Flashcards in Step 3 Deck (123):
What vaccines are indicated in newly dx HIV?
1. HAV if they are MSM, IVDU, or have chronic liver disease
2. HBV if not prev vaccinated
3. HPV if between 11-26 yo
4. Annual flu
5. Meningococcus if between 11-18, living in large groups, or asplenic/complement deficient
6. PCV13 once and PPSV23 8 weeks later, 5 years later, and at 65 yo
7. Tdap once then Td q10 years
How do you prevent anti-D alloimmunization?
In an Rh(D)-neg mother with pos child, ppx with standard dose anti-D immunoglobulin is administered at 28 weeks and within 72 hours post-partum. Higher doses are needed with massive fetomaternal hemorrhage.
What are the clinical features and dx of Cushing's syndrome?
Young patients with diabetes, osteoporosis, HTN, and hypokalemia should be considered. Screen with an overnight dexamethasone suppression test or 24-hour urinary cortisol. Suppression test in normal people should push down cortisol to < 3 mcg/dL in the AM.
When would you suspect TB as the cause of a pleural effusion and how would confirm diagnosis?
Someone with risk factors (ie HIV) who has lymphocytic-predominant, exudative effusion that is + for ADA. Confirm with pleural biopsy since cultures are often negative. This is because the effusion is a reaction and not direct infection (ie not empyema)
What are the characteristic CXR findings of sarcoidosis?
Bilateral hilar adenopathy +/- right paratracheal LAD
What are the pulmonary complications of polymyositis?
ILD, infection from immunosuppression, MTX-pneumonitis, and respiratory muscle weakness. ILD is common with anti-Jo antibody and should be differentiated from resp muscle weakness on PFTs. These would show decreased FVC, TLC, DLCO for ILD.
When are abx indicated in COPD exacerbation?
GOLD criteria: increased sputum purulence or volume or increased dyspnea
When is oral vanc recommended for c.diff colitis?
Systemic toxicity: high fever, WBC>15, or Cr 1.5x baseline. Second recurrence of c.diff (failed MTZ twice).
How do you prevent mother-to-child transmission of hep B?
1. Immunoglobulin and vax within 12 hours.
2. Vax at 2 and 6 months
3. Serology at 9 months (3 months after last dose)
What are the risk factors for iron deficiency anemia in children < 2 years of age?
Prematurity, lead exposure, predominantly breast milk after first 6 months,
What are the features of congenital toxo?
Macrocephaly, diffuse calcifications, chorioretinitis, jaundice, growth restriction, HSM; RFs include contaminated raw meat, exposure to cat feces, unwashed fruits/vegetables
What are the similarities and differences between Ehler-Danlos and Marfan?
Both can cause scoliosis and myxomatous valvular degeneration, and chordae tendinae rupture leading to acute MR. EDS however has more connective tissue and skin findings, leading to more velveting finger tips.
Which abx are associated with seizure risk?
B-lactams: PCN, carbapenems, cephalosporins, FQs
When is treatment for subclinical hypothyroidism warranted?
1. anti-TPO antibodies
2. abnormal lipid profile
3. ovulatory and menstrual dysfunction
What is an easy effective way to screen for alcohol abuse?
How many times in the past year have you had 5 or more drinks in one day?
What are the coronary heart disease equivalents?
DM, CKD, noncoronary atherosclerotic disease (PAD, AAA, carotid stenosis, CVA)
What is the most common cause of proteinuria in adolescents and how do you confirm the dx?
Orthostatic proteinuria: confirm with different supine/standing urine spot P:C or split 24-urinary protein collection.
What is labor protraction, its most common cause, and first line treatment?
It is defined during the first stage of labor which consists of the latent and active phase. Latent phase = beginning of reg contractions to 6 cm. Active phase is 6 to 10 cm and rapid cervical change. Protracted labor is dilation that is too slow = 1 cm/2hr during the active phase and most commonly caused by inadequate contractions (> every 2-3 mins). First line therapies are oxytocin and amniotomy.
What is active phase arrest and its treatment?
No cervical change for >/= 4 hours with adequate contractions or >/= 6 hours with inadequate contractions. Tx is c/s.
What is tick paralysis?
Rare life-threatening disorder caused by neurotoxins in tick saliva that are released over 4-7 days of tick attachment. It includes rapidly progressive gait ataxia, ascending paralysis, and absent DTRs. Fever uncommon and meticulous skin exam required to find the tick and remove it.
How do you assess the risk of HIT?
- thrombocytopenia: >50% drop or nadir =/>20k (2 pts), 30-50% drop or nadir 10-19k (1 pt)
- timing: 5-10 days or =1 day if prior hep exposure w/i 30 days (2 pts), consistent drop at 5-10 days but unclear due to missing CBCs or onset after 10 days or =1 if prior exposure 30-100 days ago (1 pt)
- thrombosis: confirmed new thrombosis or skin necrosis or acute system rxn after IV hep bolus (2 pts), progressive or recurrent thrombosis or non-necrotizing lesions or unproven suspected thrombosis (1 pt)
- oTher causes: none apparent (2 pts), possible (1 pt)
Score of 6-8 = high, 4-5 intermediate, 0-3 low
What are indications for voiding cysturethrogram in between 2 months - 2 years of age?
Atypical or complex presentation for UTI
Recurrent febrile UTI
Renal/bladder u/s shows: hydro, renal scarring, high-grade VUR, or obstructive uropathy
What are the key clinical features of ankylosing spondylitis, monitoring, and prognosis?
1. LBP/stiffness > 3 months that improves with activity or exercise, limited lumbar ROM, limited chest expansion
2. X-rays every 3 months or ESR/CRP
3. Good prognosis, no reduction in life expectancy
What are the extra-articular manifestations of ankylosing spondylitis?
Acute anterior uveitis, aortic regurg, apical pulmonary fibrosis, IgA nephropathy, and restrictive lung disease
What is the approach to an adrenal incidentaloma?
FIRST, hormone w/u: BMP, dexamethasone suppression test, 24-hour urine catecholamine, metanephrine, vanillylmandelic acid, and 17-ketosteroid measurement.
Surgical excision: functional tumors, malignant-appearing (heterogenous), and size >4 cm
If not surgically excised, then monitored with repeat evaluation.
What are the null hypotheses for non-inferiority and superiority trials? What are the goals of these trials in the process of drug development?
H0 non-inf: Drug being tested is not not-inferior (inferior) to the comparison.
H0 superior: Drug being tested is not superior to the comparison.
We do it staged to first establish evidence that the drug is no worse than standard with regards to efficacy. Then we establish additional threshold to prove superiority. This is all predicated on previous safety studies.
What should you think of with recurrent bacterial infections in a relatively healthy adult? And how would you test?
Humoral immunity defect. Test with quantitative measurement of Ig.
What are the manifestations of analgesic-induced nephropathy and most common cause?
Florid nephrotic range proteinuria usually caused by NSAIDS leading to abrupt decline in renal blood flow. NSAIDS can also cause an acute interstitial nephritic pattern.
Use of a first-gen antipsychotic resulting in sudden (hours to days) onset contraction of neck, tongue, eye muscles is what and how do you treat?
Torticollis and oculogyral crisis are consistent with acute dystonia, a side-effect of haldol. Tx with benztropine or diphenhydramine for anticholinergic effects.
How does TCA overdose present and how do you manage?
CNS: AMS, seizures, respiratory depression
CV: Fast Na blockade --> Prolonged QRS/QT/PR --> arrhythmias, CCB --> vasodilation --> HoTN
Anti-Ch: dry mouth, blurry vision, dilated pupils, urinary retention, flushing, hyperthermia
Mgmt: supportive, give NaHCO3 for rhythm, activated charcoal if w/i 2 hours of ingestion unless ileus
What are the clinical manifestations of occult flail chest?
Tachypnea, shallow respirations, tachycardia, anterior chest bruises, hypoxia or signs of it (cyanosis). Difficult to identify due to muscle splinting and shallow breathing.
What is the natural course of hepatitis B and how should it be managed?
70% asymptomatic, rest will have anorexia, nausea, jaundice or RUQ pain. There is low risk of fulminant liver failure or severe hepatitis.
Threshold for hospitalization: fever, impaired synthetic function, biliary obstruction, signs of fulminant liver failure (HE or TB>10)
Antiviral therapy threshold: immunosuppressed, concurrent hep C, severe hepatitis, fulminant LF
AST/ALT should drop by 8th week, regular outpatient follow up and monitoring warranted.
Chronic hep B infxn risk is inversely proportional to age. Hence, perinatal transmission has very high chronicity. <5% of adults progress.
What is the optimal duration, route, and benefits of abx for group A strep pharyngitis?
10 days of PO PCN. Reduces sxs duration and severity, prevents acute rheumatic fever BUT NOT PSGN.
What is the treatment for Pb toxicity?
< 45 mcg/dL: monitor with repeat level in a month
45-69 mcg/dL: DMSA, succimer
=/> 79 mcg/dL: dimercaprol+EDTA
What is a major complication of untreated varicocele and when is imaging warranted?
CT A/P for bilateral varicocele, right-sided varicocele (may indicate IVC blockage), and varicocele that does not reduce when supine.
What are the risk factors, presentation, dx, and mgmt of intussuception in a child?
Path: lead pt from lymphoid hyperplasia (recent viral illness or rotavirus vax), congenital malformation, HSP, celiac, tumor, polyp
Pt: sudden, intermittent abd pain, currant jelly stools, sausage abd mass, lethargy
Dx: target sign on u/s
Tx: air enema, surgery
What is lichen planus and what is it associated with?
Discrete, intensely pruritic, polygonal-shaped violaceous papules or plaques on the flexural surfaces (usually wrists), buccal mucosa, or external genitalia. Skin bx req'd for dx and commonly associated with hep C, so consider screening.
How do you determine the cause of ascites?
Serum Ascites Albumin Gradient > 1.1 is due to portal HTN, which is commonly caused by cirrhosis, alcoholic hepatitis, and CHF. < 1.1 can be due to carcinomatosis, nephrotic syndrome, TB, pancreatitis, serositis.
What is the management of cryptochordism?
Spontaneous descent rarely happens after 6 months, so at that age elective surgery should be offered.
How is acute mesenteric ischemia different from acute colonic ischemia?
The first is marked by periumbilical pain out of proportion to exam findings. It happens with sudden obstruction of either arterial or venous supply to mesentery. The latter is marked by mild pain (usually lateral) with bloody diarrhea. The difference in presentation is because the etiology is transient ischemia in watershed areas.
Densely pigmented lesion with irregular borders in the peripheral choroid is what and how is it managed?
Ocular melanoma which is a primary malignancy arising from iris, ciliary body, or choroid. Lesions <10 mm in diameter and <3 mm in thickness can be checked in 3 months and if not growing, then every 6 months. If it is bigger, causing blurry vision, or visual loss, then MRI for staging is needed and radiotherapy. Large lesions or extrascleral extension warrant enucleation.
Massive PE could show what on EKG and echo?
New RBBB, atrial arrhythmias, Q-waves or ST changes in inferior leads. Rarely S1Q3T3. Echo would show increased PAP but may also show new tricuspid regurg due to dilatation of annulus. Inferior (but not posterior) wall hypokinesis.
What is the pathophysiology and long-term complications of exercise-induced amenorrhea?
Decrease in LH secretion pulsatility and subsequent hypoestrogenemia. Leads to osteopenia, osteoporosis, breast/vaginal atrophy, mild hypercholesterolemia, and infertility.
What are the complications of isoretinoin therapy and what should you counsel the patient on?
Hyperglycemia, hypertriglyceridemia, hepatotoxicity, mucocutaneous rxns, blood dyscrasias, ocular toxicity. Female patients should be tested for pregnancy and use 2 methods of contraception. All pts should be advised to avoid alcohol due to the risk of pancreatitis, as a result of the TGs.
How do you diagnose acute rheumatic fever?
2 major JONES criteria or 1 major plus 2 minor. JONES=joints (migratory arthritis), carditis, erythema marginatum, sydenham chorea. Minor criteria: fevers, arthralgias, elevated ESR/CRP, 1st degree heart block
What is Nelson's syndrome?
The development of pituitary enlargement with visual field defect and hyperpigmentation following bilateral adrenalectomy. Loss of glucocorticoid feedback loops leads hyperpituitarism with increased MSH production.
How does chronic bacterial prostatitis present and how do you treat it?
> 3 months of recurrent UTIs, pelvic pain, pain with ejaculation. Pyuria and bacteriuria present after prostate massage. Treat empirically with 6 weeks of cipro.
What are the eye findings of disseminated Candida? How do you treat?
Endophthalmitis consists of fever, eye pain, decreased visual acuity, and fundoscopic evidence of focal, glistening, white, mound-like lesions with possible vitreous extension leading to vitreous haze. TPN through CVC is a major risk factor in neutropenic patients. Tx with vitrectomy and amphotericin B.
When would you consider scleroderma renal crisis as a cause of acute renal failure? How would you treat and why?
Severe HTN + AKI in someone with history of Raynaud's and GERD. Tx with ACE inhibitor and IV nitroprusside. The underlying pathology is hyperactivation of the RAAS system. Hence, initially Cr will worsen.
What is a major side-effect of ginko biloba?
Bleeding risk and platelet dysfunction.
Pernicious anemia is associated with what gastritis?
Autoimmune metaplastic atrophic gastritis (AMAG), which is composed of glandular atrophy, intestinal metaplasia, and inflammation. There will absent rugae in the fundus with little changes in the antrum.
What are the top 2 causes of diaper dermatitis and how do you treat it?
Contact dermatitis is the most common cause and is characterized by sparing of the creases and skinfolds. Candida dermatitis is characterized by its involvement of the creases/folds.
What is the differential for scrotal pain?
1. Epididymitis: mild-to-moderate pain with swelling, tenderness, no voiding sxs, normal u/a, decrease in pain with testicular elevation and normal cremasteric reflex, Chlamydia
2. Torsion: moderate-to-severe, high riding testis, absent cremasteric reflex, u/s with Doppler when dx unclear
3. Orchitis: severe pain and swelling, sudden onset of fever in setting of mumps infxn
4. Tumor: painless mass
5. Varicocele: dull pain relieved with laying down, bag of worms mass, usually left-sided or bilateral
What are the defining lesions of disseminated cutaneous cryptococcosis?
Rapid onset of multiple papular lesions with central umbilication and hemorrhage or necrosis in pts with CD4<100.
What are the most common bacterial causes of pediatric sepsis, what broad-spectrum abx do you use, and which do you avoid and why?
GBS and E.coli. Amp+gent or cefotaxime. CTX and sulfonamides are avoided due to their risk of interfering with albumin binding of bilirubin.
What are the two most common causes of PNA in CF and how do they change over time? What are the preferred abx?
S.a. and P.a. By adulthood P.a. exceeds S.a. Treat with vanc, ticarcillin-clavulonate, and tobra for double coverage.
What is rosacea and what can it look like? How do you manage based on severity?
Rosacea is erythema of the central face that can look like acne but key is the lack of comedones. Mild cases with erythema and telangiectasias can be managed with brimonidine or avoidance of factors like spice foods, etoh, and emotional stressors. Cases with papular/pustular components can be tx'ed with topical MNZ. More severe cases with topical clinda or similar abx.
What is a common complication of rosacea?
Ocular sxs: FB sensation, blepharitis, keratitis, recurrent chalazion, etc. Warrants ophtho consult.
When would you not tx sarcoid?
Asymptomatic pulmonary sarcoidosis. Hilar adenopathy with erythema nodosum has a very favorable prognosis with spontaneous remission, so only extrapulmonary sarcoid that doesn't warrant tx.
Erythematous, mildly itchy plaques with greasy scales located on scalp, eyebrows, and nasolabial folds makes you think of what? What associated conditions?
Seborrheic dermatitis. A/w Parkinson's and new HIV.
What are the ranges of permissive HTN in stroke?
No thrombolytics: up to 220/120 is allowed.
Thrombolytics: 185/105 for first 24h
What is the approach to DVT ppx in acute stroke patients and why?
Give LMWH immediately if there is no evidence for hemorrhagic stroke. DVT prevalence is around 2-10% and highest in the first week after stroke, especially in hemiparesis.
How do you manage a suspected ectopic pregnancy?
Hemodynamically unstable: straight to laparoscopy
Stable: get TVUS, if ambiguous, turn to beta, if <1500, then repeat beta in 2 days, if >1500 repeat beta with TVUS in 2 days
Key things to know about St. John's wort?
OTC herbal, meta-analysis showed efficacy in mild-to-moderate depression equal to TCA and SSRIs. Also used for anti-inflammatory and wound-healing properties. Not regulated well. Induces P450 and P-glycoprotein leading to tx failure for hormonal contraceptives, immunosuppressives, ARVs, narcotics, anticoagulants, and antifungals.
How do you treat latent TB?
9 months with INH, 6 mos for kids and 4 mos for adults with rifampin if INH-resistant
What is the approach to hyperthyroidism in pregnancy?
Err on the side of hyperthyroidism. First trmester treat with PTU because of teratogenic effects of methimazole. Second and third trimesters use methimazole because PTU is hepatotoxic.
What is the natural time-course of Guillain-Barre?
2 weeks of worsening, plateau for 2-4 weeks, then spontaneous recovery over months. Time to recovery is shortened with pheresis or IVIg. Severity on arrival and infxn with Campy portends worse prognosis
When would you start warfarin after HIT and why?
While you would switch to argatroban, you want to wait until thrombocytopenia resolves (>150) because you want physiologic reserve improve to withstand bleeding risk. Remember that warfarin transiently induces prothrombotic state. Argatroban will reduce that risk but HIT tips towards the pro-bleeding side.
What are absolute contraindications for combined hormonal contraceptives?
Migraine with aura, >15 cigs/day AND >35 yo, BP>160/100, heart disease, DM with end-organ damage, thromboembolic hx, APLA, h/o stroke, breast ca, cirrhosis/liver ca, major surgery with prolonged immobilization, use <3 weeks postpartum
How is gallstone pancreatitis managed?
Mild cases are those without complications (organ failure, local necrosis). These are managed with lap chole within 7 days. Severe cases are those with complications like persistent hypotension, end-organ failure, etc. These undergo delayed surgery to allow inflammation subside. ERCP is done preop if there's evidence of persistent biliary obstruction. Otherwise intraop cholangiogram.
How do you manage ASCUS?
Age 21-24: repeat Pap in 12 mos. If neg, ASCUS, or LSIL, repeat again. If neg, 12 mos later than go back to regular screening. If ASC+ then colpo.
Age 25+: immediate HPV testing. If positive, colpo.
What are current Pap smear guidelines?
Age 21 is when you start and up to age 29, Pap every 3 years. Afterwards you can continue that or do Pap+HPV every 5 years until 65. For HIV patients, do it at dx and then annual until 3+ normal tests. For immunosuppressed, annual Pap+HPV.
What are the 5 steps of doing an RCA?
1. Collect data
2. Create causal factor flow chart
3. Identify root causes
4. Generate recommendations and implement
5. Measure success of changes implemented
What is the approach to fever in a returned traveler?
< 10d, early incubation: typhoid, dengue, chikungunya, flu, legionella
1-3 weeks, medium: malaria, typhoid, leptospirosis, schisto, rickettsial dz
> 3 weeks, late incubation: TB, leishmaniasis, enteric parasitics
What is the approach to a solid pulmonary nodule on CXR?
Low risk (<0.8 cm) vs high risk (2 cm), with latter requiring immediate VATS resection
Low risk under between 5-7mm can be watched with serial CTs. Smaller requires no follow up.
Intermediate risk requires PET vs bx with surgical excision vs serial CTs.
What do you have to watch out for in repleting B12 in moderate to severe anemia?
Hypokalemia within the first 48h
What is important to know about lithium pharmacology?
Narrow therapeutic index, level > 1.5 is toxic, 2.5 mEq/L is an emergency. Presentation is confusion, ataxia, neuromuscular excitability. Precipitants are anything that impacts renal clearance: AKI, thiazides, ACEi, NSAIDS. Tx with saline infusion and/or HD.
First line treatment for narcolepsy?
Modafinil, a stimulant with good side effect profile and low abuse potential.
What is the treatment for recurrent symptoms in crypto meningoencephalitis?
How is CNS crypto treated?
1. Induction with amphotericin B and flucytosine for at least 2 weeks or when sxs abate and neg LP cx.
2. Consolidation with high dose oral fluconazole for 8 weeks.
3. Maintenance with low dose fluconazole for 1 year
What is standard post-exposure prophylaxis?
2 NRTIs + Integrase inhibitor or NNRTI. Classic combo is tenofovir, emtricitabine, and raltegravir.
How do you manage a breech presentation?
External cephalic version at 37 weeks.
What is the most important prognostic factor for COPD?
FEV1 < 40% of predicted
How do you manage adenocarcinoma found on colonic polyp?
If it is well-differentiated, confined to the head of a pedunculated polyp, and not involving the stalk or resection margins (>2 mm), then endoscopic surveillance. every 2-3 months.
How would you manage adenomas on polyps in colonoscopy?
1 or 2, < 1 cm tubular adenomas, screen in 3-5 years.
3-10 adenomas, > 1 cm, or high grade dysplasia or villous features, screen in 3 years.
Large (> 2 cm) sessile polyps removed piecemeal, screen every 2-6 months.
What is the presentation of rheumatic heart disease?
Mitral stenosis: loud S1, mid-diastolic rumble at the apex, sometimes loud split S2 (prominent P2) because of PHT.
Dyspnea, fatigue, afib, hemoptysis, hoarseness from LAE impinging recurrent laryngeal. EKG with P mitrale.
What are the two primary diagnoses of pruritus without a rash in pregnancy?
Pregnancy-induced pruritus: focal, usually abdominal, mild transaminitis
Intrahepatic cholestasis: generalized, hands and feet especially, hyperbilirubinemia
What is a hyperkeratotic painful and enlarging papule on the sole of the foot? How do you treat?
Plantar warts due to HPV. Tx with topical salicylic acid and duct tape. Will take 2-3 weeks to show response. Continue 1-2 weeks after resolution to ensure HPV eradication. You can use cryotherapy or topical imiquimoid as 2nd and 3rd line.
An asymptomatic newborn with ruddy skin and general erythema is consistent with what?
Neonatal polycythemia, hct>65%. Confirm with venous stick. Caused by erythropoiesis in setting of intrauterine hypoxia (maternal DM, HTN, smoking), erythrocyte transfusion from delayed cord clamping or twin twin transfusion, or genetic abnormalities. When symptomatic there can be cyanosis, irritability, respiratory distress. Often hypoglycemic, treat with IVF, glucose, and exchange transfusion.
What is the pathophysiology of hypoxemia in COPD exacerbation?
The key cause is low V/Q. Airflow limitation from loss of elastic tissue, bronchiolar collapse, spasm, and mucus plugging all lead to low ventilation. Hypoxic vasoconstriction attempts to adjust for the right to left PATHOPHYSIO shunting. Supplemental O2 relieves that. Dead space ventilation with high V/Q is more related to alveolar-capillary destruction leading to hypercapneia.
What would scintigraphy of subacute thyroiditis show?
This results in hyperthyroidism initially because thyroid follicles are destroyed and T4 is dumped, suppressing TSH. The destroyed follicles can't take up substrate and hence there would decreased RI uptake. Tx with NSAIDs because it is self-limited.
What is the best intervention for the negative symptoms of schizo?
Social skills training. AP do not work.
What is the classic WPW EKG?
Short PR interval, prolonged QRS but narrow looking with a delta wave (slurred upstroke)
What is the key adverse reaction of nitroprusside?
Cyanide toxicity: unexplained metabolic acidosis, flushing, AMS, especially in patient with CKD
Saw palmetto is for? And side-effect?
BPH. Bleeding risk.
What is the treatment for bacterial conjunctivitis? Important caveat?
Erythromycin or polymyxin-TMP drops. Use fluoroquinolone drops for contact wearers because of P.a. risk.
How does parvovirus B19 present in adults and adolescents?
ILI with malar rash. Swelling, joint pain, and stiffness symmetrically in MCP/PIPs 1 week later. Lyme is monoarticular.
What is post-exposure management for hepB?
If source has it and health care worker is not immunized, then give HBIG and vax.
What features prompt more work up in mastalgia?
Noncyclical, unilateral, or focal mastalgia should prompt imaging if the breast exam is normal and any abnormal findings warrant bx and referral.
What are the clinical features of androgen insensitivity syndrome?
Primary amenorrhea, bilateral inguinal masses, breast development without pubic/axillary hair. Blind vaginal pouch. 46XY.
What is the approach to a pneumothorax?
If stable, chest tube. If unstable or tension physiology, needle decompression.
What is the pathognomonic sign for CF in a newborn?
Meconium ileus: distal intestinal obstruction, terminal ileum is dilated and with inspissated meconium.
How do you monitor response in Grave's disease treatment and why?
Check total T3 and FT4 because TSH may be suppressed for weeks after RAI treatment.
How should AEDs be managed in pregnancy?
6 months before CONCEPTION, other AEDs should be trialed. Do not switch AEDs if they have been continued and pregnancy was not known. Instead give high dose folate and serum AFP with ultrasound screening.
How do you diagnosed urethritis?
Get NAATs but first you can get the discharge and GM stain to determine GU/NGU. If no intracellular diploccoci then no N.gonorrhea. Hence treat with azithro for Chlamydia and other causes.
What are the features of TB meningitis?
Choroidal tubercles: yellow-white nodules near optic disc.
Basilar meningeal enhancement.
CSF: protein 100-500, low glc<45, lymphocytes
How do you dx LBD?
Dementia + 2/3 of core features:
1.) Cognitive fluctuations
2.) Visual disturbances
What is the immune reconstitution inflammatory syndrome?
Inflammatory response that occurs weeks after ART started. Manifests as fever and respiratory symptoms after several weeks of clinical improvement. It is usually transient and self-limited.
What is the presentation of Pancoast tumors and when is it considered an emergency?
Pancoast tumors encase the apical peripheral part of the lung leading to shoulder pain but can also cause a Horner syndrome (ipsilateral ptosis, miosis, and anhidrosis). It can also impact C8-T2 roots leading to intrinsic hand muscle atrophy and paresthesias. It is an emergency when there is asymmetric hyperreflexia, suggesting spinal cord compression.
What are the criteria for DM diagnosis?
A1C = 6.5% or above
Fasting (8 hrs) BG = 126+
Random BG = 200
OGTT = 200
Need repeat measurement of same test for confirmation if asymptomatic.
If 2 different tests are concordant, no additional testing.
Random BG 200 + sxs = dx
What are the key features of scabies? Tx?
Distribution often involves web spaces of hands and spares head and neck. Pruritis worse at night. Tx with topical permethrin.
What are the key features of Hirschsprung and gold standard bx?
Intestinal obstruction: bilious vomiting, abdominal distension, delayed meconium, expulsion of stool on rectal exam. Rectal suction bx.
Most common bug for prostatitis and how do you treat?
E.coli. 4-6 weeks of bactrim or a fluoroquinolone.
What is the ddx for erythema multiforme and what is it?
Symmetric targetoid lesions on the extensor surfaces of extremities, palms, and soles. DDx is 1.) HSV, 2.) drugs, but also consider collagen vascular disease and malignancy.
What is the definition of PPH and the ddx?
> 500 cc after VD, > 1L for C/S
1.) Uterine atony: boggy uterus, prolonged labor, chorio, uterine overdistension
2.) Retained POC: boggy uterus, missing cotyledons, retained fragments on u/s, manual extraction req'd in labor
3.) Trauma: lacerations
Among incontinence types, incomplete emptying and dribbling is which type? What is the mechanism and pathology?
Overflow. Due to impaired detrusor contractility (hypoactivity) in setting of diabetic autonomic neuropathy.
Kawasaki's disease is?
Fever > 5d + 4 or more:
conjunctivitis, mucositis (strawberry tongue), erythematous morbilliform rash, erythema/edema of hands/feet.
Baby becomes cyanotic when feeding but oxygenates when crying. What is it?
Choanal atresia and dx'ed with inability to pass nasal catheter into oropharynx.
For PCP PNA, what test do you need for mgmt?
ABG, because paO2<70 or Aa gradient > 35 means give corticosteroids.
What is the most common inherited thrombophilia and what is the mechanism?
Factor V Leiden is an inherited mutation that makes it resistant to the antithrombotic effect of Protein C
At what diameter is AAA repair recommended? Once identified how is it monitored?
5 cm. 3-4cm ultrasound q2-3 years. 4-5 cm u/s q 6-12 mos.
How do you interpret joint aspirate?
< 2000 = noninflammatory (OA)
2000-75k = inflammatory (ie gout or RA)
> 100k = infectious