UWorld All Subjects 2 Flashcards
(533 cards)
1
Q
Diagnostic criteria for persistent depressive disorder (dysthymia)
A
- chronic depressed mood >/= 2 years
- > /= 2 of the following:
a. appetite disturbance
b. sleep disturbance
c. low energy
d. low self-esteem
e. poor concentration
f. hopelessness
2
Q
Diagnostic criteria for adjustment disorder with depressed mood
A
- onset within 3 months of identifiable stressor
- marked distress and/or functional impairment
- does not meet criteria for another DSM-5 disorder
3
Q
diagnostic criteria for normal stress response?
A
- not excessive or out of proportion to severity of stressor
- no significant functional impairment
4
Q
What is the treatment of adjustment disorder?
A
psychotherapy
5
Q
excessive anxiety and preoccupation with >/= 1 unexplained symptom?
A
somatic symptom disorder
6
Q
fear of having a serious illness despite few or no symptoms and consistently negative evaluations?
A
illness anxiety disorder
7
Q
neurologic symptom incompatible with known disease?
A
conversion disorder (functional neurologic symptom disorder)
8
Q
intentional falsification of illness in the absence of obvious external rewards?
A
factitious disorder
9
Q
falsification or exaggeration of symptoms to obtain external rewards?
A
malingering
10
Q
What are common etiologies of pediatric stroke?
A
- sickle cell disease
- prothrombotic disorders
- congenital cardiac disease
- bacterial meningitis
- vasculitis
- focal cerebral arteriopathy
- head/neck trauma
11
Q
What is the triad of Leriche syndrome?
A
- bilateral hip, thigh, and buttock claudication
- absent or diminished femoral pulses: from the groin distally, often with symmetric atrophy of the bilateral lower extremities due to chronic ischemia
- impotence: almost always present in men with this condition; in the absence of impotence, and alternate diagnosis should be sought
12
Q
Pathophysiology pt, dx, and tx of Guillain-barre syndrome?
A
pathophysiology: immune-mediated demyelinating polyneuropathy; preceding GI (campylobacter) or respiratory infection
Pt:
1. paresthesia, neuropathic pain
2. symmetric, ascending weakness
3. decreased/absent DTRs
4. autonomic dysfunction (arrhythmia, ileus)
5. respiratory compromise
Dx: clinical; supportive findings: increased protein and normal leukocytes on CSF; abnormal electromyography + nerve conduction
Tx: monitoring of autonomic + respiratory function; IV immunoglobulin or plasmapheresis
13
Q
What is the next step in management after diagnosis of Guillain-barre syndrome?
A
assess respiratory function with spirometry; FVC and negative inspiratory force monitor respiratory muscle strength
Serial PFTs should be performed given the rapid progressive of disease
A decline in FVC (= 20) indicates impending respiratory failure warranting intubation
14
Q
What is the treatment for symptomatic sinus bradycardia with hypotension or signs of shock?
A
atropine 0.5 mg bolus, repeat every 3-5 mins up to 3.0mg max
if no response -> transcutaneous pacing OR IV dopamine infusion OR IV epinephrine infusion
If no response -> consider expert consultation or transvenous pacing
15
Q
What are causes of sinus bradycardia?
A
sick sinus syndrome, MI, OSA, hypothyroidism, increased ICP, and medications
16
Q
toddler with impaired adaption to darkness, photophobia, dry scaly skin, dry conjunctiva, dry cornea, and a wrinkled, cloudy cornea - dx?
A
vitamin a deficiency
17
Q
characteristics of rotator cuff impingement or tendinopathy?
A
- pain with abduction, external rotation
- subacromial tenderness
- normal range of motion with positive impingement tests (Need, Hawkins)
18
Q
characteristics of rotator cuff tear?
A
- similar to rotator cuff tendinopathy
- weakness with abduction and external rotation
- age > 40
19
Q
characteristics of adhesive capsulitis?
A
- decreased passive and active range of motion
2. stiffness +/- pain
20
Q
characteristics of biceps tendinopathy or rupture?
A
- anterior shoulder pain
- pain with lifting, carrying or overhead reaching
- weakness (less common)
21
Q
characteristics of glenohumeral osteoarthritis?
A
- uncommon & usually caused by trauma
- gradual onset of anterior or deep shoulder pain
- decreased active and passive abduction and external rotation
22
Q
supraventricular aortic stenosis path and pt
A
congenital left ventricular outflow tract obstruction due to discrete or diffuse narrowing of the ascending aorta
valvular murmur similar to the murmur of valvular aortic stenosis but it is best heard at the first right intercostal space
patients can also have uneven courted pulses, differential blood pressure in the upper extremities, and a palpable thrill int he suprasternal notch
23
Q
path, pt, dx, and tx of biliary atresia
A
Path: extra hepatic bile duct fibrosis
Pt: asymptomatic at birth; infants age 2-8 weeks: jaundice, acholic stools, dark urine, hepatomegaly
dx: direct hyperbilirubinemia, elevated GGT, elevated all phos, normal or mildly elevated livery enzymes
U/S: absent/abnormal gallbladder and or CBD
Liver biopsy:
1. intrahepatic bile duct proliferation
2. portal tract edema
3. fibrosis
Intraoperative cholangiography (gold standard): biliary obstruction
Tx: surgical hepatoportoenterostomy (Kasai procedure), liver transplant
24
Q
Risk factors, pt, dx and tx of chronic venous stasis
A
Risk factors: obesity, advanced age, varicose veins, history of DVT
Pt: leg pain (achy, heavy), edema, venous dilation (varicosities, telangiectasia), dermatitis (erythema, pruritus, scaling, weeping), chronic woody induration and brown discoloration, ulcers
Dx: clinical, can do duplex u/s to confirm and rule out venous thrombosis (ankle brachial index is used for arterial insufficiency NOT venous stasis)
Tx: elevation, compression stockings
25
Which medications can cause hyperkalemia?
1. nonselective beta-blockers
2. ACE-i, ARBs, K+ sparing diuretics
3. digitalis
4. cyclosporine
5. heparin
6. NSAIDs
7. succinylcholine
26
How do nonselective beta blockers cause hyperkalemia?
interferes with beta-2-medicated intracellular potassium uptake
27
How does digitalis cause hyperkalemia?
inhibition of the Na-K-ATPase pump
28
How does cyclosporine cause hyperkalemia?
blocks aldosterone activity
29
How does heparin cause hyperkalemia?
blocks aldosterone production
30
How do NSAIDs cause hyperkalemia?
decreases renal perfusion resulting in decreased K+ delivery to the collecting ducts
31
How does succinylcholine cause hyperkalemia?
causes extracellular leakage of potassium through acetylcholine receptors
32
Pt, Dx, and Tx of HSV encephalitis
Pt: fever, HA, seizure, AMS (confusion, agitation), +.- focal neurologic findings (hemiparesis, cranial nerve palsies, ataxia)
Dx: CSF:
1. increased WBCs (increased lymphocytes), increased RBCs
2. Increased protein, normal glucose
3. HSV DNA on PCR
Brain MRI: temporal lobe hemorrhage/edema
Tx: IV acyclovir
33
What is Reye syndrome and how is it differentiated from HSV encephalitis?
encephalopathy with liver dysfunction; pt in children with AMS and generalized seizures after a viral illness
(Hepatomegaly and generalized cerebral edema without focal findings would be expected)
34
Pt and Dx of chronic autoimmune thyroiditis (Hashimoto)
Pt: predominant hypothyroid features, diffuse goiter
Dx: positive TPO Abx, variable radioiodine uptake
35
Pt and Dx of painless thyroiditis (silent thyroiditis)
Pt: variant of chronic autoimmune thyroiditis; mild, brief hyperthyroid phase; small, contender goiter, spontaneous recovery
Dx: positive TPO Abx, low radioiodine uptake
36
Pt and Dx of subacute thyroiditis (de Quervain thyroiditis)
Pt: likely postural inflammatory process; prominent fever + hyperthyroid symptoms, painful/tender goiter
Dx: elevated ESR + CRP, low radioiodine uptake
37
Epidemiology and pt of carbon monoxide poisoning
```
Epidemiology:
1. smoke inhalation
2. defective heating systems
3. gas motors operating in poorly ventilated areas
Pt:
Mild-moderate: HA, confusion, malaise, dizziness, nausea
Severe
Seizure, syncope, coma, MI, arrhythmias
```
38
Dx and Tx of carbon monoxide poisoning
Dx: ABG: carboxyhemoglobin level; ECG +/- cardiac enzymes
Tx: high flow 100% oxygen; intubation/hyperbaric oxygen (severe)
Complication: permanent hypoxic brain injury can occur (MRI showing bilateral hyper intensity of the globes pallidus, which is highly sensitive to hypoxic conditions)
39
What is a complication of antithyroid drugs in the treatment of Grave's disease?
Both: agranulocytosis
Methimazole: 1st trimester teratogen, cholestasis
PTU: hepatic failure, ANCA-associated vasculitis
40
What is a complication of radioiodine ablation in the treatment of Grave's disease?
1. permanent hypothyroidism
2. worsening of ophthalmopathy
3. possible radiation side effects
41
What is a complication of surgery in the treatment of Grave's disease?
1. permanent hypothyroidism
2. risk of recurrent laryngeal nerve damage
3. risk of hypoparathyroidism
42
How is central precocious puberty differentiated from peripheral precocious puberty?
elevated LH level at baseline or following stimulation with a GnRH agonist; in contrast, elevated sex hormones in patients with peripheral PP suppress LH levels
43
What is the treatment of central precocious puberty?
after a CNS tumor is excluded, treat with GnRH agonist therapy, which prevents premature epiphyseal plate fusion and maximizes adult height potential
44
Tx of acute mania
1. Antipsychotics (first and second generation)
2. Lithium (avoid in renal disease)
3. Valproate (avoid in liver disease)
4. Combinations in severe mania (antipsychotic + lithium or valproate)
5. Adjunctive benzos for insomnia, agitation
45
What are effects of maternal hyperglycemia on an infant during the first trimester?
1. congenital heart disease
2. neural tube defects
3. small left colon syndrome
4. spontaneous abortion
46
What are effects of maternal hyperglycemia on an infant in the second and third trimesters?
fetal hyperglycemia and hyperinsulinemia that leads to:
1. increased metabolic demand -> fetal hypoxemia -> increased erythropoiesis -> polycythemia
2. organomegaly
3. neonatal hypoglycemia
4. macrosomia -> shoulder dystocia -> brachial plexopathy, clavicle fracture, perinatal asphyxia
47
What is the difference between reactive attachment disorder (RAD) and disinhibited social engagement disorder?
Both can develop when a child has a history of neglect, abuse, prolonged institutionalization, or inconsistent care
RAD = social withdrawal, lack of positive response to attempts to comfort, and decreased emotional responsiveness, lack of positive emotions, and episodes of unexpected irritability or sadness in response to nonthreatening encounters
disinhibited social engagement disorder = overfamiliarity and an unhesitant approach to unfamiliar adults
48
What is the pathophys and what are etiologies of bronchiectasis?
Pathophys: infectious insult with impaired d clearance
Etiologies:
1. airway obstruction (cancer)
2. rheumatic disease (Ra, Sjogren), toxic inhalation
3. chronic or prior infection (aspergillosis, TB)
4. immunodeficiency
5. congenital (CF, alpha-1-antitrypsin def)
49
What is the pt and dx of bronchiectasis?
pt: cough with daily mucopurulent sputum production; rhino sinusitis, dyspnea, hemoptysis; crackles, wheezing
Dx: HR-CT scan of the chest (needed for initial diagnosis); immunoglobulin quantifications; CF testing, sputum culture; PFTs
50
What is the diagnostic imaging workup for UTIs in children?
Renal u/s should be performed first to rule out renal abscess.
A voiding cystourethrogram is performed after a first febrile UTI fi the patient has an abnormal renal ultrasound, high fever with unusual pathogen (ie not E. coli), or signs of chronic kidney injury.
51
What vessel(s) is blocked in an anterior MI? What ECG leads are involved?
vessel: LAD
| ECG leads: some or all of V1-V6
52
What vessel(s) are blocked in an inferior MI? What ECG leads are involved?
vessels: RCA or LCX
| ECG leads: ST elevation leads II, III, and aVF
53
What vessel(s) are blocked in a posterior MI? What ECG leads are involved?
```
vessels: LCX or RCA
ECG leads:
1. ST depression in leads V1-V3
2. ST elevation in leads I + aVL (LCX)
3. ST depression in leads I + aVL (RCA)
```
54
What vessel(s) are blocked in a lateral MI? What ECG leads are involved?
vessels: LCX, diagonal
leads: ST elevation in leads I, aVL, V5, and V6; ST depression in leads II, III, aVF
55
What vessel(s) are blocked in a right ventricle MI (1/2 of inferior MIs)? What ECG leads are involved?
vessels: RCA
leads: ST elevation in leads V4-V6R
56
What is the medical management for a kidney stone < 10 mm?
medical management: hydration, pain control, alpha blockers, strain urine
57
What is medical management for a kidney stone <10 mm with uncontrolled pain or no stone passage in 4-6 weeks?
urology consult
58
What is the management for a kidney stone >/= 10 mm?
urology consult
59
blepharospasm pt and tx; what is Meige syndrome?
(form of focal dystonia)
Pt: bilateral, symmetric forceful contraction of the eyelid muscles; commonly affected by sensory input (bright lights may trigger the muscle contraction whereas touching or brushing the skin around the eye may terminate the spasm
Tx: trigger avoidance, such as wearing dark glasses, but botox injection may be needed
*When associated with spasm of the lower face (jaw, tongue), it is termed Meige syndrome
60
What is the path and risk factors for uric acid kidney stones?
Path: acidic urine favors formation of uric acid over rate; supersaturation of urine with uric acid precipitates crystal formation
Risk factors:
1. increased uric acid excretion: gout, myeloproliferative disorders
2. increased urine concentration: hot, arid climates; dehydration
3. low urine pH: chronic diarrhea (GI bicarb loss), metabolic syndrome/diabetes
61
Dx and Tx of uric acid kidney stones?
Dx: radiolucent stones (not visible on X-ray), uric acid crystal son urine microscopy urine pH usually < 5.5
Tx: alkalization of urine (potassium citrate)
62
Contact dermatitis as a cause of perianal dermatoses - epidemiology, visualization, and treatment
Epi: most common cause of perianal dermatoses in infants
Visual: spares creases/skinfolds
Tx: topical barrier ointment or paste
63
candida dermatitis as a cause of perianal dermatoses - epidemiology, visualization, and treatment
epi: second most common cause in infants
Visual: beefy-red rash involving skin folds with satellite lesions
Tx: topical antifungal therapy
64
perianal strep as a cause of perianal dermatoses - epidemiology, visualization, treatment
Epidemiology: school-aged children
visual: bright, sharply demarcated erythema over perianal/perineal area
Tx: oral Abx
65
Pt, PE, Labs, and treatment of polymyalgia rheumatica?
Pt: age >50, B/L pain and morning stiffness > 1 month; involvement of 2 of the following:
1. neck or torso
2. shoulders or proximal arms
3. proximal thigh or hip
4. constitutional (fever, malaise, weight loss)
PE: decreased active ROM in shoulders, neck, + hips
Labs:
1. ESR > 40, sometimes > 100
2. elevated CRP
3. normocytic anemia possible
Tx: response to glucocorticoids
66
What are the effects and side effects of alpha-adrenergic antagonists used for tx of BPH? What are the names of the drugs?
alpha-adrenergic antagonists: terzosin, tamsulosin (usual first line therapy)
MOA: relax smooth muscle in bladder neck, prostate capsule, and prostatic urethra
Side effects: orthostatic hypotension, dizziness
67
What are the effects and side effects of 5-alpha-reductase inhibitors used for tx of BPH? What are the names of the drugs?
5-alpha reductase inhibitors (finasteride, dutasteride)
MOA: inhibit conversion of testosterone to dihydrotestosterone; reduce prostate gland size
(effectiveness may take 6-12 months)
Side effects: decreased libido, erectile dysfunction
68
What are the effects and side effects of antimuscarinics used for tx of BPH? What are the names of the drugs?
antimuscarinics = tolterodine
MOA: used to treat overactive bladder (urinary frequency, urgency, incontinence)
Side effects: urine retention, dry mouth
69
Path, Pt and Dx of chronic granulomatous disease?
Path: majority of cases X-linked recessive
Pt: recurrent pulmonary + cutaneous infections; catalase positive pathogens (Staph aureus, Serratia, Burkholderia, Aspergillus)
Dx: neutrophil function testing:
- dihydrorhodamine 123 test
- nitroblue tetrazolium test
70
What is the inheritance of leukocyte adhesion deficiency? What is the defect? Presents with?
```
Inheritance = usually autosomal recessive
defect = impaired neutrophil chemotaxis
Pt = susceptible to recurrent infections (skin and mucosal) that lack pus and have poor wound healing; delayed umbilical cord separation (>21 days); marked peripheral leukocytosis with neutrophilia
```
71
What will ECG, CXR, and echo show in the diagnosis of coarctation of the aorta?
ECG: left ventricular hypertrophy
CXR: inferior notching of the 3rd-8th ribs; "3" sign due to aortic indentation
Echo: confirms diagnosis
72
Path, Pt, Dx, and Tx of hairy cell leukemia
Path: clonal B-cell neoplasm; middle-aged/older adults; BRAF mutation
Pt:
1. pancytopenia due to bone marrow fibrosis
a. granulocytopenia (infections)
b. anemia (fatigue, weakness)
c. thrombocytopenia (bleeding, bruising)
2. splenomegaly (early satiety)
3. hepatomegaly/LAD rare
Dx: peripheral smear - "hairy" leukocyte cells
bone marrow biopsy with flow cytometry
Tx: chemotherapy (for moderate/severe); life expectancy is often near-normal
73
Acute lymphoblastic leukemia path, pt, dx
path: children (not adults)
pt: symptoms related to neutropenia, anemia, or thrombocytopenia; LAD is common
Dx: peripheral smear shows lymphoblasts (small cells, scant cytoplasms)
74
Pt, Dx, Tx of spontaneous bacterial peritonitis
Pt:
1. temp > 100
2. AMS
3. hypotension, hypothermia, paralytic ileus with severe infection
Dx:
1. PMNs >/= 250
2. positive culture, often gram-negative organisms (E. coli, Klebsiella)
3. protein < 1 g/dL
4. SAAG >/= 1.1 g/dL
Tx: empiric Abx - third gen cephalosporin (cefotaxime); fluoroquinolones for SBP prophylaxis
75
Acting out - what is it? Immature or mature defense mechanism?
expressing unacceptable feelings through actions; immature
76
Denial - what is it? immature or mature defense mechanism?
behaving as if an aspect of reality does not exist; immature
77
Displacement - what is it? Immature or mature defense mechanism?
transferring feelings to less threatening object/person; immature
78
Intellectualization what is it? Immature or mature defense mechanism?-
focusing on nonemotional aspects to avoid distressing feelings; immature
79
Passive aggression - what is it? Immature or mature defense mechanism?
avoiding conflict by expressing hostility covertly; immature
80
Projection - what is it? Immature or mature defense mechanism?
attributing one's own feelings to others; immature
81
Reaction formation - what is it? Immature or mature defense mechanism?
transforming unacceptable feelings/impulses into the opposite; immature
82
Regression - what is it? Immature or mature defense mechanism?
reverting to earlier developmental stage; immature
83
Splitting - what is it? Immature or mature defense mechanism?
experiencing a person/situation as either all positive or all negative; immature
84
Sublimation - what is it? Immature or mature defense mechanism?
channeling impulses into socially acceptable behaviors; mature
85
Suppression - what is it? Immature or mature defense mechanism?
putting unwanted feelings aside to cope with reality; mature
86
Pt, dx, and tx of transient synovitis
Pt: well-appearing, afebrile or low-grade fever, able to bear weight
Dx: normal or mildly elevated WBC, ESR, CRP; unilateral/bilateral joint effusion on u/s; diagnosis of exclusion
Tx: conservative
87
Pt, dx, and tx of septic arthritis
```
Pt: ill-appearing, febrile, non-weight bearing
Dx:
1. modernly elevated WBCs, ESR, CRP
2. +/- positive blood culture
3. unilateral joint effusion on u/s
4. synovial fluid WBCs > 50,000
Tx: joint drainage + Abx
```
88
What antibiotics, antipsychotics, diuretics, and other drugs are associated with photosensitivity reactions?
Abx: tetracyclines (doxycycline)
Antipsychotics: chlorpromazine, prochlorperazine
Diuretics: furosemide, HCTZ
Others: amiodarone, promethazine, piroxicam
89
What is the dx and tx of type 2 heparin-induced thrombocytopenia?
Dx: serotonin release assay: gold standard confirmatory test
Tx: Stop ALL heparin products; start a direct thrombin inhibitor (argatroban) or fondaparinux (synthetic pentasaccharide)
**start treatment in suspected cases prior to confirmatory tests
90
lesion, extra dermal manifestations, and tx of plaque psoriasis
lesion: well-defined, erythematous plaques with silvery scale; extensor surfaces (knees, elbows), hands, scalp, back, nail plates
Extradermal manifestations: nail pitting; conjunctivitis, uveitis; psoriatic arthritis
Tx: topical: high-potency glucocorticoids, vit D analogs, tar, retinoids, calcineurin inhibitors, tazarotene; UV light/phototherapy
Systemic: methotrexate, calcineurin inhibitors, retinoids, apremilast, biologic agents
91
Etiology, Pt, and Dx of acute epididymitis
Etiology: age < 35: sexually transmitted (chlamydia, gonorrhea); age > 35: bladder outlet obstruction (coliform bacteria)
Pt:
1. unilateral, posterior testicular pain
2. epididymal edema
3. pain improved with testicular elevation
4. dysuria, frequency (with coliform infection)
Dx: NAAT for chlamydia + gonorrhea; urinalysis/culture
92
CVP and mechanism in hypovolemic shock
CVP is decreased because of decreased intravascular volume
93
CVP and mechanism in distributive shock
CVP is decreased because of decreased systemic vascular resistance
94
CVP and mechanism in obstructive shock
CVP is increased because of increased back pressure from obstruction cardiac filling
95
CVP and mechanism in cariogenic shock
CVP is increased because of back pressure from forward pump failure
96
Path, pt, complication of nasopharyngeal carcinoma
Path: EBV, endemic to southern china
Pt: nasal congestion with epistaxis, headache, cranial nerve palsies, and/or serous otitis media
complication - early metastatic spread to the cervical lymph nodes
97
gastric cancer
Path: risk is greatest for Eastern Asia (China), Eastern Europe, and Andean portion of South America; Helicobacter pylori infection, pernicious anemia, and smoking increase risk
Pt: persistent mid-epigastric abdominal pain, N/V, weight loss, microcytic anemia (likely iron deficiency)
Comp: metastases to the liver can cause hepatomegaly, elevated alk phos/transaminases, and sings of liver failure
98
What are the first line medications for acute bipolar depression? What other medications can be used? What medication class should be avoided?
first line (according to UWorld): second-generation antipsychotics quetiapine and lurasidone, and anticonvulsant lamotrigine
Lithium, valproate, and the combo of olanzapine and fluoxetine have also demonstrated efficacy.
Antidepressant mono therapy should be avoided in patients with bipolar I disorder due to the risk of precipitating mania.
99
systemic symptoms, localized symptoms, and visual symptoms of giant cell arteritis
systemic: fever, fatigue, malaise, weight loss
localized symptoms:
1. temporal headaches
2. jaw claudication (most specific symptom)
3. PMR
4. arm claudication: associated with bruits in subclavian or axillary areas
5. aortic wall thickening or aneurysms
6. CNS: TIAs/stroke, vertigo, hearing loss
Visual symptoms
1. amaurosis fugax: transient vision field defect progressing to monocular blindness
2. anterior ischemic optic neuropathy (AION): most common ocular manifestation
100
What are the lab results and treatments for giant cell arteritis?
labs:
1. normochromic anemia
2. elevated ESR and CRP
3. temporal artery biopsy
Tx:
1. PMR only: low-dose oral glucocorticoids
2. GCA: intermediate-to high-dose oral glucocorticoids
3. GCA with vision loss: pulse high-dose IV glucocorticoids for 3 days followed by intermediate= to high-dose oral glucocorticoids
101
Pt, Dx, and Tx of angle-closure glaucoma
Pt: symptoms: HA, ocular pain, nausea, decreased visual acuity
Signs: conjunctival redness, corneal opacity, fixed mid-dilated pupil
Dx: tonometry (measure intraocular pressure; gonioscopy (measures corneal angle)
Tx: topical therapy: multidrug topical therapy (timolol, pilocarpine, apraclonidine)
systemic therapy: acetazolamide (consider mannitol)
laster iridotomy
102
What is the formula for calculating anion gap? What are some causes of an elevated anion gap?
AG = Na - (HCO3 + Cl)
Causes:
1. lactic acidosis: hypoxia, poor tissue perfusion, mintochondrial dysfunction
2. ketoacidosis: Type 1 DM, starvation, alcoholism
3. methanol ingestion: formic acid accumulation
4. ethylene glycol ingestion: glycolic and oxalic acid accumulation
5. salicylate poisoning (also causes concomitant respiratory alkalosis)
6. uremia (end-stage renal disease): failure to excrete H+ as NH4+
103
Diagnosis of idiopathic intracranial HTN/pseudotumor cerebri is considered with what 4 things?
1. features of increased ICP in an alert patient
2. absence of focal neurologic signs except for 6th nerve palsy
3. No evidence for other causes (eg, tumors) of increased ICP on neuroimaging
4. normal CSF examination except for increased CSF opening pressure
104
What medications can cause idiopathic intracranial HTN? What is the tx? MOA?
IIH can be caused by tetracyclines or isotretinoin
Weight loss can help with resolution of symptoms.
Tx: acetazolamide is the first-line treatment; MOA: inhibits choroid plexus carbonic anhydrase, thereby decreased CSF production and IH. Furosemide can be added for patients with continued symptoms
105
What is the treatment for those with idiopathic intracranial HTN with symptoms refractory to medical therapy or those with progressive vision loss?
surgical intervention with optic nerve sheath decompression or lumboperitoneal shunting
106
What are some drugs that are CYP450 inhibitors?
1. Antibiotics (metronidazole, macrolides)
2. azalea antifungals
3. amiodarone
4. cimetidine
5. grapefruit juice
107
What are some drugs that are CYP450 inducers?
1. carbamazepine
2. phenytoin
3. phenobarbital
4. rifampin
5. St. John's wort
108
What is the MOA of warfarin? How does warfarin use change lab values? How does acetaminophen affect warfarin use?
vitamin K antagonist tha Blocks gamma carboxylation of vitamin K-dependent coagulation factors (II, VII, IX, and X) leading to partial inhibition of the extrinsic coagulation cascade. This will be reflected on laboarty evaluation as a prolonged INR (PT)
Acetaminophen can prolong INR in those on warfarin due to interruption of vitamin K recycling in the liver
109
disruptive mood dysregulation disorder pt/dx
characterized by an irritable or angry mood together with temper tantrums that are out of proportion to age and situation; dx is not made prior to age 6 or after age 18
110
How is Rett syndrome different from autism?
both present with deficits in social interaction; however, Rett syndrome also has regression in speech, loss of purposeful hand movements, and gait disturbance
111
How is social (pragmatic) communication disorder different than autism?
both display deficits in verbal and nonverbal communication; however, individuals with social communication disorder do not have restricted interests or demonstrate repetitive behaviors
112
What constitutes normal aging as the cause of cognitive impairment in the elderly?
1. slight decrease in fluid intelligence (ability to process new information quickly)
2. normal functioning in all activities of daily living
113
What constitutes mild neurocognitive disorder (mild cognitive impairment) as a cause of cognitive impairment in the elderly?
1. mild decline in >/= 1 cognitive domains
| 2. normal functioning in all activities of daily living with compensation
114
What constitutes major neurocognitive disorder (dementia) as a cause of cognitive impairment in the elderly?
1. significant decline in >/= 1 cognitive domains
2. irreversible global cognitive impairment
3. marked functional impairment
4. chronic and progressive, months to years
115
What constitutes major depression as a cause of cognitive impairment in the elderly?
1. reversible mild-moderate cognitive impairment
2. features of depression (mood, interest, energy)
3. episodic, weeks to months
116
What neurologic findings are suggestive of basal ganglia hemorrhage?
1. contralateral hemiparesis + hemisensory loss
2. homonymous hemianopsia
3. gaze palsy
117
What neurologic findings are suggestive of cerebellum hemorrhage?
1. usually NO hemiparesis
2. facial weakness
3. ataxia + nystagmus
4. occipital HA + neck stiffness
118
What neurologic findings are suggestive of thalamus hemorrhage?
1. C/L hemiparesis + hemisensory loss
2. nonreactive mitotic pupils
3. up gaze palsy
4. eyes deviate Toward hemiparesis (T for thalamus)
119
What neurologic findings are suggestive of cerebral lobe hemorrhage?
1. C/L hemiparesis (frontal lobe)
2. C/L hemisensory loss (parietal lobe)
3. homonymous hemianopsia (occipital lobe)
4. eyes deviate away from hemiparesis
5. high incidence of seizures
120
What neurologic findings are suggestive of hemorrhage in the pons?
1. deep coma + total paralysis within minutes
| 2. pinpoint reactive pupils
121
What are the most common brain areas affected by hypertensive hemorrhages? (4)
1. basal ganglia (putamen)
2. cerebellar nuclei
3. thalamus
4. pons
122
Hyponatremia and low (<275 mOsm/kg) serum osmolality, hypovolemic ECV (extracellular volume), urine Na < 40 mEq/L -> cause?
nonrenal salt loss (eg, vomiting, diarrhea, dehydration)
123
Hyponatremia and low (<275mOsm/kg) serum osmolality, hypovolemic ECV, urine Na >40 -> cause?
renal salt loss (eg, diuretics, primary adrenal insufficiency)
124
Hyponatremia and low (<275 mOsm/kg) serum osmolality, euvolemic ECV, urine Osm < 100 -> cause?
psychogenic polydipsia
Beer potomania
125
Hyponatremia and low (<275 mOsm/kg), euvolemic ECV, Urine Osm > 100 and Urine Na > 40 -> cause?
SIADH (rule out hypothyroidism, secondary adrenal insufficiency)
126
Hyponatremia and low (<275 mOsm/kg) serum osmolality, hypervolemic ECV, variable urine findings -> cause?
CHF, hepatic failure, nephrotic syndrome
127
Hyponatremia and normal serum osmolality, variable ECV and urine findings -> cause?
pseudohyponatremia (eg, paraproteinemia, hyperlipidemia)
128
Hyponatremia and high (>295 mOsm/kg) serum osmolality, variable ECV and urine findings -> cause?
hyperglycemia, exogenous solutes (eg, mannitol)
129
How do you calculate serum osmolality?
2 x serum Na + (serum glucose/18) + (serum BUN/2.8) = serum osmolality
130
Why is therapy with an ACE inhibitor or ARB renal protective?
slows the progression of diabetic nephropathy by blocking angiotensin II-mediated renal efferent arteriole vasoconstriction thus reducing glomerular hydrostatic pressure, decelerating the development of glomerular capillary sclerosis
131
What dietary measures can be used to prevent recurrent nephrolithiasis? What drugs can be used?
food:
1. increased fluids
2. reduced sodium (<100 mEq/d)
3. reduced protein
4. normal calcium intake (1200 mg/day)
5. increased citrate (fruits and vegetables)
6. reduced exalt diet for oxalate stones (dark roughage, vitamin C)
Meds:
1. thiazide diuretic
2. urine alkalinization (potassium citrate/bicarbonate salt)
3. allopurinol (for hyperuricuria-related stones)
132
What is the difference in diagnosing syphilis via nontreponemal vs treponemal
nontreponemal (RPR, VDRL):
1. Abx to cardiolipid-cholesterol-lecithin antigen
2. quantitative (titers)
3. possible negative result in early infection
4. decrease in titers confirms treatment
Treponemal (FTA-ABS, TP-EIA):
1. Abx to treponemal antigens
2. qualitative (reactive/nonreactive)
3. greater sensitivity int arly infection)
4. positive even after treatment
133
How is the diagnosis of paralysis due to a tick different from paralysis due to guillan barre?
Ticks:
1. patients usually present with progressive ascending paralysis over hours to days (GBS days to weeks)
2. paralysis may be localized or more pronounced in 1 leg or arm (GBS is symmetrical)
3. fever is typically not present (or a hx of fever or prodromal illness) (GBS prodromal illness common)
4. sensation is usually normal (GBS sensation is normal to mildly abnormal)
5. no autonomic dysfunction (GBS has tachycardia, urinary rentaiton, and arrhythmias)
6. CSF is normal (GBS CSF abnormal and may so high protein with few cells)
134
Path, Pt, Dx, and Tx of neonatal HSV
Path: vertical transmission: intrauterine, perinatal, post natal
Pt:
skin-eye-mouth: mucocutaneous vesicles, keratoconjunctivitis
CNS: seizures, fever, lethargy; temporal lobe hemorrhage/edema
disseminated: sepsis, hepatits, pneumonia
Dx: viral surface cultures, HSV PCR (blood, CSF)
Tx: acyclovir
135
management of cyanide poisoning?
Decontamination:
1. dermal exposure: removal of clothing and skin decontamination
2. Ingestion: activated charcoal
3. All exposures: Antidote: hydroxocobalamin preffered, sodium thiosulphate as alternate therapy
If antidote not available: nitrites to induce methemoglobinemia
Respiratory support:
1. no mouth-to-mouth resuscitation
2. supplemental o2
3. airway protection (intubation)
Cardiovascular support:
IV fluids for hypotension
136
What are possible causes of acute hypocalcemia?
1. neck surgery (parathyroidectomy)
2. pancreatitis
3. sepsis
4. tumor lysis syndrome
5. acute alkalosis
6. chelation: blood (citrate) transfusion, EDTA, foscarnet
137
Path, Pt, Dx, Tx of atlantoaxial instability
Path: Down syndrome; excessive laxity in the posterior transverse ligament increases mobility between C1 and C2; usually asymptomatic, but symptoms can develop due to compression of the spinal cord
Pt: weakness, gait changes, urinary/fecal incontience, and verebrobasilar symptoms such as dizziness, vertigo, imbalance, and diplopia; UMN findings on exam (spasticity, hyperreflexia, and Babinski sign)
Dx: lateral X0rays of the cervical spine in flexion, extension, and in neutral position
Tx: surgical fusion of C1 to C2
138
Extensively explain when you might see the different hepatitis serum markers? (HBsAg, anti-HBs, HBeAg, Anti-HBc IgM and IgG)
HBsAg - present through the incubation period and infectious state
Anti-HBs - if a patient gains immunity to this virus, either due to infection of immunization, HBsAg changes to this
(neither will be present in the window phase)
HBeAg - Hep B early antigen; indicates active viral replication in the liver; always present in the acute phase and may or may not be present in the chronic stage
Anti-HBc - present during the acute, chronic, or previous hep B infections (including window phase)_
Anti-HBc IgM changes to IgG during the chronic infection
139
What is the gene responsible for Rett syndrome?
MECP2 gene
140
What is the typical presentation of Angolan syndrome?
happy disposition, jerky gait, hand flapping, delayed development
141
What is the presentation of Landau-Kleffner syndrome?
regression of language skills due to severe epileptic attacks (language skills typically deteriorate around age 3-6)
142
Pt, Dx, and Tx of cryptococcal meningoencephalitis? What would lumbar puncture show?
Pt: HA, fever, malaise; develops over 2 weeks (subacute); can be more acute + severe in HIV
Dx: transparent capsule seen with India ink stain, cryptococcal antigen positive, culture on Sabouraud agar
Tx: initial: amphotericin B with flucytosine
Maintenance: fluconazole
Lumbar puncture will show elevated opening pressure, low glucose, high protein, and a lymphocytic pleocytosis
143
At what CD4 count might you see CMV in an HIV patient? What does it typically present with?
CD4 <50/mm
typically causes retinitis (floaters, blurry vision)
144
What does HSV encephalitis present with?
cognitive and personality changes as well as neurological deficits and/or seizures
145
What is included in Category 1 fetal heart rate tracing patterns?
Requires all of the following criteria:
- baseline 110-160/min
- moderate variability (6-25/min)
- no late/variable decelerations
- +/- early decelerations
- +/- accelerations
146
What is included in Category II fetal heart rate tracing patterns?
not category I or III (indeterminate pattern)
147
What is included in Category III fetal heart rate tracing patterns?
>/= 1 of the following characteristics:
- absent variability + recurrent late decelerations
- absent variability + recurrent variable decelerations
- absent variability + bradycardia
- sinusoidal pattens
148
What is indicated by sinusoidal category III fetal heart rate tracings?
severe fetal anemia, likely due to fetal blood loss from ruptured vasa previa (bright-red amniotic fluid); requires urgent cesarean delivery
149
What is classical congenital adrenal hyperplasia a deficiency in? What are the symptoms?
Deficiency of 21-hydroxylase
Pt:
- inhibited conversion of progesterone to 11-deoxycorticosterone, a precursor to aldosterone: decreased aldosterone causes dehydration and salt-wasting (hypotension, hyponatremia, hyperkalemia)
- Inhibited conversion of 17-hydroxyprogesterone to 11-deoxycortisol, a procurer to cortisol: decreased cortisol results in fasting hypoglycemia
- Increased conversion of 17-hydroxyprogesterone to androstenedione, a precursor to testosterone: increased testosterone causes virilization and ambiguous genitalia in female infants; male infants typically have no abnormal newborn genital findings, but they may have an enlarged penis or scrotal hyperpigmentation
150
Risk factors, Pt, and Management of Transfusion-associated circulatory overload (TACO)
```
Risk factors:
- age < 3 and >60
- underlying cardiac or renal condition
- large transfusion volume or fast infusion rate
Pt: (< 6 hours following transfusion initiation)
- respiratory distress
- increased HR
- increased BP
- pulmonary edema (rales)
- signs of heart failure (S3 gallops and JVP)
Management:
- respiratory support
- diuresis (furosemide)
```
151
Epidemiology, Pt, X-ray, and Tx of osteoid osteoma
Epidemiology: benign, bone-forming tumor; most common in adolescent boys
Pt:
- proximal femur most common site
- Pain: worse at night, relieved by NSAIDs, unrelated to activity
- No systemic symptoms
X-ray: small, round lucency
Tx: NSAIDs, monitor for spontaneous resolution
152
Onset age, findings, and tx of chemical neonatal conjunctivitis
Onset age: < 24 hours old
Findings: mild conjunctival irritation + tearing after silver nitrate ophthalmic prophylaxis
Tx: eye lubricant
153
Onset age, findings, and Tx of gonococcal neonatal conjunctivitis
Onset age: 2-5 days old
Findings: marked eyelid swelling, profuse purulent discharge, corneal edema/ulceration
Tx: single IM dose of 3rd-generation cephalosporin
154
Onset age, findings, and Tx of chlamydial neonatal conjunctivitis
Onset age: 5-14 days old
Findings: mild eyelid swelling, watery, serosanguineous, or mucopurulent eye discharge
Tx: PO macrolide
155
What are precipitating factors to a thyroid storm?
1. thyroid or non-thyroid surgery
2. acute illness (trauma, infection), childbirth
3. Acute iodine load (iodine contrast)
156
What is the presentation and Tx of thyroid storm?
Pt:
- fever as high as 40-41.1 C (104-106F)
- tachycardia, HTN, CHF, cardiac arrhythmias (eg atrial fibrillation)
- agitation, delirium, seizure, coma
- goiter, lid lag, tremor, warm + moist skin
- N/V/D, jaundice
Tx:
- beta blocker (propranolol) to decrease adrenergic manifestations
- PTU followed by iodine solution (SSKI) to decrease hormone synthesis + release
- glucocorticoids to decrease peripheral T4 to T3 conversion + improve vasomotor stability
- identify trigger + treat, supportive care
157
Paget's disease of the breast indicates what underlying pathology?
adenocarcinoma of the breast
158
Epidemiology, risk factors, and Pt of tinea pedis?
Epidemiology: dermatophyte fungi
Risk factors: barefoot walking in public areas
Pt:
Interdigital type: pruritus, erythema, erosions between toes
Moccasin type: scales/fissures; extension onto the sole, side, or dorsal of foot
Vesiculobullous type: painful bullae, erythema (lateral mid foot)
Complications: secondary infection, recurrence
159
Dx and Tx of tinea pedis?
Dx: clinical; KOH microscopy of skin scrapings
Tx: first line: topical antifungals (miconazole, tolnaftate)
Second line: oral antifungals (fluconazole)
Keep feet dry + dispose of old footwear
160
What is the treatment for tremor-dominant Parkinson disease in a younger person (= 65)
Trihexyphenidyl (in older patients, amantadine is sometimes use to avoid the anticholinergic effects of trihexyphenidyl)
161
What metabolic disturbance is caused by hyperventilation?
respiratory alkalosis (elevated pH, low pCO2)
162
What happens to calcium with an elevated blood pH?
elevated blood pH results in dissociation of the hydrogen ions bound to albumin, leading to increased calcium binding and a decrease in serum ionized calcium
163
What happens to calcium with a decreased blood pH?
Decreased blood pH results in increased hydrogen ions binding to albumin, leading to decreased calcium ion binding and an increase in serum ionized calcium
164
What is the MOA of adenosine? When is it used?
Adenosine induces a transient block at the AV node and is used in patients with supraventricular tachycardia in whole the diagnosis is unclear
165
When is dignoxin and CCB used?
rate control in patients with atrial fibrillation
166
What is the treatment of hyperthyroid-induced atrial fibrillation?
beta blockers
167
What are the two main effects of HIT antibodies?
1. thrombocytopenia - the reticuloendothelial system removed HIT Ab-coted platelets, causing mild to moderate thrombocytopenia (~60,000)
2. thrombus - HIT Abs activate platelets, resulting in platelet aggregation and the release of procoagulant factors, putting patients at very high risk for arterial and venous thrombus
168
What cancers are responsible for primarily solitary brain metastases?
breast, colon, renal cell carcinoma
169
What cancers are responsible for multiple brain metastases?
lung cancer, malignant melanoma
170
What cancers are rarely responsible for brain metastases?
prostate cancer, esophageal cancer, oropharyngeal cancer, hepatocellular carcinoma, non melanoma skin cancers
171
What are risk factors for cervical cancer? (8)
1. infection with high-rise HPV strains (16, 18)
2. History of sexually transmitted diseases
3. early onset of sexual activity
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low socioeconomic status
8. Tobacco use
172
Pt, Triggers, and management of telogen effluvium
Pt: acute, diffuse, noninflammatory hair loss; scalp and hair fibers appear normal; hair shafts easily pulled out (hair pull test)
Triggers: severe illness, fever, surgery; pregnancy, childbirth; emotional distress; endocrine + nutritional disorders
Management: address underlying cause; reassurance (self-limited)
173
What is Trichorrehexis nodosa?
characterized by fragility of hair with breaking of strands; can be congenital or acquired (excessive heat, hair dyes, salt water); close inspection will show fractured strands with splitting of fibers
174
Path, pt, dx, and tx of hydatid cyst
Path: Echinococcus granulosus; humans contract the infection from close contact with dogs, which are the definitive host in the tapeworm's lifecycle
Pt: E. granulosus typically causes unilocular cystic lesions that can occur in any organ (liver, lung, muscle, bone); multiple lesions are usually associated with E multilocularis instead
Dx: Eggshell calcification of a hepatic cyst on CT scan
Tx: surgical resection under the cover of albendzole
175
How does an amebic liver abscess usually present?
fever, RUQ pain that can develop within weeks of intestinal amebiasis
176
How do patients get pyogenic liver abscesses?
generally develop following surgery, GI infection, or acute appendicitis; patients typically have extreme pain, high fevers, and leukocytosis
177
Prominent capillary pulsations int he fingertips or nail beds, progressive dyspnea and fatigue - dx?
aortic regurgitation
178
In what diseases do you see pulses paradoxus? What is it?
Pulsus paradoxus is an exaggerated decrease (> 10mmHg) in systolic BP with inspiration; it is commonly seen with pericardial diseases (cardiac tamponade) and can occur with severe asthma and COPD
179
What are the differential diagnoses for exertional syncope?
ventricular arrhythmias (due to MI/infarction) or outflow tract obstruction (aortic stenosis, hypertrophic cardiomyopathy)
180
What 3 physical exam findings are suggestive of aortic stenosis?
1. delayed (slow-rising) and diminished (weak) carotid pulse (pulses parvus and tradus)
2. Presence of single and soft second heart sound (S2)
3. Mid- to late-peaking systolic murmur with maximal intensity at the second right intercostal space radiating to the carotids
181
Micro and Management of cat bites
```
Micro: Pasteurella multocida; anaerobic bacteria
Management:
- copious irrigation + cleaning
- prophylactic amoxicillin/clavulanate
- tetanus booster as indicated
- avoid closure
```
182
What 3 physical exam findings are suggestive of aortic stenosis?
1. delayed (slow-rising) and diminished (weak) carotid pulse (pulses parvus and tradus)
2. Presence of single and soft second heart sound (S2)
3. Mid- to late-peaking systolic murmur with maximal intensity at the second right intercostal space radiating to the carotids
183
What are the goals of health maintenance in DM? (5)
1. glycemic control - HgbA1C = 7.0% done every 3 months
2. nephropathy prevention: annual random urine albumin/Cr ratio (normal <30), normal albumin excretion <30
3. CV risk factor reduction: regular screening + control of lipids, BP; address lifestyle factors (diet, exercise, smoking, weight); daily aspirin if 10-year CVD risk >10%
4. Retinopathy screening: ophthalmologic evaluation (every 1-3 years)
5. Neuropathy screening: annual comprehensive foot examination
184
Path, Pt, Dx, and Tx of myotonic dystrophy
Path: autosomal dominant, CTG trinucleotide repeat expansion, repeat length inversely correlating with age of onset
Pt: myotonia (delayed muscle relaxation), progressive muscle weakness (eg, face, hands); childhood form: cognitive + behavioral problems; infantile form: hypotonia, arthrogryposis (congenital joint contracture)
Associated Sx: arrhythmias, cataracts, excessive daytime sleepiness, testicular atrophy/infertility
Dx: genetic testing
Tx: symptomatic
185
What are the goals of health maintenance in DM? (5)
1. glycemic control - HgbA1C = 7.0% done every 3 months
2. nephropathy prevention: annual random urine albumin/Cr ratio (normal <30), normal albumin excretion <30
3. CV risk factor reduction: regular screening + control of lipids, BP; address lifestyle factors (diet, exercise, smoking, weight); daily aspirin if 10-year CVD risk >10%
4. Retinopathy screening: ophthalmologic evaluation (every 1-3 years)
5. Neuropathy screening: annual comprehensive foot examination
186
What is the presentation of infective endocarditis in IV drug users?
- Staph aureus is the most common organism
- Tricuspid valve involvement (right-sided) is more common than aortic valve
- holosystolic murmur increases with inspiration, indicating tricuspid involvement
- septic pulmonary emboli common
- fewer peripheral IE manifestations (splinter hemorrhages, Janeway lesions)
- HF more common in aortic involvement but rare with tricuspid valve disease
187
What murmur do you expect in tricuspid regurgitiation?
holosystolic murmur that increases in intensity with inspiration
188
In what situations would you expect an S4 heart sound?
- can be heard over the cardiac apex in the left lateral decubitus position in patient with reduced ventricular compliance
- can be heard in many healthy older adults and in patients with hypertensive heart disease, aortic stenosis, and hypertrophic cardiomyopathy (abnormal in children)
189
early decrescendo diastolic murmur that begins immediately after A2?
aortic regurgitation - high pitched with blowing quality best heard along the left sternal border at the third and fourth intercostal space when the patient is sitting up and leaning forward while holding the breath in full expiration
190
Risk factors, Pt, Tx, and complications of cryptorchidism?
Risk factors: prematurity, small for gestational age, low birth weight (< 5.5lb), genetic disorders)
Pt: empty, hypo plastic, poorly rugged scrotum or hemiscrotum, +/- inguinal fullness
Tx: orchiopexy before age 1 year
Complications: inguinal hernia, testicular torsion, sub fertility, testicular cancer (orchiopexy needs to be performed before 1 yo to avoid complications)
191
bradycardia, hypotension, respiratory depression, hyporeflexia that does not respond to naloxone - dx?
combined effects of alcohol and benzos
192
Risk factors, Pt, Tx, and complications of cryptorchidism?
Risk factors: prematurity, small for gestational age, low birth weight (< 5.5lb), genetic disorders)
Pt: empty, hypo plastic, poorly rugged scrotum or hemiscrotum, +/- inguinal fullness
Tx: orchiopexy before age 1 year
Complications: inguinal hernia, testicular torsion, sub fertility, testicular cancer
193
What is the pt of carpal tunnel syndrome due to idiopathic cause/overuse?
swelling + fibrosis of tendons and soft tissue
194
What is the pt of carpal tunnel syndrome due to hypothyroidism?
soft tissue enlargement (mucopolysaccharides)
195
What is the pt of carpal tunnel syndrome due to diabetes mellitus?
soft tissue enlargement; microvascular insufficiency + neovascularization
196
What is the pt of carpal tunnel syndrome due to rheumatoid arthritis?
extrinsic compression from joint deformity
197
What is the pt of carpal tunnel syndrome due to pregnancy?
edema/fluid accumulation
198
What is the pt of carpal tunnel syndrome due to gout?
compression from tophi
199
What is the pt of carpal tunnel syndrome due to acromegaly?
tendon enlargement, synovial edema
200
What is the pt of carpal tunnel syndrome due to gout?
compression from tophi
201
Path, pt, tx of mature cystic teratoma
Path: benign, ovarian germ cell tumor; endoderm, mesoderm, ectoderm tissue
Pt: most asymptomatic; ovarian torsion; struma ovarii subtype -> hyperthyroidism; unilateral adnexal mass; U/S: complex, cystic, calcifications; gross appearance: sebaceous fluid, hair, teeth
Management: ovarian cystectomy or oophorectomy
202
theca lutein cysts pt
appear as large, B/L cystic masses; arise from markedly elevated beta-hCG levels
203
Lemierre syndrome path, pt, dx, and tx
Path: young, immunocompetent patients, caused by Fusobacterium necrophorum (normal oral flora)
Pt: begins with oropharyngeal infection, usually tonsillitis, but can arise as a complication from dental work or mastoiditis -> causes internal jugular vein thrombosis and infection
Classic presentation: weeklong duration of sore throat with high fever, rigors, dysphagia, neck pain and swelling, along the SCM muscle
Dx: culture from blood or pus
Tx: supportive (airway), IV Abx, and surgery if needed
204
What are the steps for management of shoulder dystocia? (BE CALM)
B: breathe, do not push
E: elevate legs = flex hips, thighs against abdomen (McRoberts)
C: call for help
A: apply suprapubic pressure
L: enLarge vaginal opening with episiotomy
M: Maneuvers;
- deliver posterior arm
- rotate posterior shoulder (Woods screw) - apply pressure to anterior respect of the posterior shoulder
- Adduct posterior fetal shoulder (Rubin) - apply pressure to the posterior aspect of the posterior shoulder
- Mother on hands + knees - "all fours"
- Replace fetal head into pelvis for cesarean delivery (Zavanelli)
205
Lemierre syndrome path, pt, dx, and tx
Path: young, immunocompetent patients, caused by Fusobacterium necrophorum (normal oral flora)
Pt: begins with oropharyngeal infection, usually tonsillitis, but can arise as a complication from dental work or mastoiditis -> causes internal jugular vein thrombosis and infection
Classic presentation: weeklong duration of sore throat with high fever, rigors, dysphagia, neck pain and swelling, along the SCM muscle
Dx: culture from blood or pus
Tx: supportive (airway), IV Abx, and surgery if needed
206
Path, Pt, Dx, and Tx of hemophilia a + b
Path: X-linked recessive
Pt: delayed/prolonged bleeding after mild trauma; hemarthrosis, intramuscular hematoma, GI or GU bleeding, intracranial hemorrhage; complications: hemophilic arthropathy
Dx: increased PTT< normal platelet count + PT; absent or decreased factor VIII (hemophilia A) or factor IX (hemophilia B) activity
Tx: factor replacement; desmopressin for mild hemophilia A
207
Risk factors, pathogens, complications, and treatment of pyelonephritis in pregnancy?
Risk factors; asymptomatic bacteriuria, diabetes mellitus, age <20
Path: E. coli (MC), Klebsiella, Enterobacter, Group B strep
Complications: preterm labor low birth weight, ARDS
Tx: IV Abx, supportive therapy
208
In what areas of the world is chloroquine chemoprophylaxis used for malaria? Where is it not and what is used there?
chloroquine chemoprophylaxis is used in areas without resistance (parts of Central America, Caribbean)
Resistance is widespread in Africa, Asia (including India), and Oceania. In these areas, Mefloquine chemoprophylaxis is used
209
what mineral deficiency causes impaired glucose control in diabetes?
chromium
210
what mineral deficiency causes brittle hair, skin depigmentation, neurologic dysfunction, anemia, and osteoporosis?
copper
211
What mineral deficiency causes microcytic anemia?
iron
212
What mineral deficiency causes thyroid dysfunction, cardiomyoapthy, and immune dysfunction?
selenium
213
What mineral deficiency causes alopecia, pustular skin rash, hypogonadism, impaired wound healing, impaired taste, and immune dysfunction?
zinc
214
What vitamin deficiency causes dermatitis of sun-exposed areas, diarrhea, and dementia?
niacin (Vit B3)
215
What are risk factors (7) and protective factors (3) of epithelial ovarian cancers?
Risk factors:
1. family hx
2. genetic mutations (BRCA1, BRCA2)
3. Age >/= 50
4. hormone replacement therapy
5. endometriosis
6. infertility
7. Early menarche/late menopause
Protective factors:
1. oral contraceptives
2. multiparity
3. breastfeeding
216
What is the classic triad of disseminated gonococcal infection?
polyarthralgia, tenosynovitis, and painless vesiculopustular skin lesions
217
Cardiac myxoma path, pt, dx, and tx
path: benign neoplasm, 80% located in left atrium
Pt: position-dependent mitral valve obstruction that causes a mid-diastolic murmur, dyspnea, lightheadedness, syncope; embolization of tumor fragments (stroke), constitutional symptoms (fever, weight loss)
Dx: echo
Tx: prompt surgical resection
218
What is the classic triad of disseminated gonococcal infection?
polyarthralgia, tenosynovitis, and painless vesiculopustular skin lesions
219
What are the causes of increased maternal serum AFP?
1. open neural tube defects (anencephaly, open spina bifida)
2. ventral wall defects (omphalocele, gastroschisis)
3. multiple gestation
220
What are the causes of decreased maternal serum AFP?
aneuploidies (trisomy 18 & 21)
221
What are the causes of postoperative fever from 0-6 hours post procedure?
tissue trauma, blood products, malignant hyperthermia
222
What are the causes of postoperative fever from 24 hours - 1 week?
nosocomial infections, infections due to strep or Clostridium perfringens, noninfectious (MI, PE, DVT)
223
What are the causes of postoperative fever from 1 week to 1 month?
catheter site infection, C. diff, drug fever, PE/DVT
224
What are risk factors for chorioamnionitis (6)?
1. prolonged rupture of membranes (> 18 hours)
2. Preterm prelabor rupture of membranes
3. prolonged labor
4. internal fetal/uterine monitoring devices
5. repetitive vaginal examinations
6. presence of genital tract pathogens
225
What is the criteria for diagnosis of chorioamnionitis?
maternal fever PLUS >/= 1 of the following:
- fetal tachycardia
- maternal leukocytosis
- purulent amniotic fluid
226
What is the next step in management of a clean or minor wound and >/= 3 tetanus toxoid doses in lifetime?
- tetanus toxoid-contianing vaccine only if last dose >/= 10 years ago
- NO TIG
227
What is the next step in management of a dirty or severe wound in an unimmunized, uncertain, or < 3 tetanus toxoid doses?
- tetanus toxoid-containing vaccine
| - PLUS TIG
228
What is the next step in management of a clean or minor wound in an unimmunized, uncertain, or < 3 tetanus toxoid doses?
- tetanus toxoid-containing vaccine only
| - NO TIG
229
What is the next step in management of a dirty or severe wound in an unimmunized, uncertain, or < 3 tetanus toxoid doses?
- tetanus toxoid-containing vaccine
| - PLUS TIG
230
What is the pt of meniere's disease?
- recurrent episodes lasting 20 mins to several hours
- sensorineural hearing loss
- tinnitus and/or feeling of fullness in the ear
231
What is the pt of vestibular neuritis?
- acute, single episode that can last days
- often follows viral syndrome
- abnormal head thrust test
232
What are complications of ankylosing spondylitis? (3)
1. osteoporosis/vertebral fractures
2. aortic regurgitation
3. cauda equina
233
solitary, well-circumscribed mobile breast mass, +/- tenderness - Dx?
breast cyst
234
post trauma/surgery, firm irregular breast mass, +/- ecchymosis, skin/nipple retraction - dx?
fat necrosis
235
solitary, well-circumscribed mobile breast mass with cyclic premenstrual tenderness - dx?
fibroadenoma
236
post trauma/surgery, firm irregular breast mass, +/- ecchymosis, skin/nipple retraction - dx?
fat necrosis
237
Path, Pt, Dx, and Tx of immune thrombocytopenia
path: platelet autoAbs, preceding viral infection
Pt: petechiae, ecchymosis, mucosal bleeding (epistaxis, hematuria)
Dx: isolated thrombocytopenia < 1000,000; few platelets (size normal to large) on peripheral smear
Tx: children:
- observe if cutaneous sx only; glucocorticoids, IVIG, or anti-D if bleeding
Adults:
- observation if cutaneous symptoms AND platelets >/= 30,000
- glucocorticoids, IVIG, or anti-D if bleeding or platelets < 30,000
238
What is the pt of intraventricular hemorrhage in a newborn?
anemia, tachycardia, and bulging fontanelle due to hemorrhage; nonspecific signs such as apnea, hypotonia, and decreased movements are also common and seizures in a minority of cases
239
How are HSV and haemophilus ducreyi different?
both painful
HSV - small vesicles or ulcers on erythematous base; mild LAD
Haemophilus ducreyi - larger, deep ulcers with gray/yellow exudate; well-demarcated borders and soft, friable base; severe LAD that may suppurate
240
What is the Path, pt, dx, and tx of Miller Fischer syndrome?
Path: variant of Guillain-Barre; Anti-GQ1b Abs
Pt: rapid-onset ophthalmoplegia, cerebellar-like ataxia and areflexia, extremity weakness can occur but not usually paralysis
Dx: CSF analysis showing albuminocytolic dissociation (elevated protein, normal WBC)
Tx: plasmapheresis and IVIg
241
Extensively explain the water deprivation test
no water 2-3 hours prior to test -> urine osmolality > 600?
Yes -> primary polydipsia
No -> urine osmolality stable on 2-3 consecutive hourly measurements; plasma osmolality > 295 or plasma sodium > 145?
No -> continue testing until above end points are reached
Yes -> administer desmopressin -> central DI: increased urine osmolality 50-100%; nephrogenic DI: small or no increase in urine osmolality
242
What is the Path, pt, dx, and tx of Miller Fischer syndrome?
Path: variant of Guillain-Barre; Anti-GQ1b Abs
Pt: rapid-onset ophthalmoplegia, cerebellar-like ataxia and areflexia, extremity weakness can occur but not usually paralysis
Dx: CSF analysis showing albuminocytolic dissociation (elevated protein, normal WBC)
Tx: plasmapheresis and IVIg
243
Extensively explain the water deprivation test
no water 2-3 hours prior to test -> urine osmolality > 600?
Yes -> primary polydipsia
No -> urine osmolality stable on 2-3 consecutive hourly measurements; plasma osmolality > 295 or plasma sodium > 145?
No -> continue testing until above end points are reached
Yes -> administer desmopressin -> central DI: increased urine osmolality 50-100%; nephrogenic DI: small or no increase in urine osmolality
244
What is the difference between nephrogenic and central DI?
central DI is due to a lack of brain signaling ADH, so it responds to exogenous desmopressin
nephrogenic DI is due to the kidney not being responsive to ADH, and it will not get better with exogenous ADH (desmopressin)
245
What are HTN-related symptoms that indicate renovascular disease?
1. resistant HTN (uncontrolled despite 3 drug regimen)
2. Malignant HTN (with end-organ damage)
3. Onset of severe HTN (> 180/120) after age 55
4. Severe HTN with diffuse atherosclerosis
5. Recurrent flash pulmonary edema with severe HTN
246
Pt, and Dx of primary sclerosing cholangitis?
Pt: asymptomatic, fatigue + pruritus, associated with IBD, particularly UC
Dx: cholestatic liver injury (increased alk phos, increased bilirubin); multifocal stricutring/dilation of intrahepatic and/or extra hepatic bile ducts on cholangiography (MRCP to dx)
247
Path, Pt, Dx, and Tx of early lyme disease
Path: endemic to northeastern US; ixodes scapulars tick transmits Borrelia burgdorferi
Pt: erythema migrant, systemic symptoms: malaise, fatigue, arthralgia, regional LAD, neurologic: meningitis, CN palsy, radiculoneuritis, carditis: AV block
Dx: clinical (if erythema migrant); B burgdorferi serology (if neurologic/cardiac disease)
Tx: oral Abx (doxycycline) - skin/mild disease; IV Abs (ceftriaxone) - neurologic/cardiac disease
248
Etiologies, Pt, and Management of venous air embolism?
Etiologies: trauma, certain surgeries (neurosurgical), central venous catheter manipulation, barotrauma (eg, positive-pressure ventilation)
Pt: sudden-onset respiratory distress; hypoxemia, obstructive shock, cardiac arrest
Management: left lateral decubitus positioning, high-flow or hyperbaric oxygen
249
Path, Pt, Dx, and Tx of early lyme disease
Path: endemic to northeastern US; ixodes scapulars tick transmits Borrelia burgdorferi
Pt: erythema migrant, systemic symptoms: malaise, fatigue, arthralgia, regional LAD, neurologic: meningitis, CN palsy, radiculoneuritis, carditis: AV block
Dx: clinical (if erythema migrant); B burgdorferi serology (if neurologic/cardiac disease)
Tx: oral Abx (doxycycline) - skin/mild disease; IV Abs (ceftriaxone) - neurologic/cardiac disease
250
Pt of vascular claudication
- exertionally dependent pain
- pain relieved with rest but not with bending forward while walking
- LE cramping/tightness
- No significant LE weakness
- possible buttock, thigh, calf, or foot pain
- decreased pulses
- cool extremities
- decreased hair growth
- pallor with leg elevation
(Dx with ankle-brachial index)
251
Pt of neurogenic claudication (pseudoclaudication)
- posture-dependent pain
- lumbar extension worsens pain (walking downhill)
- lumbar flexion relieves pain (walking while bent forward)
- LE numbness + tingling
- LE weakness
- Low back pain
- normal pulses
- normal PE usually
(Dx with MRI of the spine)
252
Pt of vascular claudication
- exertionally dependent pain
- pain relieved with rest but not with bending forward while walking
- LE cramping/tightness
- No significant LE weakness
- possible buttock, thigh, calf, or foot pain
- decreased pulses
- cool extremities
- decreased hair growth
- pallor with leg elevation
(Dx with ankle-brachial index)
253
What are potential causes of diffuse alveolar hypoventilation?
narcotic overdose and neuromuscular weakness
254
Path and Pt of thoracic spinal cord ischemia?
path: rare complication of aortic dissection due to interruption of the intercostal and/or lumbar arteries that feed the anterior spinal cord; risk is greater at the T10-T12 levels
Pt: bladde rparesis, motor paresis of the LE, loss of crude touch/pain sensation (anteiror/lateral spinothalamic tracts), and diminished reflexes
255
How long do you do Abx prophylaxis for secondary prevention of rheumatic fever? What Abx is used?
uncomplicated rheumatic fever: 5 years or until age 21
with carditis but no valvular disease: 10 years or until age 21
with carditis + valvular disease: 10 years or until age 40; prophylaxis with intramuscular benzathine penicillin G q4 weeks
256
Path and Pt of thoracic spinal cord ischemia?
path: rare complication of aortic dissection due to interruption of the intercostal and/or lumbar arteries that feed the anterior spinal cord; risk is greater at the T10-T12 levels
Pt: bladde rparesis, motor paresis of the LE, loss of crude touch/pain sensation (anteiror/lateral spinothalamic tracts), and diminished reflexes
257
What are extrahepatic manifestations of chronic Hep C?
1. hematologic: mixed cryoglobulinemia syndrome
2. Renal: membranoproliferative glomerulonephritis
3. dermatologic: PCT, lichen planus
258
What is the biggest cause of morbidity and mortality in cirrhotic patients?
esophageal varices so all patients with cirrhosis should undergo a screening endoscopy to exclude varices
259
What are the steps in mangagement of cirrhosis? How does it change in compensated vs. decompensated?
periodic surveillance of liver function tests (INR, albumin, bilirubin)
Compensated: U/S surveillance for heaptocellular carcinoma +/- AFP q 6 months; EGD varices surveillance
Decompensated:
Assess complications:
1. variceal hemorrhage: start nonselective beta blockers, repeat EGD q 1 year
2. Ascites: dietary sodium restriction, diuretics, paracentesis, abstinence from alcohol
3. hepatic encephalopathy: identify underlying cause, lactulose therapy
260
Path, Pt, Dx, and Tx of anemia of prematurity
Path: impaired erythropoietin production, short RBC life span, iatrogenic blood sampling
Pt: usually asymptomatic; tachycardia, apnea, poor weight gain
DX: low Hgb + Hct, low reticulocyte count; normocytic, normochromic RBC
Tx: minimize blood draws, iron supplementation, transfusions
261
Path, Pt, Dx, and Tx of Wilson's disease
Path: autosomal recessive mutation of ATP7B -> hepatic copper accumulation -> Leak from damaged hepatocytes -> deposits in tissues
Pt: hepatic (acute liver failure, chronic hepatitis, cirrhosis)
Neurologic (Parkinsonism, gait disturbance, dysarthria)
Psych (depression, personality changes, psychosis)
Dx: decreased ceruloplasmin + increased urinary copper excretion; kayser-fleischer rings on slit-lamp examination; increased copper content on liver biopsy
Tx: chelators (D-pincillamine, Tridentine), Zinc (interferes with copper absorption)
262
Path, Pt, Dx, and Tx of cat-scratch disease
Path: bartonella henselae, fastidious gram-negative bacilli; can be transmitted by cat scratch/bite
Pt: papule at scratch/bite site; regional LAD; +/- fever of unknown organ (>/= 14 days)
Dx: clinical +/- serology
Tx: generally self-limiting, azithromycin
263
Carotid artery dissection path, pt, dx, and tx
path: trauma; spontaneous occurrence; underlying contributors: HTN, smoking, connective tissue disease
Pt: unilateral head + neck pain, transient vision loss; ipsilateral partial Horner syndrome (ptosis + miosis without anhidrosis); signs of cerebral ischemia (focal weakness)
Dx: neuromuscular imaging (CT angiography)
Tx: thrombolysis (if = 4.5 hours after sx onset); anti platelet therapy (aspirin) +/- anticoagulation
264
Path, Pt, and Management of uterine inversion
Path: excessive fundal pressure, excessive umbilical cord traction
Pt: lower abdominal pain, round mass protruding through cervix, uterine funds not palpable transabdominally, hemorrhagic shock
Management: aggressive fluid replacement, manual replacement of the uterus, placental removal + uterotonic drugs after uterine replacement
265
Neurofibromatosis type 1 Path and Pt
Path: autosomal dominant NF1 mutation
Pt: cafe-au-lait spots, clustered freckles (axilla, inguinal), Lisch nodules, neurofibromas, optic glioma
266
In what disorder might you develop renal angiomyolipoma?
tuberous sclerosis (also causes facial angiofibromas, hypopigmented ash leaf spots, and shagreen patches
267
In what disorder might you develop retinal hemangioblastoma?
VHL (also causes renal cell carcinoma)
268
What is the management of intrauterine fetal demise based on gestational age?
20-23 weeks: dilation + evacuation OR vaginal delivery
| >/= 24 weeks: vaginal delivery
269
What symptoms indicate that patients should be evaluated for secondary causes of dysmenorrhea?
1. symptom onset at age > 25
2. Unilateral (jnonmidline) pelvic pain
3. No systemic symptoms (fatigue, nausea) during menses
4. Abnormal uterine bleeding (intermenstrual, postcoital spotting)
270
reddish bumps on shins that are painful but not itchy - dx? associated disease?
erythema nodosum associated with IBD (tender, nonpruritic, erythematous, violaceous nodules; a result of a delayed-type hypersensitivity reaction); biopsy would reveal septal panniculitis without vasculitis
also associated with sarcoidosis, Hodgkin lymphoma, and certain infections (streptococcal, endemic fungal, and viral mono)
271
itchy papules and vesicles most prominent on elbows and forearms - dx? disease association?
dermatitis herpetiformis; associated with celiac disease
272
What symptoms can you see with B1 (thiamine) deficiency?
1. beriberi (peripheral neuropathy, HF)
| 2. Wernicke-Korsakoff syndrome
273
What symptoms can you see with B2 (riboflavin)
angular cheilosis, stomatitis, glossitis, normocytic anemia, seborrheic dermatitis
274
What symptoms can you see with B3 (niacin) deficiency?
pellagra (dermatitis, diarrhea, delusions/dementia, glossitis)
275
What symptoms can you see with B6 (pyridoxine) deficiency?
cheilosis, stomatitis, glossitis; irritability, confusion, depression
276
What symptoms can you see with B9 (folate) deficiency?
megaloblastic anemia; neural tube defects (fetus)
277
What symptoms can you see with B12 (cobalamin) deficiency?
megaloblastic anemia; neurologic deficits (confusion, paresthesias, ataxia)
278
What symptoms can you see with vitamin C deficiency?
scurvy (punctate hemorrhage, gingivitis, corkscrew hair)
279
pulmonary sx, CXR, JVD, auscultation, EF, and BNP in TRALI (transfusion-related acute lung injury)
```
Pulmonary sx: acute dyspnea
CXR: diffuse B/L infiltrate
JVD: absent
Auscultation: crackles/rales
EF: normal
BNP: normal
```
280
Pulmonary sx, CXR, JVD, auscultation, EF, BNP in TACO (transfusion-associated circulatory overload)
```
Pulmonary sx: acute dyspnea
CXR: diffuse B/L infiltrate
JVD: present
Auscultation: crackles/rales +/- S3
EF: decreased
BNP: high
```
281
Path, Pt, Tx, and prognosis of food protein-induced allergic proctocolitis
Path: family hx of allergies, eczema, or allergies
Pt: young infant; painless, bloody stools, +/- spit up
Tx: elimination of milk + soy from maternal diet in breastfed infants; hydrolyzed formula in formula-fed infants
Prognosis: spontaneous resolution by 1 year
282
Pt, Dx, and management of autosomal dominant polycystic kidney disease (ADPKD)
```
Pt: asymptomatic until age 30-40; Sx:
- flank pain, hematuria
- HTN
- palpable abdominal mass (usually b/l)
- CKD
Extrarenal features:
- cerebral aneurysms
- hepatic + pancreatic cysts
- mitral valve prolapse, aortic regurgitation
- colonic diverticulosis
- ventral + inguinal hernias
Dx: u/s showing multiple renal cysts
Management:
- aggressive control of risk factors for CV + CKD
- ACE inhibitors for HTN
- hemodialysis, renal transplant for ESRD
```
283
Pt of a brown recluse spider bite
- small ulcer develops at the site of a recent bite
- over the course of a few days, a deep skin ulcer develops at the site of bite with an erythematous halo and a necrotic center, which can progress to an eschar
(avoid debridement in the early stages)
284
Pt of black widow spider bite
- pronounced local and systemic manifestations due to effects of the toxin (muscle pain, abdominal rigidity, muscle cramps)
- N/V within hours of the bite is common
- wound ulceration is uncommon (as opposed to brown recluse bites)
285
What are causes of oligohydramnios? What are complications? What is the AFI cutoff for this dx?
```
AFI < 5 cm
Causes:
- preeclampsia
- abruptio placentae
- utter-placental insufficiency
- renal anomlaies
- NSAIDs
```
Complications:
- meconium aspiration
- preterm delivery
- umbilical cord compression
286
What are causes of polyhydramnios? Complications? What is the AFI cutoff for this dx?
```
AFI >/= 24 cm
Causes:
- esophageal/duodenal atresia
- anencephaly
- multiple gestation
- congenital infection
- DM
```
Complications:
- umbilical cord prolapse
- preterm labor
- preterm premature rupture of membranes
287
When should thyroid nodules be evaluated with FNA?
- thyroid nodules > 1 cm with high-risk sonographic features should undergo FNA (high-risk features = microcalcifications, irregular margins, internal vascularity)
- thyroid nodules > 2 cm should all undergo FNA
288
What is the definition of massive PE? What would you find on workup?
massive PE = PE complicated by hypotension and/or acute right heart strain
- syncope tends to occur only in massive PE
- JVD and RBBB on ECG are signs of acute right heart strain; this along with hypotension is strongly suggestive of massive PE
R heart strain progresses to RV dysfunction -> decreased return to L side of heart -> decreased CO -> L heart pump failure -> bradycardia -> cariogenic shock -> CNS system effects, such as dilated pupils and unresponsive mental status
289
What are the causes of heart failure with preserved LV EF?
1. LV diastolic dysfunction: HTN with concentric LVH, restrictive cardiomyopathy, hypertrophic cardiomyopathy
2. valvular heart disease: aortic stenosis/regurgitation, mitral stenosis/regurgitation
3. Pericardial disease: constrictive pericarditis, cardiac tamponade
4. systemic disorders (high-output failure): thyrotoxicosis, severe anemia, large AV fistula
290
Time of onset, cause, and clinical features of anaphylaxis transfusion reaction with hypotension?
Onset - seconds to minutes
Cause - recipient anti-IgA Abx
Clinical Features - shock, angioedema/urticaria + respiratory distress
291
Time of onset, cause, and clinical features of transfusion-related acute lung injury? (TRALI)
Onset - minutes to hours
Cause - donor anti leukocyte Abx
Clinical features: respiratory distress + noncardiogenic pulmonary edema, bilateral pulmonary infiltrates
292
Time of onset, cause, and clinical features of acute hemolytic transfusion reaction with hypotension?
onset - minutes to hours
Cause - ABO incompatibility
Features - fever, flank pain, hemoglobinuria + DIC
293
Time of onset, cause, and clinical features of bacterial sepsis transfusion reaction with hypotension?
onset - minutes to hours
cause - bacterial contamination of donor product
features - fever, chills, septic shock + DIC
294
Path, Pt, Dx, and Tx of chronic bacterial prostatitis?
Path: young + middle-aged men; increased risk with diabetes, smoking, urinary tract procedure; coliform enter urethra via intrprostatic reflux; E. coli causes > 75% of cases
Pt: recurrent UTI, +/- prostatic tenderness + swelling, pain with ejaculation, Hx of Abx treatment -> transient improvement
Dx: pyuria and bacteriuria on U/S, bacteria in prostatic fluid > bacteria in urine
Tx: fluoroquinolones (cipro) for 6 weeks
295
Pt, Ab, peripheral smear, and bone marrow biopsy of Waldenstrom macroglobulinemia
Pt: hyper viscosity syndrome, neuropathy, bleeding, HSM, LAD
Ab: IgM
Peripheral smear: Rouleaux
Bone marrow biopsy: > 10% clonal B cells
296
Pt, Ab, peripheral smear, and bone marrow biopsy of multiple myeloma
Pt: osteolytic lesions/fractures, anemia, hypercalcemia, renal insufficiency
Ab: IgG, IgA, light chains
Peripheral smear: Rouleaux
BM biopsy: > 10% clonal plasma cells
297
What is the pt of ventilator-associated pneumonia?
Usually occurs >/= 48 hours after intubation
- new pulmonary infiltrates
- increased respiratory secretions
- signs of worsened respiratory status, such as worsening oxygenation, lower tidal volumes, and increased inspiratory pressure
- systemic signs of infection, such as fever, leukocytosis, and tachycardia
298
Pt and DX of asbestosis
Pt: prolonged asbestos exposure (shipyard, mining), symptoms develop >/= 20 years after initial exposure, progressive dyspnea, basilar fine crackles, clubbing, increased risk for lung cancer + mesothelioma
Dx: pleural plaques on chest imaging; imagine, PFT, and histology consistent with pulmonary fibrosis
299
What are possible neuro psych sx of SLE?
acute and chronic psych sx, including psychosis, depression, mania, and anxiety; seizures, HA, peripheral neuropathy, strokes, and chorea
300
What medications should be avoided in myasthenia gravid?
1. magnesium sulfate
2. fluoroquinolones, aminoglycosides
3. neuromuscular blocking agents
4. CNS depressants
5. muscle relaxants
6. CCBs
7. Beta blockers
8. Opioids
9. Statins
301
What is the diagnosis of AAA in an unstable patient?
FAST
302
What are the symptoms of a febrile seizure? When do these patients need to be evaluated for meningitis?
Pt - usually single episode, <15 mins, rapid return to baseline, no signs of intracranial infection, age 6 months - 5 years
Children with the following alarm find gins require LP to r/o meningitis:
- sings of increased ICP (morning HA, vomiting, bulging fontanelle)
- meningeal signs (nuchal rigidity)
- prolonged AMS (poetical period > 10 min)
- petechial rash
- patients outside the typical age range (< 6 months)
303
What is the tx of peritonsillar abscess?
incision and drainage plus Abx therapy to cover Group A hemolytic strep and respiratory anaerobes
304
Pt, ESR and CK of glucocorticoid-induced myopathy
Pt - progressive proximal muscle weakness + atrophy without pain or tenderness
- lower extremity muscles are more involved
ESR and CK both normal
305
Pt, ESR, and CK of polymylagia rheumatica
Pt - muscle pain + stiffness in the shoulder + pelvic girdle; tenderness with decreased ROM at shoulder, neck + hip; responds rapidly to glucocorticoids
ESR elevated, CK normal
306
Pt, ESR, and CK of inflammatory myopathies
Pt - muscle pain, tenderness + Proxima muscle weakness; skin rash + inflammatory arthritis may be present
Elevated ESR and CK
307
Pt, ESR, and CK of statin-induced myopathy
Pt - prominent muscle pain/tenderness with or w/o weakness; rare rhabdomyolysis
Normal ESR, elevated CK
308
Pt, ESR, and CK of hypothyroid myopathy
Pt - muscle pain, cramps, + weakness involving the proximal muscles; delayed tendon reflexes + myxedema; occasional rhabdomyolysis; features of hypothyroidism are present
Normal ESR, elevated CK
309
What is required in workup/dx of Duchenne muscular dystrophy?
Echo and ECG to screen for dilated cardiomyopathy and conduction abnormalities
310
Pt and X-ray findings of transposition of the great vessels in a newborn
Pt: single S2 +/- VSD murmur
| X-ray: egg-on-a-string heart (narrow mediastinum)
311
Pt and X-ray findings of tetralogy of fallot in newborns
Pt: harsh pulmonic stenosis murmur, VSD murmur
| X-ray: boot-shaped heart (RVH)
312
Pt and X-ray findings of tricuspid atresia in newborns
Pt: single S2, VSD murmur
| X-ray: minimal pulmonary blood flow
313
Pt and X-ray of truncus arteriosus in newborns
Pt: single S2, systolic ejection murmur (increased flow through truncal valve)
X-ray: increased pulmonary blood flow, edema
314
Total anomalous pulmonary venous return with obstruction in newborns
Pt: severe cyanosis, respiratory distress
| X-ray findings: pulmonary edema, "snowman" sign (enlarged supra cardiac veins + SVC)
315
What are the possible diagnoses with urine output > 3L (polyuria) and dilute urine?
water diuresis, primary polydipsia, diabetes insipidus
316
What are the possible diagnoses with urine output > 3L (polyuria) and concentrated urine?
osmotic diuresis with increased solute excretion (glucose, urea, saline) (will have a high specific gravity)
317
Leukocyte count, cause, LAP (leukocyte alkaline phosphatase) score, neutrophil precursors, absolute basophilia of leukemoid reaction
```
Leukocyte count: > 50,000
cause: severe infection
LAP score: high
Neutrophil precursors: more mature (metamyelocytes > myelocytes)
Absolute basophilia: not present
```
318
Leukocyte count, cause, LAP (leukocyte alkaline phosphatase) score, neutrophil precursors, absolute basophilia of CML
```
Leukocyte count: > 100,000
cause: BCR-ABL fusion
LAP score: low
Neutrophil precursors: less mature (myelocytes < myelocytes)
Absolute basophilia: present
```
319
What is the management for ventricular tachycardia in a stable vs unstable patient?
stable: IV amiodarone
unstable: synchronized cardio version
320
What rhythm is diagnostic of sustained monomorphic ventricular tachycardia (SMVT)?
regular wide-complex tachycardia with 2 fusion beats
321
What factors increase the malignant probability of solitary pulmonary nodules?
1. large size (>0.8 cm require additional management or surveillance)
2. advance patient age
3. female sex
4. active or previous smoking
5. family or personal history of lung cancer
6. upper lobe location
7. spiculated radiographic appearance
322
Pt with bipolar disorder on Lithium with fatigue, constipation, and myalgias - dx?
hypothyroidism - Lithium will cause hypothyroidism in 25% of patients and another small percentage will have hyperthyroidism; Patients on lithium should have baseline TSH levels and repeated testing q6-12 months
323
If a colposcopy cannot visualize the entire squamocolumnar junction, what is the next step in workup?
best next step in management is endocervical curettage, which can sample tissue from the transformation zone
324
What are the treatment options for bipolar disorder? What medications should be avoided?
```
monotherapy maintenance options: lithium, valproate, quetiapine, and lamotrigine
severe illness (psychosis, aggression, frequent episodes/hospitalizations) requires combo therapy: lithium or valproate combined with a second-generation antipsychotic (quetiapine)
```
Antidepressants should be avoided in maintenance treatment of bipolar I disorder
325
MCV, RDW, RBCs, peripheral smear, serum iron studies, response to iron supplementation, and Hgb electrophoresis of iron deficiency anemia
MCV - decreased
RDW - increased
RBCs - decreased
peripheral smear - microcytosis, hypochromia
serum iron studies - decreased iron + ferritin, increased TIBC
response to iron supplementation - increased hemoglobin
Hgb electrophoresis - nromal
326
MCV, RDW, RBCs, peripheral smear, serum iron studies, response to iron supplementation, and Hgb electrophoresis of alpha-thalassemia minor
MCV - decreased
RDW - normal
RBCs - normal
peripheral smear - target cells
serum iron studies - normal/increased iron and ferritin due to RBC turnover
response to iron supplementation - no improvement
Hgb electrophoresis - normal
327
MCV, RDW, RBCs, peripheral smear, serum iron studies, response to iron supplementation, and Hgb electrophoresis of beta-thalassemia minor
MCV - decreased
RDW - normal
RBCs - normal
Peripheral smear - target cells
Serum iron studies - normal/increased iron + ferritin due to RBC turnover
Response to iron supplementation - no improvement
Hgb electrophoresis - increased Hgb A2
328
When should newborns be started on vitamin D and iron?
all exclusively breastfed infants should be started on 400 IU of Vitamin D bye 1 month of life and started on iron that should be continued until 1 year old
329
Path, Pt, Dx, and Tx of acute interstitial nephritis
Path: drugs (penicillins, TMP-SMX, cephalosporins, NSAIDs)
Pt: maculopapular rash, fever, new drug exposure, +/- arthralgias
Dx: AKI, pyuria, hematuria, WBC casts; eosinophilia, urinary eosinophils; renal biopsy: inflammatory infiltrate, edema
Tx: discontinue offending drug +/- systemic glucocorticoids
330
When is it normal to see endometrial cells reported on Pap tests?
women < 45; women age >/= 45 that have endometrial cells on Pap should undergo endometrial biopsy to r/o endometrial hyperplasia/cancer
331
Path, Pt, Dx, and Tx of emphysematous cholecystitis
Path: DM, vascular compromise, immunosuppression
Pt: fever, RUQ pain, N/V; crepitus in abdominal wall adjacent to gallbladder
Dx: air-fluid level sin gallbladder, gas in gallbladder wall; cultures with gas-forming Clostridium, E. coli; unconjugated hyperbilirubinemia, mildly elevated aminotransferases
Tx: emergency cholecystectomy; broad-spectrum Abx with Clostridium coverage (pip-tazo)
332
How do you diagnosis pancreatitis? (criteria)
Dx requires 2 of the following:
- acute epigastric abdominal pain often radiating to the back
- amylase/lipase > 3 times normal limit
- abdominal imaging showing focal or diffuse pancreatic enlargement with heterogeneous enhancement with IV contrast (CT) or diffusely enlarged and hypo echoic pancreas (u/s)
333
What is the treatment of an epidural hematoma?
urgent surgical evacuation for symptomatic patients
334
What is the rate of cervical dilation for the active phase of labor? What cervical dilation defines active labor?
active labor = 6-10 cm cervical dilation; cervical dilation of >/= 1 cm q 2 hours
335
disruptive mood dysregulation Pt
patients have irritable mood accompanied by repetitive temper outbursts (verbal or physical) that are out of proportion to the stimulus and inconsistent with developmental level; sx manifest prior to age 10
336
Which bugs are under airborne isolation precautions?
Bacteria: TB
Viral: varicella, SARS, measles
337
Which bugs are under contact isolation precautions?
- Multidrug resistant organisms: MRSA, VRE
- Enteric: C. diff, E. coli O157:H7
- Parasite: scabies
- Viral: RSV
338
Which bugs are under droplet isolation precautions?
Bacterial: N. meningitidis, H. flu type B, Mycoplasma pneumoniae
Viral: influenze, adenovirus
339
Path/Pt of acute stump pain as a cause of post-amputation pain
- tissue and nerve injury
| - severe pain lasting 1-3 weeks
340
Path/Pt of ischemic pain as a cause of post-amputation pain
- wound breakdown
- decreased transcutaneous oxygen tension
- swelling, skin discoloration
341
Path/Pt of post-traumatic neuroma as a cause of post-amputation pain
- weeks to months after amputation
- focal tenderness, altered local sensation
- decreased pain with anesthetic injection
342
Path/Pt of phantom limb pain as a cause of post-amputation pain
- onset usually within 1 week
- increased risk in patients with severe acute pain
- intermittent cramping, burning felt in distal limb
343
Perilymphatic fistula path, pt, dx, and tx
Path: complication of head injury or barotrauma; leakage of endolymph from the semicircular canals and cochlea into surrounding tissues
Pt:
- progressive sensorineural hearing loss caused by damage to cholera hair cells from loss of endolymph
- episodic vertigo with nystagmus triggered by pressure changes in the inner ear
Dx: Tullio phenomenon (large clap induces vertigo/nystagmus)
Tx: limit activities that increase inner ear pressure; ENT referral
344
Pt of intrahepatic cholestasis of pregnancy
present in the third trimester with generalized pruritus that is worse on the plasma and soles
345
polymorphic eruption of pregnancy pt
pruritic, erythematous papules in the third trimester that starts within the abdominal striae and spares the palms and soles
346
timing after intercourse, efficacy, and contraindications to copper-containing IUD as emergency contraception
timing after intercourse: 0-120 hr
Efficacy: >/= 99%
C/I: acute pelvic infection, severe uterine cavity distortion, Wilson disease, complicated organ transplant failure
347
timing after intercourse, efficacy, and contraindications to ulipristal as emergency contraception
Timing after intercourse: 0-120 hr
Efficacy: 98-99%
C/I: none
348
timing after intercourse, efficacy, and contraindications to levonorgestrel as emergency contraception
Timing after intercourse: 0-72 hr
Efficacy: 59-94%
C/I: none
349
timing after intercourse, efficacy, and contraindications to oral contraceptives as emergency contraception
Timing after intercourse: 0-72 hr
Efficacy: 47-89%
C/I: none
350
thyroid nodule with Low TSH -> next step?
radioactive iodine scintigraphy
351
What are the possible results and next steps after evaluating a thyroid nodule with radioactive iodine scintigraphy?
hypofunctional/cold or indeterminate nodule -> consider FNA based on size and u/s findings
hyper functional (hot) nodule -> treat hyperthyroidism
352
What are the indications for prophylactic administration of anti-D immunoglobulin for Rh(D)-negative patients?
1. at 28-32 weeks gestation
2. < 72 hours after delivery of Rh(D)-positive infant
- < 72 hours after spontaneous abortion
- Ectopic pregnancy
- Threatened abortion
- Hydatidiform mole
- Chorionic villus sampling, amniocentesis
- Abdominal trauma
- 2nd and 3rd trimester bleeding
- External cephalic version
353
Path, Pt, and Dx of aplastic anemia
Path: bone marrow failure due to hematopoietic stem cell deficiency (CD34+)
Pt: autoimmune, infections (parvo B19, EBV), drugs (carbamazepine, chloramphenicol, sulfonamides), exposure to radiation or toxins (benzene, solvents)
Dx: Labs: pancytopenia
- anemia (fatigue, weakness, pallor)
- thrombocytopenia (mucosal bleeding, easy bruising, petechiae)
- leukopenia (recurrent infections)
Biopsy: hypocellular bone marrow with fat and stroll cells
354
What Pt/Labs indicate malabsorption as a secondary cause of bone loss
Pt - diarrhea, weight loss
| Dx - decreased 25-hydroxyvitamin D, decreased urine calcium excretion
355
What Pt indicates hyperthyroidism as a secondary cause of bone loss?
Pt - weight loss, heat intolerance, tremor, goiter
356
What Pt indicates hypercortisolism as a secondary cause of bone loss?
central obesity/cushingoid habitus; hyperglycemia
357
What pt indicates hyperparathyroidism as a secondary cause of bone loss?
hypercalcemia; hypercalciuria; kidney stones
358
What pt/labs indicate an inflammatory disorder as a secondary cause of bone loss?
joint pain, morning stiffness; elevated ESR and CRP
359
What pt indicates hypogonadism as a secondary cause of bone loss? (for men vs. women)
females: amenorrhea, WL, anorexia
males: decreased libido, ED, loss of body hair
360
What pt/labs indicate multiple myeloma as a secondary cause of bone loss?
anemia; hypercalcemia, elevated Cr
361
Risk factors, Pt, Dx, and Tx of cervicofacial actinomyces
Risk factors: dental infections + trauma (extraction); immunosuppression, diabetes mellitus, malnutrition
Pt: upper/lower jaw (mandible); slowly progressive, on painful, indurated mass; sinus tracts with sulfur granules; fever/LAD are uncommon
Dx: FNA, culture >14 days
Tx: penicillin 2-6 months; surgery if severe
362
Path, Pt, Labs, and Tx of milk-alkali syndrome
Path: excessive intake of Ca + absorbable alkali; renal vasoconstriction + decreased GFR; renal loss of Na + water, reabsorption of bicarbonate
Pt: N/V/C, polyuria, polydipsia, neuropsych sx
Labs: hypercalemia, metabolic alkalosis, AKI, suppressed PTH
Tx: discontinuation of causative agent, isotonic saline followed by furosemide
363
What is the best diagnostic test for a patient with signs and sx of adrenal insufficiency?
250 microgram cosyntropin stimulation test with cortisol + ACTH levels
364
You have a patient with low basal cortisol, high ACTH, and minimal cortisol response to cosyntropin following ACTH stimulation test- Dx?
primary adrenal insufficiency
365
You have a patient with low basal cortisol, low ACTH, and minimal or suboptimal cortisol response to cosyntropin following ACTH stimulation test - dx?
secondary or tertiary adrenal insufficiency
366
What is a normal response to ACTH stimulation test, and what does it indicate?
normal response = cortisol level > 20 30-60 minuets after cosyntropin; unlikely to be adrenal insufficiency and you should investigate other causes
367
What is the pt and management of organophosphate poisoning?
Pt: DUMBELS:
Diarrhea/diaphoresis, Urination, Miosis, Bronchospasm, bronchorrhea, bradycardia, Emesis, Lacrimation, Salivation
Nicotinic: muscle weakness, paralysis, fasciculations
Management: remove patients clothes, irrigate skin; atropine reverses muscarinic sx, pralidoxime reverses nicotinic and muscarinic sx
(gas is colorless, tasteless, and has a slight, fruity odor)
368
What Abs are commonly associated with RA?
RF and Anti-CCP (highly specific)
369
What Abs are commonly associated with SLE?
ANA (95% sensitive) and Anti-dsDNA/anti-Smith (96% specific)
370
What Abs are commonly associated with drug-induced lupus?
ANA (95% sensitive) and Antihistone (95% specific)
371
What Abs are commonly associated with diffuse systemic sclerosis?
ANA (95% sensitive) and Anti-Scl-70 (99% specific)
372
What Abs are commonly associated with limited systemic sclerosis?
ANA (95% sensitive) and Anticentromere (97% specific)
373
What Abs are commonly associated with polymyositis/dermatomyositis?
ANA (75% sensitive) and Anti-Jo-1 (99% specific)
374
Risk factors, Pt, and Tx of vaginal hematoma
Risk factors; operative vaginal delivery; infant >/= 4000g (8.8 lbs); nulliparity; prolonged 2nd stage of labor
Pt: vaginal mass, rectal or vaginal pressure, +/- hypovolemic shock
Tx: non expanding: observation
expanding: embolization, surgery
375
What are the causes of primary (testicular) hypogonadism in men?
1. congenital (Klinefelter, cryptorchidism)
2. Drugs (alkylating agents, ketoconazole)
3. Orchitis (mumps), trauma, torsion
4. CKD
376
What are the causes of secondary (pituitary/hypothalamic) hypogonadism in males?
1. Gonadotroph damage: tumor, cranial trauma, infiltrative diseases (hemochromatosis), apoplexy
2. Gonadotropin suppression: exogenous androgens, hyperprolactinemia, diabetes mellitus, morbid obesity
377
What are two causes of male hypogonadism that are mixed primary + secondary causes?
hypercortisolism and cirrhosis
378
What are symptoms of metastatic testicular cancer?
dyspnea, neck mass, low back pain
379
Risk factors, Pt, Tx, and prognosis of Dressler syndrome/post-cardiac injury
Risk factors: MI, cardiac surgery o trauma, percutaneous coronary c
Pt: latent period of several weeks to months; pleuritic cost pain, fever, leukocytosis
CXR: pleural effusion +/- enlarged cardiac silhouette; echo: pericardial effusion
Tx: non steroidal anti-inflammatory drugs + colchicine; corticosteroids in refractory disease
Prognosis: usually self-limited disease course; may cause chronic/recurrent disease leading to constrictive pericarditis
380
What is a consequence of untreated hyperthyroidism?
rapid bone loss leading to osteoporosis and increased risk of fracture )thyroid hormones cause increased osteoclastic bone resorption
381
Path, Pt, and management of pubertal gynecomastia
Path: imbalance of estrogens + androgens during mid puberty (tanner stage 3-4)
Pt: small (<4cm), firm, U/L or B/L subareolar mass; no pathologic features (eg nipple discharge, axillary LAD, systemic illness)
Management: reassurance + observation; resolves within 1 year
382
BUN/Cr ratio, urine Na, fractional excretion of Na, urine osmolality, urine specific gravity, and microscopy of prerenal AKI
```
BUN/Cr ratio: typically > 20
Urine Na: < 20
Fractional excretion of Na: < 1%
Urine osmolality: > 500 mOsm/kg
Urine spec idic gravity: > 1.020
Microscopy: bland
```
383
BUN/Cr ratio, urine Na, fractional excretion of Na, urine osmolality, urine specific gravity, and microscopy of acute tubular necrosis
```
BUN/Cr ratio: typically normal (~10-15)
Urine Na: > 40
Fractional excretion of Na: >2%
Urine osmolality: ~300 mOsm/kg
Urine specific gravity: < 1.020
Microscopy: muddy brown casts
```
384
What are intervention to reduce intracrhail pressure via decreased brain parenchymal volume?
osmotic therapy (hypertonic saline, mannitol) to extract water
385
What are interventions to reduce intracranial pressure via decreased cerebral blood volume?
- head elevation to increase venous outflow
- sedation to decrease metabolic demand
- hyperventilation to decrease PaCO2, resulting in vasoconstriction
386
What are interventions to reduce intracranial pressure via decreasing CSF volume?
CSF removal (external ventricular drain)
387
What are interventions to reduce intracrhail pressure via increased cranial volume?
decompressive craniectomy
388
Pt, Tx, and disease associations of lichen planus
Pt:
- 5 "Ps": pruritic, purple/pink, polygonal, papules + plaques
- lacy, white network of lines (Wickham striae)
- Locations: skin (ankles, wrists), oral mucosa (white papules + plaques +/0 erythema, mucosal atrophy, ulcers), genitalia
Tx: topical high-potency glucocorticoids (betamethasone); widespread lesions: systemic glucocorticoids, phototherapy
Disease associations: hep C; medications: ACE inhibitors, thiazide diuretics
389
What should you look for in a patient that has bacteremia with Clostridium septicum?
colon cancer
390
neonate with rhinorrhea, diffuse maculopapular rash that desquamates, abnormal long-bone radiographs - Dx? Tx?
congenital syphillis; Tx is with penicillin to prevent late manifestations (frontal bossing, saddle nose, Hutchison teeth)
391
What lab abnormalities do you expect with Paget disease of the bone?
- elevated alkaline phosphatase
- elevated bone turnover markers (PINP, urine hydroxyproline)
- Calcium + phosphorus are normal
392
What are the criteria/scores for CHA2DS2-VASc scoring?
```
C - CHF
H - HTN
A - age >/= 75 = 2 points
D - DM
S - stroke/TIA/thromboembolism = 2 points
V - vascular disease (prior MI, PAD, or aortic plaque)
A - age 65-74
Sc - sex (female)
```
```
0 = Low store risk; no antithrombotic tx
1 = intermediate stroke risk; no tx or aspirin or oral anticoagulants
>/= 2 = high stroke risk; oral anticoagulants
```
393
What are the cardiac effects of acromegaly?
concentric myocardial hypertrophy -> diastolic dysfunction along with left ventricular dilation and global hypokinesis; complications include heart failure and arrhythmias
394
What is the treatment for inpatient tx of PID?
IV cefoxitin or cefotetan plus oral doxy
or IV clinda plus gentamicin
395
Path, Pt, and Tx of otosclerosis
Path: younger (early to mid 30s), caucasian, women > men; autosomal dominant with incomplete penetrance; imbalance of bone resorption + deposition -> stiffening of stapes
Pt: progressive conductive hearing loss, paradoxical improvement in speech discrimination in noisy environments; +/- reddish hue behind tympanic membrane
Tx: amplification (hearing aids); surgery (stapes reconstruction)
396
65 year old man with WL, constant epigastric pain, hx of smoking, DM - concern for what?
pancreatic cancer (get abdominal CT)
397
Causes, Pt, and Management of anorectal fistula
Causes: perianal abscess, Crohn disease, malignancy, radiation proctitis, infection (lymphogranuloma venereum)
Pt: perirectal pain, discharge; inflammatory papule/pustule; palpable fistula tract
Management: assess extent of fistula (gentle problems, imaging), surgery
398
Path, Pt, Dx, and Tx of selective IgA deficiency
Path: most common primary immune deficiency
Pt: usually asymptomatic; recurrent sinopulmonary + GI infections; associated with autoimmune disease (celiac) + atopy (asthma, eczema); anaphylaxis during transfusions
Dx: low or absent IgA; normal IgG, IgM levels, B cells
Tx: supportive care; medical alert bracelet for transfusion reactions
399
Describe renal vein thrombosis as a complication of nephrotic syndrome
loss of antithrombin III in the urine increases the risk of venous and arterial thrombosis. Thrombosis of the renal vein can be acute and present with abdominal pain, fever, and hematuria
400
Causes, Pt, and Management of spinal cord compression
Causes: spinal injury (MVC), malignancy (lung, breast, prostate cancer, myeloma; infection
Pt:
- gradually worsening, severe local back pain
- pain worse in the recumbent position/at night
- early signs: symmetric LE weakness, hypoactive/absent DTR
- late signs: B/L babinski reflex, decreased rectal sphincter tone, paraparesis/paraplegia with increased DTRs, sensory loss
Management: emergency MRI; IV glucocorticoids vs Abx; neurosurgery +/- radiation oncology consult
401
autoimmune metaplastic atrophic gastritis (AMAG) Path
autoimmune disorder that affects women > men; patients with other autoimmune conditions are at increased risk
Presence of Abs toward parietal cells, resulting atrophy and metaplasia of the gastric corpus, hypochlorhydria, and unchecked gastrin production; Abs toward intrinsic factor as well, resulting in Vitamin B12 def
402
What prolactin level is diagnostic of a prolactinoma? What would you expect to see on labs?
>200 ng/mL; low testosterone, low LH or inappropriately normal LH, low or normal TSH
403
Path, Pt, and Tx of Eustachian tube dysfunction
Path: inflammation (infection ,allergies, environmental irritation) -> tube obstruction
Pt: ear fullness/discomfort, tinnitus, conductive hearing loss, "popping" sensation
Tx: treat underlying cause (Abx for acute bacterial rhinosinusitis)
404
What findings are concerning for abuse in a child? What additional evaluation is warranted when abuse is suspected?
multiple fractures at various stages of healing, posterior rib fractures, skull fractures, and femur fractures in nonambulatory infants; additional evaluation includes fundoscopy to evaluate for retinal hemorrhages plus a CT scan of the head to assess for intracranial bleeding
405
Pt of a fractured clavicle as a complication of shoulder dystocia
- clavicular crepitus/bony irregularity
- decreased Moro reflex due to pain on affected side
- Intact biceps + grasp reflexes
406
Pt of a fractured humerus as a complication of shoulder dystocia
- upper arm crepitus/bony irregularity
- decreased Moro reflex due to pain on affected side
- Intact biceps and grasp reflexes
407
Pt of Erb-Duchenne palsy as a complication of shoulder dystocia
- decreased Moro + biceps reflexes on affected side
- Waiter's tip: extended elbow, pronated forearm, flexed wrist + fingers
- Intact grasp reflex
408
Pt of Klumpke palsy as a complication of shoulder dystocia
- claw hand: extended wrist, hyperextended metacarpophalangeal join's, flexed interphalangeal joints, absent grasp reflex
- Horner syndrome (ptosis, mitosis)
- Intact Moro + biceps reflexes
409
Perinatal asphyxia as a complication of shoulder dystocia
- variable presentation depending on duration of hypoxia
| - Altered mental status (irritability, lethargy), respiratory or feeding difficulties, poor tone, seizure
410
Path, Pt, and Dx of congenital Zika syndrome
Path: single-stranded RNA Flavivirus; transplacental transmission to fetus; targets neural progenitor cells
Pt: microcephaly, craniofacial disproportion, neurologic abnormalities (spasticity, seizures); ocular abnormalities
Dx: neuroimaging: calcifications, ventriculomegaly, cortical thinning, Zika RNA detection
411
What are the risk factors for uterine rupture?
1. prior uterine surgery (CS, myomectomy)
2. induction of labor/prolonged labor
3. congenital uterine anomalies
4. fetal macrosomia
412
What is the pt and management of uterine rupture?
Pt - vaginal bleeding, intraabdominal bleeding (hypotension, tachycardia), fetal heart decelerations, loss of fetal station, palpable fetal parts on abdominal examination, loss of intrauterine pressure
Management: laparotomy for delivery and uterine repair
413
Path, Pt, Labs, and Radiology of multiple myeloma
Path: plasma cell neoplasm producing monoclonal paraprotein (immunoglobulin)
Pt: bone pain, fractures; constitutional symptoms (weight loss, fatigue), recurrent infections
Labs: normocytic anemia, renal insufficiency, hypercalcemia (constipation, muscle weakness), monoclonal paraproteinemia (M-spine)
Radiology: osteolytic lesions/osteopenia (osteoclast activation)
414
Major causes and Pt of primary ovarian insufficiency? What is the management?
Major causes: turner syndrome (45, XO), fragile X syndrome (FMR1 permutation), autoimmune oophoritis, anticancer drugs, pelvic radiation, galactosemia
Pt: amenorrhea at age <40, hypoestrogenic symptoms (hot flashes), increased FSH, decreased estrogen
Management: estrogen therapy (with progestin if intact uterus)
415
Path, Pt, Dx, Tx of medullary thyroid cancer
Path: neuroendocrine malignancy arising from the calcitonin-secreting parafollicular C cells; most sporadic but 25% due to RET mutation (MEN2 with pheochromocytoma, and either parathyroid hyperplasia (2A) or marfanoid habitus and mucosal neuromas (2B))
Pt: most commonly as an asymptotic thyroid nodule; minority of patients have diarrhea and flushing; serum Ca2+ is usually normal
Dx: confirmed with FNA
Tx: total thyroidectomy and thyroid replacement
416
How can you monitor recurrence of medullary thyroid cancer?
serum calcitonin levels correlate with the risk of metastasis and are measure at the time of diagnosis; they also correlate with risk of recurrence and are therefore measured serially following surgery; CEA also correlates with disease progression and is typically measured with calcitonin
417
Risk factors, Pt, Dx of acute mesenteric ischemia
Risk factors: atherosclerosis (acute or chronic), embolic source (thrombus, vegetations), hypercoagulable disorders
Pt: rapid onset of periumbilical pain (often severe), pain out of proportion to exam findings, hematochezia (late complication)
Dx: leukocytosis, elevated amylase and phosphate levels; metabolic acidosis (elevated lactate); CT (preferred) or MR angiography; mesenteric angiography if dx is unclear
418
Defect, Etiology, and Na levels of primary polydipsia
Defect: increased water intake
Etiology: antipsychotics, anxious, middle-aged women
Na: low Na
419
Defect, Etiology, and Na levels of central DI
Defect: decreased ADH release from pituitary
Etiology: idiopathic, trauma, pituitary surgery, ischemic encephalopathy
Na: high serum Na
420
Defect, Etiology, and Na levels of nephrogenic DI
Defect: ADH resistance in kidney
Etiology: chronic lithium use, hypercalcemia, hereditary (AVPR2 mutations)
Na level: normal serum Na
421
Pt of CMV reactivation
viremia and/or tissue-invasive disease; the GI tract is the most common organ system affected, and patients usually manifest symptoms of colitis or enteritis, including fever, malaise, vomiting, bloody diarrhea, and abdominal pain; lab studies often show cytopenias and peripheral blood smear shows atypical lymphocytes; typically have multiple, large, shallow erosions or ulcers on colonoscopy
Tx: antivirals (gancicilovir) and a reduction of immunosuppressant meds usually required
422
Pt presents with amaurosis fugax (painless, rapid, and transient monocular vision loss - what is the most likely dx?
most common etiology of amaurosis fugax is retinal ischemia due to atherosclerotic emboli originating from the ipsilateral carotid artery (get duplex u/s of neck)
423
Path, Pt, Dx, and Tx of pneumocystis pneumonia?
Path: AIDS (CD4 < 200), immunosuppressive meds
Pt: indolent (AIDS) or acute respiratory failure (immunosuppressive treatment); dyspnea, hypoxia, dry cough, fever; increased LDH, diffuse b/l reticulonodular infiltrates on pulmonary imaging
Dx: induced sputum or brochoalveolar lavage
Tx: TMP-SMX +/- corticosteroids; antiretroviral (in AIDS)
424
Path, Pt, Dx, and Tx of human monocytic ehrlichiosis
Path: transmitted by tick vector (lone start tick); seen in southeastern and south central US
Pt: flu-like illness (high fever, HA, myalgias, chills); neurologic sx (confusion); rash is uncommon
Dx: leukopenia + thrombocytopenia; elevated liver enzymes and LDH; intracytoplasmic morulae in monocytes; PCR testing for E chaffeensis/E ewingii
Tx: empiric doxycycline while awaiting confirmatory testing
425
Which drugs can cause drug-induced rhabdomyolysis due to direct myotoxicity?
statins, fibrates; colchicine, ethanol, cocaine
426
Which drugs can cause drug-induced rhabdomyolysis due to vasoconstrictive ischemia?
cocaine, amphetamines
427
Which drugs can cause drug-induced rhabdomyolysis due to prolonged immobilization (compression ischemia)?
ethanol, opioids, benzodiazepines
428
Hx, murmur features, and workup needed of benign murmurs of a child
Hx: normal appetite, energy, activities and growth; no significant family Hx
Murmur features: early or mid-systolic; grade I or II intensity that decreases on standing + Valsalva; low-pitched, musical, pure, or squeaky tone at LLSB (Still's murmur) or high-pitched at LUSB (pulmonary flow murmur)
No workup needed
429
Hx, murmur features, other findings, and workup of a pathologic murmur of a child?
Hx: diaphoresis + fatigue with feeding or exercise, poor weight gain, chest pain, dizziness, syncope, SOB; family Hx of sudden cardiac death, heart defects, etc
Murmur features: harsh, holosystolic, diastolic; grade III intensity or higher; increases with standings + valsalva maneuver
Other findings: loud, fixed split, or single S2; decreased or absent femoral pulses
Workup: ECG (to assess for hypertrophy), Echo (to assess for structural abnormalities), cardiology referral
430
What are the characteristics of deliberate burns?
deliberate immersion burns usually involve the buttocks, back, and legs if the child is forced into a bathtub of hot water; they typically spare flexural creases due to ankle, knee, and hip flexion at the time of immersion; a stock or glove burn distribution with a sharp line of demarcation and uniform burn depth may also be seen; an absence of burn in the distribution of splash marks is often noted as well
431
Path and Pt of Sheehan syndrome
Path: obstetric hemorrhage complicated by hypotension; postpartum pituitary infarction
Pt: lactation failure (decreased prolactin), amenorrhea, hot flashes, vaginal atrophy (decreased FSH, LH), fatigue, bradycardia (decreased TSH), anorexia, weight loss, hypotension (decreased ACTH), decreased lean body mass (decreased growth hormone)
432
Pt, Dx, and Tx of spontaneous bacterial peritonitis
Pt: temp > 100; abdominal pain/tenderness; AMS; hypotension, hypothermia, paralytic ileus with severe infection
Dx from ascitic fluid: PMNs >/= 250, positive culture with often gram-neg organisms (E. coli, Klebsiella); protein < 1g/dL, SAAG >/= 1.1 g/dL
Tx: empiric Abx - 3rd gen chephalosporins; fluoroquinolones for SBP prophylaxis
433
What are the causes of prerenal AKI? Pt?
Causes: decreased renal perfusion (true volume depletion, decreased EAVB (heart failure, cirrhosis), displacement of intravascular fluid (sepsis, pancreatitis), renal artery stenosis, afferent arteriole vasoconstriction (NSAIDs))
Pt: increase in serum creatinine (50% from baseline), decreased urine output, BUN/Cr ratio >20:1, fractional excretion of sodium <1%, unremarkable ("bland") urine sediment
434
What are the causes of hypercapnia?
1. decreased central respiratory drive (drugs like opioids and benzos, CNS trauma, stroke, or encephalitis)
2. decreased respiratory neuromuscular function (spinal cord lesions, ALS, myasthenia gravis)
3. decreased thoracic cage or pleural function (obesity hypoventilation syndrome, pneumothorax, rib fractures, flail chest)
4. airway obstruction (OSA, COPD)
5. impaired gas exchange (cariogenic pulmonary edema, interstitial lung disease)
435
Pt, Labs, and Tx of acute fatty liver of pregnancy
Pt: N/V, RUQ/epigastric pain, fulminant liver failure
Labs: profound hypoglycemia, increased aminotransferases (2-3x), increased bilirubin, thrombocytopenia, DIC
Management: immediate delivery
436
Results of Rinne/Weber in a normal ear, conductive hearing loss, sensorineural hearing loss, and mixed hearing loss
Normal:
Rinne = AC > BC in both ears; Weber = midline
Conductive hearing loss:
Rinne = BC > AC in affected ear; AC > BC in unaffected ear; Weber = lateralizes to affected ear
Sensorineural hearing loss:
Rinne AC > BC in both ears; Weber = lateralizes to unaffected ear, away from affected ear
Mixed hearing loss:
BC > AC in affected ear; AC > BC in unaffected ear; Weber = lateralizes to unaffected ear, away from affected ear
437
What is considered low urine osmolality and low urine specific gravity? high serum osmolality? What would all of these collectively indicate?
low urine osmolality = < 300 mOsm/kg and low urine specific gravity = <1.006; high serum osmolality = > 250 mOsm/kg; reflect inappropriately dilute urine
438
Path, Pt, Dx, and Tx of ALL
Path: most common childhood cancer; peak age 2-5 yo; male > female
Pt: nonspecific systemic symptoms, bone pain, LAD, HSM, pallor (from anemia), petechia (from thrombocytopenia)
Dx: bone marrow biopsy with >25% lymphoblasts
Tx: multidrug chemotherapy
439
What is the management of acute low back pain (< 4 weeks)?
1. maintain moderate activity
2. NSAIDs or acetaminophen
3. Consider: muscle relaxants, spinal manipulation
440
What is the management for subacute (4-12 weeks) and chronic (>12 weeks) low back pain?
1. intermittent use of NSAIDs or acetaminophen
2. Exercise therapy (stretching.strengthening, aerobic)
3. Consider: TCAs, duloxetine
441
Pt, Dx criteria, and Tx of acute bacterial rhinosinusitis?
Pt: cough, nasal discharge; fever; face pain/HA
Dx criteria: (need 1 of 3):
1. persistent symptoms >/= 10 days without improvement
2. Severe onset (fever > 102.2 + drainage) >/= 3 days
3. Worsening symptoms following initial improvement
Tx: amoxicillin +/- clavulanate
442
Path, Pt, and Dx of malignant biliary obstruction
Path: cholangiocarcinoma, pancreatic/hepatocellular carcinoma, metastasis (colon, gastric)
Pt: jaundice, pruritus, acholic stools, dark urine; WL, RUQ pain, RUQ mass or hepatomegaly; increased direct bilirubin, /ALP, GGT
Dx: serum tumor markers (CEA, CA-19, AFP), abdominal imaging (u/s, CT scan); EUS or ERCP for tissue Dx if unclear)
443
Pt of ischemic/thrombotic major stroke
1. atherosclerotic risk factors (uncontrolled HTN, diabetes), +/- history of TIA
2. local obstruction of an artery (carotid, cerebral, vertebral)
3. Symptoms may alternate with periods of improvement
444
Pt of ischemic/embolic major stroke
1. history of cardiac disease (a fib, endocarditis) or carotid atherosclerosis
2. Onset of symptom abrupt and usually maximal at the start
3. multiple infarct sin different vascular territories
445
Pt of intracerebral hemorrhage major stroke
1. hx of uncontrolled HTN, coagulopathy, illicit drug use (amphetamines, cocaine)
2. Symptom progression over minutes to hours
3. Focal neurologic symptoms that appear early, followed by features of increased intracranial pressure (vomiting, HA, bradycardia, reduced alertness)
446
Pt of spontaneous subarachnoid hemorrhage major stroke
1. bleeding from arterial saccular (berry) aneurysm or arteriovenous malformation
2. severe HA at onset
3. meningeal irritation (neck stiffness)
4. focal deficits uncommon
447
What are the causes of neonatal polycythemia? What is the definition?
definition of neonatal polycythemia = Hct > 65% in term infants
Causes:
1. increased erythropoiesis from intrauterine hypoxia: maternal diabetes, HTN, or smoking; IUGR
2. Erythrocyte transfusion: delayed cord clamping; twin-twin transfusion
3. Genetic/metabolic disease: hypothyroidism or hyperthyroidism; genetic trisomy (13, 18, 21)
448
What is the definition, Pt, and Tx of neonatal polycythemia?
definition: Hct >65% in term infants
Pt: asymptomatic (most common), ruddy skin, hypoglycemia, hyperbilirubinemia, respiratory distress, cyanosis, apnea; irritability, jitteriness, abdominal distension
Tx: IV fluids, glucose, partial exchange transfusion
449
audible S3 gallop - valvular dysfunction? path?
severe MR; results from the sudden cessation of blood flow into a dilated LV during the passive filling phase of diastole (S3 gallop can also be heard with heart failure)
450
What are the symptoms of sarcoidosis based on the body systems?
pulmonary: hilar LAD, interstitial infiltrates
cutaneous; papules, nodules + plaques; erythema nodosum
ophthalmologic: anterior + posterior uveitis; keratoconjunctivitis sicca
neurologic: facial nerve palsy, central DI, hypogonadotropic hypogonadism
CV: AV block; dilated or restrictive cardiomyopathy
GI: HSM, asymptomatic LFt abnormalities
Other: hypercalcemia, peripheral LAD, parotid gland swelling, poly arthritis, fever, malaise
451
Path, Pt, Labs, Tx, and complications of primary biliary cholangitis
Path; autoimmune destruction of intrahepatic bile ducts; affects middle-aged women
Pt: insidious onset of fatigue + pruritus; progressive jaundice, hepatomegaly, cirrhosis; cutaneous xanthomas + xanthelasmas
Labs: cholestatic pattern of livery injury (very elevated alkaline phosphatase; elevated aminotransferases); antimitochondrial Ab; severe hypercholesterolemia
Tx: ursodexoycholic acid (delays progression); liver transplant for advanced disease
Complications: malabsorption, fat-soluble vitamin deficiencies, metabolic bone disease (osteoporosis, osteomalacia); hepatocellular carcinoma
452
What two diseases are associated with primary sclerosing cholangitis?
ascending cholangitis and ulcerative colitis
453
Path, Screening, Management, target blood glucose levels, and postpartum management of gestational diabetes mellitus
Path: human placental lactogen secretion
Screening: 24-28 weeks gestation; 1 hour 50g glucose challenge test; 3 hour 100g glucose tolerance test
Management: 1st line: diet; 2nd line: insulin, glyburide, metformin
Target blood glucose goals:
- Fasting: <95
- 1 hour postprandial: <140
- 2 hour postprandial: <120
Postpartum management; fasting glucose at 24-72 hours; 2 hour 75g glucose tolerance test at 6-12 week visit
454
What medications can cause hyperkalemia?
1. nonselective beta blockers: inhibit beta-2- mediated intracellular potassium uptake
2. ACE inhibitors: inhibit Angiotensin II formation, leading to decreased aldosterone secretion
3. ARBs: inhibit AT1 receptor, leading to decreased aldosterone secretion
4. K+-sparking diuretics: inhibit ENaC or aldosterone receptor
5. cardiac glycosides (digoxin): inhibit the Na+/K+-ATPase pump
6. NSAIDs: inhibit local prostaglandin synthesis, leading to decreased renin + aldosterone secretion
455
What imaging modality should be used in a patient with suspected aortic dissection with renal disease?
transesophageal echocardiography (CT angiography is preferred in other hemodynamically stable patients, but it requires iodinated contrast
456
Path, Pt, and Management of Chikungunya fever
Path: tropical/subtropical parts of central/South America, Africa, and Asia; vector: aides mosquito (also transmits dengue + zika)
Pt: incubation period: 3-7 days; high fevers + severe polyarthralgias (almost always present); HA, myalgias, conjunctivitis, maculopapular rash; lymphopenia, thrombocytopenia, transaminitis
Management: supportive care; chronic arthrlagias/arthritis occur in >50%
457
What acid base abnormality is expected in PE? What do you expect this to do to calcium?
respiratory alkalosis; will decreased calcium; increased extracellular PH will cause hydrogen ions to dissociate from albumin, freeing up the albumin to bind with calcium
458
What are the nonseminomatous forms of germ cell testicular tumors? What markers would be elevated? What are elevated with seminoma tumors?
nonseminomatous germ cell tumors: yolk sac tumor, choriocarcinoma, and embryonal carcinoma (mixed germ cell tumor is also possible)
most patients with a nonseminomatous germ cell tumor have an elevated AFP with a considerable amount also having elevated beta-hCG
seminomas have elevated beta-hCG in 1/3 patients but aFP is essentially always normal
459
Gross motor, fine motor, language, and social/cognitive developmental milestones at 12 months old
Gross motor: stand well, walks first steps independently, throws a ball
Fine motor: 2-finger pincer grasp
Language: says first words (other than "mama" + "dada")
Social/cognitive: separation anxiety, follows 1-step commands with gestures
460
Gross motor, fine motor, language, and social/cognitive developmental milestones at 18 months old
Gross motor: runs, kicks a ball
Fine motor: builds a tower of 2-4 cubes, removes clothing
Language: 10 to 25 word vocabulary; identifies >/= 1 body parts
Social/Cognitive: understands "mine" + begins pretend play
461
Gross motor, fine motor, language and social/cognitive developmental milestones at 2 years old
Gross motor: walks up.down stairs with both feet on each step, jumps
Fine motor: builds a tower of 6 cubes, copies a line
Language: vocabulary >/= 50 words; 2 word phrases
Social/cognitive: follows 2-step commands, parallel play, begins toilet training
462
Gross motor, fine motor, language, and social/cognitive developmental milestones at 3 years old
Gross motor: walks up/down stairs with alternating feet; rides tricycle
Fine motor: copies a circle, uses utensils
Language: 3-word sentences, speech 75% intelligible
Social: knows age/gender, imaginative play
463
Gross motor, fine motor, language, and social/cognitive developmental milestones at 4 years old
Gross motor: balances + hops on 1 foot
Fine motor: copies a cross
Language: identifies colors; speech 100% intelligible
Social: cooperative play
464
Gross motor, fine motor, language, and social/cognitive developmental milestones at 5 years old
Gross motor: skips, catches ball with 2 hands
Fine motor: copies a square, ties shoelaces, dress/bathes independently, prints letters
Language: counts to 10, 5-word sentences
Social: has friends, completes toilet training
465
What is the difference between a language disorder and a speech delay? When should speech be 100% intelligible?
patients with language disorders have difficulty understanding others (receptive language) and/or communicating thoughts (expressive language); in contrast, isolated speech delay is characterized by problems with: articulation, fluency, vocal quality
Speech should be 100% intelligible by age 4
466
Pt and Tx of genitourinary syndrome of menopause
Pt: vulvovaginal dryness, irritation, pruritus; dyspareunia, vaginal bleeding, urinary incontinence, recurrent UTIs, pelvic pressure
PE: narrowed introitus; pale mucosa, decreased elasticity, decreased rug; petechiae, fissures; loss of labial volume
Tx: vaginal moisturizer + lubricant; topical vaginal estrogen
467
Pathogen and presentation of laryngotracheitis (croup)
Pathogen: parainfluenza virus
Presentation: age 6 months to 3 years; barking cough, stridor, hoarseness
468
Pathogen and presentation of epiglottitis
Pathogen: haemophilus influenzae
Presentation: unvaccinated children; sore throat, dysphagia, drooling, tripod position
469
Pathogen and presentation of bronchiolitis
Pathogen: RSV
Presentation: age <2; wheezing, coughing
470
Risk factors, Pt, Dx, and Tx of idiopathic intracranial HTN
Risk factors: obese women of childbearing age; medications (retinoids, tetracyclines, growth hormone)
Pt: HA, vision loss with enlarged blind spot, pulsatile tinnitus, diplopia with palsy of the abducens nerve (CN VI), papilledema
Dx: neuroimaging, lumbar puncture: elevated opening pressure (>250)
Tx: weight loss, acetazolamide
471
membranoproliferative glomerulonephritis Path and microscopy
Path: IgG Abs directed against C3 converts of the alternative complement pathway
microscopy: dense intramembranous deposits that stain for C3
472
Which os fate glomerulopathies are caused by circulating immune complexes?
SLE and post-streptococcal glomerulonephritis
473
What is the treatment of acute bacterial prostatitis
prolonged treatment (~6 weeks) with a fluoroquinolone (levofloxacin) or TMP-SMX is generally required to ensure eradication
474
What is the difference between the levonorgestrel-containing IUD and the copper IUD In terms of side effects?
levo-IUD has a common side effect of amenorrhea, which can be used to improve anemia and abnormal uterine bleeding; a small percentage of women experience systemic side effects (mood changes, breast tenderness, HA). weight gain ins not a side effect.
The copper IUD can cause heavy menstrual bleeding and should not be placed in women with hypermenorrhea or anemia
475
What drugs are known to cause medication-induced esophagitis? What would you see on endoscopy?
Abx: tetracyclines
Anti-inflammatory drugs: aspirin + many NSAIDs
Bisphosphonates: alendronate, risedronate
Others: potassium chloride, iron
Endoscopy shows discrete ulcers with relatively normal-appearing surrounding mucosa most commonly in the mid-esophagus
476
Pt of femoral artery aneurysm
pulsatile groin mass below the inguinal ligaments; anterior thigh pain is due to the compression of the femoral nerve that runs lateral to the artery
477
mental status changes, seizures, tachycardia, hypotension, cardiac conduction delay, and anticholinergic effects (dilated pupils, hyperthermia, flushed and dry skin, intestinal ileus) - overdose of what?
TCAs
478
What is used to determine treatment of TCA overdose?
QRS duration > 100 msec is associated with increased risk for ventricular arrhythmia and seizures and is used as an indication for sodium bicarbonate therapy
479
What are the risk factors for otitis externa?
1. water exposure
2. trauma (cotton swabs, ear candling)
3. foreign material (hearing aid, headphones)
4. dermatologic conditions (eczema, contact dermatitis)
480
Mico, Pt, Tx of otitis externa?
Micro: pseudomonas aeruginosa, staph aureus
Pt: otalgia, pruritus, discharge, hearing loss; pain with auricle manipulation; ear canal erythema, edema, debris; tympanic membrane spared (clear, not inflamed, no middle ear fluid)
Tx: topical Abx (fluoroquinolone) +/- topical glucocorticoid; consider wick placement to facilitate medication delivery
481
When is thoracic and lumbar imaging indicated after trauma, such as MVC?
the presence of a single vertebral fracture (especially cervical) in a patient with blunt trauma is an indication to image the entire spine because the risk of a second, noncontiguous vertebral fracture is high; other indications include focal pain or signs of injury, corresponding neurologic deficit, AMS or distracting injury, and high-energy mechanism
482
In a negatively skewed distribution, what is the order for mean, mode, and median?
mode > medican > mean
483
In a normal distribution, what is the order for mean, mode, and median?
mean = median = mode
484
In a positively skewed distribution, what is the order for mean, mode, and median?
mean > median > mode
485
Is sarcoidosis a restrictive or obstructive lung pattern? What PFTs would you expect?
restrictive; normal or reduced FEV1, normal or reduced FVC, normal or increased FEV1/FVC, reduced total lung capacity, decreased DLC (diffusion capacity for carbon monoxide)
Note: DLCO helps differentiate intrinsic lung disease (fibrosis) from extrinsic causes of hypoventilation (chest wall weakness)
486
How do you differentaite between mild, moderate, and severe dehydration and how do you fix it in children?
1. mild dehydration (3-5% volume loss) present with hx of decreased intake or increased fluid loss with minimal or no clinical sx
2. moderate dehydration (6-9% volume loss) presents with decreased skin turgor, dry mucus membranes, tachycardia, irritability, a delayed capillary refill, and decreased urine output.
3. severe dehydration (10-15% volume loss) presents with cool, clammy skin, a delayed capillary refill, cracked lips, dry mucous membranes, sunken eyes, sunken fontanelle, tachycardia, lethargy, and minimal or no urine output
Oral rehydration therapy should be the initial treatment in children with mild to moderate dehydration; children with moderate to severe dehydration should be resuscitated with IV fluids to restore perfusion adn prevent end organ damage; isotonic crystalloid is the only crystalloid solution recommended for IVF resuscitation in children
487
Causes, Pt, and Tx of acute pericarditis
Causes: viral or idiopathic; autoimmune disease (SLE), uremia (acute or chronic renal failure); post MI (early: peri-infarction pericarditis; late: Dressler syndrome)
Pt: pleuritic chest paint hat decreases when sitting up +/- fever, pericardial friction rub, ECG: diffuse ST-segment elevation + PR-segment depression; echo: pericardial effusion
Tx: NSAIDs + colchicine for viral or idiopathic causes
488
Pt of thyroglossal duct cyst as a cause of pediatric neck mass
- located midline
- tract between foramen cecum + base of anterior neck
- cystic, moves with swallowing or tongue protrusion
- often presents after URI
489
Pt of dermoid cyst as a cause of pediatric neck mass
- located midline
- cystic mass with trapped epithelial debris
- occurs along embryologic fusion planes
- no displacement with tongue protrusion
490
Pt of a branchial cleft cyst as a cause of pediatric neck mass
- located lateral
- tract may extend to the tonsillar fossa (2nd branchial arch) or pyriform recess (3rd branchial arch)
- anterior to the SCM
491
Pt of reactive adenopathy as a cause of pediatric neck mass
- located lateral
- firm, often tender
- multiple nodules
492
Pt of mycobacterium avian lymphadenitis as a cause of pediatric neck mass
- located lateral
- necrotic lymph node
- violaceous discoloration of the skin
- frequent fistula formation
493
Pt of cystic hygroma as a cause of pediatric neck mass
- located posterior
| - dilated lymphatic vessels
494
widened mediastinum, enlarged aortic knob, and tracheal deviation
thoracic aortic aneurysm
495
Pt/side effects of androgen abuse
Types: exogenous (testosterone replacement therapy), synthetic (stanozolol, nandrolone), androgen precursors (DHEA)
Pt/side effects:
Repro: Men: decreased testicular function + sperm production, gynecomastia
Women: acne, hirsutism, voice deepening, menstrual irregularities
CV: LVH, possible increased LDL and decreased HDL
Psych: aggressive behavior (men), mood disturbances
Heme: polycythemia, possible hyper coagulability
496
What are the recommended vaccines during pregnancy?
Tdap, inactivated influenza, Rho(D) Ig
497
What vaccines are indicated for high-risk pregnant patients?
```
Hep B
Hep A
pneumococcus
Hib
Meningococcus
Varicella-zoster Ig
```
498
What vaccines are contraindicated during pregnancy?
HPV
MMR
Live attenuated influenza
Varciella
499
preload, afterload, contractile function, EF, and SV of acute MR
preload: significantly increased
afterload: decreased
contractile function: no change
EF: significantly increased
SV: decreased
500
preload, afterload, contractile function, EF, and SV of compensated chronic MR
preload: increased
afterload: no change
contractile function: no change
EF: increased
SV: no change
501
preload, afterload, contractile function, EF, and SV of uncompensated chronic MR
preload: increased
afterload: increased
contractile function: decreased
EF: decreased
SV: decreased
502
What is the modified duke criteria for dx of infective endocarditis?
Major criteria
- blood culture positive for typical microorganism (staph aureus, enterococcus, viridian's strep)
- echo showing valvular vegetation
Minor criteria
- predisposing cardiac lesion
- IV drug use
- temp > 100.4
- embolic phenomena
- immunologic phenomena (glomerulonephritis)
- positive blood culture not meeting above criteria
Definite IE: 2 major OR 1 major + 3 minor
Possible IE: 1 major + 1 minor OR 3 minor
503
What is the pt of infective endocarditis
from most common to least common findings:
- fever
- heart murmur
- petechiae
- subungual splinter hemorrhages
- Osler nodes, Janeway lesions
- neurologic phenomena (embolic)
- splenomegaly
- Roth spots (retinal hemorrhage ) (<5%)
504
heavy menses, constipation, urinary frequency, pelvic pain/heaviness, enlarged uterus - Dx?
fibroids; smooth muscle cells within the myometrium
505
dysmenorrhea, pelvic pain; heavy menses; bulky, globular + tender uterus - Dx?
adenomyosis; proliferation of endometrial glands inside the uterine myometrium
506
history of obesity, nulliparity, or chronic anovulation; irregular, intermenstrual, or postmenopausal bleeding; non tender uterus - Dx?
endometrial cancer/hyperplasia
507
What is the criteria for second-stage arrest? Tx?
>/= 3-4 hours of pushing in a primigravida without an epidural OR >/= 2 hours of pushing in a multigravida without an epidural; next step in management is operative vaginal delivery
508
neuroblastoma Path, Pt, and Dx
Path: neural crest origin; involves adrenal medulla, sympathetic chain
Pt: median age <2, abdominal mass, periorbital ecchymoses (orbital metastases), spinal cord compression from epidural invasion (dumbbell tumor), ospoclonvs-myoclonus syndrome; Horner syndrome with involvement of the cervical paravertebral sympathetic chain
Dx: elevated catecholamine metabolites; small, round blue cells on histology; N-myc gene amplification
509
villous atrophy seen on colonoscopy - Dx? What Abs do you expect to be present?
celiac disease; expect IgA anti-tissue transglutaminase and IgA anti-endomysial Abs BUT many patients with biopsy-confirmed celiac disease will have negative results on IgA Ab testing due to an associated selective IgA deficiency, which is common in celiac disease (measure IgG Abs or total IgA to check for IgA def)
510
Pt of focal nodular hyperplasia as a cause of solid liver mass
- associated with anomalous arteries
| - arterial flow and central scar on imaging
511
Pt of hepatic adenoma as a cause of solid liver mass
- women on long-term OCP
| - possible hemorrhage or malignant transformation
512
regenerative nodules as a cause of solid liver mass
- acute or chronic liver injury (cirrhosis)
513
hepatocellular carcinoma as a cause of solid liver mass
- systemic symptoms
- chronic hepatitis or cirrhosis
- elevated alpha-fetoprotein
514
liver metastasis as a cause of solid liver mass
- single/multiple lesions
| - known extrahepatic malignancy
515
involvement, microscopy, gross findings, pt, and intestinal complications of Crohn's disease
invovlement: anywhere mouth to anus (mostly ileum + colon), perianal disease with rectal sparing, skip leasions
microscopy: noncaseating granulomas
Gross findings: transmural inflmmation, linear mucosal ulcerations, cobblestoning, creeping fat
Pt: abdominal pain (often RLQ), watery diarrhea (bloody if colitis)
Intestinal complications: fistulae, abscesses; strictures (bowel obstruction)
516
involvement, microscopy, gross findings, pt, and intestinal complications of ulcerative colitis
involvement: rectum (always) + colon; continuous lesions
microscopy: no granulomas
Gross findings: mucosal + submucosal inflammation; pseudopolyps
Pt: abdominal pain (varying locations); bloody diarrhea
intestinal complications: toxic megacolon
517
ECG findings, cardiac membrane stabilization, rapidly acting tx, and removal of K+ from body (slow acting) tx for hyperkalemia
ECG findings:
- tall, peaked T waves with shortened QT interval
- PR prolongation + QRS widening
- disappearance of P wave
- conduction blocks, ectopy, or sine wave pattern
Cardiac membrane stabilization: calcium infusion
Rapidly acting tx: insulin with glucose, beta-2 adrenergic agonists, sodium bicarbonate
Removal of potassium: diuretics, cation exchange resins, hemodialysis
518
exertional dyspnea, orthopnea, PND, hemoptysis; pulmonary edema +/- right-sided heart failure; atrial fibrillation, increased risk for systemic embolization - Dx?
mitral stenosis
519
Risk factors for interventricular hemorrhage, Pt, and screening
Risk of IVH inversely correlates with gestational age; neonates brown at < 32 weeks are at highest risk because the germinal matrix involutes by week 32
Pt: first 3-4 days of life with bulging fontanel, anemia, apnea, and seizures (50% of cases are asymptomatic)
Screening: all preterm neonates born at <32 weeks shoul dundergo screening with head u/s at 1-2 weeks
520
What are the benefits of breastfeeding for the mother?
- more rapid uterine involution + decreased postpartum bleeding
- faster return to prepartum weight
- improved child spacing
- improved maternal-infant bonding
- reduced risk of breast + ovarian cancer
521
What are the benefits of breastfeeding for the infant?
- improved immunity
- improved GI Function
- prevention of infectious diseases: otitis media, gastroenteritis, respiratory illnesses, UTI
- decreased risk of childhood cancer, T1DM, + necrotizing enterocolitis
522
Associated conditions and composition of amyloid in AL amyloidosis
Associated conditions: multiple myeloma + Waldenstrom macroglobulinemia
Composition: light chains (usually lambda)
523
Associated conditions and composition of amyloid in AA amyloidosis
Associated conditions: chronic inflammatory conditions: RA, IBD
Chronic infections: osteomyelitis, TB
Composition: abnormally folded proteins: beta-2 microglobulin, apolipoprotein or transthyretin
524
What medications can be used as postexposure prophylaxis for neisseria meningitidis?
rifampin, ceftriaxone, ciprofloxacin
525
elevated Cr, u/s showing small, atrophic kidneys, bland sediment on u/a with mild proteinuria - Dx?
hypertensive nephrosclerosis
526
insidious onset of focal pain in navicular or metatarsals; abrupt increase in intensity of training, female with eating disorder, or poor running mechanics - dx?
stress fracture of foot/ankle
527
pain at plantar surface of the heel; worse when initiating running or first steps of the day - dx?
plantar fasciitis
528
burning foot/ankle pain or stiffness 2-6 cm above the posterior calcaneus - dx?
achilles tendinopathy
529
numbness or pain between the 3rd and 4th toes; clicking sensation when palpating space between 3rd and 4th toes while squeezing the metatarsal joints - dx?
morton neuroma
530
compression of the tibial nerve at the ankle that causes numbness and aching of the distal plantar surface of the foot/toes - dx?
tarsal tunnel syndrome
531
Pt, Workup, and Tx of paroxysmal nocturnal hemoglobinuria
Pt: hemolysis -> fatigue; cytopenias (impaired hematopoiesis), venous thrombosis (intraabdominal, cerebral veins)
Workup:
- CBC (hypoplastic/aplastic anemia, thrombocytopenia, leukopenia)
- elevated LDH + low haptoglobin (hemolysis)
- indirect hyperbilirubinemia
- u/a (hemoglobinuria)
- flow cytometry (absence of CD55 + CD59)
Tx: iron + folate supplementation; eculizumab (monoclonal Ab that inhibits complement activation)
532
definition, onset, cause, Pt, and management of symmetric fetal growth restriction
definition: estimated fetal weight < 10th percentile or birth weight < 3rd percentile for gestational age
Onset: 1st trimester
Cause: chromosomal abnormalities, congenital infection
Pt: global growth lag
Management: monitor/treat complications (hypoglycemia, hypothermia, polycythemia)
533
definition, onset, cause, Pt, and management of asymmetric fetal growth restriction
definition: estimated fetal weight < 10th percentile or birth weight < 3rd percentile for gestational age
Onset: 2nd/3rd trimester
Cause: utter-placental insufficiency, maternal malnutrition
Pt: "head-sparing" growth lag
Management: monitor/treat complications (hypoglycemia, hypothermia, polycythemia)
