Ultimate Merge Flashcards

Question

Unexplained elevation in CK and signs of myopathy?

Answer 1

Consider hypothyroidism

Answer 2

Agranulocytosis (methimazole) 1) !!!!HYPOTHYROIDISM (MC, unpreventable, but tx with T4) [destruction of folliciles] 2) Exace. of ophthalmopathy [ppx w/ corticosteriods before and after] SLE w/ isolated skin and joint involvement. ADR: RETINOPATHY (eye exam q6months)

Answer 3

Brown/pink/scaly plaque with central clearing; first symptom of 'pityriasis rosea' 1) actinic keratosis 2) rosacea [PRECIP. BY HEAT, HOT DRINKS, TEMP CHANGE] 3) Exczema Herpeticum tx acyclovir! esp in infants 4) thickening bc of scratching vs hyperkeratosis/HepC (pruritic, purple, polygonal, planar, papules & plaques) vs hyperplasia of vulvar squamous epi (itchy!) vs increased risk SSC vulva "parchment" 5) acne (papulopustular) rosacea 6) acne inversa (hydradenitis suppurativa) 7) sebaceous hyperplasia 8) dermatofibroma [path: fibroblast proliferation]; if symptomatic, bleeding, or evolving, tx cryosurg or shave exision 9) MC cutaneous cyst: epidermal inclusion cyst/epidermoid cyst/epidermal cyst wrong (benign nodule with normal epidermis that produces keratin [path: when epidermis is lodged into dermis due to trauma or comedones] may become inflammed; tx for cosmetic or infxn 10) icthyosis vulgaris

Answer 4

1) DHFr-ase inhibitor (purine antimetabolite); macrocytic anemia MCV^100 Hg v12; stomatitis, hepatotoxicity 2) TNF and IL-1 suppressor; G6PD def. hemolysis, GI/visual disturbance!!! (retinitis) 3) TNF and IL-1 suppressor; stomatitis, hepatotoxicity, hemolytic anemia 4) bone marrow suppression; pancreatitis 5) predisposes viral infx and lymphoma; nephrotoxic 6) pyrimidine synthesis inhibitor; hepatotoxicity, cytopenia 7) infection, demyelination, CHF, malignancy

Answer 5

decreased vs increased PRELOAD increased (hypovol) vs decreased (septic) SVR decreased (hypovol) vs increased (septic) MvO2

Answer 6

RTA = decreased urinary excretion of H+ leading to ACIDIFICATION of the TUBULES leading to ***hypERchloremic NAGMAcidosis w/ ALKALINE URINE!*** 4) "aldosterone resistance" or deficiency often seen in DM2!!!***** 2) "proximal" = lack of HCO3 reabsorption = hypERchloremic hypOkalemic NAGMA (hypokalemia bc more Na delivered to DCT) [contrast emesis: hypOchloremic hypOkalemic ma] 1) "distal" = hypOkalemia and **inability to generate HCO3 2/2 DCT's inability to secrete H+ Fanconi: PCT defect. increased secretion of all AA's phophate, bicarb etc. a) weakness, rhabdo, paresthesia, resp failure NS!

Answer 7

Class 1: Na blocker a) quinidine, procainamide, disopyramide b) Lidocaine, Mexilitine c) Flecainide and Propafenone - prolonged QRS (ONLY DURING TOLERANCE) Class 2: Beta block - increased PR Class 3: Amiodarone, Ibutilide, Dofetilide, Sotalol - increased QT Class 4: Calcium blocker - increased PR

Answer 8

Contact-lens-assoc. keratitis (medical emergency!) Pseudomonas HSV or VZV CMV

Answer 9

Aortic inury WIDENED MEDIASTINUM

Answer 10

RMSF, Secondary syphilis

Answer 11

a) Pneumocystis jirovecii ppx TMP-SMX (+steroids for pulm function IF PAO2 v70 or A-a>35) alternative to TMP: dapsone; [oropharyngeal candidiasis], IV pentamadine if refractory, PO atovaquone, [PO primaquine+clinda] b) Histoplasma (ppx Itraconazole) [ohio/mississippi river valley] c) Toxoplasma (ppx TMP-SMX) [pos. Toxo IgG Ab] TREAT: sulfadiazine, pyrimethamine candida esophagitis MC (alt HSV, CMV, apthous) NBS: tx empiric fluconazole a) if no improvement, do upper endoscopy +biopsy b) Large ulcer, deep/distal/LINERAR, tx ganciclovir/foscarnet (for CMV) c) if small, round/OVOID, tx acyclovir (for HSV) d) MAC (ppx azithromycin, clarithromycin) FC summary ppx: At CD4 count

Answer 12

1) Fatty (completely reversible) 2) hepatitis (completely reversible) 3) cirrhosis/fibrosis (completely IRreversible)

Answer 13

Porphyria cutanea tarda extrahepatic manif. of Hep C acute intermittent porphyria urine porphobilinogen primidone (MoA: anticonvulsant that converts into phenobarbital and phenylethylmalonamide)

Answer 14

Superficial BCC, actinic keratoses

Answer 15

a) Isoniazid + B6 (Pyridoxine) 9 months ***(vs RIPE-2mo+RI-4mo for ACTIVE tb)

Answer 16

Increases the risk of asystole Decreases the risk of VPBs, Vfib Overall prognosis unaffected

Answer 17

a) Necrotizing surgical site infx; emergent surgical exploration b) acute mediastinitis s/p cardiac surg; tx debridement + abx c) autoimmune postpericardiotomy syndrome: tx NSAIDs or steroids

Answer 18

a) TB!!!! Nocardia (gram+, acid fast, filamentous/branching rod) Gram neg. rods Anearobes Coccidiodomycosis (SW US) invasive Aspergillosis (halo sign on CT!) b) pneumocystis (PCP)

Answer 19

CONTIGUOUS SPREAD vs direct inoculation in trauma vs hematogenous in adults

Answer 20

a) 3+ months s/p arthroplasty: - coag negative staph (epidermidis) b) v3 months s/p arthroplasty - staph aureus c) gonococcal arthritis d) Reactive Arthritis (2/2 chlamydia, campylobacter, etc.); ****NSAIDs****

Answer 21

a) migratory asymmetric polyarthralgias tenosynovitis (wrist, ankle fingers, knees) skin rash/dermatitis/pustules OR b) isolated purulent mono/oligoarthritis without derm [purulent arthritis in sex active = gonococcal UPO] Tx IV ceftriaxone 1-2wk; switch to PO cefixime when improved ---- underlying joint dz (RA, OA, prostetic, gout), DM, IA gluc injections, IVDA, +80y px - acute monoarthritis, hot/edema/vROM, ^ESR/CRP tx - based on gram stain/blood cultures a) gram + = vanc b) gram - = 3rd gen cephalo c) negative gram stain = i) immunocompetent = vanc ii) immonoCOMPROMISD = VANC + 3RD CEPH THEN: arthroscopic washout (closed drainage) or arthrotomy (open drainage)

Answer 22

a) LYMPHOCYTIC predominance, elevated protein, nL glucose; tx IV acyclovir b) NEUTROPHILIC predominance, elevated protein, LOW glucose; tx IV dexamethasone + ceftriaxone + vancomycin (ampicillin in >50y) c) ELEVATED OPENING PRESSURE, low glucose, elevated protein; tx IV amphotericin (+flucytosine), maintenance w/ fluconazole d) mimics VIRAL

Answer 23

OHS has daytime ABNORMAL BLOOD GASES (aka hypercapnea and hypoxemia during the day) (persistent underventilation of the lungs... chronically high PaCO2, low PaO2......) (LATER, BOTH can have polycythemia, pHTN, RVfail) [therefore OHS often have concomitant OSA] 1) gouty arthritis (^cell turnover) 2) PUD (^histamine from basophils) 3) HTN (hypervolemia)

Answer 24

a) Histoplasmosis - SE/mid-atlantic/central US - acute pneumonia - cough fever malaise - hilar LAD - histoplasma serum or urine Ab - ITRACONAZOLE b) Aspergillosis - IC, chemo, glucocorticoids - invasive pulmonary dz - fever, cough, dyspnea, - CXR - cavitary - CT- halo/moon sign (air crescent) c) Coccidiomycosis - SW US/ valley (california/AZ) - primary pulm + secondary cutaneous/arthralgia - norm. pleuritic CP - ... d) Sporotrichosis - dimorphic mold (hyphae) - SQ infx, reddish nodule/papule, ulceration. lymphatic e) BLAgStomycoses ("bone, lung, and genitals/skin") - south, MIss/OH riv. valleys, midwest/great lakes - pneumonia - wartlike violaceous nodules - osteomyelitis - prostatitis, ortchitis - dx culture/microscopy, antigen - tx oral itraconazole; IV ompho if severe/i/c

Answer 25

a) UL adenoma - surgery | b) BL hyperplasia - aldosterone antagonists (spironolactone)

Answer 26

Amiodarone (sinus brady, heart block, HEPATITIS, corneal deposits, blue gray skin discoloration, peripheral neuropathy) Beta-blockers

Answer 27

Multiple Myeloma UPO Metastatic skeletal bone survey

Answer 28

1) gram neg. "HELPS" H. Flu, E. Coli, Listeria, Proteus, Salmonella

Answer 29

AV-fistula (high output CF) Increased preload, increased CO, decreased SVR

Answer 30

Viral ARthritis, (parvoB19, hepB/C, HIV, rubella) tx nsaids

Answer 31

Think Digoxin tox. [color alterations lol]; tx Dig Fab ATRIAL TACHYCARDIA W/ AV BLOCK mech: increased ectopy and vagal tone Beta blocker overdose; tx 1) IVF + atropine 2) GLUCAGON ``` Beta agonist (albuterol), insulin+glucose, Moderate w/out EKG changes- loop+IVF Symptomatic or K^ 6.5 - hemodialysis ``` ``` hyPOkalemia (muscle weakness, cramps, arrhythmia, tremor, palp/headache) vs hypER (muscle weakness, flacid paralysis, asystole) ```

Answer 32

Prior infx, FEBRILE HEMOLYTIC TXFUSION RXN, malig hyperthermia Benign condition ~2-3 days s/p a PROCEDURE W/ HYPOTENSION AND MASSIVE TRANSFUSION in which cholestasis occurs by a) hypotension leading to decreased hepatic fxn b) increased bilirubin load from transfusion c) decreased bilirubin clearance by kidneys 2/2 tubular necrosis

Answer 33

Tachycardia-mediated cardiomyopathy (reversible) tx agressive rate control (restoration of NSR?) vs CHF which is more irreversible

Answer 34

***EITHER 2 WEEKS BEFORE OR 2 WEEKS AFTER 1) PCV13 + meningococcal + Hib 2) PPSV23 [8 WEEKS LATER] impaired PHAGOCYTOSIS against encapsulated organisms. Ab won't really work till 2 weeks later 30+ y to life

Answer 35

a) Leukemic Reticuloendotheliosis [Hairy Cell Leukemia] (CD11c) tx - purine analogs {aka adenosine deaminase} inhibiors [cladribine (2-chlorodeoxyadenosine), pentostatin} b) Chronic Lymphocytic Leukemia (CLL); smudge cells, mature small lymphocytes predominant; thrombocytopenia=poorest prog; "leukemia of old age" c) Chromic Myeloid Leukemia (CML); [9,22] [bcr, abl] [philly] abnL tyrosine kinase activity d) CHOP e) ALL f) APromyelocyticL (a subtype of AMyeloidL) g) CML (tyrosine kinase inhibitor)

Answer 36

Malignant monoclonal prolif of plasma cells Increased risk for infxn 2/2 decrease in fnxnL Ab's CRAB (hyperCalcemia, renal impairment, anemia, bone lysis) bone lysis = back pain!? HypERRRreflexia, CRAMPS, convulsions rarely, periooral tingling? Caused by increased albumin-binding and BLOOD TRANSFUSION (citrate) vs "immobilization hypercalcemia" Follows Ca++

Answer 37

Cerebellar hemorrhage, evacuative craniotomy [can present with blepharospasm, 6th nerve palsy, conjugate deviation, and coma in severe cases] (FEVER IS COMMON IN ANY BRAIN HEMORRHAGE!)

Answer 38

a) Axillary b) Radial (preserved triceps, but) only weakened extension of digits c) Axillary d) Radial (but triceps preservation! wrist drop tho) e) Ulnar f) Radial g) Radial (but no motor deficits since radial n. doesn't innervate any muscles in the hand. Only sensory loss here) h) BRACHIAL ARTERY and Median n.

Answer 39

a) this is what makes antipsychotics efficacious b) delusions/hallucinations in schizophrenia; euphoria from drug use c) extrapyramidal side effects from antipsychotics: acute dystonia, akathisia, parkinsonism d) chorea, tics e) hyperprolactinemia: amenorrhea, galactorrhea, sexual dysfunction, gynecomastia f) hypOprolactinemia Shivering 2/2 hypothermia (thermoregulatory dysruption)

Answer 40

Waterhouse-Frederichson in the setting of meningococcemia, leading to adrenal hemorrhage which leads to death

Answer 41

Typically abdominal pain, palpable purpura (with normal coag panels), hematuria, arthralgia, scrotal pain/edema Intussusseption (due to bowel wall edema and localized hemorrhage, typically small bowel ileo-ileal vs usually ileo-colic, therefore may not be seen on enema) and GI bleed Tx pain control, corticosteroids if severe

Answer 42

Risk of intussusseption, therefore if patient has hx of intussuseption then don't administer vaccine. Other regular contra. are allergies to ingredients, SCID, etc. MMR, varicella, zoster, live-attenuated influenza, c/i when CD4v200

Answer 43

1) early localized: erythema migrans (targetoid rash), malaise 2) early disseminated: a) carditis: AV block, cardiomyopathy b) neuro: facial nerve palsy, meningitis, encephalopathy, conjunctivitis c) MSK: migratory polyarthralgia d) skin: multiple erythema migrans, generalized LAD 3) Late/chronic: arthritis, encephalomyelitis, peripheral neuropathy

Answer 44

Reactive: acute, asymmetric oligoarthritis, 1-4 weeks following urethritis or diarrhea Lyme: happens in the setting of untreated localized disease; history of recent travel to the northeastern/upper midwestern states; monoarticular/oligoarticular arthritis (knee) following several months of migratory polyarthralgia; NBS: ELISA and Western Blot, tx. Amoxicillin if there's no other Lyme stuff going on. Otherwise Ceftriaxone?

Answer 45

Vasa previa (maternal vitals preserved bc it's fetal bleeding) a) Normal labor - bloody show, small amount of bleeding b) Placental abruption - abdominal pain, *HYPERTONIC*/tender uterus; YOU DON'T NEED BLEEDING TO MAKE THIS DIAGNOSIS! c) Uterine rupture - abdominal pain, palpable fetal parts, *CESSATION OF UTERINE CONTRACTIONS* d) Placenta previa - painless, low lying placenta e) Vasa previa - PAINLESS; if ruptured, baby dies previas=painless ption/pture=painful

Answer 46

Gestational: new onset >20 weeks 140+/90+ Cr of 1.1 or doubling of Cr, bp 160/110 or more, transaminitis, thrombocytopenia, cerebral/visual signs, pulmonary edema STABILIZE, then DELIVER!

Answer 47

HELLP - hemolysis, proteinuria, increased LDH; delivery w/mag to prevent convulsions ICoP - NORMAL PT/PTT; ursodeoxycholic acid AFLP - increased PT/PTT, increased creatinine/uric acid, hypoglycemia; delivery

Answer 48

- Neonatal thyrotoxicosis - anti-TSH receptor antibodies cross placenta and trigger hyperthyroid symptoms - methimazole and beta-blockade (atenolol?)

Answer 49

Cervical/adnexal tenderness, orthostasis/hemodynamic instability, diffuse abdominal pain vs high hcg, hyperemesis gravidarum, theca leutein cysts, MASS/ENLARGED UTERUS ECTOPIC DOESN'T HAVE A MASS

Answer 50

Choriocarcinoma b-HCG

Answer 51

vaginal bleeding, enlarged uterus, pelvic pain choriocarcinoma

Answer 52

1) Trichomoniasis 2) Bacterial Vaginosis 3) Candida Vulvovaginitis 1) [can also cause strawberry cervix] a) trichomonas vaginalis b) THIN, yellow-green, frothy, malodorous c) motile trichomonads, pH>4.5 d) inflammation e) metronidazole, treat partner 2) a) gardnerella vaginalis b) THIN, whitish, fishy, malodorous c) clue cells, + whiff test (amine odor on KOH), pH>4.5 d) NO inflammation e) metronidazole 3) a) candida albicans b) THICK "cottage cheese" c) pseudohyphae, normal pH (3.8-4.2) d) inflammation e) fluconazole

Answer 53

``` PO Ulipristal (anti progestin, delay ovulation) PO Levonorgestrel (progestin, delay ovulation) copper IUD (inflammatory rxn hostile to ova and sperm) ``` Mifepristone + misoprostol progestin-only pills. no VTE risk and no estrogen to pass into milk or affect milk quality.

Answer 54

GALASCTOSEMIA active substance/alcohol abuse, active TB, HIV Hep B and C NOT considered contraindications, neither is mastitis

Answer 55

a) elevated: - multiple gestation (look for improper fundal height for age) - congenital nephrosis/obstructive uropathy - ventral wall defects (gastroschisis, omphalocele) - open NTDs (open spina bifida, anencephaly) b) decreased: - aneuploides (trisomy 18, 21)

Answer 56

Fibroid (uterine leiomyoma) [mass can compress colon and bladder leading to those symptoms] - enlarged uterus - clots adenomyosis - dysmenorrhea/menorrhagia, but wouldn't have bowel and urinary symptoms, wouldn't have a mass. boggy on exam - typically >40 years, MULTIPAROUS - enlarged, globular, boggy uterus (glandular hyperplasia) vs endometriosis - dysmenorrhea/menorrhagia, but wouldn't have bowel and urinary symptoms, wouldn't have a mass. laparoscopy for dx - typically younger, NULLIPAROUS - normal sized uterus (no glands, it's outside the uterus) - dyschezia, dyspareiunia, infertility! (inflamm/adhesion, etc.) -RF: early menarchy, outflow obstruction Tx - 1) nsaids +/- combined OCP 2) laparoscopy to confirm (dx and tx) endometritis -foul smelling s/p instrumetnation/abortion, FEVER TX - clinda + gent [POLYMICROBIAL] vs endometrial CA/hyperplasia - hx of obesity, nulliparity - small uterus, NON-tender - irregular bleeding

Answer 57

1) (prevented by bilateral orchiopexy) Testicular torsion (affixed to wall in orchiopexy), subfertility (better w/pexy), and malignancy (lower risk w/ pexy) 2) persitent beyond 1 yr 3) Cryptorchid testes, [absent uterus], absent upper vagina, breasts (androgens converted to estrogens), vs normal ovaries, [absent uterus], absent upper vagina, external genitalia normal ---- transillumination? yes; resolves spontaneously by 1 year, surgery if unresolved by that time transillumination? no; resolves spontaneously, surgery if a) bilateral, decreased sperm count, or painful

Answer 58

PREDNISONE FIRST!

Answer 59

Myotonic Dystrophy

Answer 60

Neutrophil HAS to be bacterial Viral usually NO ^protein Lymphocytes could be viral, TB, cryptococcal, lyme, or ricketts Cryptococcal in IVDA/AIDS

Answer 61

1) PBC 2) AUTOIMMUNE hepatitis 3) dermatomyositis 4) SLE (sens; specific) 5) acute rheumatic fever/recent strep infxn (migratory polyarthritis, pancarditis, syndenham, erythema marginatum, SQ nodules); usually LE, migratory arthritis - affects Mitral Valve (can be stenosis or regurg, ^CRP and prolonged PR. ppx PCN for GAS) 6) Sjogren 7) Scleroderma

Answer 62

a) Enterococcus faecalis b) Staph (MC) epidermidis (coag neg); aureus c) Strep bovis (gallolyticus) d) fungi e) i) viridans (STREP sanguinis, mitis, oralis, MUTANS, sobrinus, milleri) [ tx IV penicillin G -or- ceftriaxone ] ii) oral flora: HACEK (haemophilus, aggregatibacter actinomycetemcomitans/actinobacillus, Cardiobacterium hominis, Eikenella Corrodens, Kingella Kingae) --- Staph - MC HAIE Strep - MC CAIE a) b) empiric IV vanc; can switch to oxacillin if clx show MSSA c) d) e) Penicillin G (aqueous) - (amp-sulbactam for Hacek?)

Answer 63

1) Folate def. (increased RBC turnover) 2) Hydroxyurea use hypothyroidism, liver dz, myelodysplastic, AML, zidovudine, chemotherapy alcohol, B12

Answer 64

decreased PASSIVE AND active ROM; stiffness>pain vs ANTERIOR shoulder pain (lifting, carrying, overhead reach); weakness uncommon vs NORMAL ROM; pain w/ abduction, ext rotation, subacromial tenderness; Neer/Hawkins test vs Decreased passive AND act. ROM and ext. rotation; trauma vs PAIN with active ROM and passive I-rot and forward-flex; caused by repetitive overhead motions

Answer 65

a) FIRST degree heart block, benign b) a-flutter c) QRS varies from beat to beat - pericardial effusion (+JVP, muffled heart sounds, and hypotension) d) WPW e) acute right heart strain (PE) f) SECOND degree AV block 2:1 Mobitz 2 g) SECOND degree mobitz 1

Answer 66

a) microcytic hypochromic b) EPO c) iron def. bc of rapidly depleted stores 2) tx underlying (ex. methotrexate if RA)

Answer 67

Bruton's X linked (bc low B cells and normal T cells). Tx. IVIg

Answer 68

Cough, Coryza, Conjunctivitis, Koplik spots Tx - Vit A!!! In measles the rash appears when the fever peaks, in roseola (HHV-6) the rash appears as the fever resolves Similar but Rubella is milder and sorter, no oral koplik spots in Rubella. . Both cephalocaudal. Measles "darkens" but rubella doesn't. RMSF = centripetal spread (hands to in)

Answer 69

Zinc - RF: TPN; alopecia, skin lesions, abN taste, impaired wound healing Selenium - RF: TPN; CARDIOMYOPATHY A - poor night vision, hypoparathyroidism, dry skin, impaired immunity B1 (thiamine) - beriberi, wernicke's B2 (riboflavin) - angular chelosis, stomatitis, glossitis B3 (niacin) - diarrhea, dermatitis, dementia, death B5 (pantothenoate) - burning feet B6 (pyridoxine) - peripheral neuropathy B9 (FOLATE) - megaloblastic anemia/HSMneutrophils B12 (cyanocobalamin) - "folate" + dorsal column signs C - SCURVY (ecchymoses, bleeding gums, petechiae) D - rickets, osteomalacia E - peripheral neuropathy, hemolytic anemia (without MMA) K - INCREASED PT/INR; "giving warfarin"

Answer 70

THENAR ATROPHY PARESTHESIA IN FIRST 3.5 DIGITS *THENAR and MIDPALM SENSATION INTACT* distal lesions (carpal tunnel, lunate dislocation) vs proximal lesions (aka supracondylar humeral fracture) where thenar and midpalm sensation compromised (branch given off beforehand)

Answer 71

1) DEFIB (shock) first 2) 1mg Epi q3min + CPR q2min 3) repeat defib + amiodarone ``` a) NO SHOCK but same-ish algorithm as above. def of PEA: organized rhythm on monitor but no pulse ```

Answer 72

Red Flags: > 1 month, night, >50y, constant/dull/unremitting/unrelieved by rest/NOT exacerbated by movement, constitutional signs, hx of malig, IVDA, infx risk, trauma 1) If no red flags, conservative 4-6 wk 2) If RED flags, ESR+plain films a) if abN, MRI (vertebral osteomyelitis will px w/ nL xray and ^ESR) 3) If cord compression signs, MRI

Answer 73

a) cryptococcal meningoencephalitis b) CMV c) HSV-1 encephalitis d) PML (JC polyoma virus) e) 1) toxoplasma gondii (Toxo serology not necessarily specific in the US) 2) Primary CNS Lymphoma (esp. with + EBV DNA in CSF)

Answer 74

a) HYDATID cyst 2/2 echinococcus granulosus - SHEEP/dogs - albendazole+aspiration b) cysticercosis 2/2 taenia solium - PIGS c) amoebic liver abscess - entamoeba histolytica; tx METRONIDAZOLE! (+paromycin for intraluminal coverage)

Answer 75

insensate, hypopigmented patch of skin asian acid-fast bacilli (mycobacterium leprae) on skin BIOPSY

Answer 76

both have palpable purpura! Cryo - assoc/ hep C and LOW complement HSP - normal complement

Answer 77

1) a) 1-6 hrs b) cytokine accumulation during blood storage c) fever, chills 2) a) within 1 hr b) *ABO incompatibility* ; + direct coomb's c) fever, flank pain, RF/DIC 3) 2-10 days; anamnestic Ab response/+D-coomb's; fever 4) seconds; anti-IgA; shock, angioedema, resp distress 5) 2-3 hrs; angi-IgE + mast; flushing, pruitis 6) 6 hours; donor anti-leukocyte Ab; resp distress

Answer 78

STIFFNESS, vROM in shoulders/neck/hips VS point tenderness and NORMAL physical exam +/- decreased hematocrit; ESR!^ VS NORMAL glucocorticoid taper VS exercise, sleep hygiene, stress reduction + TCAs, levomilnacipran/duloxetine [SNRI], pregabalin

Answer 79

a) inferior leads (2, 3, avF) ST-elevation (RCA, LCX) b) left-most leads (1, avL) ST-depression RCA (or elevation if LCX) - right sided EKG to confirm RV infarct c) RV involvement is common in inferior infarcts, leading to RVF (JVD, kussmauls increase of JVD with inspiration, and clear lung fields) leading to marked hypotension d) V1-V3 ST- DEPRESSION 1 & avL ST-ELEVATION if (LCX) 1 & avL ST-DEPRESSION if (RCA) e) V1-V6 (LAD)

Answer 80

1) syphilis (RPR) 2) cervical cancer (PAP) 3) Hepatitis B (HBsAg) 4) HIV +HepC if IVDU

Answer 81

1) Folate + Iron supp | 2) ECULIZUMAB + N. MENINGITIDIS (bc eculizumab inhibits MAC formation)

Answer 82

1) a) FOOSH b) i) brachial artery + median nerve (MC!) ii) cubitus varus deformity (NOT limb length discrepancy!) ii) compartment syndrome + volkmann contracture Limb length discrepancy more common in more proximal humeral fractures

Answer 83

Immunosuppresed; caused by bartonella henselae/quintana angioma-like blood vessel growths; large pedunculated exophytic papules with collarette of scale; resembles pyogenic GRANULOMA (benign vascular red papular tumor, pedunculated, bleeds) or cherry angioma. [resembles Kaposi!] dx biopsy; tx abx cat scratch tx azithromycin (Ab test or +warthin starry-stain to confirm)

Answer 84

Disseminated MAC w/ hepatosplenic involvement CD4 azithromycin ppx azithromycin or clarithromycin tx most accurate test = NAA (nucleic acid amplification)

Answer 85

Sideroblastic Anemia pyridoxine

Answer 86

1) Influenza yearly 2) one Tdap then Td (booster) q10y 3) Pneumococcus a) +65y: PCV13 + PPSV23 6-12 months after b) -65y w/ high-risk: PCV13 +PPSV23 8 wks after, then q5y c) -65y w/ med-risk: PPSV23 only "medium risk" = smoker, EtOH, DM, chronic heart/lung/liver disease, nursing home "high risk" = Sickle cell, asplenic, immunocompromised, cochlear implant, CSF leak If HIV+: 1, 2, 3b + HepA Vaccine (gay sex, HepB+, HepC+, IVDU) + HepB Vaccine + HPV (9-26y) + meningococcus (11-18y, closed quarters, asplenic/complement deficiency) ***LIVE (attenuated?) VACCINES CONTRAINDICATED IF CD4 v200*** MMR, rotavirus, varicella, zoster, nasal flu, yellow fever, If Chronic Liver Dz: 1, 2, 3b + HepA Vaccine + HepB Vaccine

Answer 87

1) HIV ``` a) Age 15-65 (v65): one time *HIV p24 + antibody testing* if +, HIV-1/2 Ab immunoassay the "d-dimer" (if - but ^ios) HIV RNA (additionally pregnancy, MSM, unprotected sex, co-STD) ``` b) IVDU, MSM, homeless shelter, jail, partner of HIV+: annual 2) Syphilis a) No routine screening for syphilis. Only pregnant 1st prenatal visit, co-STD, MSM, whore, jail. 3) Gonorrhea a) No routine screening gonorrhea in men (it'll be symptomatic and obvious). b) Screen sexually active women who are v25y, no condoms, multiple partners, co-STD, pregnancy c) MSM at extra-genital sites 4) HepB! if high risk (unprotected or MSM) 5) HepC! (if transfusions before 1992 or baby boom?)

Answer 88

a) COPD, PE [hypoxic vacoconstriction in lung-> PULMNONARY ARTERY HTN> 25 -> right ventricular hyperrophy] vs TB (asia/africa), viral, *RADIATION!*, cardiac surg **AKA Hodgkin's!** b) Loud, split P2; pulmonary HTN vs (kussmaul [paradox INCLINE in CVP w/ insp], ascites/pedal edema), pericardial knock (early diastolic heart sound after S2), sharp x and y descents constrictive = CALCIF RING AROUND HEART (pericardium)! c) you see calcifications! confirm dx

Answer 89

Erysipelas [type of cellulitis that involves the superficial dermis] vs (cellulitis, not raised) Group A beta-hemolytic strep pyogenes vs (beta-hemolytic strep, Staph Aureus) Legs. (...) Purulent Cellulitis (staph aureus!): a) folliculitis b) furuncles (boils) - folliculitis into dermis leading to abscess c) carbuncles - multiple furunlces aggregated

Answer 90

a) "time to restoration of coronary perfusion" via i) PTCA (-90 min ideal) ii) fibrinolysis (-30 min ideal) b) smoking cessation, oxygen c) spironolactone, ACEi ... d) time to effective resuscitation - bystander CPR - rhythm analysis - defibrillation

Answer 91

Acute Bacterial Parotitis staph aureus MC painful chewing, erythematous parotid gland expulsing purulent saliva adequate hydration and oral hygiene both pre and post op

Answer 92

a) DEVELOPING COUNTRIES: TB (look for CALCIFICATION) | DEVELOPED: autoimmune

Answer 93

1) ^ICP? (immunosuppressed, FND, papilledema, AMS) a) YES b) NO 2) a) BLOOD CULTURES, empiric, CT-head, LP b) BLOOD CLX+LP, empiric 3) alter therapy based on LP if appropriate dexamethasone + (3rd ceph + vanc) 1 month - 50y dexamethasone + (3rd ceph + vanc + Amp) 50+y -- (4th ceph + vanc) skull penetration/NS/shunt (4th ceph + vanc+ Amp) im/comp (amp+cefotaxime/AMG) v1 month Notes: amp covers listeria (alt: TMP-SMX) steroids for when there's pneumo, d/c if no pneumo meropenem or ceftazidime can replace cefepime

Answer 94

1) ALL symptomatic 70+% stenosis 2) MEN asymptomatic 60+% stenosis 1) Clinically significant atherosclerotic dz (CAD, CVD, PAD) 2) LDL>190 (high intensity) 3) ANYONE age 40-75 w/ DM - note, you don't always give ACEi; pressure has to be 140/90 or higher 4) ASCVD>9% 1) >50y

Answer 95

a) Insidious; focal pain in navicular or metatarsals; RF: abrupt increase in training, poor running mechanics, female with eating dz; - tx rest and analgesia b) Worse when initiating running or first steps of the day c) Burning pain/stiffness d) Common digital nervitis: Numbness/pain between 3rd/4th toes; **clicking sensation when palpating space between 3rd/4th toe while squeezing metatarsal joints. (wearing heels?) e) Compression of tibial n. at ankle; burning/numbness/aching of distal plantar surface of foot/toes

Answer 96

a) E Coli; avoid empiric abx bc precip HUS b) (nonbloody, watery) 1) cryptosporidium parvum 2) cystisospora 3) microsporidia 4) cyclospora 5) GIARDIA c) 1) rotavirus/norovirus (brief, vomiting) 2) ETEC, EPEC (contaminated food/water) 3) Campylobacter (abdominal pain PSEUDOAPPY, bloody) 4) Salmonella (fever) 5) Shigella (bloody, ab pain) d) entamoeba histolytica

Answer 97

[prostaglandins normally vasodilate] 1) loop diuretics potentiate PGs! Therefore NSAIDs can cancel this therapeutic effect! 2) a) ATP-dep K+ channel opening, which leads to vasodilation b) thiazides are ATP-dependent K+ channel OPENING (like diazoxide/minoxidil), which decreases insulin release from the pancreas [contrast sulfonylureas which BLOCK K+ channels] (c/i in diabetes?) c) LOOPs and thiazides decrease urate excretion by increasing net urate reabsorption (by either increased reabsorption directly, or decreased secretion back into the lumen) 1) Natriuresis! (except with osmotic diuretics) 2) Look for Kaliuresis (if you don't see this, it's an Aldosterone antagonist) 3) Look for Bicarbonaturesis (if you see this, it's CAi/acetazolamide) 4) Look for Calciuresis (if you see this, it's Loop) 1) Acetazolamide (but paradoxical hypOkalemia) and Aldosterone Blockers cause ACIDOSIS LOOPs and Thiazides cause ALKALOSIS

Answer 98

Cervicofacial Actinomycosis (yellow "sulfur granules) actiNo aNaerobe, gram + an tx Penicillin Nocardiosis noCAERdiosis, AERobic, gram+ (****partially acid fast***) tx TMP-SMX px - TB-like, pulm nodules, pneumonia-like; CNS!

Answer 99

1) Trichinellosis - roundworm/pork a) intestinal stage (sp 1 week of ingestion) b) muscle stage (sp 4 weeks of ingestion) - eosinophilia, CK 2) Ascaris Lumbricoides a) pulm phase b) intestinal phase 3) dengue fever 4) chikungunya 5) strongyloides stercoralis both caused by AEDES mosquito

Answer 100

"not your fault" vs "YOUR fault" desire/work schedule incongruent w/ internal clock vs internal clock incongruent w/ desire/work schedule sleep problems after beginning night shift vs night-shift worker rollin' along just fine (which isn't normal, societally) until all of a sudden required to work day shift and gets fucked, *BUT CAN SLEEP IN ON THE WEEKENDS* *** delayed sleep-phase = "night owl" common in teenagers

Answer 101

1) general: NaHCO3, IVF, charcoal, supp 02/intubation - CNS (coma, convulsion, sedation), anticholinergic (hot, mydriasis/cycloplegia?, ileus, urinary retention, dry mouth), cardiac (MC cause of death) "cgACh" [anti-cardiac fast Na, anti-GABA-a, anti-Alpha1, anti-Cholinergic, anti-H1] TCAs inhibit fast Na channels in the his purkinje system and myocardium, decreasing conduction velocity and increases repolarization, prolongs absolute refractory periods, leading to hypotension, ^QRS, and vtach/vfib do NOT give physostigmine (even thought there's anti-cholinergia). it worsens heart conditions. NaHCO3 - tx cardiotox (>100 msec QRS, v-arrythmia) moa: sod-bicarb ALKALINIZES everything and increases extracellular SODIUM. The alkalinity keeps the TCA neutral (nonionized) and away from the sodium channels. The extracellular sodium increases the electrochemical gradient across cardiomyocytes, which helps keep the heart going (negates cardiodepression) Resembles hyperkalemia (except hyperkalemia has peaked T and depressed ST and no ^QT) in its prolonged PR/QRS/QT 2) MIXED resp alk (stim resp center) and AGMA (acid buildup from uncoupling of oxPhos tx- NaHCO3 - 3) NAC - nephroprotection for radiocontrast induced nephropathy - mesna is used to prevent hemorrhagic cystitis in the setting of cyclophosphamide use 4) (organophosphate = anticholinesterase = procholinergic = bradycardia, miosis, salivation) tx - atropine + pralidoxime 5) calcium gluconate; kayaxelate; SABA; insulin+glucose; loop+IV fluids 6) Mg++ SO42- 7) a) ABCs b) decontaminate c) barium esophogram w/in 24h d) strictures at 2-3 wks can form 8) iso isn't AGMA (mudpiles) and has absent ciliary reflex and dysconjugate gaze vs methanol has blindness, APD, central scotoma vs ethylene glycol has flank pain and Ca oxalate

Answer 102

a) Tinea Capitis - Trichophyton tonsurans (black dot tinea capitis) [MC in blacks] - Microsporum Canis, Microsporum audouinii - transferred thru fomites (ie combs) - scaly erythematous patch, may progress to alopecia leaving a black dot - dx KOH, tx ORAL GRISEOFULVIN (contacts tx selenium sulfide or ketoconazole shampoo) b) Autoimmune - Alopecia areata (smooth areas of hair loss w/out scaling) - Discoid Lupus Erythematosus (plaques, cutaneous lesions, inflammation of hair follicle, photosensitivity, pruitits c) pressure-induced (postoperative) alopecia - prolonged pressure on the scalp after surgery under general anesthesia d) trichotillomania - irregular pattern and length - Pediculus humanus capitis (head louse) - pruritis but NO ALOPECIA

Answer 103

Chronic Pancreatitis 2/2 EtOH Still CELIAC! it was confirmed on biopsy. they probs have IgA deficiency 1) Xylose is already fully digested; all it needs is intact sm. intestinal mucosa for absorption Pancreatic Enzymes are NOT required for carbohydrate digestion! Therefore, the utility of the D-xylose test is to determine the etiology of suspected malabsorption (steatorrhea, etc.) 2) Abnormal = DECREASED D-xylose absorption, DECREASED D-xylose in urine, INCREASED D-xylose in feces Normal = INCRESED D-xylose absorption, INCREASED D-xylose in urine, DECREASED D-xylose in feces 3) Abnormal suggests proximal small intestinal disease (celiac, etc.) Normal suggests pancreatic etiology (because the brush border is intact, the steatorrhea must be due to fat malabsorption)

Answer 104

a) GYNECOMASTIA!!!!!!!!!!!!!!!, POLYCYTHEMIA, LVH, (decrease HDL ^LDL) b) only increased hematocrit c) increased hematocrit, (HTN!, headaches, flu-like)

Answer 105

Painfus erythematous/violaceous SQ nodules on anterior LL Can be benign, but also can signify serious dz such as a) recent strep MC (ASO aka anti-streptolysin O) b) sarcoidosis (CXR) [uveitis too] c) TB (PPD) d) Histoplasmosis, Coccidiomycosis e) IBD exacerbation (stool, colon studies)

Answer 106

a) didanosine b) abacavir c) any NRTIs d) any NNRTIs e) nevirapine f) ACYCLOVIR, sulfonamides, methotrexate, ethylene glycol, protease inhibitors g) penicillins, PPIs...e tc?

Answer 107

a) thyrotoxicosis 2/2 toxic adenoma b) toxic multinodular goiter c) painless thyroiditis d) hypO or euthyroid

Answer 108

B) PAN (immune complex deposition in BV walls) C) 1. porphyria Cutanea tarda (photosensitivity; vessicles/erosion on hands) 2. membranoproliferative GN 3. mixed essential CRYOglobulinemia (immune complex deposition in BV walls, low complement) 4/5: leukocytoclastic vasculitis (HSP?), lichen planus

Answer 109

Vit K def (abx destroy gut flora, no enteral nutrition)

Answer 110

a) ST-elevations in (2, 3, avF), since RVMI is usually caused by inferior wall infarcts b) MI signs, HYPOTENSION (decreased left heart filling), JUGULAR VENOUS DISTENTION (due to RV dysfunction) c) RH is failing so they need HIGH preload to maintain CO; 1) initially tx like normal MI* 2) in patients with hypotension and low/normal JVP, give *HIGH-FLOW IVF* to increase preload 3) if JVP is elevated, IVF less helpful 4) AVOID NITRATES, OPIATES, DIURETICS (since these can precipitate hypotension) Reperfusion therapy + *MONABScH (! caution in RVMI) ``` PCI/tPA Morphine (!) Oxygen Nitrates (!) [give for CHF, CP, HTN; C/i!!! in RVMI, sildenafil] [Aspirin + P2Y12* r-block] = "dual antiplatelet" Beta-block (~) Statin Heparin/Enoxaparin/Fondaparinux ``` P2Y12 is the Gc ADP receptor (clopidogrel, prasugrel, ticlopidine, ticagrelor) aka THIENOPYRIDINES aka ADP antagonist

Answer 111

1) Giant Cell Tumor (OsteoCLASToma) is a benign, aggressive, bone tumor. -epiphysis of the distal femur and proximal tibia. -Unlike most bone tumors which occur most commonly in males, giant cell tumors of bone most commonly occur in females in early to mid-adulthood (20-40 years of age). -Radiologic imaging of giant cell tumors of bone show destructive lytic lesions near joints, with a characteristic “double bubble” or “soap bubble” appearance. less -Giant Cell/Osteoclastoma is the ONLY bone tumor in the EPIphysis! 2) An osteoblastoma is a benign, bone-producing tumor similar to osteoid osteoma, but unlike an osteoid osteoma, is not self-limited (with a nidus usually greater than 2 cm in diameter). - Osteoblastoma pain not relieved by aspirin (vs osteoid osteoma, nocturnal and relived by aspirin) - Osteoblastomas most commonly occur in the (metaphysis?) of vertebrae vs osteoid osteoma usually the cortex of the diaphysis of the long bones. - Osteoblastomas are most commonly seen in young patients (10-30 years of age). - Histology of osteoblastomas, similarly to osteoid osteomas, show a NIDUS of vascular osteoblastic tissue (interlacing trabeculae of immature woven bone lined by regularly arranged osteoblasts) surrounded by normal reactive bone. but blastoma nidus >2 cm in diameter. 3) medulla/fingers vs medulla/pelvis always medulla for chondros!

Answer 112

1) Ratio of event occurring in tx arm vs non-tx arm a) less than 1 = tx arm had lower event rate 2)

Answer 113

1) randomization to different interventions w/ additional study of 2 or more variables ex. BB, CCB, ACEi and each has two different bp endpoint groups 2) Randomizes one tx to one group and a different tx to another group. No other variables ex. Drug vs placebo 3) group of participants is randomized to one tx for some time, and the other group is given an alternate tx for the same period of time. Then switch. 4) Grouping of different data point into similar categories; randomization at the level of groups

Answer 114

Often normal in children, young adults. s/p infx, rubbery Bad signs: Painless, firm, immobile Biopsy if >2 cm. Observe otherwise ---- - MRSA - bioterrorism - Legionella (+urine Ag/ab?) - TB - fungal

Answer 115

Cyclical fever + random shit. BABESIOSIS is "malaria" in america (NE/MW) px endemic area w/ tick bite, esp. if hemolysis or splenectomized. HEMOLYSIS/JAUNDICE! AVMs (pulm, R-L) px recurrent nose bleeds and oral lesions "ruby papules on the lips that blanch"

Answer 116

1) RMSF 2) 2ndary syphilis 3) Measles tx vita A! 4) Rubella

Answer 117

1) Chi square 2) two sample z/t test 3) ANOVA

Answer 118

1) Patau (13), cleft lip, microphthalmia, cardiac malformations 2) Edward (18), microcephaly, prominent occiput, micrognathia, closed fists with index finger overlapping middle finger and pinky overlapping ring finger, rocker bottom feet 3) Down (21), upward slanting palpebral fissues, epicanthal folds, brushfield spots, flat face a) decreased AFP, decreased estriol, increased beta-hcG, increased inhibin A b) decreased AFP, decreased estriol, DECREASED b-hcG, NORMAL inhibin A c) INCREASED AFP, normal everything else

Answer 119

CMV pneumonitis 1) cryptosporidium parvum 2) could also be isospora belli (LC) TMP-SMX! HepB vaccine, influenza, pneumococcus Ganciclovir for CMV!!!! TMPSMX for PCP UTI and others CVASCULAR DZ! (50%)

Answer 120

def: proliferation of myeloid lineage (RBC, neutro/basoph/eosino, monocyte, megakaryo); can transform to acute leukemia a) P. Vera (JAK2 kinase mutation) [BUDD CHIARI!] b) Essential Thrombocythemia (JAK2) [unique: no gout risk, marrow fibrosis, or AL]; hemorrhagic and thrombotic sx c) Primary Myelofibrosis (JAK2) [you see extramed hematopo] d) CML (granulocytes) [aka BASOPHIL, eosino, neutro]; 9,22; bcr-abl. left shift LEUKEMOID (granulocytosis 2/2 infection) vs CML (bad)! ``` Leukocyte AlkPhos (inflammation) POSITIVE NO basophilia or (9,22) -vs- LAP NEGATIVE BASOPHILIA and (9,22) present ``` Sa02 nL in p. vera, EPO LOW (negative feedback) Sa02 LOW in reactive, EPO HIGH [COPD] Sa02 nL in ectopic, EPO HIGH [RCC]

Answer 121

MENINGOCOCCAL MENINGITIS

Answer 122

1) MM 2) MGUS 3) Waldenstrom (HYPERVISCOSITY!) of blood due to IgM spike) 4) Amyloidosis MGUS vs MM: ``` NO anemia, renal, hyperCa, lytic bone vs YES v3 g/dL M protein vs ^3 v10% plasma cells in BM vs ^10% MM HAS ELEVATED B2-MICROGLOB! NO end-organ damage vs YES ```

Answer 123

PSVT (aka AV nodal reentry tachy) RE-ENTRY AV accessory conduction pathways tx VAGAL MANEUVERS (decrease AV conduction) a) cold water immersion b) carotid massage c) valsalva

Answer 124

(don't forget CXR, EKG, ABG to r/o CHF, pneumonia etc) 1) inhaled SABA +/- ipratropium 2) PO Glucocorticoids 3) PO Abx * if these fail 1) Noninvasive positive-pressure ventilation (mask) * if 2 hours of this fails 2) Invasive mechanical ventilation (endotracheal tube)

Answer 125

1) MIDDLE a) bronchogenic cyst b) tracheal tumors c) pericardial cysts d) lymphoma/LAD e) aortic aneurism (arch!) 2) ANTERIOR (4 T's) a) Thymoma b) retrosternal thyroid c) teratoma, mixed germ cell tumor d) "terrible" lymphoma 3) POSTERIOR (all neurogenic tumors are here!) a) Esophageal Leiomyoma (symptomatic when >5cm) b) meningocele c) enteric cysts

Answer 126

1) Ectopic focus within pulmonary veins 2) Re-entrant circuit around tricuspid annulus 3) Re-entrant circuit from accessory (total 2, 1 fast 1 slow) 4) SA node discharge 100-180/min 5) AV bypass tract (aberrent)

Answer 127

1) Progesterone analogs (megestrol, medroxyprogesterone) 2) Corticosteroids (less preferred than ^) 3) Mirtazapine

Answer 128

Parvovirus B19 viral arthritis dx anti-B19 IgM Ab (w/in 10-15 days of ifxn) tx- reassurance; will resolve within 1 month

Answer 129

a) Trisomy 21 (Down) b) Trisomy 18 (Edward) c) William's Syndrome d) Truncus arteriosus, Tetralogy of Fallot, interrupted aortic arch; DiGeorge, Velocardiofacial syndromes e) Neonatal Lupus f) Kawasaki disease

Answer 130

Lyme: Amoxicillin and preg! RMSF: Doxycycline (not sure about preg) Lyme meningitis w/ heart block? IV ceftriaxone

Answer 131

a) pseudomonas vs NEUTROPHILIC ULCERATION b) hemorrhagic pustules w/ surrounding erythema -> necrotic ulcers vs inflammatory pustule/papule/vesicle/nodule -> expanding ulcer w/ purulent base and ragged violaceous borders c) commonly occurs as a pseudomonas skin infxn in the setting of neutropenia vs occurs w/ underlying systemic dz (IBD, RA, AML) PG - dx biopsy tx steroids pyogenic granuloma - benign vascular tumor (resembling Kaposi) that grows into a pedunculated or sessile shiny mass and bleeds easily; upper lip and oral mucosa MC. px first as red papule

Answer 132

AGRANULOCYTOSIS D/C METHIMAZOLE/PROPYLTHYOURACIL

Answer 133

1) distinguish cardiogenic vs hepatogenic lower extremity edema a) edema 2/2 HF: ^JVP, +HJR b) edema 2/2 Liver: nL or vJVP, -HJR 2) LEFT!!!!! atrial pressure (LVEDP) 3)

Answer 134

(symmetric proximal muscle weakness and tenderness [delts, hip flexors]) +(thyroidism) = thyroid myopathy!

Answer 135

"RMSF without the spots" Erlichia chaffeensis, ewingii within the amblyomma americanum tick se/south central US MORULATED RBC! tx Doxy (just like RMSF!)

Answer 136

aldosterone:renin ratio a) both elevated and ratio ~10, 2ndary hyperaldo - diuretic, cirrhosis/CHF, RVHtn, renin-oma, maligHTN, coarctation b) both decreased, "other" - CAH, glucocorticoid resistance, exogenous, cushings c) increased aldo, decreased renin and ratio +20, PRIMARY hyperaldo: ADRENAL CT POLYCYSTIC KIDNEY DISEASE not sure... u/s? NBS is to watch out for BERRY ANEURYSMS and hepatic cysts! lol (diverticula, hernia, and valvular dz too)

Answer 137

a) accumulation of fluid in carpal tunnel (3rd trimester) b) MUCOPOLYSACCHARIDE-PROTEIN COMPLEX DEPOSITION that presses on peri/endoneurium of median nerve [BL AND MOST SEVERE] c) Amyoid fibril deposition w/in carpal tunnel d) BL medial n. compression 2/2 soft tissue enlargement caused by synovial edema and tendon hyperplasia e) tenosynovitis -> increased compartment pressure

Answer 138

BLOOD, mucous memb, broken skin, bodily fluids other than feces/urine/nasal/saliva/sweat/tears * IMMEDIATE 3-drug antiretroviral for 4 weeks* 1) TWO NRTI's (tenofovir, emtricitabine) 2) integrase inhibitor (raltegravir), protease inhibitor, or NNRTI prenatal: Triple HAART therapy during pregnancy (dual NRTI + NNRTI *or* protease inhibitor) intrapartum: zidovudine if dx late postpartum: continue triple therapy, zidovudine for neonate for 6 weeks with serial PCR testing summary: triple therapy for mom, zidovudine for baby

Answer 139

``` ANTERIOR UVEITIS (not bechet) Sacroiliitis Apophyseal (facet) joint arthritis, Enthesitis (inflammation of insertion of tendons) ``` etc.

Answer 140

non-caseating grandulomas 60% can also be seen in yersinia, sarcoidosis, and GI-TB

Answer 141

Hemodialysis [uremic pericarditis!] AEIOU Acidosis: refractory, pH 7.1 Electrolyte AbN: EKG changes, K>6.5 Ingestion: toxic alcohol, salicylate, lithium, valproate, carbamazepine Overload: of vol, refractory to diuretic Uremia: symptomatic (encephalopathy, pericarditis, bleeding)

Answer 142

a) dequervain's b) TSH-secreting pituitary adenoma c) exogenous!

Answer 143

a) PREGNANCY, chloroquine-resistant (SE asia, sub-saharan) b) same but not good for preg c) not good for resistant areas d) p. ovale and p. vivax ONLY (korea, mexico, s. amer) e) inexpensive

Answer 144

Hypovolemic Shock vBP3..., vCO2...vPCWP1...^SVR 4(compensation) Bacterial infection (bronchopneumonia/burn wound infxn) leading to septic shock.

Answer 145

hypOmagnesemia can lead to refractory hypokalemia (and torsaddes!?) (chronic alcoholics have low Mag, low phosphorus, and low potassium) Hepatorenal syndrome doesn't respond to fluids and labs mimic prerenal! (high creatinine, low urine Na)

Answer 146

a) MC skin cancer: BCC i) excision ON TRUNK (electrodessication, curretage) ii) mohs ON FACE - -- b) SSC, PUNCH BIOPSY - -- c) 1) nbs: confirm dx w/ histopath: - EXCISIONAL BX! remove the entire lesion w/ narrow margins and depth thru SQ fat. 2) a) if depth v1mm, excise tumor w/ 1cm tumor-free margin b) if depth ^1mm, SENTINEL LN BX - --- d) 5-FU

Answer 147

Migratory superficial thrombophlebitis that signifies occult visceral malignancy (aka pancreatic tumor), stomach, lung, prostate, etc. NBS ct ab to look for malig

Answer 148

Trousseau's sign (migratory thrombophlebitis) CT ab for malig

Answer 149

pphx- excessive fluid production by inflamed synovium 1) RA 2) OA 3) cartilage tears Can rupture into the calf, resembling DVT!

Answer 150

Picture that CT w/ bronchial dilation XRAY nonspecific findings: linear atelectasis, dilated/thickened airways, irregular peripheral opacities Other: cough, SPUTUM, dyspnea, hemoptysis, fatigue, weight lossf Think of that picture. a) simple cyst - thin walls, very round (unilocular), no solid component, no enhancement, no septae, ASYMPTOMATIC, no followup needed (reassurance) vs b) malignant cystic mass - thick irregular wall (multilocular), heterogenous components (solid and cystic); contrast enhancement present!!!; hematuria/hypertension/pain; requires followup imaging and uro eval for malig "vacuum tube" looking thing in wide mediastinum; atherosclerosis

Answer 151

(in spleen!) G6PD def! acute hemolysis, the old cells get lysed early and the reticulocytes (w/ normal g6pd fnx) predominate, which is why you may see nL enzyme activity vs Pyruvate Kinase def. chronic hemolysis NOT assoc w/ sulfa, NO BITE CELLS vs Sickle crisis painful assoc w/ howell jolly bodies

Answer 152

1) Pre renal >20:1 Low urine Na (v10 mEq/L) (hypovolemia, orthostatic hypotension) 2) Intra v20:1??? (crystal) 3) Post renal a) >20:1 early b) v20:1 late "BUN follows Na" BUN reabsorp req intact tubule "Aldosterone reabsorbs Na (and BUN!)" [aldosterone increased in prerenal bc hypovolemia] **BUN:Cr most sensitive indicator of pre-renal azotemia/hypovolemia/orthostasis because often patients may be on diuretics and therefore urine sodium may not be that reliable

Answer 153

APL M3 subtype

Answer 154

a) HEMOPHILIA (hemarthrosis, skeletal muscle hemorrhage) | b) vwD (abnormal platelet plug formation)

Answer 155

!!!PROLONGED PTT (dz is procoagulant but is ANTI in vitro) Lupus anticoagulant 2/2 SLE

Answer 156

a) - WEIGHT LOSS + COMBINATION OCP (for hyperadrogenism and menstrual dysfxn) - clomiphene for FERTILITY/ovulation induction - (metformin if co-morbid DM2) b) estrogen is adequate, progesterone is lacking. this is unopposed estrogen so there is increased endometrial cancer risk c) androgen-secreting neoplasm of ovary or adrenal; serum test and DHEAS - test + DHEAS = ovarian source (could still be CAH?) - NO test + DHEAS = androgen-secreting adrenal PCOS = NO! ^17-OH

Answer 157

Variable decels - Cord compression/prolapse, oligohydramnios Early decels - Head compression Accels - Ok (normal fetal oxygenation) Late decels - (utero)placental insufficiency

Answer 158

Trochanteric bursitis Osteoarthritis TENDER TO PALPATION vs not

Answer 159

Ludwig's Angina (rapidly progressive bacterial cellulitis of the submandibular and sublingual spaces) staph / anaerobes s/p dental? ampicillin-sulbactam (unasyn) + tooth extraction (intubation if needed) asphyxiation

Answer 160

Neurogenic Arthropathy! (Charcot joint!) ["Diabetic joint ulcer"] Conditions that cause neuropathy/ DECREASED PROPRIOCEPTION/PAIN/TEMP (2/2 DM vasculopathy, trauma, syringomyelia, spinal cord injury, vit B12, TABES DORSALIS), causes patients to unknowingly traumatize their weight bearing joints Xrays will show DJD, osteophyte, loose bodies tx underlying + mechanical devices (special shoes)

Answer 161

1) obtain serial BLOOD CULTURES (3 from separate venipuncture sites) 2) a) if stable/subacute (general malaise w/ no fever) - culture-directed therapy b) if unstable, begin empiric while cultures are cookin' - vanc+gent vanc = staph, strep, enterococci

Answer 162

A: 1) Exclude polydipsia (urine osmolality corrects) 2) distinguish between central and nephrogenic DI (when it doesn't correct after H20 dep., administer desmopressin to see if there's response) - central DI if response; tx - desmopressin? - nephrogenic DI if no response; tx - gentle diuresis? ----- 1) free water - if euvolemic 2) .9 NS - symptomatic hypovolemia (HD instabl., dry MM, vTurgor etc.) 3) D5 (hypotonic) - Asymptomatic hypovolemia B: 1) if asymptomatic: fluid restriction +/- salt tablets 2) if symptomatic: HYPERtonic saline (3%) +/ -vaptans NOT normal saline! C: Primary polydipsia, central DI, nephrogenic Di

Answer 163

1) a) irradiated - BM transplant recipients - Cellular immunodeficiency b) LEUKOREDUCED - chronically transfused patients - transplant - previous FEBRILE NON-HEMOLYTIC TRANSFUSION REACTION c) Washed - IgA deficiency - complement-dependent autoimmune hemolytic anemia - continued allergic rxns D) pRBC can increase oxygen carrying capacity in severe anemia: pRBC: trauma patient who doesn't respond to 2L IVF "stable" GIB with Hgb v7 "unstable" GIB with Hgb v9 *** 1 unit pRBC should increase Hgb 1 for every ^3 in Hct 2) TAUMA where MASSIVE transfusions are needed (Donor's blood is colleced as WHOLE blood and THEN separated into components like FFP, pRCB, platelets, cryoprecipitate). 3) a) Platelet Transfusion i) spontaneous hemorrhage risk:platelet count v10,000/microL ii) active bleeding + v50,000/microL iii) CNS risk + v100,000 b) cryo (factor 8, fibrinogen, vWF, factor 13 [fibrin stabilizing factor]) i) given in deficiencies of any of those c) FFP (contains all clotting factors and plasma proteins) i) INR > 1.5 ; given during severe coagulopathy (liver dz, DIC, supraTx warfarin)

Answer 164

PK = middiastolic sound constrictive pericarditis vs amyloidosis (you'd see LV thickness) vs valvular (could be, but you'd have to see evidence on echo)

Answer 165

a) GOODPASTURE - anti-GBM tx EMERGENCY PLASMAPHERESIS, +/- (cyclophosphamide, steroids) b) Granulomatosis w/ polyangiitis (wegeners) tx cyclophosphamide + steroids c) PAN, idiopathic RPGN TTP and Myasthenic Crisis ALSO NEED EMERGENT PLASMAPHERESIS ("plasma exchange")

Answer 166

*** do not vaccinate if px w/ symtoms 1) Oseltamivir: a) if presenting WITHIN 48 hours of sx onset b) if >48 hours BUT high risk (old, preg, immunosuppresed, native american, morbid obese, etc.) c) if >48 hours BUT haven't shown any improvement 2) all others: supportive

Answer 167

Thall | iron def

Answer 168

Splenic Abscess + left pleuritic CP, left pleural effusion, splenomegaly infection w/ hematogenous spread (ENDOCARDITIS) immunospurres

Answer 169

Not TB, since negative; so TB mimicking dz (histoplasma, blastomyces, coccidiooides) *remember to exclude these before using immunosuppresives! Histoplasma - hilar LAD, erythema nodosum, Mississippi Blastomyces - less likely if hilar LAD, mississippi Coccidio - need southwest. ----- Non-caseating Granulomatous and eosinophilic rxn to an antigen leading to *interstitial fibrosis and restrictive LD* Farmer's lung is caused by exposure to Actinomycetes spores in moldy hay. Pigeon breeders lung is caused by environmental exposure to birds/poo (pets, pet shop worker). Humidifier (or "air conditioner") lung is caused by thermophilic bacteria in heated water. ----- Silicosis - path: impaired PHAGOLYSOSOME formation by alveolar macrophages (increased risk for TB) - resembles TB due to calcifications in upper lobe Berylliosis - path: leads to NON-caseating granulomas + BL HLA - resembles Sarcoidosis

Answer 170

1) Bullous impetigo: S Aureus, yellow enlarging flaccid bullae, tx cephalexin, dicloxacillin, clindamycin 2) NON-bullous impetigo: S Aureus/S Pyogenes, painful, non-itchy pustules/honey crusted lesions, topical muciprocin

Answer 171

Methemoglobinemia results from oxidation of ferrous iron (Fe2+) to ferric iron (Fe3+) leading to a reduced affinity for oxygen. (Fe2 binds O2) Classic findings for patients with methemoglobinemia include cyanosis and chocolate colored blood. Caused in general by oxidant stress Methemoglobinemia is treated with: Methylene blue, acting as a cofactor to propagate the methemoglobin to hemoglobin transition Vitamin C, which may be beneficial by acting as an electron donor to limit reactive oxygen species formation or by altering iron levels

Answer 172

Tx Rituximab when symptomatic; chemotherapy low dose is an option MoA: anti-CD20 B-symptoms are fevers, chills, night sweats Reed Sternberg cells secrete cytokines and attrack lymphocytes (which make up the bulk of the tumor) MC HL is nodular sclerosing (70%) [lacunar, fibrosis]

Answer 173

1) Gastric hyperplasia of mucosa…hypertrophied rugae…excess mucus production with resultant protein loss and parietal cell atrophy with achlorhydria. Precancerous. Rugae resemble brain gyri 2) TGF-alpha/EGFR overexpression (epidermal growth factor receptor) 3) Treatment of any associated cytomegalovirus or Helicobacter pylori infection Antisecretory agents (H2-receptor antagonists, proton pump inhibitors) Octreotide (somatostatin analogue that may regulated EGFR signaling downstream) Cetuximab (monoclonal antibody to EGFR) Angiodysplasia

Answer 174

Duodenal hematoma (blunt abdominal trauma); tx with NG suction

Answer 175

Thumb pain "Fist thumb twist" (closed fist, ulnar deviation elicits pain, radial no pain) [new mother holding newborn with open thumb] Jersey finger – torn flexor tendon; can't flex finger; tx splint Mallet finger – torn extendor tendon; affected finger can't extend; tx splint Trigger finger - fascia of middle finger; difficulty with flexion; tx steroids [trigger thumb: pain over palmar aspect of 1st MCP ]Dupuytren's contracture - fascia pulls on all the fingers; scandinavian alcoholic; tx surg to release fasia Felon – abscess of nail pulp; TENDER, fever, leuk; tx I&D + abx

Answer 176

a) Median nerve injury (at wrist) - loss of THUMB OPPOSITION b) Median nerve injury (at elbow) - when you ask patient to make a fist, digits 4 and 5 CAN be flexed bc of .5 FDP innervation from intact ulnar nerve but 2 and 3 CAN'T bc affected .5 FDP from median nerve injury. Thumb CAN'T be flexed either - or- AT REST, ulnar nerve injury which reverses z-position in lumbricals 3+4 (digits 4+5), *BUT THUMB CAN BE FLEXED* - vs- AT REST, median nerve injury can lead "ok" sign from reversed z-position in lumbricals 1+2 (digits 2+3) c) median nerve injury (at elbow) - FCU acts unopposed but FCR is paralyzed - vs- ulnar nerve injury (at elbow) - opposite d) INFERIOR TRUNK C8-T1 injury (essentially median and ulnar both) - AT REST! all lumbricals paralyzed, so over time, z-position get reversed, leading to full claw

Answer 177

1) increased URINARY cAMP! PTH hits the tubules, and the PTH receptor is Gs coupled, activating adenylate cyclase, which affords cAMP, leading to cAMP in the urine. 2) increased SERUM alkaline phosphatase alk phos generates an alkaline environment in the bone which allows MINERALIZATION (lay down bone) "so why is this elevated in hyperPTH?" read on: PTH receptors are on osteoBLASTS, therefore PTH activates osteoBLASTS (osteoblasts mineralize bone and also activate osteoCLASTS) osteoBLASTS produces alk phos when it lays down bone

Answer 178

Botulinum toxin (botox) and tetanus toxin (tetanospasmin)—both cleave the releasing protein synaptobrevin, thereby inhibiting neurotransmitter release. However, although they share a similar mechanism, these toxins affect the release of different neurotransmitters: Tetanus toxin cleaves synaptobrevin → inhibits release of GABA and glycine → rigidparalysis. Botulinum toxin cleaves synaptobrevin → inhibits release of ACh → flaccid paralysis.

Answer 179

Serovars: A-C: trachoma (follicular conjunctivitis and corneal **neovascularization** [pannus]) scarring, blindness) tx. topical tetracycline or oral azithromycin D-K: NEONATAL conjunctivitis and neonatal atypical pneumonia; STI tx. oral erythromycin L1-L3: lymphogranuloma venereum tx PO doxycycline or azithromycin ddx: 1) Chemical; v24 hours; caused by silver nitrate/no exudates or purulence tx supportive, lubrication 2) Gonnococcal; 2-5 days; eyelid swelling + purulence; tx IM/IV ceftriaxone/cefotaxime single dose; [ppx erythromycin ointment] 3) Chlamydial (D-K); 5-14 days; eyelid swelling + bloody/mucoid tx *oral* erythromycin Note: Chlamydial (A-C) results in follicular conjunctivits, as well as pannus (corneal neovascularization), is more common in immigrants on young children (not neonates)

Answer 180

[tocolytics:] MgSO4 beta-agonists (ritodrine, terbutaline) halothane Risk of Uterine Atony, and in turn, Postpartum hemorrhage

Answer 181

STaB M(ellitus) A(nd) G(lucose) S(ucks) D(ick) Sulfonylureas (tolbutamide, chlorpropamide, acetohexamide; glipizide, glyburide) [K+ channel blockade->depolarization beta cells-> opens Ca++ channels-> release of insulin] Thiazolidinediones (-glitazone) [increased target insulin sensitivity, decreased hepatic gluconeogenesis] alpha-glucosidase inhibitors (acarbose, miglitol) [induces malabsorption of disacharrides -> osmotic diarrhea/flatulence] Biguanides (metformin) [decreased hepatic gluconeogenesis, decreased glucose-6-phosphatase activity] Meglitinides (repaglinide, nateglinide) ["sulfonylurea analog"] Amylin Analog (pramlintide) [decreased gastric emptying, decreased glucagon] GLP-1 Analogs (exenatide, liraglutide) [increase insulin, decrease glucagon] SGLT-2 inhibitor (canagliFLOzin) [decresased glucose reabsorption in the PCT] DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin) [increased insulin, decreased glucagon, by preventing degradation of GLP-1 by DPP-4] Hierarchy (alternatives in parenthesis) Start with Metformin (TZD). Next try more Met (TZD) and add sulfonylurea. Now try Insulin (GLP-1 analog, DPP-4 inhib) General approach to dosing: [qHS=bedtime, qAC=preprandial] 1) Basal (qHS) 2) Meal Coverage (qAC) a) .5 units/kg body weight b) half of this to qHS, half of this to qAC c) use all of the qHS allotment as long-acting (glargine, detemir, protamine-zinc) d) spread the qAC allotment over the meals as rapid-acting (lispro, aspart, glulisine) [note: the remaining insulins not addressed in this regimen are short-acting (regular, semilente) and intermediate-acting (isophane/NPH, lente)]

Answer 182

a) Duodenal Atresia, Annular Pancreas b) Intestinal Atresia c) Malrotation 1) Duodenal Atresia and Annular Pancreas present exactly the same 2) Double bubble on all; DA/AP have paucity of gas distal to obstruction (there was no chance for gas to even get there bc failure of recannalization happened in utero) IA does have *multiple air fluid* levels distal to obstruction (bc multiple levels of obstruction) M has *normal gas pattern* (bc this happens after birth) 3) tx Surgery (for IA resection+ counsel mom)

Answer 183

a) yes, yes, NO!, no, no b) multiple/erythematous base, multiple/deep, single/indurated, small/shallow, extensive/beefy c) HSV, H. Ducreyi, T. Pallidum, C. Trachomatis, Klebsiella Granulomatis d) Yes, Yes, YES!, No, No! e) Acyclovir, Ceftriaxone/Macrolide, IM Penicillin Benzathine x1, Doxycycline/Erythromycin, Doxycycline/TMP-SMX 3wk

Answer 184

IC - spares rectum, acute (s/p AAA repair), ULCERATIONS ON COLONOSCOPY and cyanotic mucosa. CT shows thickening of bowel wall can be seen IBD - doesn't spare rectum chronic Periumbilical pain, out of proportion to PE essentially same as MI ^lactate, ^amylase, metabolic acidosis, leukocytosis 1) CT (preferred) or MRA 2) mesenteric angiography is stills suspicious tx abx, NG decompression, surg if needed,

Answer 185

When you give O2, CO2 retention happens via: 1) Decreased RR 2/2 loss of "hypoxic drive" 2) Hyperoxic vasodilation (aka loss of compensatory vasoconstriction) leading to V/Q mismatch 3) The increase oxyhemoglobin has a reduced affinity for CO2 (for pickup) in the periphery [haldane effect] In the CNS, CO2 retention leads to: 1) Hypoxic vasodilation (seizures) 2) Acidosis (upregulation of GABA and glutaMINE; downregulation of aspartate and glutaMATE, leading to AMS)

Answer 186

Orotracheal Corticosteroid-use

Answer 187

Ca >1 above normal age v50y DEXA T-2.5 GFR v60

Answer 188

A hemangioblastoma is a tumor of vascular origin that is most often located in the cerebellum. Hemangioblastomas can produce erythropoietin, leading to a secondary polycythemia Hemangioblastoma can be associated with the von Hippel-Lindau syndrome when found with a concurrent retinal angioma. Angiofibroma: benign vascular tumor usually px with adolescent male with UL nasal obstruction and hx of recurrent epistaxis; assoc. w/ tuberous sclerosis Angiomyolipoma: hamartoma of the kidney; assoc. w/ Tuberous Sclerosis Retroperitoneal Lymph Nodes IVC invasion; Bone, Brain, Lung, Liver

Answer 189

etiology: HPV 6 and 11 (remaining etiologies below for contrast) Laryngeal Papilloma is single in adults and multiple in children! HPV-1 through HPV-4 cause verruca vulgaris (common skin and plantar warts) HPV-6 and HPV-11 cause condyloma acuminata (genital warts) and laryngeal papillomasin children HPV-16 and HPV-18 are associated with intraepithelial neoplasia and anogenital carcinoma of the uterine cervix, penis, and anus (HPV-16 and 18 together account for 70% of cervical cancers). Gardasil, the HPV vaccine, contains capsid proteins of types 6, 11, 16, and 18. The Gardasil (quadrivalent) HPV vaccine is given in three doses to boys and girls age 11-12. (It may be given up to age 26 if the patient did not receive the vaccine at the recommended age.)

Answer 190

1) Normally N5,10-methyleneTHF is "methylated" by MTHFR to N5-methylTHF, which along with B12 is a COFACTOR for homocysteine methyltransferase (aka methionine synthase) to convert homocysteine to methionine 2) Normally, cystathionine beta-synthase uses B6 to convert homocysteine to cystathionine (and then to cysteine) [homocysteine damages endothelium and is pro-thombotic.] this is the key to all the mentioned pathogeneses 1) B12/Folate def. (TAI, these deficiences will prevent homocyteine from being used/disposed of) 2) Cystathionine beta synthase def. (similar: can't get rid of homocysteine to cystathionine) --- a) increased homocysteine (need B6 for CBS); increased methionine (excess homocysteine spilling into methionine synthesis bc nowhere else to go) b) increased homocysteine (HMT/MS not working, homocysteine backs up); decreased methionine (need "folate" for HMT/MS) c) increased homocysteine (HMT/MS not working, homocysteine backs up); decreased methionine (need B12 for HMT/MS); increased methylmalonic acidemia/uria (need B12 for MMCM) ``` CBS= cystathionine beta-synthase HMT/MS = homocysteine methyltransferase/methionine synthase MMCM = methylmalonate CoA mutase ```

Answer 191

1) Central: vertigo cerebellar or brainstem lesions, usually assoc w/ with CN signs (e.g. diplopia, dysarthria, dysphagia), weakness, ataxia, and other changes that may indicate a central process. Post. Fossa Tumor, Acoustic Neuroma Stroke MS -hearing loss, -tinnitus, +CN signs, +Brainstem Signs NBS: MRI 2) Peripheral: vertigo assoc w/ with inner ear etiology BPPV Meinier's (Endolymphatic Hydrops) Labyrinthitis/Vestibular Neuronitis +Hearing Loss, +Tinnitus, -CN Signs, -Brainstem Signs Labyrinthitis - acute inflammation of the middle ear - couple weeks after URI, classically - HEARING LOSS, TINNITUS, VERTIGO, DYSEQUILIBRIUM, NAUSEA/VOMITING (versus central which has NO HL/T) - tx supportive Vestibular Neuronitis = Labyrinthitis WITHOUT the hearing loss

Answer 192

B1 def (thiamine) IVDU/prison; tx doxy, cipro, raxibacumab (spores(

Answer 193

1) nephrotox, htn, neurotox, glucose intolerace, infection, malignancy (SSC skin), diarrhea/gi 2) tacrolimus + GINGIVAL HYPERTROPHY, HIRSUITISM 3) MMMMMarrow suppression 4) dose-related diarrhea, leukopenia, hepatotox 5) hyPERkalemia; give vecuronium or rocuronium instead

Answer 194

DC CARDIOVERSION (bc he's not stable) pharm cardioversion (amiodarone, quinidine) if STABLE. DC cardio (unstable); vagal maneuvers +/- ADENOSINE

Answer 195

Based on whether the wound is CLEAN/MINOR or DIRTY/SEVERE as well as IMMUNIZED (+3 toxoid doses) or UNIMMUNIZED (-3 toxoid doses) **Tetanus IMMUNOGLOBULIN is only given for DIRTY/SEVERE + UNIMMUNIZED [toxoid=(Td, Tdap, TT, or DT) Give toxoid: clean + immunized + last dose >10 years ago clean + unimmunized dirty + immunized + last dose >5 years ago Give toxoid PLUS TIG: dirty + unimmunized High risk animal (bat/racoon/skunk/fox/coyote): try to test animal, if +, give Rabies PEP Low risk animal (squirrel, chipmunk, mouse/rat, rabbit) NONE Dog, cat, or ferret try to quarantine and observe for 10 days. if neg., no PEP. if pos., PEP Contact health dept if livestock or other unkown animal

Answer 196

Babesiosis (via ixodes tick); azithro-atovaquote or quinine-clindamycin Q fever (coxiella burnettii)

Answer 197

(low LH and test) + (low TSH and T4) nonfunctioning pituitary adenoma not risperidone bc that doesn't affect the pituitary-thyroid axis

Answer 198

1) WHISTLING NOISE S/P RHINOPLASTY 2) Trauma/ manual 3) syphilis/TB/sarcoid 4) cocaine 5) wegeners

Answer 199

px - vague (fatigue, anxiety, depression), spec. (tetany, perioral tingling, carpopedal spasms? treausseau/chovstek?) 1) ***repeat and consider alternative causes*** - ^Mg++ - recent blood transfusion (^citrate, hemodilution) - 2/2 to drug 2) **MEASURE PTH** a) normal, low - (para)thyroidectomy - polyglandular autoimmune syndrome - Cancer mets, hemochromaosis, Wilson's b) high - Vit D def. (rickets/osteomalacia) - CKD - pancreatitis/sepsis/tumor lysis syndrome ------ px: Stones, bones, groans/moans, psychiatric overtones NBS: repeat or check PTH a) High (meaning this shit is PTH dependent) - primary/tertiary hyperPTH (tertiary=longstanding, gets numb) - familial hypercalcemic hypocalciuria - lithium or teriparatide induced b) Low, NBS: measure PTHrP, 25D and 1,25D, and ELECTROPHORESE urine and serum - calc of malig (low 1,25 w/ super high calcium >13) - VitD tox - hctz, theophylline (usually v11) - milk alkali (acute hypercalcemia, alkalosis, and RF from overdosing calcium containing antacids) - thyrotox - vit A tox - immobilization - misc (adrenal insuff, acromeg, pheo)

Answer 200

(stye) Abscess located over the upper or lower eye lid. Staph aureus. Frequent hot compresses + abx px as lid discomfort. chronic granulomatous inflammation of the MEIBOBIAN gland; NBS bx/histopath to r/o BCC Inflamm changes in the medial canthus. Staph aureus, strep beta hem Mild pain, super red, discharge, patchy

Answer 201

non-deforming in SLE (even though it's severe pain)

Answer 202

DX: AUTIMMUNO HEMOLYTIC ANEMIA Warm vs Cold IgG vs IgM (both have direct coomb and anti-C3) penicillins/immuno/viral infx vs MYCOPLASMA, MONO (both lymphoprolif) tx steroids/spenectomy vs rituximab/fludarabine and avoid cold complications: VTE vs Ischemia/gangrene 2/2 cold, levido reticularis

Answer 203

a) fever b) thyroid signs c) potassium a) fever vs NO FEVER vs fever b) LID LAG vs none vs none c) normal vs normal? vs HYPERkalemia (and CK, rigidity, hypercarbia)

Answer 204

``` Leukocytoclastic vasculitis (HSP is a subtype but yea) Leukemic Reticuloendotheliosis ```

Answer 205

ACh receptor antibody single fiber EMG Muscle biopsy Nerve conduction velocity

Answer 206

Ommaya reservoir (intraventricular catheter) infection (this thing is used to dump chemo right into the brain for CNS lymphoma; this could get infected so put vanc right in there)

Answer 207

MCA (90%) a) CONTRA weakness or sensory loss b) CONTRA homonymous hemianopsia; eyes "look at lesion" - ex. left MCA results in right-deficits, eyes can't see right side so they compensate by looking left (aka towards lesion) c) aphasia if stroke is on dominant hemisphere - speech and handedness are on same hemisphere (aka if right handed, then you have left-dominant brain and left-sided speech centers)

Answer 208

Hemi-neglect syndrome RIGHT (non-dominant) parietal lobe

Answer 209

HIV HepC 1) Noncontrast head CT (emergency); MRI (non-emergency) 2) EEG to dx 1) then you can use a) benzos etc. a) benzo b) phosphenytoin c) phenobarbital d) neuromuscular blockade (succinylcholine) e) midazolam; propofol + intubation

Answer 210

a) (rupture of Charcot Buchard aneurysm 2/2 hyaline art 2/2 HTN) - contra. hemiparesis and hemisensory loss - gaze palsy b) - contra. hemiparesis and hemisensory loss - upgaze palsy - conjugate AWAY from lesion, towards hemiparesis (vs MCA infarct which is TOWARDS lesion, away from hemiparesis) - nonreactive miotic pupils c) - contra. hemiparesis (frontal) or hemisensory (parietal) - homonymous hemianopsia (occipital) - conjugate TOWARDS lesion, away from hemiparesis - seizures d) -facial weakness -ataxia/nystagmus -occipital h/a and neck stiffness NO: hemiparesis d) - pINpoint reactive pupils - deep coma & total paralysis w/in minutes

Answer 211

1) absence of brainstem reflexes (corneal, oculovestibular, pupillary, caloric, pharyngeal) 2) "not dead until warm and dead" aka exclude hypothermia 3) prove irreversibility (imaging showing herniation, etc.) DTRs (spinal cord still working)

Answer 212

a) - ataxia, wide based; - ROMBERG, dysdiadochokinesia, dysmetria, nystagmus - EtOH/drug, vitB12 def., b) - magnetic (freezing) - NPH, frontal lobe degeneration c) - festinating (shuffling), hypokinetic, narrow-based - bradykinesia, resting tremor, postural instability, decreased arm swing [cogwheel rigidity] d) - foot drop, high step + slap - assoc/distal sensory loss and weakness - caused by motor neuropathy (MC L5 or common peroneal) - also caused by dorsal roots or post. columns e) - disequilibrium - normal sensation, reflexes, motor - nausea, vertigo - [acute labyrinthitis/vestibular neuritis, meniere's dz] f) -waddling (2/2 gluteal weakness)

Answer 213

a) [does not present with cortical signs or AMS] - pure motor (face, arm, and leg equally) - unilateral hemiparesis - (mild dysarthria) - NO: sensory, agnosia, apraxia, aphasia, neglect, hemianopsia, (stupor, coma, LOC) b) - contralateral SensoriMotor in 1) face 2) arm 3) legs - aphasia (if dominant hemisphere) - hemineglect (if non-dominant hemisphere) - conjugate eye deviation TOWARDS infarct - homonymous hemianopsia c) - contralateral sensorimotor in lower limbs - urinary incontinence - emotional, dyspraxia - abulia (lack of will/initiative) d) ["alternate syndromes"] - ipsilateral cranial nerve involvement - contralateral hemiplegia - (ataxia)

Answer 214

1) Pure sensory syndrome (VPL thalamus) 2) Pure motor hemiparesis (post. limb of int. capsule) 3) Ataxic Hemiparesis (anterior limb of int. capsule?) 4) Sensorimotor syndrome 5) Dysarthria-clumsy hand syndrome (basal pons) HYPERTENSION is MC cause

Answer 215

1) a) stroke - ^40 temp, +AMS!!!; inadequate thermoregulation b) exhaustion - v40 temp, -ams; inadequate fluid/electrolyte replacement 2) a) exertional, young - ice water immersion b) non-exertional elderly - gastric cold lavage, evaporative cooling

Answer 216

1) Heat Stroke (+AMS!!!!!!, +40 temp) [vs exhausion no AMS and -40 temp] - path: thermoregulatory dysfunction - assoc/ rabdo (41+) a) Exertional b) non-exertional 2) Heat Exhaustion - path: inadquate fluid/electrolyte replacement leading to inability to maintain CO 3) Malignant Hyperthermia - path: uncontrolled Ca++ efflux from Sarc. Retic - assoc w/ anesthetics and temp can be up to 45 4) Fever - path: cytokine activation - assoc w/ upreg of thermoreg setpoint temporarily (hypothalamus); heat dissipation intact, usually v40

Answer 217

Solitary - surgical resection Multiple - whole brain radiation

Answer 218

any seizure >5 min -or- cluster of seizures without regaining consciousness PERMANENT INJURY 2/2 EXCITATORY CYTOTOXICITY

Answer 219

1) stroke within 3-4.5 hours, no c/i: - tPA (IV alteplase) [nc-CT head to r/o bleed before tPA!] 2) stroke + no prior antiplatelet/not candidate for tPA - aspirin 3) stroke + already on aspirin - aspirin + dipyridamole - aspirin + clopidogrel (esp. if athero) 4) stroke + afib - long term anticoag (warfarin, dabigatran, rivaroxaban) Note: aspirin is the only one shown to reduce recurrence --- aspirin + clopidogrel (12 months of 2ndary prevention) aspirin + clopidogrel (30 days post op) clopidogrel alone can substitute ASA if intolerant

Answer 220

These syndromes typically all have long tract signs with unique cranial nerve involvement. Violation of this rule is *pontocerebellar angle syndrome* in which you have (d) but without long tract signs. Usually caused by a tumor (shwannoma) rule: CN deficits are ipsi, body are contra a) CN 9, 10! - [contralateral body pain & temp loss (STT)] - [ipsilateral face pain & temp loss (spinal nucleus of CN 5); ex. loss of direct CORNEAL reflex but not consensual] - [ipsilateral horner's (hypothalamic/sympathetic)] - ipsilateral dysphagia, dysarthria, dysphonia, hoarseness, diminished gag (bulbar CN 9, 10) - *****ipsilateral ataxia (inferior cerebellar peduncle)***** - *****ipsilateral vertigo, nystagmus (vestibular nucleus)***** ie. falling towards side of lesion, difficulty sitting upright b) CN 7, 8! - [contralateral body pain & temp (STT)] - [ipsilateral face pain & temp loss (spinal nucleus of 5); ex. loss of direct CORNEAL reflex] - [ipsilateral horner's (hypothalamic/sympathetic)] - ipsilateral facial weakness (CN 7) - ipsilateral sensorineural hearing loss/tinnitus (CN 8) c) CN 12! - [contralateral spastic paresis (CST/pyramid)] - [contralateral loss of vibration/proprioception (dorsal column/medial lemniscus)] - ipsilateral flaccid paralysis of tongue; deviation TOWARDS lesion (CN 12) d) CN 6! - [contralateral spastic paresis (CST)] - [contralateral loss of vibration/proprioception (medial lemniscus)] - ipsilateral? medial strabismus (CN 6) e) CN 3! - [contralateral spastic paresis (CST)] - contralateral LOWER face weakness - ipsilateral oculomotor palsy: dilated pupil, strabismus, ptosis (CN3)

Answer 221

bleed: hyperdense infarct: hypodense

Answer 222

Central cord syndrome: 1) HYPEREXTENSION injury 2/2 pre-existing spondylosis (MC) 2) Syringomyelia 3) Intramedullary Tumor hyperextension of neck -vs- burst fracture of the vertebrae (or ASA issue) burning sensation? and paralysis in UPPER limbs only -vs- BL loss of motor and pain/temp below the lesion (STT) Weakness/hyporeflexia (CST/ventral horn) Urinary Incontinence (descending autonomics) 3) more pronounced in UL bc those fibers are situated more central in the CST

Answer 223

Both have weakness and stuff, but GBS has hypOreflex BUT IF YOU SEE BABINSKI or incontinence, IT'S SPINAL CORD. PERIOD. also look for hx of CA/mets ``` prEsynaptic NMJ (LEMS), impaired reflexes pOstsynaptic NMJ (MG), reflexes intact ``` If there are sensory issues, it's not NMJ in origin Severe hyporeflexia indicative of PN?

Answer 224

1) Resting Tremor (asymmetric MC px!!!!!) 2) Rigidity (uniform leadpipe or oscillating cogwheel) 3) Bradykinesia - hypophonia (soft speech) - hypomimia (decreased facial expression) - micrographia (small writing) - festinating gait (narrow, shuffling, short strides, NO ARM SWING) - difficulty initiating movements Need 2/3 for a clinical diagnosis. Can be further confirmed w/ physical examination (MAT) 4) Postural instability - frequent falls - flexed axial posture - loss of balance when turning or stopping suddenly! or when pushed lightly

Answer 225

*****injection, pupillary dilation/unresponsiveness**** "halos" eye pain, headache, lacrimation anticholinergics and other things that cause pupillary dilation (like darkness). (ex. tolterodine for urinary incontinence, sympathomimetics, nasal decongestants) [can lose eyesight just like in temporal arteritis]!!!!!!

Answer 226

DILATED, NON-REACTIVE PUPIL Glucocorticoid-induced myopathy; pt should have gotten steroids in the EC. Pt with LE more than UE weakness, painLESS

Answer 227

Cluster can have horner tx 100% O2, intranasal zolmitriptan, subQ sumitriptan ppx VERAPAMIL, lithium, ergotamine, steroids, topiramate Migraine: -triptan IV anti-emetics (prochlorperazine, metoclopramide, chlorpromazine) if there is vomiting b-blockade Amitryptiline anti-convulsant (valproate, topiramate) verapamil

Answer 228

THALAMIC-VPL STROKE (Dejerine-Roussy sndrome) the dysesthesia is characteristic (thalamic pain phenomenon)

Answer 229

TRIGEMINAL V1 (ophthalmic) *ABSENCE OF EYE PAIN SUGGESTS CORNEAL ABRASION WITH DYSFUNCTION OF V1* 1) PUPILLARY LIGHT REFLEXES, inspect for foreign body w/ penlight 2) visual acuity w/ ophtho referral if decreased 3) if 1 and 2 show corneal staining defect, THEN FLUORESCEIN exam

Answer 230

Dx: 1) +10% plasma (clonal) cells -OR- 2) Plamsacytoma on BM bx - AND- 1 of the following: a) end organ damage (RF, ^Ca++, anemia, lytic bone) Tx: 1) autologous hematopoietic stem cell transplantation [IF ELIGIBLE] [if INELIGIBLE] 1) lenalidomide + dexamethasone 2) bortezomib RADIATION: 1. palliative for lytic lesions/ cord compression 2. plasmacytoma tx ZOLEDRONIC ACID (anti-MM)

Answer 231

Pro-coagulant: - Factor V Leiden (MC!?!) - Anti-PLA - AT3 def. - Protein C/S def. Anti-coagulant: -TTP (ADAMTS) -

Answer 232

1) a) i. renal artery: refractory HTN, flank bruit, flank pain ii. cerebrovascular: amarousis fugax, TIA, carotid bruits iii. other: horner's, neck pain, headache b) CT-angiography; duplex U/S c) angioplasty + stent 2) - HTN - hypeRcalcemia - nephrolithiasis - neuropsychiatric sx (could be MEN2a or b [pheo]) 3) brachial-femoral delay

Answer 233

A: - ***THENAR CUTANEOUS SENSORY SPARING*** - THENAR ATROPHY (motor fibers of median n.) - PARESTHESIA IN FIRST 3.5 DIGITS (palmar DIGITAL sensory branch of median n.) ***palmar CUTANEOUS sensory branch of median n. given off proximally, therefore this is spared in CTS (bc CTS affects right at the wrist)*** B: ``` 1) Splint (nocturnal) if refractory: 2) Steroid injection (oral is an option) if refractory: 3) Surgery (Carpal Tunnel Release/Transv. Carpal Ligament) ``` --- 1) Hypothyroid - matrix deposition - BL AND WORST 2) Amyoidosis - Fibril deposition (ESRD... beta 2 microglob 3) Pregnancy - fluid accumulation (3rd trimester) 4) RA - tenosynovitis 5) Acromegaly - hypertrophy BL!

Answer 234

!!!LOWER!!! MOTOR NEURON DZ (LMN) as well as flacidity!

Answer 235

Normal ESR: 1) Glucocorticoid (nL CK) 2) Statin (+CK) 3) Hypothyroid Normal CK: 1) Glucocorticoid 2) PMRheumatica Elevated ESR: 1) POLYMYALGIA RHEUMATICA 2) inflammatory (dermatomyositis, polymyositis) 1) GIM - painLESS, LE first; nL labs 2) PMR - painful, resp. to steroids; ^ESR 3) Inflammatory myositis - proximal, TtPalp, may have rash assoc.; ^BOTH 4) Statin & hypothyroid; muscle pain, weakness, +/- rhabdo; nL ESR, ^CK

Answer 236

Multiple System Atrophy (Shy Drager Syndrome) triad: 1) parkinsonism/cerebellar ataxia 2) dysautonomia/urogenital dysfxn 3) pyramidal signs tx. fludrocortisone, alpha-agonists, salt supplements, constrictive garments in LL Riley-Day syndrome - AR, ashkenazi children, dysautonomia/orthostasis DM if longstanding can cause autonomic neuropathy but not just with 6 months

Answer 237

1) striatonigral degeneration 2) dysautonomia (shy-drager) 3) olivopontocerebellar atrophy

Answer 238

a) you know vs b) pt w/ MG on AChEi with Edrophonium (short-acting AChEi) test: a) will improve, b) will worsen

Answer 239

A) 1) ABC/intubate if necessary 2) d/c AChEi (decrease airway secretions) 3) PLASMAPHERESIS preferred over IVIG bc of its faster onset +4) initiate immunomodulators (prednisone, azathioprine, mycofenolate mofetil, cyclosporine, tacrolimus) B) 1) Pyridostigmine 2) Prednisone - other immunomodulators if refractory 3) Thymectomy if less than 60y

Answer 240

[don't forget Ramsay Hunt (herpes zoster oticus) can also cause Bell's Palsy] ``` Central (stroke, tumor, ischemia, etc.): forehead sparing (because there is BL UMN innervation of forehead by CN7; therefore if it's affected, the contralateral side will compensate) ``` Peripheral (Bell's): - forehead affected (bc UniL LMN innervation; therefore if it's affected, there's no CL innerv. to compensate) - hyperacusis (denervation of stapedius) unique in Bell's = saggy brow/forehead + ptosis + inability to close eye + loss of taste

Answer 241

a) ankle edema, levido reticularis b) somnolence, confusion, hypOtension c) insomnia, confusion

Answer 242

mild, moderate, severe tx all with warmed IV fluids -AND- a) mild: INCREASED shivering, tachycardia, tachypnea 90-95F [32-35C] -Passive EXTERNAL warming (remove wet clothes) b) moderate: DECREASED shivering, bradycardia, hypoventilation 82-90F [28-32C] -Active EXTERNAL warming (warm blankets, heating pads, warm baths) c) severe: coma, shock, arrhythmias v82F [28C] -Active INTERNAL warming (warmed peritoneal/pleural irrigation, warmed humidified oxygen)

Answer 243

1) Doxylamine-Pyridoxine (D-P=diclegis, D=unisom, P=vit B6) +ginger +hydration 2) add anti-H or anti-5-HT3 (diphenhydramine, meclizine, dimenhydrinate, ondansetron) 3) add anti-Dop (prochlorperazine, metoclopramide); methylpred taper and chlorpromazine if extreme w/ dehydration [remember to replete fluid, elec, + thiamine (B1)]

Answer 244

1) Cerebral Toxoplasmosis - usually multiple spherical lesions in basal ganglia - pos. Toxo serology is common in USA and therefore non-specific - shouldn't be Toxo if pt is on TMP-SMX 2) Primary CNS Lymphoma - usually SOLITARY, PERIVENTRICULAR - !!! pos. EBV DNA in CSF is specific! Peds: cmV periventricular, toXo scattered thru corteX

Answer 245

1) Fleshy exostosis of the hard palate in a young person; painless No tx necessary, surg if interfering 2) - EBV infection! - China, Mediterranian - Biopsy + MRI - classic: neck mass, epistaxis, recurrent otitis media 2/2 eustacian tube dysfnx; common: headache, neck mass, CN involvement - radiation

Answer 246

1) CYP inhibitors: (anti-coagulant) - ACETAMINOPHEN - nsaids - amiodarone - cimetidine/omeprazole - cranberry juice/vitE - thyroid hormone - SSRIs - abx/antifungals (metronidazole) 2) CYP inducers: (pro-coagulant) - vit K (ginseng, spinach, brussel sprouts) - carbamazepine - OCP - phenobarb - rifampin - St. John's wort

Answer 247

Emotion distress, painful stimuli, prolonged standing NBS: clinical dx, but in uncertain cases TILT-TABLE TESTING

Answer 248

1) ABCs 2) Trauma Resuscitation (FAST, AP supine CXR, EKG) 3) Specific tx: i) pneumothorax [v breath sounds unilat.] - needle (2nd ICS) THEN tube thoracostomy (5th ICS) ii) hemothorax [CXR signs] - tube thoracostomy iii) pericardial tamponade [U/S showing pericardial effusion] -pericardiocentesis 4) i) Chest CT (preferred) ii) angiography/aortography (if CT is equivocal) iii) TEE (if unstable) iv) ED thoracotomy (if pulseless or Chest Tube output +20 mL/kg) a) LEFT-hemothorax, RIGHT-deviation of mediastinum, DEPRESSION of left main bronchus; *widened mediastinum* [otherwise hypotension, AMS, trauma signs] -vs- NO MEDIASTINAL WIDENING! b) SubQ Emphysema, pneumomediastinum, pneumothorax refractory to chest tube placement c) ^JVP, hypotension, tachycardia; REFRACTORY to fluid resuscitation d) hypoxemia WORSENED by IVF + resp. distress s/p blunt trauma e) herniation of abdominal contents into thoracic cavity; NG tube in the thorax is diagnostic

Answer 249

1) ABCs 2) Trauma Resuscitation (FAST, AP supine CXR, EKG) 3) Specific tx: i) pneumothorax [v breath sounds unilat.] - needle (2nd ICS) THEN tube thoracostomy (5th ICS) ii) hemothorax [CXR signs] - tube thoracostomy iii) pericardial tamponade [U/S showing pericardial effusion] -pericardiocentesis 4) Remaining algorithm: i) Chest CT (preferred) ii) angiography/aortography (if CT is equivocal) iii) TEE (if unstable) iv) ED thoracotomy (if pulseless or Chest Tube output +20 mL/kg)

Answer 250

-angiography to r/o subclavian and plexopathic injury a) bracing, rest, ice (closed reduction with figure eight brace) b) ORIF (open reduction, internal fixation)

Answer 251

Headache +/- proptosis +/- CN3,4,5,6 palsy = cavernous sinus thrombosis!*** PrEseptal pEriorbital cellulitis vs pOstseptal Orbital cellulitis anterior to orbital septum vs posterior to orbital septum outpatient oral Abx vs inpatient IV Abx Seen in both: - eyelid tenderness, erythema, and edema - fever, leukocytosis Unique to pOstseptal Orbital cellulitis: - diplopia - ophthalmoplegia - pain with extraocular eye movements - proptosis - vision impairments ----- Bacterial Sinusitis ``` --- Orbital: 1) CT head to confirm 2) Empiric Abx (staph, strep pneumo) IV Vanc + one of the following -pip/tazo -amp/sulbactam -ceftriaxone -cefotaxime ``` ``` Periorbital: 1) if SUSPICIOUS OF orbital, CT head to r/o 2) Empiric Abx (staph, strep pneumo) PO Clinda +/- TMP-SMX + one of the following -amox -amox/clav -cefdinir -cefpodoxime ```

Answer 252

Iron poisoning: hematemesis, acidosis, hypovolemic shock, tx deferoxamine Lead poisoning: anemia, poor appetite, headaches, ab pain, irritability suspect LP/risk factors? then: 1) VENOUS lead level 2) stratify and NBS: a) v44 mcg/dL: no tx; repeat levels in 1 mo. b) 45-69 mcg/dL: tx DMSA (dimercaptosuccinic acid) or succimer c) 70+ mcg/dL: tx EDTA (british anti-Lewisite) + dimercaprol (Ca di-Na edetate)

Answer 253

1) TEA-TIME ``` T-cell dysfunction Hyper IgE, A Thrombocytopenia (impaired platelet production) Infection (otitis media) LOW IgM Eczema ``` 2) a) ABSENT v50 IgA, ***NORMAL IgM!*** b) assoc. w/ anaphylactic rxn; need washed transfusion! c) recurrent sinopulmonary, Gi, uro infxns 3) a) ^IgM, ***LOW IgG, IgA*** 4) ***NORMAL B CELLS BUT DECREASED !OUTPUT of B cells*** 5) Neonate w/ hypocalcemic seizures and "cardiofacial" defects i) Bruton's (BOYS, XLINKED) has reduced B-cells (tyrosine kinase issue) while CVID does not. They both can have low [Ig] however. Bruton's earlier in life and boys. ii) Bruton's X linked (bc low B cells and normal T cells). Tx. IVIg

Answer 254

7.5+g dose or 150+mg/kg peds pre) CHARCOAL (gastric decontamination) [if v4 hrs] 1) check Acetaminophen level 2) NAC [if 10+mcg/mL or ^nomogram]

Answer 255

HYPERGLYCEMIA, hypertrigliceridemia, hyper-LDL HYPERCALCEMIA, hyponatremia, hypokalemia [via K+ channel potentiation in the pancreas, INHIBITING insulin release] 1) HTN 2) dyslipidemia (^TGL, ^HDL, [^fast Glu]) 3) abdominal obesity

Answer 256

a) first degree [delayed conduction thru AV node] - ^PR interval - (a?) P always follows QRS!!! (unlike other blocks) tx - normal QRS: reassure; prolonged QRS: electrophys testing b) second degree - mobitz 1 [Wienkiebach]- dropped QRS!, increasing PR, decreasing RR, constant PP - mobitz 2 - 2:1 P:QRS (2p's before each QRS) [seen in RCA occlusion bc AV nodal artery] {inferior MI} c) complete 3rd degree AV block - no P w/ QRS! - needs a reentry circuit, otherwise death (escape rhythm) - tx temporary pacemaker

Answer 257

a) - cystic medical necrosis (aging) - 2/2 Ehlers-Danlos, Marfans b) atherosclerosis a) PRECAPILLARY (arterial) preferential dilation by CCB leads to edema b) POSTCAPILLARY (venous) preferenial dilation by ACE/ARB to mitigate

Answer 258

AEIOU Acidosis (metabolic) - pH v7.1 Electrolytes - K+ ^ 6.5 or *symptomatic* [remember, insulin+glucose is the fastest way though] Ingestion - alcohols - lithium/valproate/carbamazepine - ASA Overload (fluid overload refractory to diuretics) Uremia - uremic pericarditis - uremic encephalopathy - bleeding

Answer 259

a) In a pt with longstanding hyperthyroid (Graves, Toxic Adenoma, Toxic Multinodular Goiter), b) sometimes after a precipitating event (surgery, trauma, infection, acute iodine load) c) showing evidence of: 1) Biochemical hyperthyroidism + 2) signs of life threat (high output CF, hyperpyrexia, AMS, etc.) [also can have n/v/ab pain, ophthalmopathy, lid lag, tremor, moist/warm skin] 1) reduce adrenergic tone 2) block new synthesis 3) block release 4) block peripheral conversion from T4 to T3 5) promote vasomotor stability and tx concomitant adrenal insufficiency 6) decrease enterohepatic recycling of thyroid hormone First!: (1-2 are for IMPENDING storm aka severe thyrotox; 3-4 are added if storm) 1) beta-blockade (propranolol!, atenolol if reactive airway?) 2) thionamide (PTU blocks periph conversion, methimazole does not) a) PTU (***if ICU, first trimester, or refract to radioablation and methimazole) b) otherwise METHIMAZOLE bc longer half life and less tox 3) hydrocortisone 4) cholestyramine ONE HOUR LATER: - iodine***** Long term: - radioablation

Answer 260

Low = hypovolemic (2/2 vperfusion and increased 02 extraction) High = septic shock both have low PCWP and low right atrial pressures acute massive PE!

Answer 261

1) Echo 2) Right Cath 3) Graded Exercise improves mortality; Lung Transplant is curative! 4) Pharm based on etiology: a) sympomatic idiopathic: - epoprostanol, sildenafil, bosentan b) 2/2 left ventricular failure: - ACE/ARB, diuretic c) 2/2 hypoxemia from chronic lung dz: - oxygen, bronchodilator d) 2/2 chronic thromboembolic occlusion of pulmonary vasculature - long term anticoagulation

Answer 262

``` sinus bradycardia sinus pauses SA block AV block Nonsustained v-arrythmia short or long QTc ```

Answer 263

a) STEMI i) +1 mm in 2 contiguous leads ii) +2 mm in V2 and V3 iii) new LBBB + signs of ACS b) NSTEMI / Unstable Angina (+biomarkers / -biomarkers) i) ST-depression, deep T-wave inversion Initial EC Approach: 1) ABCs, Heart/O2 Monitors, IV access, serial EKGs, supp. O2 goal SaO2 90+ 2) Aspirin 325 mg 3) CBC, BMP, Troponin, Coag studies 4) 3 Nitro (IF! chest pain, CHF, HTN) [NOT IF! aortic stenosis, sildenafil user] 5) Tx Left Heart Failure with (Nitro, Furosemide, BiPAP) 6) Metoprolol [NOT IF! asthma, bradycardia, CHF, cocaine] 7) Morphine (IF! chest pain, anxiety) 8) IV atropine (IF! unstable sinus bradycardia) 9) Atorvastatin *STEMI treatment for Licensed Physicians (post-EC): 1) Coronary Reperfusion (within 12 hours of symptom onset) i) Percutaneous Coronary Intervention (PCI) [preferred] - within 90 min. of presentation to EC - within 120 min. of first medical contact (EMS) ii) Fibrinolysis (tenecteplase) [if PCI not possible] - within 30 min. of first medical contact 2) anti-PLATELET [aspirin + (clopidogrel, ticagrelor, prasugrel) 3) anti-COAGULANT [Heparin, Bivalirudin] {Enoxaparin, Fondaparinux} * NSTEMI treatment w/ high TIMI score (post-EC): 1) Diagnostic Angiographic Catheterization 2) Revascularization i) Angioplasty + Stent (PCI) [1 or 2 vessel disease] ii) Coronary Artery Bipass Graft (CABG) [3+ vessel disease] 3) anti-PLATELET [as above +/- eptifibatide, tirofiban, abciximab} 4) anti-COAGULANT [as above] {as above} ``` possible preferred regimens - aspirin + ticagrelor + heparin - aspirin + prasugrel + heparin - aspirin + clopidogrel + bivalirudin {in NSTEMI, +/- eptifibatide, tirofiban, abciximab to above regimens} ``` {replace heparin/bivalirudin with enoxaparin or fondaparinux if patient underwent fibrinolysis for STEMI or noninvasive angioplasty for NSTEMI}

Answer 264

Ocular massage + high flow O2 "pharm D" peripheral vision vs "OPEN ANUS!" TUNNEL vision OR!!!! central vision loss vs peripheral vision loss

Answer 265

after 20 weeks gestation but before onset of labor (otherwise abortion?) dx - real time ultrasonography (absence of fetal cardiac activity) Autopsy of fetus to determine cause and help prevent/guide future Induce labor and deliver, now. (avoid frank DIC) Same Observation, self-limiting

Answer 266

threatened: closed cervix, FETAL CARDIAC ACTIVITY inevitable: dilated cervix, NO CARDIAC ACTIVITY threatened ab. is any bleeding

Answer 267

- abdominal pain - fetal HR abnormalities (variable decels) - recession of the presenting part of the fetus (loss of fetal station) tx emergency c-section to avoid exsanguination

Answer 268

Obstructive (FEV1:FVC v70): - Emphysema! - Bronchiectasis? (2/2 CF, post infx, A1ATd, toxic, etc.) Restrictive (FEV1:FVC ^70): - Asbestosis - Sarcoidosis - Heart Failure - ILD!!!!!!!!!m Normal Spirometry: - Anemia - PE - pHTN -------- 1) Decrease FiO2/decrease RR (if alkalotic?) 2) increase peep

Answer 269

a) Squamous, central +necrosis, smoker, PTHrP b) Small cell, central, ...., LEMS/ACTH/SIADH c) AdenoCA, peripheral + a-Sx solit. nodule, nonsmoker/women, clubbing, hypertrophic osteoarthropathy d) large cell, peripheral, ..., gynecomastia/galactorrhea e) pancoast = superior, C8/T1, horners, (superior sulcus syndrome?) adeno MC overall aka nonsmall smoking RF for squamous, small, and large.

Answer 270

A) asthma B) asthma exacerbation 1) ***PEF (or FEV1)**** a) +40% = mild/moderate b) -40% = severe c) (impending) respiratory failure 2) Initial Treatment a) O2 + SABA + PO steroid (refract or recent steroid use) b) O2 + SABA + ipratropium + PO steroid c) intubate/BiPAP? + O2 + SABA + ipratropium + IV steroid (+/- mag, epi, terbutaline) 3) Reassess PEF a) +70% = good response b) 40-69% = incomplete response c) -40% = poor response 4) Dispo a) home b) floor c) ICU - INCREASE in CO2 (2/2 resp. muscle fatigue, loss of tachypneic drive, decreased breath sounds/absent wheezing, AMS, hypoxia/cyanosis

Answer 271

serum Ig level (quantitative) -establish Humoral immunodeficiency as dx vs CT chest -establish BRONCHIAL OBSTRUCTION (2/2 cancer?) --- Observation, as long as there isn't sign of PNA or malig or RF acute bronchitis 2/2 virus -- BRONCHOGENIC CA (works synergistically w/ smoking) mesothelioma CAN happen but isn't MC

Answer 272

Digital Clubbing - widening of the distal digits that often signifies underlying malignancy; path: VEGF^ (NOT seen in COPD!) Hypertrophic Osteoarthropathy (pulmonary subtype) = clubbing + arthralgia either? ---- then CXR --- AVMs! like osler-weber-rednu, etc. (papules on the lips) -- days vs hours abx vs spportive oral flora/anaerobes vs gastric content

Answer 273

1) O2, establish IV 2) 1L 0.9 NS /hr +/- pantoprazole to prevent coag protein degradation 3) pRBC - unresponsive to 2L NS? - Hgb v7 in stable/healthy - Hgb v9 in unstable/comorbidity 4) Reverse coagulopathy a) d/c anticoagulant meds b) FFP if INR ^ 1.5; IV vit K c) Platelets if v50,000 (active bleed) or v10,000 (spontaneous bleed risk) A: UPPER GIB B: LOWER GIB 1) consider upper 2) investigate lower 3) treat 1) ABCs, CBC/CMP/Coag, type/cross 2) First consider UPPER Bleed source a) NG Aspiration i) + bile, - blood = pylorus open and NO UPPER BLEED! ii) + coffee ground/blood = YES upper GIB (assuming pylorus open) iii) no blood or bile = indeterminate *** ii or iii, do an upper endoscopy. i, continue:*** [basically, you want bile, otherwise the results are useless bc the pylorus could be closed and there still could be upper bleed] 3) COLONOSCOPY 4) no? then arteriography (+/- tagged RBC radionucleide to localize) 5) no? evaluate small bowel will pill endoscopy or duodenoscopy

Answer 274

*sentences: HIV and cervical stop at 65y colon, breast, AAA stop at 75y aspirin and Lung CA ct stops at 80y odd: if UC/or Chron's, 8 yrs later begin colonoscopy q1-2 years USPSTF: 1) Colonoscopy 50-75y;q10, q5 sig q3FOBT, qY FOBT - high risk 40 or 10 prior to fam dx; q5 2) Aspirin 81 - Males: 45-79y for MI - Female: 55-79y for ischemic stroke 3) AAA - 65-75y if ever smoked 4) a) MALE Cholesterol screen - 35+y - 20-35y if high risk for HD b) FEMALE Cholesterol screen - 45+y - 20-45y if high risk for HD 5) Hep C baby boom (1945-1965), IVDA, transfusion v'92 HIV screen OFFER to pts v65y or high risk Chlamydia v25y sexually active or high risk 6) Lung CA - low dose CT 55-80y, 30pack-year, quit in last 15 yrs, reasonably willing to get surg 7) Cervical CA - PAP cytology 21-65 q3 - PAP + HPV DNA 30-65 q5 8) Mammography (50-75) q2 DEXA 65+ 9) anhedonia - last 2 weeks ever felt down/depressed --- Vaccines: - TdaP 11y, Td q10y thereafter - HPV 11-26y female, 11-21y male [can be 9]

Answer 275

a) CONJUGATED buildup [you'll have to see unconj too, tai?] - implies post-hepatic (aka obstructive jaundice) - ex. pancreatic CA, choledocholithiasis, etc. intrahep cholestasis, hepatitis. [dubin john, rotor] b) UNconjugated buildup - implies pre-hepatic - ex. hemolysis, Gilbert/CNajj, intrahepatic chol of preg c) i) increased UROBILINOGEN ii) increased urine BILIRUBIN d) Dubin johnson, rotor

Answer 276

Increased bone loss Siderblastic anemia, Anemia of chronic dz, Hemachromatosis

Answer 277

1) "triple therapy" to eradicate H. Pylori - amoxicillin - clarithromycin - omeprazole 2) Combo chemo if refractory (CHOP+ bleomycin) - cyclophosphamide - adriamycin - vincristine - prednisone - bleomycin ---- ``` SSC of head/neck. (hx alchohol, tobacco) Panendoscopy (triple endoscopy) - esophagoscopy - laryngoscopy - bronchoscopy ```

Answer 278

"Low T3 syndrome" with nL TSH

Answer 279

1) Testosterone 2) Androstenedione 3) DHEA 4) ***DHEA-S**** [suggests adrogen-producing adrenal tumor]

Answer 280

1) a) (secondary) adrenal insufficiency- glucocorticoid deficiency (2/2 low ACTH, low cortisol) - low appetite, hypoglycemia, hyponatremia, eosinophilia; PALLOR (2/2 low MSH) b) hypogonadism (2/2 low LH/FSH, low testosterone) - low T, low libido, ED (women: amenorrhea, infertility) c) (central) hypothyroidism (low TSH, low T4) - cold intolerance, constipation, bradycardia 2) ALDOSTERONE is NORMAL IN HYPOPITUITARISM (2ndary adrenal insuff.) because aldosterone is regulated by RAAS, but in primary, it's just not produced

Answer 281

Glucagonoma with (necrolytic migratory erythema) Glucagon +500 is dx

Answer 282

Happens in HEMOLYSIS (+hemosiderin) likely 2/2 G6PD def. exac. by recent infection, fava beans, sulfa/antimalarials/nitrofurantoin that creates OXIDATIVE STRESS [nitorfuratoin, TMP-SMX! for uti!] REVIEW: G6PD creates reduced glutathione which protects the RBC. Otherwse, you precipitate out heinz bodies

Answer 283

1) painless thyroiditis 2) granulomatous thyroiditis (painful, DeQuervain's) 3) iodine-induced thyrotoxicosis 4) levothryoxine overdose 5) struma ovarii (ovarian tumor that secretes thyroid hormones)

Answer 284

NEXT BEST STEP IS FIRST GET IGF-1 LEVEL! - Failure to suppress GH after glucose tolerance test is diagnostic of acromegaly! - Failure to elevate GH after insulin stimulation test is diagnostic of CHRONIC hypopituitarism cardiac --- Legionaire

Answer 285

A: Px - cushingoid (either from ACTH drive or primary cortisol^) i) r/o exogenous glucocorticoid use ii) confirm hypercortisolism - 24 hour urine - low dose dexamethasone suppression - PM cortisol iii) ACTH-INdependent vs ACTH-dependent iv) localize source 1) ***24 hour urine cortisol?*** L-DDSt, PM cortisol 2) *ACTH level* a) low = INdependent = feedback intact b) high = dependent = feedback not intact 3) Localize a) Adrenal CT b) Pituitary MRI (+ high dose dex and CRH, yielding + suppression and ^ ACTH) = Cushing's DISEASE 4) if b is negative: inferior petrosal sinus sampling, +central step up = Cush Dz 5) if no, or if high dose dexa is NEG, then ECTOPIC ACTH lung B: Px - signs of adrenal insufficiency (hypotension, HYPERPIGMENT, hyponatremia, hyperkalemia, eosinophilia, fatigue, NAGMA) 1) ***AM urine cortisol*** (pend ACTH, takes forever) a) low cortisol, HIGH ACTH = primary AI b) low cortisol, LOW ACTH = secondary/tertiary (central) AI 2) COSYNTROPIN stimulation (cosyntropin = ACTH analog) - pos. response = rise in cortisol a) + = NOT primary AI (rules it out) b) - = primary AI 3) tx a) MRI + tx cortisol b) tx cortisol AND fludrocortisone (ald?) C: Px - hypertension and hypOkalemia 1) ***aldo:renin*** a) aldo^, ratio +20, aldo +15= primary hyperaldosteronism b) aldo^ renin^ ~10 = secondary hyperaldosteronism c) vAldo, vRenin = other (CAH, Glucoc. resistance, exogenous, cushing's) 2) a) Adrenal CT; then adrenal vein sample, petrosal sample?

Answer 286

1) TSH, FT4 a) FT4^, TSH^ = secondary, MRI the pituitary. Done. b) FT4^, TSHv = primary 2) R/o Graves clinically 3) RAIU a) High = de novo synthesis - nodular = toxic adenoma, multinod. goiter - diffuse = Grave's b) Low = exogenous (will see low thyroglobulin!) 4) if low (b), measure Thyroglobulin (Tg) a) high = thyroiditis, iodine-exposure b) low = exogenous! (factitious) *low Tg bc not made in the body!

Answer 287

Niacin (pellagra: 4d's dermatitis, dementia, diarrhea, death) Carcinoid tumor cells use up tryptophan (from niacin) to produce serotonin [degradement if pre-hepatic or whatever? something from pathoma?]

Answer 288

a) cystalline AKI (ppx IVF) b) tender transplant, autoimmune attack? (ppx corticosteroids) c) steroids (IVF?) [NAC?] non-ionic contrast! d) urate crystal nephropathy (ppx allopurinol)

Answer 289

alternatively: 1) "Is there high serum Osm? +290; - hyperglycemia or RF 2) "Is there low urine Osm? -100; - primary polydipsia or beer potomania (malnutrition) 3) "no? Ok then what about Urine Na+ ^ or v25? - ^ means SIADH, AI, hypothyroid - v means CHF, Cirrhosis, volume depletion 1) EuOsmolar a) 2/2 hyperproteinemia, hyperlipidemia 2) Hyperosmolar a) 2/2 hyperglycemia, mannitols 3) HypoOsmolar a) Euvolemic i) urine osm ^than serum osm = SIADH ii) urine osm and serum osm both decreased = polydipsia/beer potomania b) Hypervolemic - CHF, nephrotic syndrome, liver fail c) Hypovolemic i) renal salt loss = diuretics, ACE, mineralocort. def. ii) non-renal salt loss = diarrhea, emesis, dehydration

Answer 290

a) RA b) MM.... waldenstrom a) Beta-2 microglobulin, apolipoprotein, transthyretin b) light chains (lambda) [beta 2 microglob?]

Answer 291

Dyspaeunia; bladder pain improved with voiding exac. by filling Kidney biopsy OBJECTIVE weakness vs arthralgia prendisone vs amitriptyline etc. 1) compression frxr, esp. in older woman w/ osteo. (can be asx, loss of stature, etc.) 2) -OR- spinal cord compression (if picture fits; hx mets) - 3) or vertebral osteoyelitis (if fever) vs Lumbosacral strain with paraspinal tenderness

Answer 292

``` Paget's dz bone (osteitis deformans) - urine hydoxyproline - urine C/N-telopeptide - urine pyridinoline [above are markers of bone breakdown] ``` {also consider MAC esp. if CDv50 and HIV+} ASYMPTOMATIC! tx - NEED ADEQUATE VIT D! w/ NITROGEN-containing bisphosphonates (IV zoledronate, IV pamidronate) [bc PO is poorly absorbed] acetaminophen or NSAID for acute phase of tx ADR - osteonecrosis of jaw Calcitonin only if intolerant to above

Answer 293

Lidocaine injection will IMPROVE pain/ROM in rotator cuff tendinitis/impingement, but NOT IMPROVE those pain/weakness in a tear Pain and guarding during Neer's Test (passive motion of arm above head) vs Positive drop arm 90 degrees Foosh/trauma vs overuse dx tear w/ MRI

Answer 294

autoimmune vs Parvovirus b19 morning stiffness +30 min vs v30min lasting +6 wks vs resolving within 6 weeks arthroedema and ^inflammatory markers vs none

Answer 295

1) First MACROLIDE +/- doxycycline 2) EtOH! phenytoin phenobarb b) vOCPs, clofibrates 3) CMV tx ganciclovir 4) cath (but scan first? question didn't have that option)

Answer 296

a) malasezzia GLOBOSA!!!!!!!! b) Trichophyton Rubrum (confirm hyphae on KOH, tx topical terbinafine, griseofulvin if refractory) - def. ring shaped scaly patches w/ central clearing and clear borders Dentist who comes in contact with infected orotracheal secretions (HSV1/2); px throbbing non purulent vessicles on finger; self-limiting First appears in ORAL MUCOSA; Painful FLACCID blisters, +Nikoslky's sign, auto-IgG against desmoglein, IF shows IgG deposits intercelllularly in the epidermis; tx steroids +/- azathioprine, methotrexate vs Pruritic TENSE blisters; IF shows IgG and C3 deposition in the dermal-epidermal jxn

Answer 297

MC DRUG IS PRAZOSIN! (classic assoc. is Trazodone) 1) sickle cell, leukemia (adolescents) 2) trauma (2/2 laceration of the cavernous artery) 3) neurogenic (spinal cord, cauda equina) 4) drugs (PRAZOSIN, trazodone)

Answer 298

Scabies! (can mimic eczema, seborrheic dermatitis, tinea) path. sarcoptes scabiei, confirmed w/ mites, ova, feces on microscopy wash bedding, clothes and put in plastic bag for 3 days (mites can't live away from skin this long) tx. topical permethrin or oral ivermectin -- 2) cutaneous verrucae (plantar MC in young and immunodef.) HPV!!!! --- 3) porphyria cutanea tarda! - urinary porphyrin elevated - phlebotomy or hydroxychloroquin may provide relief - IFN-a can provide relief if HepC comorbid - --- 4) sand with dog/cat hookworm larvae of ancylostoma braziliense

Answer 299

HPV (16/18) [mc STD in US!] vs 2ndary syphilis verrucous papilliform lesions in anogenital area vs flattened pink or gray velvety papules in genitals or MOUTH ``` HPV increased SSC risk tx 1) trichloroacetic acid or podophylin 2) imiquimod 3) sx (cryosurgery, excision, laser) ```

Answer 300

PPD is positive when a) +5 mm and HIV b) +10 mm and "high risk" c) +15 mm a) active TB = RIPE 2mo + RI 4mo b) latent TB or ppx = 9 months B6+isoniazid or = isoniazid + rifampetine qWeekly for 3 months (supervision) - ethambutol = red/green color blindess and optic neuropathy - isoniazid hepatotoxicity??? need f/u w/ LFTs. monitor neuropathy (B6 should help) - - a) NO GRAM (only acid fast) b) NO ACID FAST (only gram + ) c) BOTH gram + and partially acid fast (+ filamentous, branching)

Answer 301

Leukoreduction EtOH!!!! Obesity is actually weight bearing and adipose yields estrogen which is osteoprotective

Answer 302

Severe temper outbursts, verbal aggression, persistent, unremitting baseline irritability The outbursts occur an average of three or more times per week. +1 year Irritability is observed in at least two out of three settings (home, school, with peers) and is severe in at least one of these locations. The diagnosis can not be made prior to the age of 6, nor after the age of 18. Historical assessment finds that these symptoms were present prior to the age of 10. There has been no prior diagnosis of a mania or euphoric mood lasting longer than 1 day. The behaviors do not occur as a result of a major depressive or other dis- order, such as anxiety, persistent depressive disorder, or posttraumatic stress disorder. vs Intermittent explosive disorder (3 months with remittance)

Answer 303

Criterion for both: 1) history of absence of adequate caregiving (social neglect) before the age of 5 that leads to inability to appropriately form attachments 2) child must be at least 9 months old 3) persistent if +12 month's duration RAD (anaclitic depression): emotional withdrawal limited positive affect rarely seeks or responds to comfort when distressed lack of basic trust poor socialization/language skills poor feeding, immunodeficient, failure to thrive Disinhibited Social Engagement Disorder: Reduced hesitancy in approaching and interacting with unfamiliar adults overly familiar with strangers (that is inconsistent with age-appropriate behavior or culture) Lack of concern about checking back with an adult caregiver, or wandering away without supervision Willingness to go off with an unfamiliar adult with little or no hesitation

Answer 304

+famHx, negative Coomb's vs -famHx, POSITIVE coomb's --- Warfarin inhib. vit-K dep.: 10, 9, 7, 2, C, S C and S are ANTI-coag 2,7,9,10 are pro-coag protein C inhibited first; if underlying def., then there will be unopposed PROcoag from 27910, hence necrosis

Answer 305

1) hypOcalcemia 2) hypERkalemia 3) hypERphosphatemia 4) hypERuricemia hypocalcemia 2/2 phosphate binding and (release of intracellular products to which it also binds to?) --- Watery to bloody diarrhea = E Coli (ehec?)

Answer 306

1) Primary - painless chancre 2) Secondary - condyloma lata - diffuse rash (on hands too) - LAD - oral, hepatitis 3) LATENT - asx [TX ^^^ IM Benzathine PCN; doxycycline if allergic] 4) Tertiary - CNS: ARPupil, tabes dorsalis, dementia - Cardio: Aortic aneurysms/insufficiency - Skin: Gummas [TX ^ IV PCN G; IV ceftriaxone if allergic] 5) pregnancy - risk of transmission/congenital dz [TX ^ PCN; desensitize + PCN if allergic]

Answer 307

140/90 1) Primary/preexisting HTN (v20wk or ^2wk postpartum) 2) Gestational HTN (^20wk) 3) Pre-E (^20wk+ proteinuria/end organ) 4) E (pre-E + grand mal) Tx: 1) labetalol or methyldopa 2) hydralazine or CCB 3) clonidine, thiazides (less acceptable) pre-E (add IV or IM Mag?)

Answer 308

1) anovulation (2/2 to obesity and leading to co-PCOS?) -FSH/LH normal -estrogen normal -progesterone LOW! [no withdrawal bleeding bc no P; hence amenorrhea]

Answer 309

Langerhans Cell histiocytosis X (eosinophilic granuloma) ddx hyperPTH but usually you're older.

Answer 310

1) Aromatase Def. 2)

Answer 311

1) most common type of spinocerebellar ataxia - ataxia, frequent falling, dysarthria (resulting from degeneration of the spinal tracts [spinocerebellar tracts, posterior columns, pyramidal tracts]) - HYPERTROPHIC CARDIOMYOPATHY [mc death] (90%), skeletal deformities (scoliosis, "hammer toes"), diabetes

Answer 312

pancytopenia vs erythrocytopenia labs (crisis?): severe anemia, low hemoglobin, LOWWWW reticulocyte crisis: (transient arrest in erythropoiesis, typically due to parvovirus B19,

Answer 313

- Neonatal thyrotoxicosis - anti-TSH receptor antibodies cross placenta and trigger hyperthyroid symptoms - methimazole PLUS beta-blockade

Answer 314

Primary = absence of menarche at age 15 Primary: Start with pelvic U/S (uterus present?), if yes, do FSH. If that's high, do karyotyping. If low, do MRI (pituitary/hypothalamic). If uterus is absent, go straight to karyotyping (female w/ nL T, abN mullerian developmen vs male w/ nL T, androgen insensitivity syndrome.) ---- Secondary = absence for >3 cycles or >6 months Always start with SERUM!!!*** (sens.) b-HCG (pregnancy), then prolactin and TSH (prolactinoma or hypothyroidism) then FSH and LH (asherman's, ovarian failure, hypothalamic-pituitary disorders, etc.) remember, MRI to confirm prolactinoma; hysteroscopy/hyperosalpingogram to confirm asherman's

Answer 315

1) Cocaine Abuse 2) give BOTH passive and active immunity (HBIG, HBV) 3) Upper extremities HTN, lower under-perfused. 4) XRAY neck to r/o dislocation/fracture 5) Cyclic vomiting syndrome 6) Alports

Answer 316

1) mild: 3-5% (asymptomatic) 2) moderate: 6-9% (decreased skin turgor, irritability, dry mucous membranes, tachycardia, oliguria) 3) severe: 10-15% (cool clammy skin, cracked lips, sunken eyes, sunken fontanel, tachycardia, lethargy, oliguria/anuria) capillary refill: Moderate (2-3 seconds) Severe (>3 seconds) Mild: oral rehydration Moderate-Severe: bolus NS

Answer 317

Laryngotracheobronchitis (croup): barky, age 6 months to 6 years Laryngomalacia: worse when supine, better when prone Foreign body aspiration: acute onset Vascular ring: better with neck extension; px before 1 year Epiglottitis: tripoding (sitting up and leaning forward), dysphagia, DROOLING, toxic-appearing, ALSO IMPROVES WITH NECK EXTENSION (increases airway diameter), ACUTE, thumb sign. INTUBATE IN OR

Answer 318

Typically abdominal pain, palpable purpura (with normal coag panels), hematuria, arthralgia, scrotal pain/edema ***Intussusseption a) HSP/***ileo-ileal dx TARGET sign on u/s b) Normal/sp viral infx/peyer patch hptrphy Meckel/***ileo-colic dx air enema (due to bowel wall edema and localized hemorrhage, typically small bowel ileo-ileal vs usually ileo-colic, therefore may not be seen on enema) and GI bleed Tx pain control, corticosteroids if severe --- If super classic go straight to air enema (dx and tx), but MAT is U/S

Answer 319

a) Spontaneous Abortion (v20wk) NBS: usually pelvic U/S then see below! 1) Inevitable; OPEN; not dead yet! 2) Incomplete; OPEN; poc usually in cervix 3) Missed; closed; dead, preg sx decrease * **then: DandC/surg if esp. if HD unstable. (PGs and exp options) 4) Threatened; closed, VIABLE PREGNANCY * **then: Expectant mgmt until progression to 1, 2, or 3 5) Septic; usually opeN; foul smelling, retained poc * **then: 1) endometrial and blood clx 2) ABX 3) DandC [vowels = open; i/o + septic usually open ]

Answer 320

1) if asx or +30,000 platelets, OBSERVE 2) if bleeding or v30,000 platelets: STEROIDS OR IVIg

Answer 321

A: Goal: v95th percentile -or- v120/v80 Goal w/ comorbid or end-organ: v90th percentile [comorbid = obesity, dyslipidemia, CKD, CVD] [lifestyle = weight reduction, exercise, diet and Na restriction!] [end-organ= left ventricular hypertrophy] Normal: v90th Pre-htn: 90th-95th HTN: 95th [HTN1 95th-99th; HTN2 99th+] ---- B: sentences: a) only time you'll ever use pharm (5) : i) comorbids ii) end-organ iii) HTN2 iv) refractory 2ndary v) refractory HTN1 (refract. 4-6 mo.) b) LIFESTYLE always a component of tx regardless. You never won't do lifestyle. ("strep pneumo?") 1) LIFESTYLE ONLY, FOR: - pre-htn 2) 4-6 months LIFESTYLE **then** PHARM, FOR: - refractory HTN1 3) LIFESTYLE + PHARM, for - pre-htn w/ comorbid - HTN1 w/ comorbid - HTN1 w/ end-organ - HTN2 - secondary htn REFRACTORY to underlying cause tx

Ultimate Merge Flashcards

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