT: ground-glass opacities in lung adjacent to affected chest wall Pain control Pulm hygiene (incentive spirometry, chest PT) Supplemental oxygen and ventilatory support

Answer 371

Rfs: Joint laxity Misaligned lower extremity Tight iliotibial band Patellar subluxation Competitive sports, dance, military training Quick, twisting motion around a flexed knee Feeling of knee giving way, severe pain, popping noise Examination: LATERAL dislocation of patella, decreased extension

Answer 372

ECHO to characterise any assoc pericardial effusion and rule out any other post-MI complications (e.g. free wall rupture). Monitor if pericardial effusion becomes large enough to cause tamponade although rare in PIP Supportive mx Paracetamol for pain control but NSAIDs avoided for at least 7d due to poss increased risk of free wall rupture

Answer 373

Invasive asperigillosis Triad: fever, pleuritic chest pain and haemoptysis. CT: pulmonary NODULES with SURROUNDING GROUND-GLASS OPACITIES ("HALO SIGN") Tx: voriconazole + echinocandin (caspofungin)

Answer 374

DUPLEX USS before any tx (e.g. compression stockings) To determine if pt has correctable cause of venous reflux (e.g. in superficial system) and plan for any interventional procedure N.B: mild CVD (varicose veins or oedema only) or preg pts -> compression stockings Advanced CVD (skin changes: pruritic dermatitis, venous ulcer) /correctable cause -> endovenous thermal ablation provided no CIs (DVT, PAD) All pts w CVD to be counselled on lifestyle changes

Answer 375

SCHISTOSOMIASIS Genitourinary sch -> SCC bladder Hepatosplenic sch -> presinusoidal portal HTN -> portosystemic shunts -> embolisation of sch eggs into pulm circulation -> granulomatous pulmonary endarteritis (pulm sch) -> irreversible pulm HTN

Answer 376

Both caused by Taenia solium Cysticercosis: Ingestion of T solium eggs excreted in human faeces Intestinal taeniasis: Ingestion of larva from raw/undercooked pork

Answer 377

CT scan abdo w oral + IV contrast CT: bowel wall thickening (>4mm) and inflam of pericolic fat w fat stranding (visible traces of fluid in fat) CT also helpful in ruling out complications e.g. abscess (fluid collections surrounded by inflam changes), obstruction (dilated air loops, air-fluid levels), perforation (free air in abdo cavity) and fistula (air in other organs other than bowel)

Answer 378

Type of SIBO that develops in pts who have a blind intestinal loop following abdo surgery Blind pouch no longer connected to stomach -> decreased intestinal motility and a lack of acidity -> SIBO (loose, fatty stools, malabsorption, vit B12 def) Dx SIBO w endoscopic cultures from jejunum (gold standard) or pos lactulose breath test

Answer 379

HAP or sepsis: IV vanc & IV cefepime (covering Pseudomonas and Staph aureus) CAP: IV ceftriaxone & IV azithromycin

Answer 380

Cannabis intox

Answer 381

DRESS syndrome Type IV hypersensitivity reaction Caused by anticonvulsants, allopurinol or antibiotics (e.g. sulfonamide)

Answer 382

Septic pulmonary emboli N.B: peripheral disease manifestations (e.g. Janeway lesions, Osler nodes) occur in left sided IE

Answer 383

Tripled birth weight 1/5 times size at birth

Answer 384

IMMEDIATE Abdo USS as serious complication is hepatic subcapsular haematoma which can rupture Pts develop abdo pain w HELLP due to stretching of Glisson capsule from hepatic swelling

Answer 385

Seizures, headaches, visual disturbances, AMS BILATERAL VASOGENIC OEDEMA in subcortical white matter in PARIETO-OCCIPITAL regions Dx NEUROIMAGING Rfs: hypertensive emergency, preeclampsia, renal failure, sepsis, immunosuppressive meds Tx: supportive, tx underlying condition CF herpes simplex encephalitis affects temporal lobes and gives lymphocytosis in CSF

Answer 386

Oes ring (Schatzki ring) Tx: MECHANICAL DILATION w a bougie or balloon dilator N.B: assoc w hiatal hernia but first tx oes ring w mechanical dilation then perform Nissen fundoplication to tx hernia (as otherwise if done first, it would further narrow the lower oes and worsen dysphagia)

Answer 387

Ipsilateral atrophy of optic nerve (due to nerve compression), CONTRALATERAL papilloedema (raised ICP) and anosmia. Usually caused by FRONTAL LOBE tumours (e.g. meningioma) Anosmia from meningiomas arising from olfactory groove

Answer 388

TVUSS 2-3 days after initial test (TVUSS may give false-neg result if beta hCG < 1500-2000 or if < 5wks gest) Repeated measurement of beta hCG to check appropriate rise (double approx every 2.5d); slow rise = ectopic/abortion; rapid rise = hydatidiform mole/chorioca or twin preg

Answer 389

Strongly assoc w UNCONTROLLED DIABETES during PREG CRS = caudal half of spine develop abnormally; m/c pres = absent sacrum and coccyx Can also manifest as part of VACTERL syndrome

Answer 390

Recurrent andioedema and/or pruritic wheals >6 weeks, can be physical/non-physical by cause If suspected, PROVOCATION & THRESHOLD TESTING performed to identify triggers and confirm dx Tx = trigger avoidance, pt education, second gen H1 receptor antagonist

Answer 391

Propranolol (causes splanchnic vasconstriction -> less blood in portal veins -> less portal venous pressure) and EVL every 1-2 weeks until all varices obliterated N.B: TIPS only used as secondary prophylaxis in pts w recurrent variceal bleeding despite first line mx as TIPS can cause HE

Answer 392

Incurable or metastatic malignancy, sepsis, transmissible spongiform encephalopathies (CJD) and a cardiac arrest that occured before brain death N.B: HIV pts can donate organs to HIV recipients; similarly for HCV who can donate to HCV recipients

Answer 393

Optimise sleep hygiene MODAFINIL (+- sodium oxybate/pitolisant) Second line = dextroamphetamine, methylphenidate N.B: narcolepsy = EDS (excessive daytime sleepiness) with cataplexy, hypnagogic/hypnopompic hallucinations and sleep paralysis

Answer 394

DOXYLAMINE Also dietary changes (cut out spicy/high fat/acidic foods) and avoidance of triggers (loud noises, strong odours) may help improve N If P+D unsuccessful, antiemetics can be trialled (e.g. promethazine, diphenhydramine)

Answer 395

Common in whiplash-type injuries (hyperextension) in older adults with underlying cervical spondylosis Upper extremity motor, sensory and reflex abnormalities; sacral (bowel/bladder) and lower extremity function preserved N.B: syringomyelia can also cause central cord syndrome

Answer 396

TTE: only for prox ascending aorta; fast, non-invasive but low sensitivity/specificity TOE: fast, high S/S; preferred in HD unstable pts/renal insufficiency (CT angio w contrast not best in these cases); N.B: if interscapular pain suggests prox descending aorta involvement so TOE not TTE

Answer 397

Before dx, evaluate for confounding factors: Core body temp >36C for min 24hrs as hypothermia may impede neuro assessment and affect apnoea test Also poisoning, drug intox, electrolyte imbalances, hypotension, BD mimics (e.g. locked-in syndrome), SBP >100 (may need vasopressors) If these conditions met, plus pts still present w coma and brainstem areflexia, apnoea testing performed to make dx

Answer 398

Hepatic adenoma (if taking OCPs, increased risk of haemorrhage so stop) Not FNH (central hypoattenuated scar on CT) so can continue OCP and just observe

Answer 399

Well-circumscribed anechoic mass w posterior acoustic enhancement on USS in premenopausal woman If sx/concerned about breast ca, FNA dx and tx N.B: core needle biopsy only if solid mass on USS/mammo and if malignant features on FNA (i.e. does not resolve upon aspiration)

Answer 400

Severe: sx, 1st degree AV block PR >= 300ms, second or third degree; encephalopathy, polyneuropathy and persistent arthritis IV CEFTRIAXONE (not oral doxy)

Answer 401

Malignant melanoma

Answer 402

Improve control of underlying asthma Premedicate before exercise: ICS-formoterol (10min before) preferred over SABA, LTRA (2hr before) Daily ICS-beta agonist or LTRA may be needed for frequent, prolonged exercise

Answer 403

Throat culture if still suspect bacterial infection (no viral tonsillitis signs: conjunctivitis, hoarseness, cough, stomatitis) Rapid strep test low sensitivity high specificity

Answer 404

GENTAMICIN, ampicillin, cefotaxime N.B: vanc and cefotaxime/ceftriaxone used instead in adults if >50: V, A, C if immunocompromised: V, A, C/M (cefepime/meropenem)

Answer 405

Osteochondral # repaired and removed BEFORE reducing patellar dislocation to prevent osteochondral damage, which can occur during reduction due to shearing forces Repair osteochondral # with ARTHROSCOPY

Answer 406

High risk for intrauterine foetal demise so require immediate UMBILICAL ARTERY DOPPLER USS to assess placental perfusion

Answer 407

Oral AMOXICILLIN (also tx of choice if preg/lactating) Doxy is an alternative N.B: tetracycline CI in children < 8 due to bone growth inhibition and teeth discolouration

Answer 408

Colposcopic surveillance w HPV-based testing every 12-24 weeks (or deferring colposcopy until >= 4 weeks after delivery) Excisional procedure only if invasive ca suspected

Answer 409

Vitamin A and its analogues e.g. ATRA, isotretinoin. Also tetracyclines, growth hormones and lithium

Answer 410

Common cause of heel pain in children (growth spurts) who play running or jumping sports Tenderness at base of heel with calcaneal compression Supportive tx CF plantar fasciitis: unilateral not bilateral; pain on first stepping out of bed and improving throughout the day; pain also worsens after long periods of standing or walking; tenderness at insertion of plantar fascia on calcaneus, worse during PASSIVE DORSIFLEXION of TOES

Answer 411

Precursor to thyroid hormones Produced only by thyroid tissue (normal or malignant) Serum thyroglobulin measurements used as a tumour marker once normally functioning thyroid tissue removed N.B: levo given after thyroidectomy for 2 reasons: replace thyroid hormone and to suppress TSH release from pituitary (less thyroid tissue growth so prevent thyroid cancer recurrence)

Answer 412

Contrast oesophagography with gastrographin if HD stable (better than barium swallow which can cause mediastanitis/fibrosis) CT scan chest if HD unstable/not suited to contrast oes

Answer 413

Both cause coronary vasodilation and can cause coronary steal syndrome (diversion of blood flow from stenotic coronary arteries) leading to tissue ischaemia (see Amboss diagram) and subsequent ECG changes CF exercise stress test/dobutamine stress test increases myocardial oxygen demand so won't cause ischaemia/ECG changes

Answer 414

IV ceftriaxone (4 weeks) Staphylococci MSSA: nafcillin, oxacillin MRSA: vancomycin Prosthetic valve endocarditis (≤ 1 year after placement): Add GENTAMICIN PLUS RIFAMPIN to the regimen Viridans group streptococci: beta-lactam (e.g., penicillin G, ampicillin) Enterococci: combination therapy (e.g., ampicillin PLUS gentamicin) N.B: empiric therapy: Native valve endocarditis: vancomycin PLUS ceftriaxone Prosthetic valve endocarditis: Add GENTAMICIN PLUS RIFAMPIN to vancomycin PLUS a beta-lactam (if ≤ 1 year after placement).

Answer 415

Nonoperative measures (IV abx, fluids, bowel rest) and percutaneous drainage of abscess if large (>4cm) Do not perform emergency OR interval appendectomy Only perform interval appendectomy if age >40 and worried about appendiceal tumour/recurrent sx

Answer 416

Bacterial invasion of pleural space resulting in fibrinopurulent consolidation Strep pneumo, Staph aureus (e.g. MRSA) Pneumonia sx No improvement with routine pneumonia tx Signs of pleural effusion (e.g. dullness to percussion) Lab evidence of inflam (leukocytosis, thrombocytosis) Supportive care Empiric abx (ceftriaxone/cefotaxime + VANCO/clinda to cover MRSA) and Drainage (chest tube w intrapleural fibrinolytics/step up to surgical VATS if advanced or highly loculated)

Answer 417

Euphoric/dysphoric mood (anxiety, irritability) Agitated behaviours (restlessness, tremours) Bruxism, POOR DENTITION, gingivitis "METH MOUTH" CARDIOMYOPATHY/HEART FAILURE TRANSIENT Psychotic sx (d/h/formication) (CF primary psychotic disorder) Anorexia Decreased need for sleep Sympathomimetic effects (as it is a stimulant!) SKIN EXCORIATIONS due to recurrent skin picking

Answer 418

Acute pericarditis: friction rub Chronic constrictive pericarditis: pericardial knock (high pitched early diastolic sound, like a premature S3)

Answer 419

GENETIC PREDISPOSITION

Answer 420

SCLC: polychemo (cisplatin & etoposide) & radiation therapy N.B: SCLC is non-resectable (surgery only considered is very small lesions and no nodal involvement) NSCLC: lobectomy

Answer 421

ESRD & aortic stenosis (destruction of circulating vWF multimers when pass through valve)

Answer 422

Age > 55 Degenerative cervical spine/disks -> canal stenosis -> cord compression GAIT DYSFUNCTION - usually first Extremity weakness & numbness LMN signs (arms): muscle atrophy, hyporeflexia UMN signs (legs): Babinski, hyperreflexia Decreased proprioception/vibration/pain sensation MRI of cervical spine CT myelogram Nonsurgical - immobilisation Surgical decompression

Answer 423

Pulsus parvus et tardus LATE-PEAKING crescendo-decrescendo systolic murmur Soft and single S2 during inspiration (split narrowed during inspiration and paradoxical split during expiration)

Answer 424

Prior C SECTION (uterine scar and change in vascularity alter early preg implantation) Prior PP, multiple gestation (increased placental SA) and advanced maternal age

Answer 425

Defect (e.g. fatigue fracture) of pars interarticularis commonly seen in young athletes Pain on LUMBAR EXTENSION which stresses fracture site (low central back pain) and occasionally compresses nerve roots (radicular pain); flexion offloads fracture site and relieves pain Dx on AP & lateral X RAY of lumbar spine, which are obtained if low back pain persists for 2-4 weeks Tx: activity reduction for 90 DAYS

Answer 426

Primary or secondary Primary: Compression of left renal vein between SMA and aorta Incompetent venous valves Bag of worms mass Pubertal onset Left-sided Decompresses when supine (increases with standing/Valsalva) Reassurance and observation Secondary: Extrinsic compression (renal or retroperitoneal mass) of IVC Venous thrombus Bag of worms mass Prepubertal onset Right-sided Persists when supine Abdo USS (to ix for secondary cause)

Answer 427

Tube thoracostomy often sufficient to manage haemothorax but some pts need EMERGENT THORACTOMY for extreme bleeding: Initial bloody output > 1500ml Persistent haemorrhage: >200ml/hr for > 2hr or continuous need for blood tx to maintain HD stability N.B.: clamping chest tube not recommended as does not stop internal bleeding and can negatively impact chest expansion

Answer 428

RAPIDLY progressing ascending paralysis (may be asymmetrical CF GBS which is symmetrical and not as rapid), absence of fever and sensory abnormalities, NO AUTONOMIC DYSFUNCTION (e.g. tachy, urinary retention, arrhythmias seen in GBS), NORMAL CFS findings (as due to neurotoxin release by tick) METICULOUS SEARCH for ticks and removal -> resolution

Answer 429

Trauma to BOTH THORAX & ABDOMEN Therefore may need emergent exploratory laparotomy even if equivocal FAST exam (and obv evisceration, signs of peritonitis, free air under diaphragm) N.B: haemothorax can present with lower lobe opacification on CXR but would expect to have blunting of CP angle, meniscus line due to pleural effusion etc, dyspnoea, diminished breath sounds

Answer 430

A condition of severe hypothyroidism characterized by altered mental status, hypothermia, myxedema (PERIORBITAL OEDEMA & NON-PITTING OEDEMA of LOWER EXTREMITIES - seen in Graves disease and hypothyroidism), hypoventilation, hypotension, and bradycardia. Etiologies include nonadherence to thyroid replacement therapy, infections, surgery, and/or trauma that result in decompensation of an existing thyroid hormone deficiency. Treatment with liothyronine and levothyroxine should be started immediately if myxedema coma is suspected; patients should also be treated with glucocorticoids until coexisting adrenal insufficiency can be ruled out.

Answer 431

Hyperactive phase: crampy abdo pain w bloody, loose stools Paralytic phase: diffuse pain, bloating, absent bowel sounds, cessation of stools Shock phase: signs of peritonitis and septic shock

Answer 432

Oral albendazole 1-6 mo Check CBC before initiating as can cause leukopaenia Surgery/PAIR (aspiration) if cyst >5cm or assoc w complications (rupture, pulm cyst, biliary fistulae)

Answer 433

PHENOTHIAZINES (FLUPHENAZINE, PROCHLORPERAZINE), which are used for maintenance therapy in patients with chronic psychotic disorders (e.g., schizoaffective disorder), cause impaired thermoregulation (i.e., hypothermia or hyperthermia), resulting in intolerance of extremes in environmental temperature. This side effect is believed to be due to the drug's effect on the hypothalamus, which leads to inappropriate responses to heat (e.g., lack of sweating/peripheral vasodilation) or cold (e.g., lack of shivering). Therefore, patients on fluphenazine therapy who are likely to be exposed to extreme temperatures (e.g., those who are homeless) should be closely monitored.

Answer 434

HYPERCA Due to increased osteoclastic activity, esp in individuals with high baseline bone turnover rate (e.g. young individuals, Paget) BISPHOSPHONATES tx to prevent bone loss and reduce hyperca N.B: corrected ca = measured ca + 0.8 x (4-albumin) Hyperalbuminaemia assoc w increase in total serum ca but does not affect ionised levels so will not have ca related sx

Answer 435

Naltrexone (mu opioid receptor antagonist)/acamprosate (glutamate modulator) Naltrexone: can be initiated while pt still drinking, CI in pts taking opioids as can precipitate withdrawal, and in pts w ACUTE HEPATITIS/LIVER FAILURE Acamprosate: used to maintain abstinence, CI in pts w SEVERE RENAL IMPAIRMENT N.B: disulfiram (alcohol dehydrogenase inhibitor) can only be used in abstinent pts (causes unpleasant reaction when drinking), pts must be highly motivated/taken in supervised setting and used 2nd line after naltrexone/acamprosate

Answer 436

PARADOXICAL REACTION TO BENZOS Most commonly occurs in older individuals and children; risk factors include substance use (e.g., alcohol use disorder) and preexisting psychiatric conditions (e.g., anxiety disorder, personality disorders). Tx = Taper and discontinue drug

Answer 437

CO-AMOXICLAV Or oral cephalosporins (cefpodoxime, cephalexin), fosfomycin, and nitrofurantoin (during 2nd and 3rd trimesters) N.B: TMP-SMX for uncomplicated cystitis in nonpreg women (can be given second line in 2nd/3rd trimesters) Cipro for complicated UTIs in nonpreg women (CI in preg) Preg and acute pyelonephritis: IV 3rd gen ceph (USS kidneys only if anatomic anomaly/structural renal disease/immunocompromise/hx of recurrent UTIs/do not respond to appropriate antibiotic therapy within 48–72 hours)

Answer 438

First trimester: D&C IUFD (absent foetal cardiac activity after 20 weeks gestation): spont expulsion usually occurs within 2 weeks but offer vaginal misoprostol/oxytocin infusion if spont expulsion not occurred by 2 weeks or pt wants immediate intervention N.B: retention of dead foetus for more than 2 weeks leads to systemic absorption of THROMBOPLASTIN (tissue factor) produced by placenta and dead foetus -> coag cascade activation -> DIC

Answer 439

URINALYSIS: can give info about DM (glucosuria) /UTI (pyuria and bacteriuria) and haematuria (?malignancy) N.B: PSA not routinely done in pts w LUTS and suspected BPH; only perform if suspect prostate ca and life expectancy > 10 years and candidates for tx

Answer 440

UROLITHIASIS (poorly soluble and renally excreted) As well as metabolic abnormalities and lipodystrophy

Answer 441

IM BENZATHINE PENICILLIN every 4 weeks for 10 YEARS (- carditis: ... for 5 years) (+ permanent valve disease: ... until age 40)

Answer 442

Could be underlying/preceding systemic illness, esp STREP PHARYNGITIS/SARCIDOSIS CBC & ASO TITRES CXR (hilar lymphadenopathy) LATENT TB TESTING (TST/IGRA) N.B: ANA is NOT part of dx workup

Answer 443

Septic CVT assoc with cavernous sinus syndrome: A condition caused by compression of the cranial nerves that pass through the cavernous sinus (i.e., III, IV, V1, and V2). Empiric therapy with VANCOMYCIN (for coverage of MRSA) should be combined with a third- or fourth-generation CEPHALOSPORIN (ceftriaxone or cefepime) and, if the infection originated from the sinus or the teeth, METRONIDAZOLE (for anaerobic coverage). Affected patients should be treated with high-dose, prolonged antibiotic therapy to reach bacteria sequestered within thrombi. Antifungal therapy (amphotericin B) is indicated in confirmed cases of fungal origin. N.B: Anticoagulation: indicated for all patients with CVT (intracerebral hemorrhage and underlying infection are not absolute contraindications) Acute phase First line: low molecular weight heparin (LMWH) Second-line: unfractionated heparin Long-term anticoagulation: Transition to vitamin K antagonists

Answer 444

ATYPICAL DEPRESSION Hypersomnia, weight gain, leaden paralysis, hypersensitivity to rejection

Answer 445

Spontaneous abortion (ie miscarriage) before 20 weeks gest IUFD (ie stillbirth) absent cardiac activity after 20 weeks gest Spont abortion: based on pt preference (expectant, medical, surgical - surgical indicated for other reasons eg septic abortion, heavy bleeding etc) IUFD: 20-23 wks: dilation and evacuation or vaginal delivery (C section if requested and prior hx of C section) >= 24 wks: vaginal delivery (or C section...) N.B: INDUCTION OF LABOUR IMMEDIATELY OR WITHIN A WEEK due to maternal coagulopathy complication after several weeks of retention

Answer 446

Seen in pts w mucin-producing tumours (e.g. pancreatic ca) due to periodic release of tissue factor into bloodstream Normal plt counts and coagulation times (CF acute DIC) but at increased risk for venous and arterial thrombosis and also mucocutaneous bleeding (e.g. gums/nose) N.B: acute DIC more likely to present w bleeding; chronic with thromboembolism

Answer 447

Early onset (age <7d): usually within 24hrs; sepsis, pneumonia, meningitis Late onset (age >= 7d): typically at age 4-5 weeks; bacteraemia, meningitis, focal infection (e.g. CELLULTIS-ADENITIS)

Answer 448

RECURRENT HIP DISLOCATION (diff in leg length w ext rotation of affected leg) Autosomal recessive condition caused by apoptosis of lower motor neurons. Hypotonia, BULBAR PALSY symptoms (e.g., tongue fasciculations, difficulty feeding), and hyporeflexia Cranial nerves III, IV, and VI are not affected in SMA, resulting in normal ocular movement (CF infant botulism which is descending paralysis affecting eyes). In addition, cognition and behavior in these patients are normal. Diagnosis is confirmed with genetic testing. Treatment with nusinersen, risdiplam, or onasemnogene abeparvovec is considered definitive therapy. Patients with SMA also often need supportive therapy with respiratory and nutritional support, physical therapy, and/or orthotics.

Answer 449

BOTTLE FEEDING Infants who are breastfed have a lower incidence of pyloric stenosis compared to infants who are bottle-fed. Infants who are bottle-fed (whether breastmilk or formula) tend to consume a larger volume in less time compared to infants who are breastfed, which may lead to pylorus muscle hypertrophy via overstimulation. In addition, higher levels of vasoactive intestinal peptide (VIP) in breast milk may help mediate pyloric relaxation, facilitating gastric emptying compared to infants who are formula-fed.

Answer 450

HAPE: Recent arrival at high altitude (<1wk) Absent/mild leukocytosis (<15,000, no bands) Procalcitonin normal Marked early improvement with supplemental oxygen Vice versa for multifocal pneumonia

Answer 451

Cutaneous injury -> pathogen invasion of lymphatics in deep dermis STREP PYOGENES & MSSA Tende, erythematous streaks prox to wound Regional tender lymphadenopathy (lymphangitis) Systemic sx (fever, tachycardia) CEPHALEXIN tx CF sporotrichosis causing nodular lymphangitis characterised by nodules and develops over weeks not days

Answer 452

Autoimmune related e.g. PERIPHERAL NEUROPATHY, ATROPHIC GLOSSITIS, depression/anxiety plus all other malabsorption nutrition related sx

Answer 453

EXERCISE PROGRAM 6-8 WEEKS AFTER DELIVERY to help strengthen abdominal rectus muscles and reduce abnormal extension of linea alba Weight loss if caused by obesity Surgical repair only if conservative measures fail or if recurring and sx etc N.B: compression garment for seroma

Answer 454

Iatrogenic interventions (e.g., induction of labor, assisted vaginal delivery), fetal prematurity and low birth weight, polyhydramnios, multiple gestations, long umbilical cord, FOETAL MALPRESENTATION (e.g., BREECH presentation) is another important risk factor for umbilical cord prolapse. In breech presentation, an unengaged fetal head creates enough space for the umbilical cord to prolapse through the cervical opening past the fetal presenting part.

Answer 455

Fasting <= 95 1hr PP <= 140 2hr PP <= 120 Mx: 1st line = diet 2nd line = insulin, glyburide, metformin N.B: weight loss NOT indicated due to FGR, preterm delivery etc

Answer 456

Normochromic, normocytic with increased retic But with chronic haemolysis and inadequate folate intake, can get folate deficiency anaemia (raised MCV as BM using folate to produce more RBCs) and inappropriately normal retic (due to inadequate erythropoiesis)

Answer 457

IV penicillin Minor pen reaction (e.g. nonpruritic MP rash): cefazolin Severe pen reaction w high risk for anaphylaxis (e.g. resp distress/urticaria): dual testing for erythro/clina (as erythro resistance can induce clinda resistance); if both sensitive then clinda; if both resistant/inconclusive then vanc (but need to monitor neonate if given vanc as does not reach as high conc in amniotic fluid CF pen)

Answer 458

EXECUTIVE DYSFUNCTION (CF frontotemporal = change in personality, hyperorality; AD = memory loss) PROGRESSIVELY WORSENING COURSE: can be step-wise if large/multiple infarcts (e.g. overt strokes) but can be smooth decline if small vessel disease; abrupt decline in cognitive functioning if single, strategic infarction (medial frontal lobes, medial temporal lobes, thalamus) LOCALISING NEURO SIGNS SUBCORTICAL DEFICITS: urinary incontinence, gait disturbance CF poststroke depression: sadness not apathy; evidence of strategic infarct causing abrupt decline in cog functioning more consistent with vasc dementia

Answer 459

Woman in 20s/40s with regular monthly menses (do not affect ovulation) and additional painless INTERMENSTRUAL BLEEDING If sx: tx = hysteroscopic polypectomy

Answer 460

Recommended: Fentanyl (has inactive metabolites) Hydromorphone Methadone (not renally excreted) Buprenorphine Avoid: Morphine, mepiridine, codeine, tramadol (all have active metabolites and are renally excreted)

Answer 461

PAC:PRA > 20 suggestive of primary hyperaldosteronism but SALINE INFUSION TEST to confirm it Failure to inhibit aldosterone release (PAC > 10) upon saline infusion indicates autonomous (renin-independent) aldosterone release and confirms dx Other confirmatory tests: oral sodium loading test, fludrocortisone suppression test, captopril suppression test After dx confirmed, ADRENAL CT to identify cause

Answer 462

Hypovolaemia, GI bleeding, electrolyte disturbances (e.g. HYPOKOLAEMIA) Hypokalemia, which can be precipitated by the use of diuretics, is accompanied by the intracellular movement of hydrogen ions into cells to maintain electrical neutrality. The resulting intracellular acidosis in renal tubular cells can lead to increased production of ammonia and bicarbonate from glutamine to maintain acid-base balance. Metabolic alkalosis, which can also be precipitated by the use of diuretics, leads to increased conversion of ammonium to ammonia. Ammonia is then able to cross the blood-brain barrier, resulting in increased neurotoxin accumulation in the brain. Tx = CORRECT PRECIPITATING FACTORS, lactulose to allow ammonia (rifaxmin given with lactulose to prevent recurrent episodes after 2nd episode)

Answer 463

Chloroquine resistant P falciparum (widespread) endemic region (e.g. sub Saharan Africa/SE Asia): MEFLOQUINE (doxy can be given for nonpreg pts) N.B: Primaquine CI during preg and only for vivax and ovale Atovaquone-proguanil covers chloroquine resistant falciparum but not used in preg

Answer 464

During early preg corpus luteum produces progesterone which prepares endometrium for implantation, promotes implantation and maintains preg through 10 weeks gest (luteal-placental shift after) If corpus luteum removed prior to 10 weeks gest, pts require PROGESTERONE SUPPLEMENTATION to prevent preg loss (discontinue after 10 weeks gest)

Answer 465

CT SCAN CHEST & ABDO Can present months - years after blunt thoracoabdo trauma in children More commonly on left side due to lack of liver protection and diaphragm pos CXR findings: bowel loops in thorax, mediastinal shift

Answer 466

M/c cause of eye discharge in infants NLD obstruction due to incomplete canalisation of distal duct in utero Intermittent or chronic tearing, mucoid discharge Eyelash crusting/matting Absence of conjunctival injection Mx: lacrimal sac massages, reassurance (resolution typical at age 6-12mo) Complications: dacrocystocoele; dacrocystitis

Answer 467

NORMALISATION OF SERUM ANION GAP (reflecting disappearance of ketoacid anions) and SERUM BETA HYDROXYBUTYRATE levels (predominant ketoacid in severe DKA)

Answer 468

VITRECTOMY (if severe vision loss) followed by INTRAVITREAL ABX Acute-onset visual loss, ocular pain, conjunctival injection, hypopyon, and a hazy retina after undergoing cataract surgery Ophthalmological emergency as patients can rapidly develop permanent vision loss. Abx to cover coagulase-negative Staphylococci and Staphylococcus aureus (e.g., vancomycin plus ceftazidime) - most common causative pathogens. Intraocular lens placed during cataract surgery left in place

Answer 469

Pts unlikely to tolerate large vol of bicarb needed, e.g. ESRD, renal failure and salicylate-induced resp failure (noncardiogenic). Also in severe ingestions, refractory acidosis or clinical worsening despite bicarb use Activated charcoal within 2 hours of acute ingestion

Answer 470

TRANSURETHRAL CATHETERISATION (or suprapubic aspiration but invasive) Clean catch not recommended as very easily contaminated N.B: A renal ultrasound to evaluate the urinary tract for conditions that may predispose to UTIs is indicated in children < 2 years with a FEBRILE UTI as well as in children with structural abnormalities of the urinary tract, recurrent UTIs, or UTIs not responsive to antibiotic therapy

Answer 471

Non-muscle invasive: low grade - TURBT w intravesical chemo high grade - TURBT w intravesical BCG vaccination Muscle invasive: radical cystectomy w construction of urinary diversion (e.g. neobladder, ileal conduit); neoadjuvant cisplatin chemo

Answer 472

Home BP monitoring and follow-up exam 1-2 times per week (PLT count, liver enzymes, Cr) Fetal monitoring should also be performed, including a nonstress test at every follow-up visit and an ultrasound every 3 weeks. Patient education about findings of preeclampsia with severe features (e.g., SBP ≥ 160 mm Hg, DBP ≥ 110 mm Hg, severe headache, epigastric pain, blurry vision, reduced fetal movement) and the need to seek medical attention if any of these findings are present. If the patient develops preeclampsia with severe features, she should be admitted to the hospital for antihypertensive therapy with intravenous hydralazine, intravenous labetalol, or oral nifedipine; eclampsia prophylaxis with magnesium sulfate; and antenatal corticosteroid therapy. Delivery should be considered after stabilization.

Answer 473

Stretch-induced dysfunction of spinal cord Closely related with CLOSED SPINAL DYSRAPHISM (e.g. dimple, hair tuft, haemangioma or subcut mass e.g. lipoma) Back/leg pain worse with activity Neuro findings (weakness, hyporeflexia) Leg weakness due to muscle denervation can lead to gait abnormalities, muscle atrophy and foot drop New-onset scoliosis due to improper pos to relieve back discomfort Lumbosacral cutaneous abnormality

Answer 474

MEDIAN N.B: FOOSH can cause displaced supracondylar fractures of the humerus with posterior displacement of distal humerus fragment. Anteriorly displaced prox humerus fragment can entrap BRACHIAL ARTERY & MEDIAN NERVE, which pass anterior to humerus N.B.2: ulnar nerve injury is a rare type of supracondylar fracture that occurs with flexed (rather than hyperextended) elbow. Anterior displacement of distal humerus fragment, impinge on ulnar nerve located posterior to medial epicondyle of humerus

Answer 475

BA: bright red, firm, friable, exophytic nodules, fever KS: lesions also occur on trunk and extremities; papules then plaques/nodules; light brown to pink to dark violet

Answer 476

SKELETAL SURVEY & FUNDOSCOPY Findings that support physical child abuse include multiple fractures at different stages of healing, metaphyseal and epiphyseal corner fractures, posterior rib fractures, spiral diaphyseal fractures of long bones (e.g., humerus), retinal hemorrhage, and vitreous hemorrhage. Suspected child abuse warrants an immediate notification of Child Protective Services.

Answer 477

IV CLINDA & ORAL PRIMAQUINE (N.B: Glucocorticoids are added to treat PCP in the case of respiratory insufficiency (PaO2 < 70 mm, arterial‑alveolar oxygen gradient > 35, or room air oxygen saturation < 92%).

Answer 478

Neuropsychiatric symptoms including anxiety, erethism mercuralis (abnormal irritability), ataxia, and tremor. Polyneuropathy may also be observed. Another common sign is GINGIVAL and/or BUCCAL INFLAMMATION with a characteristic bluish‑violet discoloration. Lead poisoning would manifest with symptoms very similar to the ones in this case, including neuropsychiatric disturbances and anorexia. DIMERCAPROL is also the first-line treatment (also used in arsenic poisoning). However, this patient's prominent excess salivation, odynophagia, and gingival inflammation would not be expected in cases of lead poisoning N.B: lead poisoning: Blood lead < 45: address risk factors for lead poisoning (e.g., by treating pica) and limiting lead exposure by removing the source (e.g., paint, furniture, water, toys, soil, dust, secondhand exposure). Blood level > 45: Chelation therapy (e.g., with oral succimer) Blood level > 70/acute lead encephalopathy: chelation with IM dimercaprol N.B. 2: pica is a rf for lead poisoning (pica can be caused by IDA, preg, stress, psych illnesses)

Answer 479

Hepatitis B immunoglobulin (HBIG) is included as part of the PEP for hepatitis B in individuals with occupational exposure who have not undergone a 3-dose vaccination schedule or did not properly respond to it (as with this patient). The HBV vaccine is a recombinant vaccine that uses hepatitis B surface antigen (HBsAg) and is always given as part of HBV PEP. Since this individual did not respond to his initial 3-dose vaccination regimen, he should undergo another regimen, starting with an initial dose of the HBV vaccine along with the HBIG. The next 2 vaccine doses should be administered according to the vaccination schedule. It is recommended that all healthcare personnel, including this patient, are vaccinated with a complete 3-dose series of the HBV vaccine. If after ≥ 6 doses of HBV vaccine this individual still has an anti-HBs < 10 mIU/mL, he would be considered a nonresponder.

Answer 480

THIAZIDE DIURETICS/DCCB

Answer 481

Pasteurella: cellulitis within days of dog/cat bite Bartonella: initial papule (may go unnoticed) followed by painful regional lymphadenopathy in subsequent 1-2 wks

Answer 482

TOPICAL SALICYLIC ACID Can also be combined with other first-line treatment options, such as cryotherapy with liquid nitrogen, for a faster and more effective therapeutic response. N.B: pulsed dye laser therapy is a second line tx option, side effects: skin discoloration, scarring, pain

Answer 483

Oral abx if 1st line: amox if age < 6mo or >= 6mo plus high fever, bilateral, severe pain 2nd line: co-amox if refractory to 1st line or recurrent AOM (within 30d) after abx

Answer 484

Urgent/emergency splenectomy: Most immunisations given 2 WEEKS after op (e.g. PCV15, meningococcal & Hib; CF PPSV23 given 10 weeks after op) If elective splenectomy, immunisations given 14d pre-op Since the risk of developing sepsis is low in asplenic adults compared to asplenic children, daily antibiotic prophylaxis is not recommended for adults. However, adult asplenic patients should be advised to immediately start broad-spectrum antibiotics (e.g., oral amoxicillin/clavulanate, cefuroxime, or fluoroquinolones) at the first sign of possible infection (e.g., fever, chills).

Answer 485

Suspect OESOPHAGEAL CA So perform GO ENDOSCOPY to r/o malignancy as secondary cause of achalasia (ie pseudoachalasia)

Answer 486

CV = SD/mean CV, which is a statistical relative measure of dispersion, allows SD to be interpreted relative to the mean, allowing for the comparison of multiple data sets that may have means of different magnitudes or units of measurement. A high CV indicates that values are widely spread around the mean. In a system with multiple processes, such as the various aspects of a patient's visit, the process with the highest CV should be optimized first to improve the system's overall reliability and efficiency. Optimization of vital parameter measurements, which has the highest CV (5 ÷ 8 = 0.62), will therefore most likely have the greatest impact on reducing the average time that patients spend in the practice. In contrast, SD, which is an absolute measure of dispersion, describes the variability of data in relation to the mean within a single data set.

Answer 487

CT HEAD (or MRI head) as worried about BRAIN STEM COMPRESSION and SPINAL STENOSIS. Narrowing of the foramen magnum commonly occurs in achondroplasia because of increased growth of the head compared to the torso, which can cause compression of the cervical medulla and lead to subsequent muscular hypotonia/quadriparesis, apnea/hypopnea, and sudden infant death.

Answer 488

INDOMETHACIN (inhibits renal prostaglandin synthesis, which promotes the action of ADH on the collecting ducts, resulting in decreased diuresis). Other therapeutic measures to treat nephrogenic DI are adequate hydration, dietary salt and protein restriction (to prevent solute diuresis), and hydrochlorothiazide (HCTZ) therapy. Although HCTZ is a diuretic, in patients with nephrogenic DI it paradoxically decreases urine volume by an incompletely understood mechanism.

Answer 489

Chronic cough (> 8 weeks), a history of rhinitis, evidence of a postnasal drip (e.g., cobblestone mucosa in the posterior pharynx), and no features of lower respiratory involvement (e.g., dyspnea, crackles, stridor) are compatible with upper airway cough syndrome (UACS), the most common cause of chronic cough. FIRST-GEN ANTIHISTAMINE (e.g., dimetindene, diphenhydramine) for 2 WEEKS to achieve decongestion and subsequent reduction of postnasal drip. If symptoms improve within these 2 weeks, the diagnosis of UACS is confirmed. The underlying cause of UACS (e.g., allergic rhinitis, nonallergic rhinitis, chronic rhinosinusitis) should be subsequently treated. Intranasal corticosteroids (e.g., fluticasone, budesonide) can be considered in patients with treatment-refractory UACS.

Answer 490

Anterior TF dislocation: Immediate CLOSED reduction (then reevaluate pulses, ABPI to consider vascular ix ie doppler, CT angio) Posterolateral TF dislocation (tibia posterior to femoral condyles plus medial collateral ligament and medial capsule invaginate into the joint): ORIF

Answer 491

>=18 In a 3-day-old term newborn who is medically well and lacks certain risk factors (e.g., lethargy, G6PD deficiency, isoimmune hemolytic disease), this threshold is at ≥ 18 mg/dL. If treatment is not initiated swiftly, the risk of neurotoxic damage (e.g., kernicterus) due to hyperbilirubinemia increases. Exclusively breastfed newborns are at increased risk of developing neonatal jaundice. This patient's jaundice is most likely caused by cephalohematoma acquired during vacuum-assisted delivery. Hemolysis of erythrocytes within the hematoma results in hyperbilirubinemia. N.B: Exchange transfusion is indicated in newborns with total bilirubin serum levels above the age-adjusted threshold (≥ 24 mg/dL in a 3-day-old term newborn), an inadequate response to phototherapy, a rapid rise in total serum bilirubin levels, or signs of neurotoxicity (e.g., hypotonia, lethargy, shrill cry).

Answer 492

Initiate RIFAMPIN therapy A 4-month course of rifampin monotherapy is one regimen for the treatment of latent TB infection (LTBI). Children < 5 years of age have an underdeveloped immune system, which increases the likelihood of FALSE-NEGATIVE TST results, a rapid progression from LTBI to active TB, and a severe disease course. WINDOW PROPHYLAXIS should therefore be offered to all children of this age with significant exposure to TB in the past 8 weeks, regardless of the initial examination findings and/or test results. A follow-up TST should be performed 8–10 weeks after the child was last exposed to TB. If the follow-up TST is negative and there is no suspicion of a false-negative result, the treatment may be discontinued. HIV-positive individuals should be managed similarly but receive full-length prophylaxis, even if the follow-up TST is negative. Isolation measures apply only to those with suspected or confirmed active TB.

Answer 493

Primary hyperPTH Familial hypocaliuric hypercalaemia Lithium Urine calcium creatinine clearance ratio (UCCR) = (Ca urine/Ca serum) / (Creatinine urine/Creatinine serum) UCCR < 0.01 = FHH UCCR > 0.02 = PH

Answer 494

Acidic substances -> coagulative necrosis Alkaline substances -> liquefactive necrosis Chemical burn or liquefactive necrosis resulting in: Laryngeal damage (hoarseness, stridor) Esophageal damage: dysphagia, odynophagia Gastric damage: epigastric pain, bleeding ABC Decontamination: remove contaminated clothing & visible chemicals; irrigate exposed skin CXR if resp sx and to identify perforation Endoscopy within 24 hours N.B: activated charcoal decreases absorption of poisons (CF ingestions cause immediate local damage on contact with oesophagus)

Answer 495

Can tolerate penicillins: Amoxicillin or co-amox (if severe disease ie >65, smoking, recent abx, major comorbidities, alcoholic) PLUS Macrolide/doxy Cannot tolerate penicillins, can tolerate cephalosporins: 3rd gen ceph PLUS Macrolide/doxy Cannot tolerate penicllins/ceph: Resp fluoroquinolone N.B: aspiration pneumonia caused by anaeobes and aerobes so tx in same way as CAP if no abscess/empyema (ie metro insufficient as only covers anaerobes)

Answer 496

AMITRYPTILLINE Episodes occurring at least 15 days per month for more than 3 months. Plus lifestyle and behavioral modification Acetaminophen can be used to treat episodic tension headache, which is defined as 1–14 episodes of headache per month.

Answer 497

GASTROGRAFIN ENEMA Bilious vomiting, a distended abdomen, and sparse bowel sounds, all of which are consistent with bowel obstruction. The findings of dilated small bowel loops on abdominal x-ray and a microcolon indicate meconium ileus as the cause for obstruction and explains why he has not yet passed stool. Gastrografin enema is both diagnostic and therapeutic for meconium ileus. A gastrografin enema will allow visualization of the rectum and bowel to rule out other anatomical causes for bowel obstruction (e.g., intestinal atresia or volvulus) and, in the case of meconium ileus, can reveal the Neuhauser sign, microcolon, or meconium pellets. The contrast agent can also induce a laxative effect as the increase of osmolarity within the lumen of the bowel results in the breakdown and passage of the meconium obstruction. More than 90% of patients with meconium ileus will have cystic fibrosis (CF). For unknown reasons, newborn screens for CF in patients with meconium ileus are often initially negative and require additional testing. Infants with meconium ileus should undergo diagnostic testing for CF through a sweat test or, if sufficient amounts of sweat cannot be obtained, through genotyping.

Answer 498

Acute (<48hr): at risk for brain herniation. So Na <130 with any sx of raised ICP: hypertonic 3% saline boluses to correct it rapidly (low risk of ODS) Chronic (>= 48hr): hypertonic saline only if Na < 120, severe sx (seizure), or concurrent intracranial pathology Hypertonic saline tx goal: raise Na by 4-6 over a period of hours (to reduce risk of herniation). Max rate of correction is 8 in 24 hrs to reduce risk of ODS

Answer 499

Frank: hips flexed & knees extended (buttocks presenting) Complete: hips & knees flexed Incomplete: 1 or both hips not flexed (feet first) Rfs: Advanced maternal age Uterine didelphys, septate uterus Uterine leiomyomas (esp submucosal) Foetal anomalies (e.g. anencephaly) Preterm Oligo/polyhydramnios Placenta previa Mx: ECV (if no CI to vaginal delivery e.g. placenta previa, prior classical C section) C section

Answer 500

Breast: Mammography biennially age 50-74 Screening from 40-49 and over 75 not recommended but can be considered on individual basis Colon: Recommended at age 45 but definitely from 50 Annual FIT or 10 yearly colonoscopy Flexi sig every 5 years (or every 10 years with annual FIT) FDR w CRC/high-risk adenomatous polyp: Colonoscopy at 40 (or 10 years prior to age of diagnosis in FDR, whichever first) Rpt every 5 years (every 10 years if FDR dx > 60 y/o) Pts w UC: Start screening 8-10 years after dx Colonoscopy every 1-3 yrs Surveillance after colon ca resection: Stage 1: Colonoscopy in 1 year and then every 3-5 years Stage 2/3: As above, periodic CEA screening, annual CTAP Stage 4: individualise, as above but more frequent CT scans Cervical: 21-29: cytology alone (ie Pap smear) 30-65: Primary HPV every 5 years or HPV/Pap co-testing every 5 years or cytology alone every 3 years Discontinue screening of average-risk individuals with a cervix at age ≥ 65 years if all the following criteria are fulfilled: Documented adequate screening with negative results over the last 10 years, defined as any of the following: 2 consecutive negative primary HPV tests 2 consecutive negative cotests 3 consecutive negative cytology-alone screening The most recent screening test should have been performed within the last 3–5 years. No history of CIN 2+ within the past 25 years Discontinue screening in individuals (of any age) with a limited life expectancy. Lung: Smokers: low-dose CT scan Cholesterol screening: every 3-5 years Resting ECG: once at 65 with Medicare DM: >= 35 regardless of rfs <35 and overweight/obese and >= 1 other rf (FDFH, race/ethnicity e.g. Native American, hypertension)

Answer 501

Because bacterial meningitis is associated with severe neurological sequelae and can be fatal (especially when treatment is delayed), a bacterial etiology must be presumed until the results of CSF analysis prove otherwise. If any ALARM SX (mnemonic: FAILS: Focal neurological deficits, AMS, Immunocompromised, ICP elevated, Lesions in brain or skin near LP site, Seizures) are present, CT HEAD BEOFRE LP to mitigate the risk of brain herniation. If LP is delayed for any reason (e.g., the need for a CT scan ie if ALARM sx present), obtain BLOOD CULTURES and administer empiric ANTIBIOTIC THERAPY until it can be performed. In the absence of alarm symptoms, the patient should first undergo an LP and then immediately receive empirical therapy. The empiric therapy of choice for immunocompromised patients with suspected bacterial meningitis is vancomycin and ampicillin with either cefepime or meropenem. Additionally administering dexamethasone to reduce the risk of hearing loss may be considered for children with bacterial meningitis, especially if infection with Haemophilus influenzae type b is suspected.

Answer 502

Needle aspiration: within 2d of injury and small (< 2cm) I&D: larger (>= 2cm) and <7d old Plus: 7–10 day course of LEVOFLOXACIN administered as prophylaxis against infection with skin flora or Pseudomonas aeruginosa. Patients should be followed up daily to assess for reaccumulation of the hematoma or signs of infection and can return to sports after 7 days if the hematoma does not reaccumulate.

Answer 503

Probability that an individual is CORRECTLY CLASSIFIED by a test Accuracy = (TP+TN)/(TP+FP+FN+TN) NOT the same as PPV!

Answer 504

Spinal meningioma Rfs: Older age Female Genetic predispositions (e.g. NF2, schwannomatosis) Exposure to IONISING RADIATION ( long latency period)

Answer 505

Hyperacute/chronic: removal of graft as irreversible Acute (1wk - 3mo after): PULSE STEROID THERAPY as reversible

Answer 506

Simple transfusion: acute mx of severe anaemia in SSC, aplastic crisis & nonsevere acute chest syndrome. Avoid raising Hb to >8. Splenectomy if hypersplenism/life-threatening/recurrent episodes Exchange transfusion: severe acute chest syndrome, treatment and secondary prevention of STROKE (N.B: DAPT not helpful), and treatment of hepatic sequestration crisis.

Answer 507

4-5 years (ie preschool): BEHAVIOURAL INTERVENTIONS (incl behavioural parent training) >=6: pharmacotherapy (methylphenidate; atomoxetine 2nd line if p/fhx of substance abuse/parents object to stimulants)

Answer 508

FRANCISELLA TULARENSIS - normally causes ulceroglandular disease: single papuloulcerative lesion, tender, suppurative lymphadenopathy; if gets in contact w eye -> oculoglandular disease Other causes: Bartonella henselae & HSV

Answer 509

CILOSTAZOL Therapeutic trial for 3-6 mo Cilostazol improves symptoms of claudication and walking distance but has not been shown to decrease major cardiovascular events. Adverse effects are common and include headache, palpitations, diarrhea, and dizziness. In addition to cilostazol, all patients with PAD should receive medical therapy with an antiplatelet agent (aspirin or clopidogrel), a statin to reduce the risk of myocardial infarction, stroke, and mortality, and antidiabetic agents if appropriate. N.B: PTA/bypass surgery for patients with PAD and critical limb ischemia (ie rest pain, ulcers, gangrene) or lifestyle-limiting claudication persisting despite conservative and pharmacologic treatment.

Answer 510

Intraoperative ventilation with PEEP provides positive pressure to the lungs, which reduces alveolar collapse by stenting open the airways, thereby reducing the risk of postoperative atelectasis. Postoperatively, lung expansion maneuvers that increase PEEP can also be used, such as CPAP or INCENTIVE SPIROMETRY. Other strategies to prevent postoperative atelectasis include deep breathing exercises, adequate pain control, and early mobilization. N.B: postop atelectasis: early after op (e.g. 1d CF DVT/PE d5) and can also cause wedge-shaped opacity in lung region

Answer 511

Pyruvate kinase deficiency (PKD) is an autosomal recessive enzyme defect of the glycolytic pathway that results in extravascular hemolytic anemia. It is the second most prevalent erythrocyte enzyme disorder (after glucose-6-phosphate dehydrogenase deficiency). The severity of the disease is highly variable; PKD can manifest with fetal demise due to hydrops fetalis, symptomatic anemia from birth that requires lifelong transfusions, or chronic compensated hemolysis. A peripheral blood smear typically shows normal erythrocyte morphology, but echinocytes are sometimes seen. Diagnosis is confirmed by measuring pyruvate kinase enzyme activity.

Answer 512

POLIO VIRUS Weakness ascends over hours/days

Answer 513

Paralysis of ipsilateral lower lip Marginal mandibular branch of the facial nerve, which provides motor control of the lower lip, is one of the most commonly injured branches of the facial nerve. Most cases of post-parotidectomy facial nerve palsy resolve within one month.

Answer 514

Airborne (require N95 repirator, neg pressure room): TB SARS, measles, varicella Contact (single occupancy room): MRSA, VRE, ESBL (multi-drug resistant bug) C diff, E coli O157:H7 Scabies RSV Droplet (surgical masks within 6 feet): N meningitidis, Hib, Mycoplasma pneumoniae Influenza, adenovirus

Answer 515

Mallet finger: extensor tendon injury of distal phalanx (DIP held in flexion) Tx: if uncomplicated - stack splint in hyperextension (tendon repair if complicated, failure of conservative mx etc) Jersey finger: flexor tendon injury of distal phalanx Tx: tendon repair

Answer 516

When humans interact with medical equipment, three types of errors occur: human errors, device errors, and errors at the level of the device-human interface. Failure at the level of the device-human interface (e.g., disconnection of the patient from or improper connection of the patient to the telemetry device) is the most common cause of inpatient cardiac telemetry-related errors (approx. 50% of cases) and typically occurs after patients are shifted (e.g., for a test). CF desensitisation to alarms from telemetry device can lead to cardiac events going undetected but not as common as failure at device-human interface

Answer 517

Small vessel endothelial damage -> THROMBOTIC MICROANGIOPATHY -> renal vasc occlusion -> intrinsic AKI Also thrombotic microangiopathy causes: Thrombocytopaenia due to PLT consumption Haemolytic anaemia by shearing of rbcs N.B: other causes of paediatric renal vasc disease inducing AKI: vasculitis, renal artery thrombosisstone

Answer 518

<= 10mm: observe (can give tamsulosin/nifedipine) >10mm: intervention URS: mid or distal ureter stones OR ESWL (avoid if obese/mid/distal ureter stones) >20mm or lower renal pole stones >10mm: PCNL N.B: ureteral stenting if (infected) hydronephrosis/sepsis. Also only done after above interventions

Answer 519

Sezary syndrome SS is a subtype of cutaneous T-cell lymphoma (CTCL) characterized by leukemic dissemination of malignant T cells in the skin. This condition can evolve from mycosis fungoides (another CTCL subtype) or arise de novo. The evaluation of SS should include a skin biopsy to assess cell morphology, immunophenotype, and clonality as well as a peripheral blood smear with flow cytometry and clonality studies. The diagnosis is confirmed by the presence of Sézary cells (atypical T cells with cerebriform nuclei) in the peripheral blood. Treatments include skin-directed therapies (e.g., topical corticosteroids, topical nitrogen mustards) and systemic therapies (e.g., phototherapy, chemotherapy, monoclonal antibodies).

Answer 520

S PNEUMONIAE From non-vaccine serotypes Therefore prophylactic penicillin until age 5 Pts at high risk for sepsis from encapsulated organisms (S pneumo, H influenzae, N meningitidis but S pnuemo m/c)

Answer 521

2mo: 1. raises head 2. recognises familiar voices 3. social smile 4mo: 1. holds head 2. holds toy 3. coos 6mo: 1. rolls over 2. laugh 3. reaches for toy 9mo: 1. sits unsupported 2. babble 3. transfers objects between hands 4. separation anxiety/stranger anxiety 12mo: 1. cruises 2. pincer grip 3. says "mama, dada"

Answer 522

Causes: asthma pulm HTN (from chronic intravasc haemolysis -> depletion of NO -> pulm vasoconstriction -> vasc remodelling -> PVR (N.B: normal spiro but decreased DLCO as loss of vasc bed) pulm fibrosis (following recurrent episodes of acute chest syndrome)

Answer 523

Decreases LV preload (decreases RV preload and increases RV afterload); LV afterload (decreases MAP and decreases LV transluminal pressure) Leading to enhanced stroke vol in systole (due to decrease in LV afterload) and improved filling in diastole (improved LV relaxation)

Answer 524

Late complication of transmural (STEMI) MI ECG: PERSISTENT ST ELEVATION & DEEP Q WAVES Progressive LV enlargement -> heart failure, refractory angina, ventricular arrythmias, secondary MR; mural thrombus -> systemic arterial embolisation (e.g. stroke)

Answer 525

ENDOVENOUS STENTING followed by RADIATION tx (high-dose corticosteroids may be helpful if malignancy causing SVC syndrome is a lymphoma, but of no help if caused by e.g. small cell lung ca)

Answer 526

24HR URINARY PROTEIN EXCRETION (NOT one time urine dip as may miss nonalbumin proteinuria and less s/s) Kidney biopsy to establish dx

Answer 527

Adolescents Absence seizures MORNING MYOCLONUS Generalised tonic-clonic seizures EMG: bilateral polyspike and slow wave activity Tx: valproic acid, avoid triggers (etoh, sleep deprivation) CF Lennox Gastaut syndrome: childern <5, various, severe seizure types, intellectual disability

Answer 528

Central: low arterial o2 sat (e.g. CHD: tachypnoea, diaphoresis with breast feeding) Peripheral: increased o2 extraction secondary to SLUGGISH BLOOD FLOW (e.g. increased venous pressure/neonatal polycythaemia)

Answer 529

Mild - mod: erythema, tenderness Severe: as above + BLISTERING, systemic sx (fever, vom, headaches) Tx: Mild-mod: topical (cool compresses, aloe vera, calamine lotion); oral (NSAIDs) Severe: hospitalisation, IVF, wound care

Answer 530

Deposition of ca in basal ganglia leading to extrapyramidal manifestations Also nephrocalcinosis and cataracts Ca-PO4 product (serum ca x serum PO4) > 55 increases risk of soft tissue calcification

Answer 531

Aeitiologies: Major surgery, traumatic injury, severe infection Electrolyte derangement Meds (opiates, antichol) Neuro disorders (dementia, stroke) Abdo distension, pain, obstipation, vomiting Tympanic to percussion, decreased bowel sounds Can lead to colonic ischaemia and perforation X ray: colonic dilation, normal haustra, nondilated small bowel CT: colonic dilation W/O ANATOMIC OBSTRUCTION Mx: NPO, NG tube/rectal tube decompression Neostigmine if no impv within 48hrs CF postop ileus: does not cause severe colonic dilation and develops before a return of bowel function ie no bowel mvt

Answer 532

Hypokalaemic periodic paralysis (hypoKPP) HypoKPP, the most common cause of periodic paralysis, is typically caused by incompletely penetrant, autosomal dominant mutations of sarcolemmal calcium or sodium channels. These mutations exaggerate the potassium influx that occurs in response to physiological triggers such as sympathetic activation (e.g., during stress or physical exertion) and insulin release (e.g., following a high-carbohydrate meal). Therefore, affected individuals develop episodic hypokalemia and reduced muscle excitability in the context of low serum potassium. The episodes of weakness usually resolve within a couple of hours after onset but can last for several days. The respiratory muscles, bulbar muscles, and extraocular muscles are typically spared during these episodes, and in between episodes, patients typically have normal serum potassium levels.

Answer 533

Spironolactone In patients with renal dysfunction, spironolactone should be avoided because it can lead to metabolic and electrolyte imbalances, such as hyperkalemia, hyponatremia, and metabolic acidosis. If used as monotherapy (e.g., in women with contraindications to COCs), spironolactone should be combined with other contraceptive methods since it carries a risk of undervirilization in male fetuses.

Answer 534

Screen for ca with USS/mammo If neg for ca then conservative mx

Answer 535

LISTERIA Consumption of unpasteurized milk products is a risk factor for listeriosis, which typically manifests with self-limiting gastroenteritis in healthy adults. In pregnant women, however, listeriosis can cause complications (e.g., fever, chorioamnionitis, PPROM) and result in preterm birth or spontaneous abortion. Transmission from an infected mother to the fetus can either occur transplacentally or via direct contact with infected vaginal secretions and/or blood during delivery. This patient likely has early-onset neonatal listeriosis (granulomatosis infantiseptica), manifesting with severe systemic infection and disseminated organ involvement (i.e., of the liver and lungs). Signs of meningitis (e.g., fever, seizures, hypotonia, abnormal cerebral ultrasound) may develop as early as seen here, especially in preterm neonates, or have a delayed onset in the 3 weeks after birth, typically in full-term neonates with perinatal infection. Both mother and newborn should be treated with IV ampicillin and gentamicin. CF toxoplasma gondii: infected mothers usually asx and severity of neonate's infection decreases with gest age: while first-trimester infection usually results in a classic triad (chorioretinitis, diffuse intracranial calcifications, hydrocephalus) and other nonspecific features (e.g., blueberry muffin rash, jaundice, macrocephaly), second- or third-trimester infections are mostly subclinical or mild.

Answer 536

Caused by KLEBSIELLA Large, painless vascular lesions in the absence of inguinal lymphadenopathy that appear up to one year after exposure. Diagnosis is based primarily on clinical findings, although Donovan bodies in ulcer smears or biopsies can confirm the diagnosis. Management focuses on antibiotic treatment with azithromycin, which is continued until the ulcers have completely healed.

Answer 537

CES: asymmetric muscle weakness, decreased reflexes, and saddle anesthesia due to damage of LMNs; bowel/bladder late findings; pain radiates along dermatomes as nerve roots compressed CMS: compression of most distal region of SC; both UMN and LMN signs. Bladder and bowel dysfunction within hours of the injury, hyperreflexia of the ankles, symmetric lower extremity weakness, and back pain

Answer 538

GAS cause WELL-DEMARCATED, erythematous, perianal rash that can also develop a pseudoexudate, crusting, and superficial anal fissures or cracks. Pruritus, rectal pain during defecation, and blood-streaked stools. Signs of systemic infection (e.g., fever, abnormal vitals) are usually absent because of the superficial nature of the infection. A history of intrafamilial spread of perianal dermatitis or of close contact with people with streptococcal infection (e.g., pharyngitis) is common. The diagnosis is primarily clinical but can be confirmed with bacterial culture. While penicillin is an effective agent against GAS, amoxicillin is often preferred for pediatric patients because it can be administered as an oral emulsion. Topical monotherapies are ineffective in the treatment of perianal streptococcal dermatitis, likely because deeper layers of the epidermis are infected.

Answer 539

Renal artery thrombosis Can present up to several weeks after catheter removed

Answer 540

Microcephaly, spasticity, sensorineural hearing loss, and pigmentary retinal mottling CF Toxoplasma: hydrocephalus, chorioretinitis, diffuse intracranial calcifications

Answer 541

Most common parasitic cause of diarrhoea in US Drinking contaminated untreated water TINIDAZOLE (type of abx) or metronidazole (higher rates of resistance) Plus supportive care

Answer 542

Cryptosporidium (<180): SEVERE WATERY DIARRHOEA, low grade fever, weight loss Microsporidium/isosporidium (<100): watery diarrhoea, crampy abdo pain, weight loss, FEVER RARE MAC (<50): watery diarrhoea, HIGH FEVER, weight loss Cytomegalovirus (<50): FREQUENT SMALL VOL DIARRHOEA, HAEMATOCHEZIA, ABDO PAIN, low-grade fever, weight loss

Answer 543

Cystoscopy PLUS Renal USS (intermediate risk) CT UROGRAPHY (high risk - smoking hx, recurrent UTIs etc) to evaluate for urothelial ca of lower AND upper urinary tract

Answer 544

Thalamus The combination of hemiparesis, hemisensory deficits, miotic and nonreactive pupils, and gaze deviation downward and toward the affected side of the body (i.e., away from the side of the brain lesion) is a phenomenon known as “wrong way eyes” and characteristically occurs in thalamic hemorrhage.

Answer 545

Cholestatic hepatitis: check AST/ALT in pts with underlying liver disease/coagulopathy N.B: causes of IM = EBV, CMV, HIV If severely elevated transaminases, consider CMV/viral hepatitis as cause

Answer 546

Ampulla (most common), isthmus, cornuate (interstitial)

Answer 547

Type 1 error As alpha level describes chance of type 1 error each time data analysis performed

Answer 548

CT abdo w contrast (ie before ERCP etc)

Answer 549

OGD to visualise mucosa Suspect gastritis if nonspecific GI sx but no alarm features

Answer 550

Decline in left ventricular function leading to congestive heart failure and cardiogenic shock After an acute myocardial infarction, consider complications based on the post-MI time frame. Immediate complications (within 24 hours) include arrhythmias and heart failure, while structural complications like ventricular septal defect and papillary muscle rupture tend to occur days after the event.

Answer 551

Immediate treatment takes precedence over serial monitoring to prevent developmental issues (e.g. intellectual disability)

Answer 552

Suspect if growth beyond wound (CF hypertrophic scar) and assoc trauma (e.g. ear piercing) Intralesional corticosteroid: reduces the size and itchiness of keloids by decreasing collagen synthesis and increasing collagenase activity.

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