UWorld Flashcards
Erythematous, hot, shiny, swollen area in skin with irregular borders - hx of DM - dx?
Cellulitis - infxn involving deep dermis and superficial fat (vs. erysipelas which involves superficial dermis and lymphatics)
Can you use lidocaine in cases of cellulitis? Why?
Areas of infections tend to be slightly acidic and local anesthetics tend to be basic in nature, thus easily neutralized and become ineffective. If the cellulitis progressed to abscess formation, local anesthetic should still be used to anesthetize the epidermis for draining purposes (not pain control)
Locally aggressive benign tumor arising from fibroplastic elements in muscle or fascial planes w/ very low potential for metastasis or proliferation = dx? Complications? Trmt?
Desmoid tumor. Deeply seeded painless mostly in the trunk/extremity, intraabdominal bowel and mesentery, and abdominal wall. Complications = intestinal obstruction and bowel ischemia. HIGH RATE OF RECURRENCE!
Work-up includes CT/MRI if large, symptomatic, or worrisome for histologic dx. Trmt = surgery or radiation for non-surgical candidates
Firm hyper pigmented nodule MC on lower extremities seen after trauma = dx?
Dermatofibroma
Results from normal epidermal keratin becoming lodged in the dermis = dx?
Epidermoid cyst
Asymptomatic skin lesion and benign collection of fat cells = dx? Recurrence risk?
Lipoma. Low risk
Capillary proliferation after trauma and is usually dome-shaped papule with recurrent bleeding; seen in pregnant women = ?
Pyogenic Granuloma
SIRS Criteria? Desired CVP in suspected hypoperfusion from sepsis?
> 38.5 T, HR > 90, RR > 20, WBC > 12,000 (need 2/4 criteria)
CVP 8-12 via fluid resuscitation (central venous line if necessary). Vasopressors may be needed if persistently hypotensive (Norepinephrine; Dobutamine = more inotropic in suspected poor CO)
Cushinoid appearance clues you in to chronic use of what? How does this affect management in sick patients?
Chronic use of steroids; could lead to HPA suppression. Low cortisol level (even in non-chronic corticosteroid users) can be dangerous in shock situations. Should begin tapering dose after 8hrs of presentation for those in shock without chronic use of steroids w/ SBP
ADHD course from childhood to adulthood? Increased risk of substance use/abuse w/ stimulant therapy?
Hyperactive physical symptoms tends to subside into adolescence while one to two-thirds of children dx’d with ADHD will experience persistent ADHD into adulthood,
No data supporting increased substance use/abuse with stimulants.
Cardiac exam signs (3) indicating severe AS?
Soft/single S2, delayed and diminished carotid pulse “parvus and tardus”, loud and late systolic murmur
Work-up of Thyroid Nodule: ?
First: Clinical Eval (fam hx, past radiation, cervical lymphadenopathy, compressing sympt, symptomatic) / TSH Level (NL or elevated TSH) / US (hypoechoic, microcalcifications, internal vascularity)
No RF’s and Low TSH - I-123 Scintigraphy > hot (increased uptake) can treat as hyperthyroid, cold (low uptake) = concerning, get FNA.
RF’s - get FNA
No RF’s and NL or Elevated TSH - FNA, treat findings
What should your work-up include with someone who has medullary thyroid cancer? What’s included in each of these categories?
Serum calcitonin and carcinoembryonic antigen, neck U/S (regional mets?), genetic testing for germline RET mutations, and eval for coexisting tumors (hyperparathyroidism, PCCs)
MEN 1 - (PPP) pituitary tumor, primary hyperparathyroidism, enteropancreatic tumors
MEN 2A - (MPP) MTC, parathyroid hyperplasia, pheochromocytoma [Familial Medullary Thyroid Cancer = subset of 2A w/ only MTC]
MEN 2B - (MMP) MTC, pheochromocytoma, mucosal/intestinal neuromas, marfinoid habitus
In the setting of a new pleural effusion w/ a patient being treated for TB, what should you order?
Thoracentesis to analyze it. Usually exudative with a lymphocytic predominance secondary to an enhanced immunologic response.
Acute jaundice, hepatomegaly, and elevated transaminases - DDx and patterns? Consideration for hospitalization?
Acute viral hepatitis (Hep A/B), alcoholic hepatitis (AST>ALT 3:2), toxic liver injury or drug-induced (acetominophen poisoning), autoimmune hepatitis (likely chronic onset), ischemic liver injury (in setting of trauma), herpesvirus etio (EBV, varicella, herpes simplex, CMV)
Hospitalize if unstable, poor f/u, acute risks, older, unable to tolerate PO
Young/middle-aged women who develop severe abdominal pain and have ascites on U/S - dx?
Budd-Chiari Syndrome due to hepatic vein obstruction (from thrombosis); thrombolytic therapy is a treatment option
Treatment considerations for acute hepatitis include?
Supportive - most can be followed with appropriate f/u and supportive measures if mildly symptomatic or asymptomatic; low risk of sig complications or fulminant hepatic failure w/ or w/o treatment
Antiviral therapy - for patients with immunosuppression, concurrent Hep C, severe hepatitis or fulminant hepatic failure
Lamivudine - for severe acute Hep B with impaired synthetic function (prolonged PT)
Treatment for Hep C?
Interferon alfa-2b and ribavirin
Risk of chronic hepatitis after acute Hep B infection? Best prognostic factor?
90% if perinatal transmission; 25-50% if within the first year of life
PT is the best prognostic factor for risk of developing chronic hepatitis. Elevated ALT > 6months also a sign.
Acute vs. Chronic Hep B labs?
Acute = HBsAg, HBeAg, IgM Anti-HBc, > ALT Chronic = HBsAg with Anti-HBe, IgG anti-HBc
Child 6months - 5yrs old with sudden refusal to move arm after a pulling force - dx? Workup? Trmt?
Nursemaid’s elbow (radial head subluxation). No radiographs needed. Hyperpronation and Supination/Flexion = 2 primary reduction methods
Adequate INR level for someone on Warfarin?
INR 2-3
Important complication seen commonly in patients with hip fractures? How to prevent this?
DVT leading to fatal PE. LMWH or low-dose unfractionated heparin with continuation for 10-35 days depending on patient’s risk for thrombosis. It can be stopped 12hrs prior to surgery, low risk of bleeding
Pruritic rash on flexor surfaces typically starting on hands and spreading to abdomen, groin, skin folds, axilla, between fingers and toes - worse at night - excoriations with small, crusted red papules - dx? Workup? Trmt considerations?
Scabies - spread via contact; delayed type IV hypersensitivity to mites, ova, and feces.
Dx confirmed by skin scrapings.
Trmt Goals = mite eradication, decrease pruritis, and oral abx for any signs of secondary bacterial skin infection. If widespread, 5% topical permethrin over whole body; if localized, 1% terbinafine cream. Oral Ivermectin is also a treatment option for outbreaks in groups of people (nursing home). Oral antihistamines can help decrease dermatitis. Clothing/bedding cleaned and bagged for 3 days at minimum - mites cannot survive >3 days without human host.
Pruritic erythematous rash, circular, scaly lesions with central clearing - dx? Workup?
Tinea. Potassium hydroxide staining of skin sample can confirm dx by showing segmented hyphae and arthrospores.
Considerations for the workup of testicular trauma?
Minimal pain/swelling & Normal Exam - supportive care with f/u
Moderate pain/swelling - U/S with f/u, or furthered by findings
Severe pain/swelling and/or Abnormal PE - experienced U/S and expert surgical consultation
Get retrograde urethrography if blood seen at the meatus or if frank blood on urine dip
Screen for what in veterans with new onset insomnia, inadequate pain control, substance use, interpersonal conflicts? Trmt options?
PTSD. Trmt includes CBT and/or anti-depressants. Prazosin for nightmares
Elderly patients having difficulty with discriminating speech in noisy environments - dx?
Presbycusis - sensorineural hearing impairment
Difference in testing considerations b/w suspected active and latent TB?
Active (travel, cough, fever, night sweats, weight loss) - obtain chest imaging; abnormal or high suspicion continue with 3 sputum specimens for AFB and culture.
Latent - PPD or IGRA for patient’s with previous BCG vaccine. These both do not allow differentiation between active and latent
What can be used to tell if TB patient is infectious?
3 negative sputum smears. Patient could still have active TB though, just not infectious. Culture will dictate active TB but emperic therapy can be initiated if high suspicion.
Progressive dysphagia with solid, then liquids, in pt w/ h/o GERD - dx?
Esophageal Stricture - complication from healing process of ulcerative esophagitis in GERD pts.
vs. Achalasia = dysphagia of both solids AND liquids
Tricuspid vegetations, septic pulmonary emboli, systolic murmur increased with inspiration = dx?
Right sided endocarditis secondary to IV drug users. Peripheral manifestations are uncommon in these patients.
Bradykinesia, tremor, rigidity, unilateral onset of symptoms - dx? Trmt considerations?
Parkinsons - dopamine problem.
Initial therapy = dopamine agonists (Bromocriptine, Pramipexole) or Levadopa. However, levadopa can sometimes increase destruction of substantial nigra - begin in patients > 65yrs old with severe symptoms. Entacapone is a COMT inhibitor, helps by prolonging effect of levadopa.
Tremor in both hands/forearms that worsens with fine motor activity = dx? Trmt?
Essential tremor. Propanolol and primidone
Tamoxifen is used for?
Hormone responsive (estrogen +) BC and for the prevention of BC in woman at high risk. Associated w/ endometrial hyperplasia and cancer.
Side effects of the following supplements: Kava kava, Thiazide diuretics, Ginseng, Ginko?
Kava kava - hepatotoxicity, liver failure
Thiazides - hypokalemia, hyponatremia, hyperuricemia, elevated glucose and cholesterol
Ginko - bleeding 2/2 platelet and anticoagulant effects
Ginsing - HA, insomnia, GI symptoms, VB and hypoglycemia
Intracellular Gram-negative diplococci - treatment considerations?
Gonorrhea trmt = Ceftriaxone 250mg IM with concurrent Chlamydia trmt 2/2 coinfection rate. Oral doxycycline 100mg BID x7d or oral Azithromycin 1g single dose for Chalmydia trmt
Additional vaccinations for HIV + patients? Contraindicated vaccines?
Hep A and B unless previously documented immunity. Pneuomona vaccine PCV13 and PPSV23 8 weeks apart and every five years.
Contraindicated: lives vaccines (intranasal influenza - EXCEPTIONS are MMR and varicella zoster IF CD4 >200 and no hx of AIDS defining illness
Side effects of Isoniazid? MC and monitoring? Continuation of therapy?
Self-limited transaminitis, drug-induced lupus, nerve damage/muscle weakness.
MC = hepatotoxicity in 2 months; get baseline and monthly LFT’s
If asymptomatic but LFTs > 5x ULN OR Symptomatic with LFT’s >3x ULN- discontinue. Give B6 to prevent neuropathy.
Asymptomatic hyperuricemia associated with what TB drug?
Pyrazinamide - competes with uric acid excretion in kidneys
Side effect of ethambutol?
Ocular toxicity.
MC’ly responsible for drug-induced lupus (2 agents)?
Procainamide and hydralazine
AIDS patient with hemiparesis, speech/vision/gait disturbances with multiple demyelinating, non-enhancing lesions w/o mass effect, gradual onset - dx?
Progressive Multifocal Leukoencephalopathy - seen in immunocompromised patients via the JC virus - primarily involves cortical white matter. Dx with MRI.
VS. Toxo, CNS lymphoma, brain abscess with are ring-enhancing lesions w/ mass effect
VS. HIV encephalopathy w/ dementia as main sympt; similar MRI findings but bilateral and symmetric
MCC of fecal incontinence in elderly? Trmt?
Fecal impaction. Suppositories for complete emptying.
Would use rectal tube for acute pseudo obstruction resultng in dilated colon and abdominal distention
Trmt for grouped vesicles or bulla in specific unilateral dermatomal pattern with pain after bodily stress? Unresolved pain trmt months later?
Antiviral acyclovir or valacyclovir started within 72 hrs of onset of rash. Results from reactivation of lent infection in dorsal root ganglion.
Post-herpetic neuralgia trmt = amitriptyline (TCA), topical caspaicin, Gabapentin, and long acting oxycodone
Give varicella zoster vaccine s/p infection? Precautions?
If >60 yo, reduces the risk of zoster and post-herpetic neuralgia. If patient is immunocompetent, contact precautions with covering until lesions are completely crusted over 2/2 transmission from direct contact. If immunocompromised, hospitalized.
VS. primary varicella infxn (chickenpox) transmitted by airborne droplets
Vague symptoms like anorexia, decreased activity, irritability, abdominal pain, and insomnia in children should suspect was type of intox? Order what labs?
Lead! CBC, serum Fe, ferritin, reticulocyte count to assess for anemia and iron deficiency.
Possible drugs that could increase Lithium levels? Side effect of Lithium involving constipation and fatigue?
Thiazide diuretics, NSAIDs, ACE.
Lithium-induced hypothyroidism.
Two MC procedure for tattoo removal?
Dermabrasion and laser therapy
Continue anticoagulation for how long s/p initial DVT therapy?
3-6 months. Or lifelong if this is the second one.
D/c RF’s: obesity, smoking, OCP’s, HRT, Tamoxifen
What lab will prompt initiation of antibiotics in setting of Spontaneous Bacterial Peritonitis?
Neutrophil count >250 in the ascitic fluid
What formula used to calculate mortality rate in those with liver disease?
MELD Score = 3.8 (serum bilirubin) + 11.2 (INR) + 9.6(serum creatinine) + 6.4.
95% survival - score 40
Difference b/w breast milk jaundice and breastfeeding failure jaundice?
Breast Milk Jaundice - starts end of 1 week and peaks by 2 weeks; high B-glucuronidase in breast milk deconjugates intestinal bilirubin and thus increased level of unconjugated bili
Breastfeeding Failure Jaundice - bili secondary to decreased bili elimination; ppor latching, occurs first week, baby looks dehydrated
Recent asymmetric oligoarthritis that is inflammatory (elevated WBC’s) but sterile (culture negative) with a recent hx of infection - dx? Workup?
Reactive Arthritis - inflammatory (>2,000 WBC’s) synovial fluid extraarticular symptoms = urethritis, uveitis, circinate balantitis (painless shallow ulcers on glans penis persist for months). Retest for suspected infections even if asymptomatic or no evident signs.
Sources: GI (Salmonella, Shigella, Yersinia, Campylobacter, C Dif) and GU (Chlamydia)
Trmt - Abx and NSAIDS
Describe pathophys for neonatal breast hypertrophy and galactorrhea.
High estrogen crosses placenta in 3rd trimester; s/p delivery, estrogen drop off stimulates fetal prolactin production. Self-limited - 6 months
Episodes of well-circumscribed & raised erythematous plaques - associated intense pruritis - associated with angioedema in 40% - they worsen over minutes to hrs and dissipate within 24 hrs - dx? Trmt? Prog?
Chronic urticaria - from idiopathic stressor or stimulus.
Acute - H1/H2 blocker
Chronic - second generation H1 blocker (Loratadine, Cetirizine)»_space; increase the dose»_space; additional H1 blocker (hydroxyzine), leukotriene receptor antagonist (Montelukast), or H2 blocker (Ranitidine) o brief steroids
Prog - most have complete resolution 2-5 yrs
When to give Oseltamivir in pts with flu?
> 65yrs, pregnant, high risk medical comorbiditis - hospitalized patients or have involvement of lower respiratory tract - if they present within 48hrs of onset
Recent abdominal sx (2-3wks), swinging fevers, leukocytosis, right shoulder tip pain, cough - dx? Workup?
Subphrenic Abscess. Abdominal U/S
Types of hypersensitivity?
Type I - IgE mediated, release of vasoactive mediators from mast cells and basophils (anaphylaxis)
Type II - IgG mediated, antibody attack with complement (autoimmune hemolytic anemia)
Type III - Antibody-complex deposition causing damage (serum sickness, PAN, glomerulonephritis in Hep B)
Type IV - Cell mediated; memory cell activation of macrophages - delayed hypersensitivity (contact dermatitis)
Likelihood ratio of having and not having the disease given a positive/negative result respectively? Formula?
Likelihood ration:
(+) = sensitivity / (1 - specificity)
(-) = (1 - sensitivity) / specificity
Elevated TSH and normal T4 w/o symptoms, dx? Trmt necessary? Workup?
Subclinical hypothyroidism. Treat if: +antithyroid ab’s, abnormal lipid profile, symptomatic, ovulatory/menstrual dysfxn
Workup: get anti-thyroid ab’s; only get U/S if abnormal PE finding
How to calculate RR when only one relation is known?
If you know the RR of A compared to B = x, then the RR of B compared to A = 1/x
Saw palmetto = alternative med trmt for? St. John’s wort? OA? Garlic?
Saw palmetto - BPH
St. John’s Wort - anxiety/depression
Garlic - hypercholesterolemia
Glucosamine and Chondoitin = OA
Popular alternative meds with increased bleeding risk?
Ginko biloba, saw palmetto, ginseng, black cohosh, and garlic
St John’s Wort side effects?
GI distress, dizziness, fatigue, photosensitivity, and dry mouth
2 MCC of diaphragmatic paralysis in the newborn = ?
Birth injury and cardiothoracic injury causing damage to phrenic nerve
Strongest known risk factor for male BC?
Klinefelter Syndrome = 47 XXY, resultant hypogonadism, low T, and gynecomastia
CVS sampling best done at what GA? why?
> 11 wks GA 2/2 lowest risk for limb reduction anomaly
Neurologic symptoms that vary in time and space with intermittent recovery - common symptom = optic neuritis (monocular vision loss and eye pain w/ movmt) - dx? Best test? If atypical, helpful test?
Multiple Sclerosis. MRI shows ovoid periventricular white matter lesions. If unsure, LP will show elevated oligoclonal bands and elevated IgG index.
MS patients can also develop transverse myelitis = UMN signs and sensory deficits below the level of the lesion
Trmt considerations for MS?
Acute exacerbation = IV/Oral Corticosteroids
If optic neuritis involved, IV route b/c increased risk of recurrence with PO steroids
Refractory to glucocorticoids = plasmapharesis
Maintenance = disease-modifying = beta-interferon and glatiramer acetate are indicated for chronic maintenance in relapsing-remitting MS
Treated similarly in pregnancy - higher rate of assisted deliveries
Management of MS comorbidities? Depression, fatigue, muscle spasticity, neuropathic pain, urge incontinence…
Depression - SSRI’s
Spasticity - Baclofen, massage
Fatigue - Amantadine
Neuropathic pain - Gabapentin or duloxetine
Urge Incontinence - Oxybutynin, timed voiding
Diagnostic considerations for Allergic Bronchopulmonary Aspergillosis? Presentation? Trmt and monitoring?
Hx of Asthma, + skin test reactivity to Aspergillus, + serum Ab’s, serum IgE concentration > 1000, eosinophilia, bilateral upper lobe infiltrates, central bronchiectasis.
Intense IgE and IgG response in asthmatic patients with ABPA causes fever, malaise, cough w/ brown expectorant, wheezing, and signs of bronchial obstruction
Treat with oral steroids (NOT inhaled) - follow serum IgE concentration and clinical symptoms for improvement
3 considerations to help distinguish cause of hypoglycemia?
Serum insulin, C-peptide, and hypoglycemic drug assay:
- insulinoma will have negative drug assay; U/S or CT to investigate (or 72hr fasting challenge)
- exogenous insulin will have negative c-peptide and assay
- exogenous hypoglycemia agent will have + assay
Considerations for giving tetanus rx’s w/ injuries?
If the patient’s hx is good (has >3 immunizations):
- minor/clean cut: only give tetanus toxoid IF last shot was >10 yrs ago
- major/dirty cut: only give tetanus toxoid IF last shot was > 5 yrs ago
If the pt’s hx is bad (
Proximal symmetric muscle weakness in upper/lower extremities, Gottron’s papules, heliotrope rash, ILD, dysphagia, myocarditis = dx? Work up? Trmt?
Dermatomyositis. Elevated CPK, Anti-RNP, Anti-Jo-1, Anti-Mi2 (EMG and muscle biopsy if uncertain)
Trmt = high dose glucocorticoids + glucocorticoid-sparing agent
** Screen for malignancy ** Adenocarcinoma of cervix, ovaries, pancreas, bladder, lung, stomach
Mostly seen in women, 30-65 yo, with milady elevated LFT’s with elevated Alk Phos, itching - dx? Tests? Trmt? Screen for what complication?
Primary Biliary Cirrhosis - autoimmune problem of small to mid-sized bile ducts - causing progressive fibrosis, ESLD
Antimitochondrial Ab’s (AMA) = high sensitivity and specificity; diagnostic confirmation requires liver bx
Can see xanthelasma from elevated LDL and hypercholesterolemia
Trmt = ursodeoxycholic acid / transplant
Complication = Osteoporosis via bone densitometry 2/2 malabsorption of fat soluble vitamins A, D, E, K
Anti-smooth muscle Ab’s association = ?
Type 1 Autoimmune Hepatitis
Liver disease, skin hyper pigmentation, DM, arthropathy, cardiac involvement, and hypogonadism - dx? Abnormal lab profile?
Hemochromotosis - abnormal deposition of Fe. Elevated LFT’s > Alk Phos
Treatment for patients that have white/blue discolored fingers in the cold? Additional workup?
Dihydropyridine Ca-channel blockers (nifedipine/amlodipine) and diltiazem; nitroglycerin in refractory pts
Workup with ANA, RF, CBC, blood chem, UA and complement levels in pts with systemic manifestations
How can an infant get botulism? Trmt considerations?
Infant vs. Foodborne Botulism via ingestion of Clostridium Botulinum spores from environmental dust vs. performed c. botulinum toxin with canned foods.
Human-derived botulism Immune Globulin vs. Equine-derived botulism antitoxin
Toxin inhibits presynaptic release of cholinergic transmission. It can predominate in infant GI flora b/c still developing flora.
Higher in CA, PA, UT - disturbed soil (farming/construction)
Most infants require hospitalization for 1-3 months with complete recovery
HIV rxs in pregnancy?
HAART - 2NRTI’s (Zidovudine and Lamivudine) + 1 protease inhibitor or NNRTI; Efavirenz is preferred after 8th wk gestation b/c risk of NT, cleft lip, anopthalmia. However, DONT CHANGE AN EFFECTIVE REGIMEN IF THE PATIENT STARTED IT ALREADY - risk of transmission from changing a regimen outweighs risk of teratogenicity. Reduces rate of transmission from 25% to 2%
Delivery considerations with HIV+ its?
C/S if VL> 1,000. UD viral load and complaint with HARRT can have vaginal delivery
Reasons to not BF?
HIV infection (unless in developing country), active TB (can start after 2 wks s/p trmt initiation), herpetic breast lesions, Varicella infxn
Causes of acquired long QT Syndrome?
Bradyarrhythmias = MCC of Torsades
Meds: diuretics (electrolyte imbalance), antipsychotics, tricyclic antidepressants, antiarrhythmics (amiodarone, sotalol, flecainide), anti-infective drugs (macrolides, fluoroquinolones
Other: hypothermia, hit, MI
% correlations for std deviations 1, 2, and 3?
68%, 95%, 99.7%
Risk factors for invasive aspergillosis? Presents with?
Allogenic transplantation, older age, acute graft-vs-host disease and corticosteroid therapy. Fever, sinus symptoms, and pulmonary complaints
Formula for NNT?
1/ARR = NNT
ARR = percentage of relapse/disease in treated group subtracted from placebo group
Common side effects of:
1) CCB’s
2) ACEi’s
3) HCTZ
1) Lower extremity edema 2/2 precapillary vasodilatation (25% with DHP’s like Amlodipine/Nifedipine in 6mo’s of therapy); headache, flushing, dizziness
2) Angioedema (0.1-0.7%)
3) Hyponatremia, hypokalemia, renal failure, hyperuricemia (acute gout),. and elevated glucose and lipid levels
What is Type II Polyglandular Autoimmune Failure?
Addison’s disease w/ Type 1 DM
Considerations for breast mass work up?
- Spontaneous, unilateral, and bloody = concerning and warrants work up with mammo (MCC of pathologic nipple discharge = papillary tumor)
- Bilateral milky white discharge should first be assessed with prolactin levels 2/2 hyperprolactinemeia from prolactinoma, medications (antipsychotics), hypothyroidism, and pregnancy
RF for developing reactive arthritis?
HLA-B27 positive with gram-negative rods
Athletic women with secondary ammenorrhea have low levels of what three hormones?
GnRH, LH, and estrogen
Common causes of recurrent sinusitis?
Smoke exposure (via damage to cilia), inadequately treated acute sinusitis. structural abnormalities of palate or septum, and allergic rhinitis
Monitor what value to reassess asthmatics in ED? Considerations?
PEF:
- > 70% and no distress = good to d/c
- 40-69% = admit to hospital ward
- 42 and severe signs = admit to ICU
Treatment of syphylis by stage?
- Primary, Secondary, Early Latent (12 months), unknown, gummatous/CV sylph = Benzathine PCN 2.4M IM weekly x 3 wks
- Neurosyph = Aqueos PCN 3-4M IV q4hrs for 14 days
- Congenital Syph = Aqueos PCN 50,000units/kg IV q 8-12hrs for 10 days
Rxn developing within 24hrs after initiation of treatment for spirochetal infxn = dx? Prevention?
Jarisch-Herxheimer Rxn - no prevention. constituted by fever + malaise/chills/HA/myalgias
RF’s for Lithium toxicity? Levels? Presents?
Low GFR (elderly, renal pts), volume depletion, drug interactions (thiazide diuretics, ACEi’s, NSAIDs)
Sympt = confusion, ataxia, neuromuscular excitability (tremor), N/V/D
Trmt = Lithium levels q2hrs, IV hydration, hemodialysis
Pathophys for:
- Toxic Shock Syndrome
- Bacterial Endocarditis
- Septic Shock
- TSS = (MCC Staph Aureus) exotoxin (TSS toxin-1) causes widespread activation of T cells, acting like super antigens - leading to massive cytokine production
- Endocarditis = bacterial overgrowth and dissemination
- Septic Shock = massive bacterial lysis and subsequent circulating endotoxin
Treatment of Toxis Shock Syndrome =
Fluid replacement (up to 20L/day), Clindamycin theoretically prevents toxin synthesis, and Antistaph antimicrobial therapy (vancomycin, oxacillin or nafcillin)
Frequency of UTI’s to start prophylaxis? Meds?
2 in six months or 3 in 1yr
Bactrim, fluoroquinolones, and Nitrofurantoin
What thionamide rx’s to use in pregnancy and at what GA? Why?
Propylthiouracil (PTU) - risk of liver disease - use in 1st trimester
Methimazole (MMI) - teratogenicity - use in 2nd/3rd trimester
Whipple’s triad confirming true hypoglycemia?
1) low BG 2) symptomatic 3) relief of symptoms with glucose
Advice for hypoglycemia during exercise for diabetics with insulin reqmt?
Exercise increases insulin uptake by exercising muscles so avoid injections into exercising limbs, can try snack before exercising, and decrease prior dosage. Check BG before and after exercising
Different presentation of Giardia based on acuity? Trmt and prevention?
Asymptomatic - shed cysts for 6 months
Acute - diarrhea, steatorrhea, flatulence, N, F, weight loss
Trmt - not for asymptomatic; if symptomatic, use Metronidazole, nitazoxanide, or tinidazole.
Prevent by contact isolation and hand hygiene
What’s a positive apnea test?
Can confirm brain death: absent respiratory response off the vent for 8-10 minutes with a PaCO2 >60mmHg and a final aerial pH
Symptoms of B12 def? Complication with hematologic phenomena?
Dementia, subacute combined degeneration, dorsal spinal column probs (loss of vibratory sense, + Romberg test) and lateral corticospinal tract abnormalities (spastic paresis, hyperreflexia)
Secondary to poor DNA synth in RBC’s, they mature improperly and are megaloblastic, eventually lysing in the bone marrow and causing indirect hyperbili (can see decreased haptoglobin, elevated LDH)
Difference b/w nightmare d/o and night terrors?
Night terrors = non-REM poor/little recollection
Nightmare D/O = REM stage d/o and child has vivid dream recall
Symptoms of carbon monoxide poisoning and lab?
Multiple people having fatigue, malaise, throbbing HA’s, nausea. Get a carboxyhemoglobin
Knee pain, decreased ROM, skin changes, and vasomotor changes (skin color changes) after a recent injury = dx? Trmt? Pathogenies?
Complex Regional Pain Syndrome.
Patho = nerve injury causing increased sensitivity to sympathetic nerves, abnormal response to and sensation of pain, and increased neuropeptide release causing allodynia
Presentation of HSV encephalitis?
Hemorrhagic infarction of the temporal love with elevated RBC on CSF analysis
Patients are at risk for what who have history of chronic lymphocytic infiltration of the thyroid? Presentation? What PE test?
Hashimotos is a RF for Thyroid lymphoma. Rapid and acute swelling of thyroid area. Pemberton’s test = raising hands over head and + if patient becomes plethoric, indicating thyroid is the cause of obstructive symptoms.
A1c goal range for DM2?
6-7%
Contraindication to HPV vaccine?
Hypersensitivty to yeast
RF’s for intussusception? Presentation? Dx and trmt?
Recent viral illness or rotavirus vaccination, polyps, tumors, HSP, celiac disease, meckels. Occurs 6mo - 3yr. Episodic crampy abdominal pain, sausage mass, currant jelly stools. Target sign on U/S = clue. Don’t need imaging if clear dx from presentation - use air or water soluble enema.
Distinguishing characteristics and labs of CAH types? Trmt?
21-hydroxylase = ambiguous genitalia in girls, hypotension, hypoglycemia 2/2 increased testosterone (shunted products), decreased cortisol and aldosterone causing hypoglycemia, hyperkalemia, hyponatremia. See elevated 17-hydroxyprogesterone. = MC type of CAH. Give glucocorticoids and mineralocorticoids
11B-hydroxylase = HTN
17a-hydroxylase = HTN
Findings in gout arthro? vs. pseudogout?
Monosodium urate crystals = negatively birefringent, needle shaped crystals under polarizing light (yellow)
Pseudogout = positively birefringent rhomboid shaped crystals (blue) CPPD crystals (calcium pyrophosphate dihydrate); more likely to present in RA or OA - MC’ly seen in knees
Trmt considerations in gout?
NSAIDS (Indomethicin) - contra = AKI/CKD, CHF, PUD, Anticoagulation
Colchicine - contra = severe or liver disease
Intraarticular steroids - contra = >2 joints involved
Types of common causes of male urethritis? Trmt considerations?
Gonorrhea - purulent, gram negative rods
Chlamydia - PCR, give azithro
Trich - metronidazole
Mycoplasma Genitalium - covered by azithro
Ureaplasma - covered by azithro
Differential for moving paralysis?
Tick paralysis - normal CSF, occurs hours to days (remove tick)
GBS - days to weeks, elevated CSF protein w/ normal WBC (IV immunoglobulin or plasmapharesis)
Myasthenia gravis - not ascending paralysis, end of day onset (acetyl cholinesterase inhibitors)
Botulism - descending paralysis
Side effects of amiodarone?
Thyroid dysfunction, corneal deposits, skin discolorations, pulmonary fibrosis, and liver toxicity
When do you give prophylactic acyclovir to pregnant patients?
At 36wks GA if they have hx of HSV; c/s if active at term.
If no hx but exposed, type specific antibody testing for HSV1/2 is appropriate to determine infections; if negative nothing is needed, but if + can begin prophylactic trmt at 36 wks
MCC of malignant otitis media? Trmt options?
Pseudomonas
Fluoroquinolones = cipro
PCN’s - Piperacillin, Ticarcillin
3rd Gen Cephalosporins = Ceftazidime
Should start trmt IV then switch to PO
What is Ramsay Hunt Syndrome?
Reactivated zoster virus causing ear pain, vesicles in external auditory canal and ipsilateral facial paralysis
Characteristics of: NF1, NF2, Tuberous Sclerosis, Sturge Weber Syndrome, Osler Rendu Weber?
NF1 - unilateral acoustic neuromas, cutaneous neurofibromas, axillary freckling, hyperpigmented cafe-au-lait spots
NF2 - hypo pigmented spots, hx of bilateral deafness from bilateral acoustic neuromas
SW - facial port wine and leptomeningeal angiomatosis
TS - congenital hypopigmented maculae (ash leaf), glial proliferation, and several organ hamartomas/cysts
ORW - multiple telangiectasias and vascular lesions of CNS
Common type of PTHrP releasing malignancy?
Squamous Cell Carcinoma
Describe Hand-Foot-Mouth Disease. Cause?
Exanthem can be on palms, soles, genitalia, and/or buttocks with herpangina (vesicles on posterior oropharynx). Caused by Group A Coxsackievirus
Intoxication causing: confusion, lethargy, bradycardia, skin flushing, miosis, wheezing, garlic like odor?
Organophosphate poisoning. Test with RBC cholinesterase
Treatment of ACS?
MONA HABS Clopidogrel - Morphine, Oxygen, Nitrates, Aspirin, Heparin, B-blockers, Statin, Clopidogrel
- 2 antiplatelet therapies = aspirin and clopidogrel
Risk factors for elder abuse?
Female gender, mental/physical illness, and old age.
Factors protected by confidentiality in minors:
pregnancy, contraception, substance use, STD’s, psych illness - UNLESS they become a danger to themselves
Molluscum contagiousum is caused by what virus? spread? Suspect any additional infections?
Poxvirus - skin to skin contact. Test for HIV if these are widespread and/or involve the face
How to treat chlamydia in pregnancy?
Erythromycin base 500mg PO QD x7days
Amoxicillin 500mg PO TID x7days
Nonpregnant: azithromycin 1g PO, doxycycline 100mg BID x7days
Non-SSRI antidepressant options for people with sexual dysfunction on SSRI’s?
Bupropion or Mirtazapine; can consider adding sildenafil (phosphodiesterase-5 inhibitor)
Dx for decreased sensation over the anterolateral thigh without any muscle weakness or DTR abnormalities - hx of chronic flexion at waist? Nerve involved?
Meralgia paresthetica - entrapment of lateral femoral cutaneous nerve (purely sensory, direct branch from lumbar plexus runs under inguinal ligament)
T-scores for assessing bone mineral density? via DEXA. When to add rx’s?
above - 1 = normal
-1 to -2.5 = osteopenia
below -2.5 = osteoporosis
Pharm therapy with T less than -2.5 or those with fragility fractures (hip/vertebral fractures from low-trauma) = bisphosphonates generally 1st line (Alendronate decreases bone resorption) + 1200mg/day elemental calcium and 800IU/day Vitamin D
Episodic HA, young age htn, refractory htn, adrenal mass, sweating, tachycardia = screen for? Via? If elevated next steps?
Pheochromocytoma with plasma free metanephrine levels or 24-hr urine collection for catecholamine and metanephrine
If elevated: CT/MRI of abdomen and surgical veal, genetic testing, alpha (maybe beta) blockade w/ phenoxybenzamine prior to surgery, MIBG (functional scintigraphy w/ norepi-like substance) scan if >5cm. Surgery only after 10-14 days of BP control, IV fluids.
If elevated and negative imaging, get MIBG to assess for undetected tumors
Complications with pheochromocytoma surgery and how to handle them?
1) HTN Crisis - IV nitroprusside, phentolamine, or nicardipine
2) Hypotension - normal saline bolus, pressers if unresponsive
3) Hypoglycemia - IV dextrose
4) Cardiac tachyarrhythmias - IV lidocaine or esmolol
Cardiac resynchronization w/ biventricular pacing device is recommended in pts w/: ???
Sinus rhythm and: severe LVSD w/ EF 150msec)
Next step in pulseless electrical activity? What rhythms are shockable? Cardiovert?
CPR. Defibrillate someone with Vfib or pulseless Vtach. Can cardiovert with unstable tachycardia (has pulse still)
Indications for IVC filter? Acute/longterm risks?
Indicated in those who have contraindications to anticoagulation (recent surgery, hemorrhagic stroke, bleeding prob, active bleeding). Acute probs = insertion site thrombosis, hematoma, AV fistula. Chronic probs = recurrent DVTs (stops them from traveling but not their recurrence)
Hyperglycemia, metabolic acidosis, + ketones = dx? Important formula? Therapy algorithm.
DKA - Anion Gap = (Na - [Cl + HCO3-]), normal = 7-13.
Initially, IV fluid support with continuous IV insulin (be wary of hypokalemia); add to K to fluids if K 135.
Insulin: switch to SQ when patient can eat, glucose 15. Overlap SQ and IV by 1-2hrs
Bicarb: if pH
What to start in asthmatic exacerbation?
Immediate O2 > inhaled B2 agonist > systemic IV steroids
Life threatening exacerbations, IV Magnesium
MC type of bias in case-control studies?
Recall bias - those with disease more likely to report exposure.
Unilateral HA’s occuring 1-3x daily, lasts 30min - 3hrs, severe retroorbital pain, lacrimation, conjunctival injection, rhinorrhea, sweating, and pallor occurring for 4-8 wks at a time = dx? Prevention? Abortifactant?
Cluster HA. Verapamil can be used for prevention with duration of HA’s longer than two months (Lithium if refractory). Can use prednisone if expected use is
When to use injection sclerotherapy for varicose veins?
Failed 3-6 months of conservative treatment. Try conservative measures first: leg elevation, wt loss, compression stockings (don’t use if they have underlying arterial insufficiency)
Hemodynamic measurements of heart?
R Atrial P = 4 PCWP (L atrial surrogate) = 9 Cardiac Index (pump fxn) = 2.8-4.2 SVR = 1150
Septic shock has low SVR and increased CO = differentiates this from cardiogenic and hypovolemic causes. While increased R atrial and PCWP are increased in cardiogenic secondary to back up.
3 criteria for Lewy Body Disease? Trmt?
Cognitive FLUCTUATIONS, visual hallucinations, and parkinsonism. Mix of Alzheimers and Parkinsons.
Trmt = cholinesterase inhibitors (AD) and levadopa and dopamine agonists (PD)
Dx: disinhibition, personality changes, extremem agitation, and urinary incontinence?
Frontotemporal dementia - occurs in 50’s.
Urge to move legs and is exacerbated with inactivity, relieved with movement = dx? Other causes? Trmt?
Restless leg syndrome. Secondary causes = iron deficiency anemia, uremia, DM, MS, pregnancy, antidepressants.
Trmt - start with iron if ferritin low
Diagnostic criteria for acute pancreatitis? Workup for etiology? Complication if the patient deteriorates days later with supportive care?
Classical symptoms of abdominal pain radiating to the back with elevated amylase and lipase (more specific). CT not absolutely necessary.
Alcohol is leading cause; can order U/S if suspecting gallstones, LFT’s, Calcium, or lipid panel for hypertriglyceridemia
Pancreatic necrosis can cause SIRS.
Treat this first in AF?
Rate control with beta blockers.
What is the Standardized Incidence Ratio?
Used to see if the incidence is higher in a particular group in relation to larger population = Observed Cases / Expected Cases
Treatment for Hidradenitis Suppurativa?
RFs = hx of HS, obesity, smoking, skin stress
Topical Clindamycin or oral antibiotics for flare up in those with initial; solitary lesion
Abscess formation and purulent sinus tracts oral tetracyclines are preferred (Doxy)
Diffuse tracts and severe disease = infliximab (tnf alpha inhibitors), surgical excision
HIV testing timeline after exposure? How often to check CD4 and VL in confirmed cases?
Using ELISA (HIV RNA PCR) or test for p24 antigen at 6, 12, and 24wks. Check every 3-4months
Considerations for who to take to the cath lab?
Take STEMI patients immediately. Take NSTEMI in 24-48 hrs (differentiated from unstable angina with elevated troponins). Cardiac enzymes might not rise for 6 hrs!!!! Need to monitor! Stress test those after r/o acute MI
Periarticular erosions, elevated RF levels, symmetric swelling and mild hyperemia of the proximal small hand joints, wrists and knees = dx? Treatment considerations?
RA. Start with methotrexate; if refractory to this + steroids for 6 months, can use infliximab or etanercept (get TB testing first!!!!); if refractory can try hydroxychloroquine, methotrexate, and sulfasalzine OR switching to cyclosporine
MCC of hemoptysis? Trmt?
Acute bronchitis; antibiotics
Window of time for tPA? Considerations prior to therapy?
Given less than 3-4.5hrs after the onset of symptoms. Assess for: active internal bleeding, platelets 185/110
Recurrent lapses into sleep, napping multiple times in day at least 3x/wk for 3 months with cataplexy by trigger, REM sleep latency
Narcolepsy. Get a polysomnography. Modafenil.
Can also use SNRI (Venlafaxine) or SSRI, or TCA if refractory treatment with cataplexy specifically.
Protective factors in SI?
Social support/family connectedness, Pregnancy, Parenthood, Religion
How to decide when to treat strep?
CENTOR Criteria: tonsillar exudates, anterior cervical lymphadenopathy, fever, absence of cough.
If 1 or less = treat symptoms
If 2 = get rapid strep test
If 3 or more = 50% PPV for strep
Elevated glucose levels without ketones in a DM2 patient = dx? Start by giving?
Hyperosmolar hyperglycemic state - FLUIDS (8-10L behind)
Pathophys for pernicious anemia? What to monitor after starting B12 in patients?
Atrophic gastritis secondary to autoimmune destruction of parietal cells, leading to achlorhydria, and decreased production of intrinsic factor. This causes less binding of B12 which then cannot be taken to terminal ileum for absorption.
Monitor K because sudden uptake of K for newly formed RBC’s can be life threatening.
Acromegaly long term risks?
Cardiac disease!!! DM, respiratory probs, increased colon cancer risk.
Screen for what in patients with short stature, hypogonadism, short 4th metacarpal bones, multiple nuchal folds, large carrying angles, 45 XO ? Dx?
Turner Syndrome - screen for cardiac probs with echo (coarctation, bicuspid aortic valve, MVP, hypo plastic heart), renal U/S (horseshoe kidney) , TSH 9hypothyroidism), and hearing test.
Work through diagnostics of delayed gastric emptying?
Could be from obstruction (internal/external) or impaired motility. R/o obstruction first with upper GI endoscopy, then consider CT ONLY if suspicious of external compression after non diagnostic endoscopy. Then consider scintigraphic gastric emptying study.
GI Motility agents?
Erythromycin and Metoclopromide.
Adolescents are at increased risk of what in pregnancy compared to those 20-24yrs?
perinatal mortality, preterm delivery, premature, and LBW infants
Indications for lung cancer screening?
Age 55-80 with 30 pack yr hx of smoking and still smoking OR recently suit within 15 yrs.
Increased incidence in spring/summer of skin infection with multiple, coalescing, small circular maculae that vary in color (white, pink, or brown); asymptomatic, seen on upper trunk, arm, neck, and abdomen = dx? Trmt?
Tinea Versicolor - organism prevents pigment tranfer to keratinocytes and makes affected skin paler than unaffected tanned skin.
Trmt = topical ketoconazole/terbinafine/clotrimazole/selenium sulfide
Seborrheic Dermatitis = looks like?
Inflammatory d/o with erythematous patches with oily scales, where there are many sebaceous glands
Glascow score
Intubate
Kids with fever, chills, flank/suprapubic pain = dx? Trmt considerations? Imaging?
Pyelonephritis. Oral cephalosporins are first line UNLESS patient is vomitting, failed oral abx before, or are hemodynamically unstable, or had positive blood culture.
If failing all antibiotics, renal U/S to assess for renal or perinephric abscess. Can also work up in kids
RF’s for constipation in children? Look for? Complications? Trmt?
RF’s = starting solid foods, cow’s milk, toilet training, school entry
Straining with BM, pellet stool, 2days s/p delivery
Complications = anal fissures, hemorrhoids, encopresis, UTI’s, vomiting, laxative, suppositories
Trmt - increased fiber, limit cows milk,.
Preexcitation syndrome w/ an accessory pathway resulting in a shortened PR interval (delta wave), widened QRS (> 0.12) = dx? Likely caused by? Trmt?
Wolff-Parkinson-White Syndrome - tachyarrhythmia. If symptomatic, catheter ablation recommended; controversial for those asymptomatic.
Atrial fib is especially dangerous because it can precipitate vfib in these patients.
MCC of SAH? Workup considerations?
Ruptured saccular aneurysm. Noncontrast Head CT = first choice. Lumbar puncture is required to exclude SAH.
+CSF = elevated openning pressure, xanthochromia, elevated RBCs in 4 tubes of CSF (if the RBC’s decrease in 4 subsequent tubes, it’s a traumatic tap)
Side effects of Nicotinic Acid?
Can lower triglyceride level but has Seffx: flushing, pruritus, and hepatotoxicity.
Rx’s for Triglycerides > 500 or
Fibrate (gemfibrozil) for >500; statin or Nicotnic Acid for
Who’s at risk for developing toxic megacolon early in their disease? Signs/symptoms? Mgmt considerations?
Those with IBD. 6cm dilated traverse colon, multiple air-fluid levels, loss of austral markings, pneumoperitoneum if perforated. Peritonitis signs may be absent!!! Patient look toxic (fever, tachycardia, “dry”).
Try medical mgmt first: fluids, abx, bowel rest, NG tube. Start steroids IF the underlying reason isn’t for infectious etiologies. AVOID ANTICHOLINERGICS AND OPIATES
Emotional/orthostatic stress (venipuncture, prolonged standing, heat exposure, exertion)
Vasovagal syncope. Clinical dx, only do tilt table if unclear dx.
Long term risks with PPI’s?
Osteoporosis/hip fracture (2/2 decreased Ca absorption, inhibits ocsteoclastic activity, reduces bone mineral density); higher risk of infections (C Diff), hypomagnesemia, interstitial nephritis, and decreased absorption of Vitamin B12 and Fe.
60% of head and neck cancers are locally advanced at time of diagnosis; what treatment modalities should be considered?
Combined chemo and radiotherapy.
List manifestations of Sarcoidosis. Pathophys of hypercalcemia?
Formation of non-caseating granulomas in lymph nodes and organs causes: bilateral hilar adenoapthy, interstitial;infiltrates, anterior uveitis, posterior uveitis, peripheral lymphadenopathy, hepatomegaly, splenomegaly, acute polyarthritis, central DI, hypercalcemia, maculopapular rash, nodular lesions, erythema nodosum
erythema nodosum, hilar adenoapthy, migratory polyarthralgias, fever = Lofgren’s Syndrome
Macrophages in sarcoid granulomas make 1-alpha-hydroxylase coverting 25-hydroxyvitamin D to 1, 25-dihydroxyvitamin D leading to increased absorption of Ca (see elevated Ca in urine with decreased serum PTH)
Give steroids to bring down Ca levels
Tremor presenting in upper distal extremities, more pronounced with outstretched arms, increases at end of activity = dx? rx? inheritance?
Familial tremor or benign essential tremor. Autosomal dominant inheritance. Can give beta-blockers
Acute PAINLESS monocular vision loss ddx?
Central Retinal Artery Occlusion - MCC = carotid atherosclerosis - lower intraocular pressure FAST with massage, anterior chamber paracentesis, IV acetazolamide, or mannitol. Cherry red spot and surrounding pallor
Central Retinal Vein Occlusion - likely non-embolic cause. Tortuous dilated veins, diffuse hemorrhages, disk swelling, and cotton wool spots. “flame storm”
Acute loss of vision with severe eye pain, injected conjunctiva, poorly reactive but dilated pupil, HA, N/V = dx?
acute angle-closure glaucoma
What are patients at risk for with TURP therapy?
Dry ejaculate 2/2 bladder neck failing to close after the procedure which enables sperm to flow backward to the bladder. (70% incidence)
Amiodarone’s effect on thyroid functions include:…
Can decrease peripheral conversion of T4 to T3 with minimal change in TSH = f/u
If it induces frank hypothyroidism, treat with levothyroxine
If it causes thyrotoxicosis, give steroids
RR and tidal volume correlate with = ? This is changed to regulate what ? Fi02 and PEEP are used to regulate what?
Ventilation - affects CO2
P02 - increasing PEEP can worsen hypotension by reducing preload and can recruit non-functioning alveoli with resultant barotrauma.
How do glucocorticoids cause bone loss and low Ca?
They decrease Ca gut absorption, cause renal Ca wasting, and have direct anti-anabolic effect on the bone. They suppress GnRH which can lead to hypogonadism and aggravate bone loss
Appearance of sporotrichosis? Trmt?
Ulcerates with non-purulent d/c and similar lesions forming along lymphatic tract. Trmt = itraconazole for 3-6months
Actinomysis RF’s?
Gingivitis, dental caries, extraction, and oromaxillofacial trauma. Chronic slow growing mass evolving into multiple abscesses, fistulae, and draining sinus tracts with thick yellow or serrous d/c
Tests to see if appropriate Rhogham given?
Rosette test = qualitative test to determine presence of feto-maternal hemorrhage. If negative, standard dose given. If positive, evaluate with Kleihaur-Betke stain or fetal red cell stain using flow cytometry
What’s the MCC of postoperative hypoxemia in post-op patient with recent thoracoabdominal sx occurring around 2-5 days?
Atelectasis - secondary to splinting, retained secretions, and diminished lung compliance. Obesity and OSA = RF’s
Differentiate nonallergic rhinitis and allergic rhinitis. Trmt?
NAR = nasal congestion, rhinorrhea, post nasal drip, no obvious trigger, develops later in life, erythematous nasal mucosa - intranasal glucocorticoids (fluticasone) or antihistamine (azelastine)
AR = watery rhinorrhea, sneezing, eye symptoms predominate, earlier age of onset, identifiable allergen, pal/bluish nasal mucosa, associated with other allergic d/o - intranasal glucocorticoids and antihistamines
Presentation for cardiac tamponade?
JVD, hypotension, diminished heart sounds, pulses paradoxus (drop in SBP > 10mmHg with inspiration), electrical alternans, right atrial and ventricular collapse during diastole
New onset DM, arthropathy in 2nd 3rd metacarpophalangeal joints, morning stiffness, decreased libido, hepatomegaly, subchondral cysts, sclerosis, osteopenia and hook like osteophytes on xray = dx? labs?
Hemachromatosis. Presents b/w 50-60 normally. Common for there to be CPPD crystals in joint. Get transferrin saturation, serum iron, and ferritin levels
Problem adducting the leg and sensory loss of small area in medial thigh?
Obturator neuropath - pelvic trauma or surgery
Inability to extend knee, loss of knee jerk reflexes, and sensory loss over anterior and medial aspects of the thigh, medial aspect of shin, and arch of foot = ?
Femoral nerve injury.
Problem with foot drop and weakness in foot dorsiflexion and eversion, paresthesias over dorsum of the foot and lateral shin = ?
Common personal nerve injury
Common complication of CABG, develops after pericardial effusion, develop peripheral edema, ascites, hepatic congestion with hepatomegaly, elevated JP, hepatojugular reflux, Kussmauls sign (lack of decrease in JVP with inspiration) and pericardial knock = dx? trmt?
constrictive pericarditis - antiinflammatory agents and pericardiectomy.
Modifiable RF’s for ischemic stroke?
HTN (most important), DM, smoking, and dyslipidemia
Common causative bugs in acute otitis media?
Strep Pna, H. Influe, and Moraxella Catarrhalis
Match it’s associated autoimmune d/o:
1) Ant-dsDNA
2) Anti-Centromere
3) Anti-Smith
4) Anti-Ro/SSA
1) SLE - anti dsDNA also helpful in following course of disease
2) CREST
3) SLE (less than dsDNA)
4) Sjogrens
Lupus treatment considerations:
Prednisone-cyclophosphamide = serious lupus manifestations (lupus nephritis, CNS or vasculitic manifestations)
Methotrexate-prednison = significant organ involvement with had incomplete response to prednisone alone
Hydroxychloroquine-prednisone = arthralgias, serositis, and cutaneous symptoms
Dermatitis herpetiformis = what presentation? association?
Associated with Celiac disease, and has pruritic vesicles and papules on elbows, knees, lower back, and buttocks
Human bites tend to have = infection type? Trmt?
Polymicrobial infections. Associated with alpha-hemolytic streptococci, step aureus, and anaerobic bacteria, Eikenella corrodes. Primary closure should be avoided. Start antibiotics and consider tetanus booster
Trmt = Oral amoxacillin/Clavulanate
Abnormal deposition of collagen in multiple organ systems associated with GERD, and Raynauds= dx? Dangerous effect on kidneys? Trmt for this complication?
Systemic Scleroderma - malignant htn can result!!! ACEi and IV nitroprusside
Meds for Strep Pharyngitis? Helps prevent ______ but not ______.
Oral PCN x 10 days; single IM PCN if cannot tolerate PO. 5 day course of Azithromycin is acceptable for PCN allergic patients
Prevents Rheumatic Fever but not post-strep glomerulonephritis (1-3wks s/p infxn)
Mesenteric ischemia MCC = ? from ?
Thrombus/emoblism from superior mesenteric artery
Papillary/follicular thyroid cancer surgery decision based on?
Neck U/S and LN biopsy - lobectomy for 1cm and/or tumor extension, multi-node involvement, mets
When to give joint injections for gout?
Contraindiciations to NSAIDS (bleeding, renal failure)
MCC’s of demyelinating ascending polyneuropathy = ? Monitor what?
Campylobacter jejuni, CMV, EBV, HSV. Monitor vital capacity!
ADPKD BP range and when to screen for berry aneurysms? MCC extra renal manifestation? How to screen asymptomatic family members?
BP
When to test for H Pylori?
Dyspepsia (abd fullness or pain w/o heartburn) - test if 55yo use endoscopy to r/o malignancy
Septate uterus has problem with _____ but not _____?
miscarriages, not implantation; abnormal blood flow to septate causes recurrent miscarriages. Treat with hysteroscopic metroplasty
Red, painful, sharply demarcated, edematous, elevated - MC on lower extremities but if seen on the face is butterfly distribution - has systemic symptoms like fever, chills, malaise - dx? Etiology?
Erysipelas secondary to Group-A Streptococcus
When to draw labs for lead poisoning? Treatment algorithm?
Test if: home built before 1978, peeling paint, pica, sibling with poisoning, low SES, immigrant. If level 70 = Dimercaprol + Ca disodium edentate (EDTA)
Which chromosomal abnormalities increase or don’t with AMA?
No increased risk = Turners; increased risk = Downs and Klinefelters
All children
> 7days. Renal and bladder U/S to evaluate for anatomical abnormalities. Voiding cystourethrogram is indicated in children with abnormal findings OR w/ recurrent UTI’s
