Uworld Questions Flashcards

Question

Low TSH, high free T4 in a pregnant woman at 10-weeks gestation...

Answer 1

Physiologic response to the thyroid-stimulating actions of beta-hcg

Answer 2

Congenital adrenal hyperplasia (likely 21-hydroxylase deficiency) Note: treat with hydrocortisone and fludrocortisone

Answer 3

Hyponatremia and hyperkalemia

Answer 4

Measure levels of 17-hydroxyprogesterone (which builds up because there’s no 21-hydroxylase to convert it to cortisol) Note: 21-hydroxylase also helps convert progesterone to aldosterone so progesterone and testosterone levels will be high and aldosterone and cortisol levels will be low

Answer 5

Met form in should be stopped on the day of any procedure that requires a large dose of IV contrast (including caths) and restarted two days later Note: This is due to the concern for potentially fatal lactic acidosis

Answer 6

Doses of short-acting insulin that are due 1-3 hours prior to exercise should be reduced to decrease risk of hypoglycemia Note: if exercise is expected to be prolonged (>60 minutes), then the previous nights basal insulin dose should also be reduced (if the exercise will occur before breakfast, just the basal dose should be lowered)

Answer 7

Methimazole, except during the first trimester when propylthiouracil/PTU should be used Note: PTU is avoided when possible due to hepatotoxicity

Answer 8

To achieve a state of mild hyperthyroidism, as defined by trimester-specific ranges for TSH and T4 Note: Mild hyperthyroidism is targeted because overtreatment can lead to fetal hypothyroidism and goiter

Answer 9

Euthyroid sick syndrome, due to decreased conversion of T4 to T3 Note: this does not require treatment unless thyroid dysfunction persists after pts acute illness has resolved

Answer 10

Amiodarone has 3 effects on thyroid function, all of which can be managed without stopping Amiodarone: Amiodarone decreases the peripheral conversion of T4 to T3 (elevated T4, reduced T3), which doesn’t have clinical effects and doesn’t need to be treated Amiodarone has a high iodine content (this can produce primary hypothyroidism (elevated TSH, reduces T4) which can be managed with levothyroxine Amiodarone can also produce amiodarone induced thyrotoxicosis by directly increasing thyroid hormone synthesis (AIT type 1, treated with anti thyroid drugs) or destructive thyroiditis (AIT type 2, treated with glucocorticoids)

Answer 11

Very, very long (half life of 100 days)

Answer 12

Likely androgen-insensitivity syndrome Note: PT is genetically male but excess androgens are aromatized to estrogen and produce breast development

Answer 13

Hyperglycemia, metabolic acidosis, and positive serum ketones

Answer 14

Aggressive IV fluids with normal saline and continuous insulin infusion with Q1H fingersticks (potassium should be added to the fluids if serum K levels are <5.2 because the insulin will push K into cells) Note: bicarbonate can also be added if serum pH is 6.9 or lower and serum phosphate and calcium levels should also be monitored

Answer 15

You can switch from continuous IV to intermittent subQ insulin (as long as the pt is eating) when the glucose is <200 AND two of the following are present: Anion gap <12 Bicarbonate 15 or greater Venous pH >7.3 Note: insulin infusion should be continued for 1-2 hours after subQ insulin is given

Answer 16

When serum glucose is less than 200

Answer 17

If no testicular enlargement by age 14

Answer 18

Bone age radiographs, FSH, LH, testosterone, TSH, and prolactin

Answer 19

Screening for everyone at 24-28 weeks gestation with a 50g glucose challenge test and then a 100g glucose tolerance test if the screen is positive Note: Gestational diabetes mellitus can be treated with insulin, metformin, and/or glyburide (none appear to be teratogenic)

Answer 20

Congenital hypothyroidism, levothyroxine should be started immediately to prevent developmental delay Note: T4 and TSH will be normal at birth because they cross the placenta

Answer 21

Radiocontrast agents, Amiodarone, topical antiseptics, and kelp-based dietary supplements Note: thyrotoxicosis most often occurs in people who were iodine deficient and often with preexisting nodular thyroid disease; treat with beta blockers (and methimazole if persistent) until resolution

Answer 22

Target TSH level of 0.1-0.5 to reduce risk of cancer recurrence Note: if low risk for recurrence you can target low normal range for TSH after ~1 year, and if high risk for recurrence you should target TSH level <0.1

Answer 23

Pituitary enlargement and hyperpigmentation following bilateral adrenalectomy for Cushings disease Note: this is why transsphenoid surgery is preferred over adrenalectomy now

Answer 24

As soon as the pregnancy is detected, levothyroxine dose should be increased by 30%. Then, after 4 weeks check the TSH and make adjustments every 4 weeks based on the TSH

Answer 25

Cerebral edema Note: get CT head for any pt with persistent AMS, lethargy, headache, vomiting

Answer 26

Her TSH should be checked after starting OCPs and levothyroxine dose should be increased accordingly Note: Elevated estrogen levels in pts on OCPs cause increased thyroglobulin. Pts with normal thyroid function just produce more T4 to achieve the same free level, but pts with hypothyroidism need to increase their levothyroxine to keep up with the increased binding globulin

Answer 27

- functional masses - malignant massed - masses > 4cm - mass that’s increasing in size on repeat imaging Note: All adrenal incidentalomas should be worked up with dexamethasone suppression, 24-hour urine catecholamines, metenephrine, vanillylmandelic acid, and 17-ketosteroid (to see if the incidentaloma is functional)

Answer 28

- hba1c > 6.5% - fasting blood glucose > 126 - blood glucose > 200 after oral glucose tolerance test - random blood glucose > 200 (with symptoms of hyperglycemia)

Answer 29

Think hyperaldosteronism (measure plasma renin:aldosterone ratio)

Answer 30

Capergaline (or other dopaminergic medications)

Answer 31

No, they generally do not require any insulin starting after the placenta is delivered; however, they should be screened for diabetes a few months postpartum and every 3 years

Answer 32

Think thyroid lymphoma

Answer 33

- insulin - sulfonylureas (glyburide, glimipride, glipizide) - meglitinides (nateglinide, rapaglinide)

Answer 34

A sulfonylurea (along with glyburide and glimepride) in the insulin-secretagogues family of diabetes medications. It increases insulin secretion by inhibiting beta cell potassium channels. Note: watch out for hypoglycemia and weight gain

Answer 35

A diabetes medication in the meglitinide subsection (along with repaglinide) of insulin-secreagogues that increases endogenous insulin secretion by inhibiting beta cell K channels Note: Biggest side effects are hypoglycemia and weight gain

Answer 36

A biguanide diabetic medication that increases peripheral uptake of glucose, decreases hepatic glucose production, and inhibits mitochondrial Gluconeogenesis Note: Look out for diarrhea and lactic acidosis

Answer 37

A thiazolidinedione diabetic medication that decreases insulin resistance by activating a transcription regulator (PPAR-gamma) Note: can make heart failure worse and cause weight gain

Answer 38

A DPP4 inhibitor diabetic medication that increases endogenous GLP-1 and GIP levels Note: Can cause nasopharyngitis

Answer 39

An alpha-glucosidase inhibitor (along with miglitol) that can be used to treat diabetes by decreasing intestinal disaccharide absorption Note: often causes diarrhea and flatulence

Answer 40

An SGLT2 inhibitor that can treat diabetes by increasing excretion of glucose in the urine Note: can cause urinary tract infections and hypotension

Answer 41

TSH, free T3, and T4 If TSH and thyroid hormones are high, then get MRI of pituitary If TSH is low, then check for signs of Graves’ disease and order tests (if no goiter or opthalmopathy, perform radioactive iodine uptake and if that’s low order serum thyroglobulin levels)

Answer 42

Exogenous hormone administration (ask about supplements)

Answer 43

Think thyroiditis or iodide exposure

Answer 44

Think toxic adenoma or multinodular goiter

Answer 45

Subacute (de Quervain) thyroiditis caused by release of stored thyroid hormone. Treat symptomatically with NSAIDs and propranolol.

Answer 46

Increase meds to reach a goal calcium level 8.5-9 Note: This requires high dose vitamin D and calcium (some pts will also need a thiazide diuretic to reduce urinary excretion of calcium)

Answer 47

Calcium supplements, aluminum hydroxide, iron supplements, PPIs, bile acid-binding agents (e.g. cholestyramine)

Answer 48

Plasma glucose less than 60

Answer 49

Estrogen/progesterone menopausal hormone therapy (or estrogen alone in pts who have had a hysterectomy) can be used for a short period (3-5 years) in younger, low-risk women (nonsmokers, no history of breast cancer, no history of venous thromboembolism, no coronary artery disease) Note: there is a significant increased risk of stroke

Answer 50

Levothyroxine Note: lithium does not have to be discontinued if it has been effective for the PT

Answer 51

- symptomatic hypothyroidism - TSH>10 - positive anti thyroid antibodies - abnormal lipid profile - ovulatory/menstrual dysfunction

Answer 52

Older pts and those with significant cardiovascular risk factors (diabetes, CAD, etc) should receive pretreatment with methimazole to achieve euthyroidism prior to radioiodine ablation All pts getting thyroid surgery should be pretreated

Answer 53

- pts with very large goiters - pts with obstructive symptoms (e.g. dysphagia) - suspected thyroid cancer - contraindications to radioiodine (e.g. breastfeeding)

Answer 54

TSH level and thyroid ultrasound

Answer 55

Fine needle aspiration

Answer 56

Fine needle aspiration (if normal or high TSH) Iodine 123 scintigraphy (if low TSH)

Answer 57

Propranolol, methimazole, and/or ablation Note: A cold or intermediate nodule that doesn’t show increased iodine uptake should be biopsies with an FNA

Answer 58

Think decreased effectiveness of parathyroid hormone (either due to decreased levels of parathyroid hormone in hypopararhyroidism or pseudohypoparathyroidism due to increased resistance to parathyroid hormone, which would be elevated) Note: hyperphophatemia itself can also acutely decrease calcium, but this rarely causes chronic hypocalcemia

Answer 59

Think chronic hypocalcemia (as in pseudohypoparathyroidism)

Answer 60

Baseline ACTH levels and ACTH stimulation test If there is a subnormal cortisol response it’s either primary adrenal insufficiency (high ACTH level) or central adrenal insufficiency (low ACTH level) Note: Even if cortisol response to ACTH storm test is normal, if you have high clinical suspicion you should pursue with a metyrapone or insulin hypoglycemia test

Answer 61

Reduction in micro vascular complications (nephropathy, retinopathy, etc) Note: macro vascular complications (MI, CVA) have not been shows to be affected yet

Answer 62

Less than or equal to 7%

Answer 63

Onset of secondary sex characteristics in boys younger than 9 or girls younger than 8

Answer 64

Think peripheral precocious puberty (due to excess androgens from the gonads, adrenals, or an exogenous source) Note: central precocious puberty is caused by early maturation of the hypothalamic-pituitary-gonadal axis and would present with normal progression of puberty (enlargement of testes first)

Answer 65

Frequent high-intensity exercise can lead to low estrogen levels, which can cause amenorrhea Note: These women are at high risk for osteoporosis

Answer 66

Thiazolidinediones (e.g. pioglitazone) Note: These increase sodium retention

Answer 67

IV dextrose and Octreotide Note: glyburide is a sulfonylurea, which increases insulin secretion. Dextrose infusions alone won’t be enough to treat hypoglycemia in these pts because the added dextrose will cause extra insulin secretion and rebound hypoglycemia so octeotide is needed to stop additional insulin from being secreted

Answer 68

Euglycemic diabetic ketoacidosis (treated the same way as DKA, but with less insulin requirements) Note: All SGLT2 inhibitors can cause euglycemic diabetic acidosis(where you have ketoacidosis with a blood glucose <250), especially during prolonged periods of fasting because the insulin to glucagon ratio is reduced in these patients

Answer 69

Hormone replacement therapy with estrogen and progesterone (or estrogen alone if PT doesn’t not have a uterus and therefore not at risk for uterine cancer). Treatment should continue until average age of menopause (~age 50) Note: POI is often caused by chemotherapy/radiation

Answer 70

Fine needle biopsy Note: All nodules associated with normal or elevated TSH should be biopsied

Answer 71

Primary hyperparathyroidism Enteropancreatic tumors Pituitary tumors

Answer 72

Medullary thyroid cancer Pheochromocytoma Parathyroid hyperplasia

Answer 73

Medullary thyroid cancer Pheochromocytoma Mucosal and intestinal neuromas Mariano is habitus

Answer 74

``` Oligo/amenorrhea Infertility Galactorrhea Hot flashes Osteoporosis Bitemporal hemianopsia Decreases libido Gynecomastia ```

Answer 75

Cabergoline (dopamine agonist) Note: Trans-sphenoid all surgery may be needed if medications aren’t effective

Answer 76

Gonadotropin releasing hormone agonist (to suppress LH and FSH levels)

Answer 77

Get DEX scan for women age 65 and older and any postmenopausal woman with risk factors for osteoporosis (low body weight, smoker, family history of hip fracture, glucocorticoids, etc.) Note: Repeat DEX scan every 3-5 years in women with osteopenia

Answer 78

- T score -2.5 or less on DEX scan - T score -1 or less AND 10-year FRAX score of 20% or greater for major osteoporotic fracture OR 3% or greater for hip fracture - low bone mass with history of fragility fracture

Answer 79

Arrhythmia, dilated cardiomyopathy, osteoporosis

Answer 80

- age < 50 - PT has symptomatic hypercalcemia (bone pain, abdominal pain, psych symptoms) - Pt has complications (osteoporosis, nephrolithiasis, kidney disease) - increased risk of complications (moderate-severe hypercalcemia)

Answer 81

Chronic lymphocytic (hashimoto) thyroiditis Note: These pts develop hypothyroidism and should be treated with levothyroxine

Answer 82

Coronary artery disease (even if lipid panel is normal)

Answer 83

Think about infiltration liver diseases (such as hepatic sarcoidosis)

Answer 84

2/3 of the following: - characteristic epigastric pain - serum amylase or lipase > 3 times normal - imaging findings consistent with pancreatitis

Answer 85

Pts should be NPO until their pain resolves Note: nasojejunal feeds should be started if the PT is still not tolerating food after 3 days

Answer 86

Gallstones and alcohol use Note: hypercalcemia and hypertriglyceridemia are less common causes

Answer 87

Think angiodysplasia (vascular ectasias or AV malformations) Note: most of the time these don’t bleed, but pts with bleeding diathesis (ESRD platelet dysfunction, von willebrand disease, aortic stenosis leading to von willebrand dysfunction, anticoagulation, etc)

Answer 88

MRCP (or CT abdomen) Note: Amylase and lipase may not be elevated in chronic pancreatitis, so MRCP is a better diagnostic test

Answer 89

- lifestyle modifications (small low-fat meals, avoiding alcohol and tobacco) - fat-soluble vitamin supplementation (if steatorrhea indicating malabsorption is present) - pancreatic enzyme supplementation (if fecal elastase-1 levels are low) - pain control if persistent with: - amitriptyline or other tricyclics - NSAIDs - pregabalin - opioids (if refractory) - celiac nerve blocks, Ducati decompression therapy, extracorporeal shock wave lithotripsy, and surgical resection

Answer 90

- Diabetes (due to autonomic neuropathy) - medications (opioids, anticholinergics) - Vagus nerve injury (e.g. surgery) - Neurologic (multiple sclerosis, spinal cord injury, etc) - idiopathic/postviral

Answer 91

- lifestyle modifications (small frequent meals with low fat and no insoluble fiber) - promotility drugs (erythromycin, metoclopramide) - gastric electrical stimulation or jujunal feeding (for refractory cases)

Answer 92

- Upper GI endoscopy or barium swallow (to r/o mechanical obstruction) - Abdominal CT (if extrinsic compression from mass/vessel is suspected) - nuclear gastric emptying study (to assess for motility disorders)

Answer 93

- signs of infection (fever, leukocytosis, elevated CRP) - Labs suggesting biliary obstruction (jaundice, elevated bilirubin, abnormal liver chemistries) - biliary dilation or evidence of etiology of obstruction on imaging Note: Pts with acute cholangitis require urgent ERCP to drain the infected bile

Answer 94

- Regurgitation of acidic material in mouth - heartburn (postprandial, retrosternal burning sensation) - odynophagia (usually indicates reflux esophagitis) - extraesophageal manifestations (cough, hoarseness, wheezing)

Answer 95

- New onset dyspepsia - hematemesis/melena/hematochezia - anorexia - unexplained weight loss - dysphagia - odynophagia - persistent vomiting - GI cancer in a first degree relative

Answer 96

8-week trial of low dose (once daily) PPI, followed by 8-week trial of high dose (BID) PPI Note: Pts with alarm symptoms or who failed high-dose PPI should get an upper endoscopy

Answer 97

Exclusively breastfed: More liquid stool 6-10 times per day at first then decreasing to once every 1-2 days Formula-fed: More solid stool 1-2 times per day Note: Normal varies a lot and if there are no signs of pathology (abdominal distension, emesis, poor feeding, failure to thrive), reassurance is appropriate

Answer 98

#1 infections such as SBP, UTI, respiratory infections, aspiration PNA (these pts should be placed on prophylactic antibiotics, usually ciprofloxacin for 7-10 days) - hepatic encephalopathy - renal failure

Answer 99

To confirm suspected acute cholecystitis E.g. RUQ abdominal pain, normal LFTs, gallstones on RUQ u/s, negative sonographic Murphy sign

Answer 100

Think primary biliary cholangitis

Answer 101

- Ursodeoxycholic avid to slow progression - liver transplant for cure Note: These pts should also be given calcium and vitamin D supplements to help prevent osteopenia

Answer 102

Think intussuaception Note: Treat with an air enema

Answer 103

Abdominal ultrasound showing a target sign Note: Abdominal radiographs should also be obtained to rule out abdominal free air

Answer 104

Medical emancipation (emergency care, STIs, mental health and substance abuse treatment, pregnancy care, and contraception) Legal emancipation (financial independence, minor has a child, minor is married, minor is in active military service, minor is a high school graduate)

Answer 105

Increase fiber and water in diet Osmotic laxatives (if dietary changes are insufficient)

Answer 106

Diffuse esophageal spasm Note: Treat with calcium channel blockers (nitrates or tricyclics can also be used)

Answer 107

Fecal antigen testing or urea breath testing 4 weeks after the completion of therapy

Answer 108

Omeprazole, clarithromycin, and amoxicillin

Answer 109

``` Drugs (sedatives, narcotics) Hypovolemia (diarrhea, diuretics) Electrolyte changes (hypokalemia) Increased nitrogen load (GI bleed) Infections Portosystemic shunts (TIPS) ```

Answer 110

Correct precipitating causes (fluids, antibiotics, etc) Decrease blood ammonia concentration with lactulose or rifaxamin

Answer 111

Think acute mesenteric ischemia

Answer 112

Breast milk jaundice, thought to be due to high beta-glucuronidase activity in breast milk that deconjugates intestinal bilirubin Note: This is benign and pts can continue exclusively breastfeeding

Answer 113

Epigastric pain/fullness (possibly with nausea)

Answer 114

H. Pylori testing (in pts younger than 60 with no alarm symptoms) Upper endoscopy (in pts 60 or older or with alarm symptoms)

Answer 115

Fever, chest pain, mediastinitis, left pleural effusion, and hemodynamic instability point towards esophageal perforation (Boerhaave)

Answer 116

Esophagography or CT scan with water-soluble contrast Note: If you’re suspecting Mallory Weiss syndrome instead, you should get an upper endoscopy

Answer 117

Emergency surgical consultation Acid suppression, antibiotics, and make pt NPO

Answer 118

Acid suppression Note: Most heal spontaneously

Answer 119

Endoscopic ultrasound and aspiration Note: This cyst is not categorizable by CT as pseudocyst, non-neoplastic, or neoplastic. Therefore, biopsy is needed.

Answer 120

Trial of lactose-restricted diet (can also do a lactose breath hydrogen test)

Answer 121

Paracentesis with fluid analysis to calculate SAAG SAAG of 1.1 or greater indicated portal hypertension

Answer 122

CHF Cirrhosis Alcoholic hepatitis Note: These all cause portal hypertension

Answer 123

``` Peritoneal carcinomatosis Peritoneal tuberculosis Nephrotic syndrome Pancreatitis Serositis ```

Answer 124

Think about splenic vein thrombosis (causing isolated gastric varices that are now bleeding) Note: SVT most often occurs when a thrombus forms just inferior to the pancreas due to compression during a pancreatitis episode

Answer 125

CT abdomen with contrast, Doppler ultrasound of splenic vein, MRI abdomen Upper endoscopy showing isolated gastric varices is also confirmatory

Answer 126

Splenectomy

Answer 127

- Coagulopathy (platelets < 50,000; INR > 1.5; PTT >2x normal) - mechanical ventilation >48 hours - GI bleeding pretty ulceration in last 12 months - head trauma, spinal cord injury, or major burn -any 2 of: glucocorticoid therapy, >1 week ICU stay, occult bleeding >6 days, sepsis

Answer 128

Think porcelain gallbladder due to chronic cholelithiasis Note: Pts with symptoms or punctuate calcifications should have a cholecystectomy due to increased risk of gallbladder cancer (asymptomatic pts with curvilinear calcifications do not require cholecystectomy)

Answer 129

Start screening at age 50 with one of the following: - colonoscopy every 10 years - yearly FOBT - FIT-DNA every 1-3 years - CT colonography every 5 years - Flexible sigmoidoscopy every 5 years (or every 10 years when combined with annual FIT testing)

Answer 130

1st degree relative with colon cancer or adenomatous polyp when younger than 60 2 or more 1st degree relatives with colon cancer or adenomatous polyps at any age Note: These pts should be screened with colonoscopy every 3-5 years starting at age 40 OR 10 years younger than the age of cancer diagnosis in family

Answer 131

Increase intake of fruits and vegetables Decrease red meat consumption Avoid tobacco and alcohol Exercise regularly

Answer 132

Oropharyngeal dysphagia (characterized by difficulty initiating a swallow, often with coughing/drooling/aspiration) Esophageal dysphagia (characterized by delayed sensations of food sticking in the upper or lower chest)

Answer 133

Barium esophogram (not barium swallow) Nasopharyngeal laryngoscopy (if pt has oropharyngeal dysphagia) EGD (if pt has esophageal dysphagia)

Answer 134

Marasmus (characterized by wasting) Kwashiorkor (characterized by edematous malnutrition, protuberant abdomen, pitting edema)

Answer 135

- rewarming for hypothermia - oral rehydration using an NG if needed (IV fluids only if in shock and even then a smaller, slower bolus due to the risk of fluid overload and heart failure) - cautious refeeding Note: Look out for heart failure and refeeding syndrome during treatment

Answer 136

- pts with chronic GERD (>5 years) - pts with frequent symptoms and 2 of the following - make sex - age>50 - Caucasian - hiatal hernia - obesity - current or former tobacco use - first degree relative with Barrett’s or esophageal adenocarcinoma Note: These pts should have a one time screen with an EGD, with surveillance screening if positive

Answer 137

PPI and surveillance EGDs every 3-5 years

Answer 138

PPI and surveillance endoscopy in 6-12 mont OR Endoscopic eradication

Answer 139

Endoscopic eradication therapy

Answer 140

Diagnostic paracentesis with 250 or more neutrophils OR positive peritoneal fluid culture

Answer 141

Empiric antibiotic coverage with a 3rd generation cephalosporin (eg cefotaxime) IV albumin (to reduce risk of renal failure) Note: Id creatinine levels worsen while on IV albumin, you should consider treating for hepatorenal syndrome

Answer 142

Octreotide, midodrine, and albumin (or norepinephrine and albumin if in the ICU) Note: TIPS can be considered if pt failed medical management

Answer 143

MELD score (which includes bilirubin, INR, creatinine, and sodium levels) Note: This predicts 90-day mortality (pts with higher MELD scores are prioritized on transplant lists)

Answer 144

A benign epithelial tumor of the liver primarily seen in young women on oral contraception Note: Most cases are asymptomatic and managed conservatively by discontinuation if the OCP (unless otherwise is symptomatic or rumor is > 5cm, in which case surgical resection is the management)

Answer 145

Think hepatic adenoma Note: Discontinue oral contraceptive if PT is taking

Answer 146

If 5cm or less, conservative management by discontinuing oral contraceptive If > 5cm or PT is symptomatic, then surgical resection Note: PT should be followed with serial imaging and alpha-fetoprotein levels (there is a 10% chance of malignant transformation). They can also rupture or hemorrhage.

Answer 147

Fluid resuscitation followed by EGD to look for possible upper GI bleed Note: If EGD is negative, then pursue colonoscopy to look for source (if PT presents with signs suggesting lower GI bleed such as passage of large clots or a known recent diverticula bleed, then the colonoscopy should happen first)

Answer 148

IR angiography to identify bleed with embolization

Answer 149

Toxic megacolon (characterized by nonobstructive colonic dilation and signs of systemic toxicity)

Answer 150

- Immediate surgical consultation (though surgery can often be avoided with aggressive medical management) - Fluid resuscitation, NG tube placement, bowel rest, and admission to ICU - glucocorticoids (if due to IBD) - avoid medications that slow peristalsis (e.g. opioids, anticholinergics, etc) Note: C. diff should be ruled out and glucocorticoids avoided if positive

Answer 151

No change (every 10 years)

Answer 152

Every 5 years Note: this applies if 1-2 small (< 1cm) tubular adenoma s are found

Answer 153

Repeat colonoscopy in 3 years if: - 3-10 adenoma - any adenoma >1cm - adenoma with villous features or high grade dysplasia Note: If nothing is found on repeat the pt can have screening colonoscopies every 5 years

Answer 154

Less than 3 years if more than 10 adenomas Note: These pts should also be worked up for an underlying familial syndrome

Answer 155

Repeat colonoscopy in 2-6 months

Answer 156

2-3 months

Answer 157

Endoscopic removal if battery is stuck in esophagus Close monitoring with serial xrays if battery is in the stomach or beyond Note: Endoscopic or surgical removal is required if the battery stops progressing or the PT becomes symptomatic

Answer 158

Urgent endoscopy for removal of foreign body is indicated it pt is symptomatic (e.g. odynophagia) or history of sharp object ingested (e.g. fish/chicken bone, toothpick, etc) Note: These objects are often not seen on radiographs (small bones and wood often appear radiolucent)

Answer 159

Sulfonamide medications Thiazide diuretics (HCTZ, chlorthalidone) Loop diuretics (furosemide) Antibiotics (tetracycline, TMP-SMX) Antiepileptics (valproate) Immunosuppressants (azathioprine, corticosteroids) Note: DIP is common in pts with heart failure, HTN, autoimmune diseases, chronic pain, seizure disorders, or HIV due to the medications they are commonly on

Answer 160

Pyloric stenosis Note: Diagnosis should be confirmed with abdominal ultrasound and treated with volume resuscitation and electrolyte repletion followed by surgical pyloromyotomy

Answer 161

Hypokalemia hypochloremic metabolic alkalosis from volume contraction and loss of stomach acid

Answer 162

- first born boy - erythromycin exposure (e.g. pt receives pertussis prophylaxis) - bottle feeding

Answer 163

It decreases splanchnic blood flow which reduces the pressure within esophageal varices

Answer 164

- Surveillance endoscopies - non selective beta blocker (propranolol or nadolol) - oral nitrate (optional)

Answer 165

Oral rehydration if possible Early return to normal diet Note: PT should be hospitalized for IV fluids if they cannot tolerate oral rehydration

Answer 166

Diverticula occur when the mucosa and submucosa herniate through the muscular layer at points where an artery pierces the muscular layer, creating a point of weakness. Once the diverticula are formed, that artery is exposed and at high risk for bleeding

Answer 167

Rectal prolapse with strangulation and possible gangrene, get a surgical consult

Answer 168

Medical management for partial thickness prolapse: - increased fiber and fluid intake - pelvic floor muscle exercises - biofeedback (if fecal incontinence) Surgical management via intraabdominal or perineal approach for full thickness prolapse or symptomatic pts (fecal incontinence, constipation, sensation of mass)

Answer 169

Think enteropathy-associated T-cell lymphoma (EATL) Note: This is an aggressive malignancy that can develop in the proximal jejunum of untreated celiac pts and can lead to bowe obstruction, perforation, and GI bleeding. Prognosis is poor with median survival of 10 months

Answer 170

Irritable bowel syndrome Inflammatory bowel disease Chronic infection Malabsorption syndromes (e.g. celiac disease, lactose intolerance, chronic pancreatitis, small intestinal bacterial overgrowth)

Answer 171

Stool studies: - stool O and P - FOBT - stool pH - stool fat content - stool electrolytes (to calculate osmotic gap)

Answer 172

A stool osmotic gap > 125 is consistent with osmotic diarrhea Note: A stool osmotic gap < 50 suggests secretory diarrhea

Answer 173

290 - (2 x (stool Na + stool K))

Answer 174

Think small intestinal bacterial overgrowth (macrocytic anemia due to vitamin B12 deficiency)

Answer 175

Immunoglobulin A anti-tissue treansglutaminase and anti-endomysial antibody Upper endoscopy with small bowel biopsy (shows villous atrophy, intraepithelial lymphocytic infiltrates, and crypt hyperplasia in celiac patients)

Answer 176

- gluten free diet - vitamin supplementation as needed (iron, calcium, vitamin D, folic acid) - screening for osteopenia with DXA scan - administer pneumococcal vaccine (due to associated hyposplenism)

Answer 177

Dumping syndrome (can happen in pts with gastrectomies due to faster transit of food through the stomach. The high similar load of food being dumped into the small bowel leads to the dumping of water from plasma into the small bowel causing diarrhea and hypotension) Note: Treatment is dietary modification with smaller more frequent meals low in simple carbohydrates, high in fiber and protein. Separating solids from liquids by at least 30 min can help too.

Answer 178

Surgery if complete small bowel obstruction Close observation and monitoring for partial small bowel obstructions (early surgical intervention if PT does not improve in 12-24 hours)

Answer 179

Think pancreatic pseudocyst Note: Treatment is supportive unless pt has mod-severe symptoms, which then warrants surgical or endoscopic drainage)

Answer 180

Pancreatic pseudocyst (a late, walled-off colllection of pancreatic fluid) Walled-off necrosis (a late, walled collection of necrotic tissue) Acute necrotic collection (early collections without a wall that occur within one month of acute episode and cause more complications) Peripancreatic fluid collection (early collection of fluid without a wall)

Answer 181

- biliary or pancreatic duct obstruction - fistulization into adjacent organs - erosion of blood vessels - infection/abscess

Answer 182

Only ones that cause moderate-severe symptoms should be drained

Answer 183

ANA Anti-topoisomerase I (anti-Scl-70) Anticentromere

Answer 184

- interstitial lung disease - pulmonary arterial hypertension - hypertension - scleroderma renal crisis (oliguria, thrombocytopenia, MAHA) - myocardial fibrosis and pericarditis

Answer 185

CREST syndrome (Calcinosis, raynaud, esophageal dysmotility, sclerodactyly, and telangiectasias) Diffuse cutaneous systemic scleroderma (often involves the lungs, kidneys, and/or GI tract) Note: Limited cutaneous sclerosis is a non-systemic form of scleroderma that only affects the skin

Answer 186

- Superior mesenteric artery occlusion due to thromboembolism (often in the setting of a fib) - superior mesenteric vein occlusion (often in the setting of portal hypertension, hypercoagulable states, and abdominal infections) - nonocclusive ischemia (in the setting of low cardiac output)

Answer 187

Think Meckel diverticulum (AV malformations are another possibility) Note: Get a technetium-99m pertechnetate scan to confirm the diagnosis by identifying ectopic gastric tissue in the diverticulum and treat with surgical resection

Answer 188

- stable coronary artery disease - pts being prepared for major surgery Note: Pts with acute coronary syndrome, severe thrombocytopenia, or cancer with high bleeding risk may require a transfusion goal >8

Answer 189

Think about esophageal stricture

Answer 190

Suspect bacterial enteritis Note: obtain stool culture for diagnosis and treat with fluid repletion (avoid using empiric antibiotics unless PT is septic or immunocompromised)

Answer 191

Do not start empiric antibiotics unless the pt is septic or immunocompromised Note: Antimicrobials can prolong symptoms and predispose children with E. coli O157:H7 to develop hemolytic uremic syndrome (wait until cultures grow something to start targeted antibiotics when possible)

Answer 192

Fecal impaction Note: Diagnose with a digital rectal exam and treat with manual disimpaction followed by an enema or suppository to empty the colon

Answer 193

Think biliary colic if intermittent, get RUQ ultrasound to confirm Note: In pancreatitis you would expect abdominal tenderness on exam and right shoulder pain would be unusual

Answer 194

To evaluate for a functional gallbladder disorder in a pt with typical symptoms of biliary colic, but no gallstones on imaging Note: Pts with a low gallbladder ejection should get a cholecystectomy

Answer 195

No specific treatment unless pt has episodes of biliary colic (in which case treatment is elective cholecystectomy or ursodecholic acid if not a surgical candidate)

Answer 196

Acute cholangitis, start emergent antibiotics and plan for ERCP

Answer 197

Any of the following: - visualized choledocholithiasis - evidence of acute cholangitis - high risk features (dilated CBD on imaging, elevated serum bilirubin) Note: Pts with suspected choledocholithiasis but none of the above features should get an MRCP

Answer 198

CT abdomen with oral and IV contrast

Answer 199

Bowel rest | Antibiotics (ciprofloxacin and metronidazole)

Answer 200

Percutaneous drainage and IV antibiotics, followed by elective partial collecting several weeks later

Answer 201

Likely acute dysentery, get stool studies (stool culture, shiga toxin, fecal leukocytes) Note: Get a CT abdomen if concerned about ischemic colitis or an endoscopy if concerned about inflammatory bowel disease

Answer 202

More likely to be bacterial if: - Diarrhea with visible blood or mucous - significant abdominal pain - systemic symptoms (fever, malaise)

Answer 203

Bacterial infection (EHEC, shigella, campylobacter, salmonella) Intestinal amebiasis (rare in developed countries) Inflammatory bowel disease Ischemic colitis

Answer 204

Consider invasive amebiasis (especially if pt was recently in a developing country)

Answer 205

Rehydration (preferably oral) | Oral empiric antibiotics, usually ciprofloxacin (unless EHEC is suspected)

Answer 206

- sofosbuvir-velpatasvir - hepatitis A and hepatitis B vaccination (if not already immune) - screening for complications of HCV (liver fibrosis, renal disease, cryoglobulinemia)

Answer 207

A type of pleural effusion that can develop in pts with cirrhosis and ascites because the ascitic fluid passes through the diaphragm to enter the pleural space. It is usually right-sided and transudative by lights criteria. Note: treatment is with furosemide, spironolactone, and sodium restriction to prevent ascites buildup (initial management includes paracentesis to remove excess ascitic fluid)

Answer 208

Think about radiation proctitis if pts cervical cancer was treated with radiation Note: Treat with fluids and antidiarrheals in the acute setting (can use sucralfate or glucocorticoid enemas if chronic)

Answer 209

``` Older age Obesity Elevated hematocrit Elevated CRP BUN of 20 or more ``` Note: BUN is the best value to track disease progression

Answer 210

- Dietary modification - bile salt-binding resins (cholestyramine) for refractory cases Note: Post cholecystectomy or port ileal resection diarrhea is most often due to excess secondary bile acids reaching the colon

Answer 211

They should pass meconium within 48 hours of delivery

Answer 212

Think hirschsprung disease Note: get rectal mucosal suction biopsy to confirm absence of ganglion cells and treat with surgical resection of the aganglionic portion of bowel

Answer 213

White plaques on the buccal mucosa that can typically be scrapped off, which might reveal inflamed tissue beneath. Usually asymptomatic, but might give pt a strange cottony taste in their mouth. Note: if pt has odynophagia, they may have esophageal candidiasis and should get systemic therapy

Answer 214

Gastroesophageal reflux (“happy spitters”) is natural in infants because their esophagus is shorter and stomachs smaller. This is not dangerous and can be managed with upright positioning after feeds, smaller more frequent feeds, and burping during feeds. If the infant is experiencing weight loss, feeding refusal, aspiration, or significant pain and irritability during feeds then it is called gastroesophageal reflux disease.

Answer 215

Think about functional abdominal pain (abdominal pain with no identifiable organic pathology) and ask the pt to record a symptom diary to try to identify triggers/patterns Note: An FOBT should be obtained to evaluate for GI bleeding, but other tests should not be ordered unless suspicious of a particular disease

Answer 216

The treatment for all types of hernias, whether they are reducible or not is surgical repair to avoid possible incarceration or strangulation

Answer 217

Only if all of the following are true: - adenocarcinoma is only in the head of the polyp - tumor was removed during endoscopy with at least a 2mm margin - no lymphovascular invasion - tumor is well differentiated Note: These pts are candidates for avoiding surgery with surveillance colonoscopies with the first in 2-3 months, then at 1, 4, and 9 years after polyp removal (the area the tumor was removed from should be tattooed so it can be found and monitored again)

Answer 218

- Triple therapy (PPI, amoxicillin, and clarithromycin for 10-14 days) - quadruple therapy (PPI, bismuth, metronidazole, and tetracycline for 10-14 days) Note: If pt has a penicillin allergy you can use metronidazole instead of amoxicillin in triple therapy. Quadruple therapy should be used in areas with clarithromycin resistance of 15% or more.

Answer 219

Pts with any of the following: - persistent symptoms - H pylori-associated ulcer on endoscopy - evidence of H pylori-associated malignancy (MALT) Note: Test for cure with urea breath test or fecal antigen testing 4 or more weeks after treatment is completed

Answer 220

Only 3 possible situations: - during the window period of acute hep B infection - years after recovery from acute HBV after HBs antibodies have declines - after many years of chronic HBV infection Note: You should get IgM anti-HBc antibodies and liver enzyme levels to further evaluate. If IgM is negative but liver enzymes are abnormal, you should get HBV DNA to test for chronic infection

Answer 221

- hep B immunoglobulin and hep B vaccine within 12 hours of birth - completion of hep B vaccine series (at age 0, 2, and 6 months) - hep B serology at the 9 month well-child visit

Answer 222

- Probe to bone (if diabetic ulcer probe to bone is positive, no need for imaging, probe to bone is most specific) - MRI (most sensitive) - bone scan (if you can’t get MRI)

Answer 223

Chagas disease (ask if pt spent time in central or South America years ago) Note: Cardiac apical aneurysm is virtually pathognomonic for chagas

Answer 224

- CXR (look for upper lobe cavitation lesions, hilar lymphadenopathy, or pleural effusions) - Three sputum samples spaced by 8-24 hours with at least one early morning sample (if CXR is suspicious) - tuberculin skin testing or interferon-gamma release assay (to prove exposure, can not show active disease)

Answer 225

Yes, and the healthcare worker should be given post-exposure prophylaxis as quickly as possible regardless of whether the pt agrees or not (prophylaxis can be stopped if a negative test result is obtained) Note: Some states do allow testing for HIV without consent in these cases, but not all

Answer 226

Yes, UTI can be diagnosed over the phone with history alone. However, if the pt is likely to be pregnant (no contraception, no recent menstrual period) or likely to have pyelonephritis (fever, chills, flank pain) then a physical exam and urine culture are required Note: You should prescribe Bactrim for 3 days or nitrofurantoin for 5 days

Answer 227

Think about necrotizing fasciitis and treat with immediate hemodynamic support (IV fluids and pressers as needed) IV antibiotics and surgical debridement of necrotic tissue

Answer 228

-Streptococcus pyogenes (group A strep) is the most common - Staph aureus - Clostridium perfringens (if crepitus on exam) - polymicrobial (common in diabetics)

Answer 229

- Zosyn or a carbapenem (to cover Group A steep and anaerobes) - vancomycin (to cover staph and MRSA) - clindamycin (to inhibit toxin formation by strep and staph species)

Answer 230

Rectal distension due to constipation can cause a mass effect on the urethra, leading to obstruction of bladder emptying and urine stagnation

Answer 231

Yes, but only if none of these are present: - hemodynamic instability - unable to tolerate oral meds (e.g. persistent vomiting) - pt is less than 2 months old - failure of improvement on oral antibiotics

Answer 232

- initiation of solid foods - initiation of cows milk - toilet training - school entry

Answer 233

- increased dietary fiber and water - limit cows milk intake to <24 oz - laxatives - suppositories/enemas

Answer 234

Latent tuberculosis, which should be treated with a 9-month course of isoniazid Note: Induration > 15mm is not likely due to BCG vaccine (in cases of smaller induration a gamma release assay can be used to distinguish between TB exposure and BCG vaccine)

Answer 235

Enzyme linked immunosorbent assay to screen and western blot confirmation if positive

Answer 236

Erythema migrans Fatigue, headache Myalgias, arthralgias

Answer 237

``` Unilateral/bilateral Bell’s palsy Multiple erythema migrans rashes Meningitis Carditis (AV block) Migratory arthralgias ```

Answer 238

- Lyme arthritis (usually a mono articulate arthritis not as bad as septic arthritis) - echephalitis - peripheral neuropathy

Answer 239

Doxycycline or amoxicillin (if under the age of 8, though children with late Lyme complications should still get doxycycline)

Answer 240

Think about cryptococcus neoformans infection causing cryptococcal meningoencephalitis. Confirm with India ink preparation or cryptococcal antigen test and treat with amphotericin B and flucytosine for two weeks, followed by high dose oral fluconazole for 8 weeks, followed by low dose fluconazole for at least a year

Answer 241

Think about elevated intracranial pressure Note: This should be treated with serial lumbar punctures to avoid brain herniation

Answer 242

Oral rehydration therapy Note: Antibiotics are reserved for children less than 12 months and immunocompromised adults (use ciprofloxacin, TMP-SMX, or ceftriaxone)

Answer 243

The tendency of HIV pts on antiretrovirals to develop central adiposity and buffalo humps whil also having peripheral atrophy of adipose tissue (pts have thin arms/legs and large midsections) Note: This often is associated with increased insulin resistance, dyslipidemia, and an increased risk of cardiovascular disease, so these pts are often started on a statin (definitely if 10-year ASCVD risk is over 7.5%)

Answer 244

Cesarean delivery with antiretroviral drugs including zidovudine given to the mother during deliver and multi drug antiretroviral therapy given to the infant after birth Note: If the mother’s viral load is <1000, they can deliver vaginally and only need regular antiretroviral therapy during delivery (zidovudine does not need to be given to the mother); however, the infant should receive zidovudine after birth

Answer 245

No, in developed countries with access to clean water HIV mothers should formula feed their infants

Answer 246

- active untreated tuberculosis - HIV infection - herpetic breast lesions - active varicella infection - chemotherapy or radiation therapy - active substance abuse - infant has galactosemia

Answer 247

Think ecthyma gangrenosum (an infection of perivascular structures that disrupts blood supply to the skin causing necrosis), most likely due to pseudomonas infection in this pt who likely has neutropenia with greenish exudate Note: most commonly acquired via an implanted chemo port the bacteria seeds the blood and infects the walls of blood vessels

Answer 248

Zosyn and gentamicin is commonly used Note: anti-pseudomonas cephalosporins, monobactams, fluoroquinolones, and carbapenems can also be substituted

Answer 249

Non-gonococcal urethritis, likely secondary to chlamydia, and should be treated with a single dose of Azithromycin (if pt fails therapy, then other organisms should be considered such as ureaplasma urealyticum, mycoplasma genitalium, or trichomonas vaginalis) Note: If pt had purulent urethral discharge and stain showed intracellular gram-negative diplococci, then it would be gonococcal urethritis and he should be treated with ceftriaxone AND azithromycin

Answer 250

Moxifloxacin Note: M. Genitalium is the second most common cause of nongonococcal urethritis after chlamydia

Answer 251

Pneumocystis jirovecii pneumonia (PCP), pt should give sputum sample for confirmation (though sensitivity is low for sputum samples) and treated empirically with trimethoprim-sulfamethoxazole in addition to standard PNA empiric antibiotics +/- steroids based on oxygenation Note: Pneumocystis jirovecii is an atypical fungus that often causes pneumonia in HIV pts with CD4 counts < 200

Answer 252

ABG showing alveolar-arterial oxygen gradient of 35 or more (or a PaO2 less than 70 in room air) Note: HIV pts with PCP often have respiratory decompensation during the first 2-3 days of treatment due to the inflammation caused by lysis of the fungal cells

Answer 253

- macrolide, such as azithromycin, or doxycycline (if healthy) - azithromycin + fluoroquinolone, such as levofloxacin, or beta-lactam (if comorbidities)

Answer 254

- IV fluoroquinolone, such as moxifloxacin | - IV azithromycin + IV beta-lactam, such as ceftriaxone

Answer 255

Levofloxacin or moxifloxacin

Answer 256

- Eikenella corrodens - viridans group streptococci (alpha-hemolytic) - staph aureus - other anaerobes (fusobacterium, prevotella, etc) Note: Wound should be irrigated and left open (unless on the face then you can do primary closure) and pt should be given a tetanus booster if needed and empiric therapy with amoxicillin-clavulanate

Answer 257

- Wound should be debriefed, irrigated, and left open to heal by secondary intention (unless on the face then you can do primary closure) - tetanus booster, if wound is deep and pts hasn’t been vaccinated recently - empiric therapy with amoxicillin-clavulanate (or ampicillin-sulbactam if IV therapy is needed)

Answer 258

Fourth generation HIV test (p24 antigen and HIV antibodies) Note: Everyone 13-65 should be offered this regardless of risk factors, and MSW don’t need any other STI screening unless they engage in high risk behaviors (such as sex with sex workers)

Answer 259

- percutaneous injury from a contaminated needle stick or sharp object such as a scalpel - mucous membranes or nonintact skin contact with an infected bodily fluid (high risk: blood, any other fluid with visible blood, semen, vaginal secretions; possible risk: CSF, synovial fluid, pleural fluid, pericardial fluid, or amniotic fluid) Note: Urine, feces, tears, and vomitus are considered non infectious as long as there is no visible blood present

Answer 260

Cutaneous cryptococcus, confirm diagnosis with biopsy of the lesion and treat with 2-weeks of IV amphotericin B followed by oral fluconazole for a year

Answer 261

- HAV (if IV drug user, chronic liver disease, or gay) - HBV - HPV (if age 11-26) - meningococcus - pneumococcus (PCV13 initially, followed by PPSV23 at multiple time points after)

Answer 262

Think about acute HIV infection Note: Mononucleosis-like illness with prolonged symptoms, mucocutaneous ulcers, or a generalized rash should raise suspicion for HIV

Answer 263

An immune-complex mediated hypersensitivity reaction (type III) that occurs when circulating antibodies combine with an antigen and overwhelm normal clearance mechanisms. The compliment system becomes activated leading to systemic signs like fever, skin rash, and polyarthralgias. Treatment is mostly supportive (most important to remove the offending agent), but can include steroids or plasmapheresis if severe Note: Some antibiotics and acute hepatitis B can also cause serum sickness-like reactions

Answer 264

Think of congenital toxoplasmosis acquired by transplacental transmission (mom may have had undercooked meat, unwashed fruits/vegetables, or been around cat feces) and treat with pyrimethamine and sulfadiazine along with supplemental folate for a year

Answer 265

- metronidazole or tinidazole | - avoidance of recreational water venues and staying home if incontinent (to avoid spread)

Answer 266

Recurrent UTIs (at least 2 UTIs within 6 months or at least 3 in one year) while adhering to behavioral modifications (postcoital voiding, oral hydration, avoiding spermicides) Note: If the UTIs always happen after sex you can prescribe postcoital antibiotic prophylaxis but if the UTIs don’t seem to be related to sex they should get daily antibiotic prophylaxis

Answer 267

Rabies immunoglobulin and rabies vaccine on days 0, 3, 7, and 14 Note: If the pt has been vaccinated against rabies before they only need to get the rabies vaccine on days 0 and 3 (and do not need to get rabies immunoglobulin)

Answer 268

Lumbar puncture and CSF analysis for possible neurosyphilis

Answer 269

Primary (painless chancre) Secondary (diffuse rash, condylomata lata) Teriary (neurosyphilis, aortitis) Latent infections are asymptomatic

Answer 270

Benzathine penicillin G (2.4 million units IM as a single dose)

Answer 271

Benzathine penicillin G (2.4 million units IM) single dose (if known to be less than 1 year infected) or weekly for 3 weeks (if unknown duration of infection)

Answer 272

Benzathine penicillin G (2.4 million units IM as a single dose)

Answer 273

Aqueous penicillin G (3-4 million units) given IV every 4 hours for 10-14 days

Answer 274

Aqueous penicillin G (50000 units/kg/dose) given IV every 8-12 hours for 10 days

Answer 275

Jarisch-Herxheimer reaction (an acute febrile syndrome that occurs in some people after initiating treatment for a spirochete infection, such as syphilis, leptospirosis, and tick-borne diseases) Note: There is no effective way to prevent this reaction to spirochete lysis and symptoms usually go away within 48 hours

Answer 276

- all household members - roommates or other intimate contacts - child care center workers - anyone directly exposed to respiratory secretions (kissing, mouth to mouth, intubation, suctioning) - anyone seated next to pt for at least 8 hours (e.g. on a plane or bus) Note: Prophylaxis can be with rifampin (unless pregnant or on oral contraceptives), ceftriaxone, or ciprofloxacin (not in children)

Answer 277

Rarely: - pregnant women - pts undergoing urologic procedures - within 3 months of renal transplant

Answer 278

At least 3 watery bowel movements within 24 hours and positive C. Diff stool antigen Note: they may also have lower abdominal pain, low grade fever, and leukocytosis

Answer 279

- gastric acid suppression - recent antibiotic use (especially fluoroquinolones, clindamycin, and broad spectrum penicillins) - hospitalization - advanced age

Answer 280

A worsening of symptoms that can happen a few weeks after starting antiretrovirals for HIV infection that occurs because the immune system is getting better and causes more inflammation. It can be symptomatically managed with NSAIDs or a short course of corticosteroids Note: Most common in pts being treated for tuberculosis when they start antiretrovirals

Answer 281

Starting at age 65 with the PCV13, then also with the PPSV23 at a later time Note: the PPSV23 vaccine alone is recommended for adults younger than 65 with other chronic medical conditions, such as smoking/diabetes/heart disease/liver disease (only very high risk pts such as Sickle cell and HIV pts get both pneumococcal vaccines before age 65)

Answer 282

Cephalexin Amoxicillin-clavulanate Fosfomycin

Answer 283

- hospitalization for IV fluids and IV broad spectrum beta-lactams (e.g. ceftriaxone, cefepime, etc) - once afebrile for 48 hours they can be discharged on oral antibiotics for 10-14 days - after treatment, they should receive daily suppressive therapy with low-dose nitrofurantoin or cephalexin until 6 weeks postpartum

Answer 284

Outpatient supportive care and close follow-up to monitor liver function Note: Only pts with hemodynamic instability, impaired hepatic synthetic function (increased INR), or other signs of acute liver failure (such as encephalopathy) need to be hospitalized

Answer 285

5% (infants born with acute hep B have a 90% chance of progressing to chronic disease) Note: if hep B surface antigen isn’t cleared from the body after 6 months, then they have progressed to chronic hep B

Answer 286

Cystic fibrosis confirm with sweat chloride level, nasal potential difference, or CFTR genetic testing Treat with nutritional support, pancreatic enzymes as needed, airway clearance with chest PT, and antibiotic coverage for exacerbations

Answer 287

Vancomycin PLUS 2 anti-pseudomonal antibiotics (e.g. cefepime and amikacin)

Answer 288

- Some cephalosporins (cefepime and ceftazidime) - Some aminoglycosides (to rant in and amikacin) - Some fluoroquinolones (ciprofloxacin and levofloxacin) - carbapenems (except for ertapenem) - Aztreonam - Colistin

Answer 289

Rubeola (measles) Note: Treatment is supportive, but includes vitamin A for hospitalized patients

Answer 290

An arterial aneurysm that forms due to a bloodstream infection, usually due to a septic embolism from infective endocarditis. The aneurysm can cause focal neurological deficits or rupture and cause a stroke or subarachnoid hemorrhage. Confirm with CT angiogram Treat with broad-spectrum antibiotics and surgical intervention (endovascular or open)

Answer 291

- Valvular insufficiency (a common cause of death) - perivalvular abscess - conduction abnormalities - mycotic aneurysm

Answer 292

Bartonella henselae (cat scratch disease) Treat with azithromycin Note: Pts often don’t remember being scratched or bitten

Answer 293

Pt has latent tuberculosis with no pulmonary imaging findings and should be treated with isoniazid first 6-9 months (or rifampin for 4 months or isoniazid and rifapentine weekly for 3 months). Pts who do not work in high risk settings and are not at high risk of developing active TB (e.g. immunocompromised) do not require treatment for latent TB Note: Latent tuberculosis is noninfectious and this pt can continue working with no restrictions

Answer 294

Vancomycin plus cefepime (or gentamicin)

Answer 295

No, catheter should definitely be removed if: - severe sepsis - hemodynamic instability - evidence of metastatic infection (e.g. endocarditis) - pus at the exit site of the catheter - continued symptoms after 72 hours of empiric antibiotics - blood culture evidence of Staph aureus, Pseudomonas, or fungi Note: Pts who do not need to have the catheter removed should still have the catheter exchanged over a guidewire once afebrile (alternatively they can get antibiotic lock therapy after each access)

Answer 296

Test for Strep pharyngitis (group A strep) with a rapid antigen testing and culture Treat Strep pharyngitis with penicillin for 10 days (to prevent peritonsilar abscess, cervical lymphadenotis, and acute rheumatic fever) Note: Post streptococcal glomerulonephritis is not avoided but antibiotic use

Answer 297

Cephalosporin (if it was a mild reaction) Azithromycin or clindamycin (if it was anaphylaxis)

Answer 298

Hand foot and mouth disease due to coxsackievirus Treatment is supportive with hydration and pain control Note: A similar appearance can happen in pts with herpes infection, but oral lesions are usually external on the lips/vermillion border and spread to the hands, if present, is usually only unilateral

Answer 299

Think about disseminated gonococcal infection in pts with dermatitis (pustules), tensynovitis (pain with passive flexion of joint), and polyarthalgia (especially if asymmetric and involving both large and small joints) Confirm with nuclei acid amplification test if the urogenital tract along with blood cultures and synovial fluid sampling. They should also be tested for HIV and chlamydia.

Answer 300

Single dose of intramuscular ceftriaxone and single dose of azithromycin

Answer 301

Think herpangina due to coxsackie A infection in pts with vesicles/ulcers on the posterior oropharynx Treatment is supportive with saline gargles, analgesics, and antipyretics (non-acidic popsicles or cold fluids can help with the pain)

Answer 302

“Canker sores,” which are recurrent ulcers on the anterior mucosa and do not cause systemic symptoms (e.g. fever)

Answer 303

Think sporotrichosis due to infection with the fungus Sporothrix schenckii Diagnosis is clinical, but collection of lesion fluid or biopsy cultures is common Treat with 3-6 months of oral itraconazole

Answer 304

Think dengue fever (endemic to tropical/subtropical regions of south/Southeast Asia, pacific islands, Caribbean, and americas) Treatment is mostly supportive (dengue virus causes increased vascular permeability, so look out for hemodynamic collapse due to extravasation of plasma and loss of intravascular volume)

Answer 305

Infection with Vibrio vulnificus (a gram negative bacteria that lives in marine environments and infects through open wounds or ingesting oysters) Collect blood and wound cultures Treat with IV ceftriaxone and doxycycline (give empirically if suspected as V. Vulnificus is highly fatal in pts with liver disease, diabetes, or rheumatoid arthritis)

Answer 306

Hepatotoxicity (usually asymptomatic transaminitis that does not require discontinuation unless aminotransferases are at least 5 times the upper limit of normal or if they develop symptoms with aminotransferases at least 3x ULN) Note: INH is usually given with pyridoxine (vitamin B6) to prevent peripheral neuropathy, parenthesis, and ataxia

Answer 307

Intestinal helminth infection (most coughs while in a developing country) Treat with oral albendazole (mebendazole is better for Trichuris trichiura/whipworm)

Answer 308

Intestinal helminth infection (worm larvae enter through the skin and travel to the lungs where they cause a dry cough, then some are swallowed and attach to the GI tract walls, leaving eggs in the stool

Answer 309

Lactational mastitis (infection of the breast milk within clogged milk ducts) Most common culprit is Staph aureus and diagnosis is clinical Treatment is with oral dicloxacillin or cephalexin, frequent breastfeeding or pumping, and evaluation by a lactational consultant because poor latching is usually the cause

Answer 310

Erysipelas, a common, rapidly spreading, superficial bacterial infection of the skin (most commonly due to Strep pyogenes, group A strep) Note: cellulitis is a deeper infection and causes much less well demarcated erythema and is flat

Answer 311

Rabies (Ask about possible exposure, especially caves, even if they don’t recall seeing bats that is a huge risk factor) Note: Hydrophobia (fear of drinking water due to induction of pharyngeal spasm) is pathognomonic for rabies

Answer 312

Bats (in the United States) | Dogs (in the developing world)

Answer 313

Penicillin desensitization followed by intramuscular penicillin G benzathine (this treats the mother, prevents vertical transmission, and treats the fetus) Note: Confirm successful treatment with repeat serologic titers (a 4-fold or greater decrease indicates treatment success)

Answer 314

Yes, all pregnant women should be screened for syphilis at their first prenatal visit (high risk pts should get a second screening in the third trimester and at delivery)

Answer 315

Think about chlamydia Confirm with nuclei acid amplification test Treat empirically with azithromycin and ceftriaxone (if confirmed chlamydia infection give only azithromycin, if confirmed gonorrhea infection give both ceftriaxone and azithromycin)

Answer 316

``` Preterm premature rupture of membranes Preterm labor Postpartum endometriosis Neonatal conjunctivitis (most common cause of infectious blindness) Neonatal pneumonia ```

Answer 317

Think trichomoniasis Confirm with wet mount microscopy Treat with single dose 2g oral metronidazole (if pt is breastfeeding when they take the dose they should express and discard their milk for the 24 hours following the dose because it has high concentration of metronidazole during this time, then they can resume normal breastfeeding)

Answer 318

Infectious mononucleosis, most often due to EBV Confirm with heterophile antibody test (Note: there is a 25% false negative rate during the first week) Treatment is symptomatic with avoidance of contact sports for at least 4 weeks

Answer 319

If lymphadenopathy reaches the point of obstructing the airway, aplastic anemia, overwhelming infection, or thrombocytopenia

Answer 320

Otitis-conjunctivitis syndrome secondary to most often secondary to nontypeable H. Influenzae infection Note: Strep pneumonia and moraxella catarrhalis are also common causes of otitis media but do not cause concurrent conjunctivitis

Answer 321

First-line: 10 days of amoxicillin Second-line: amoxicillin-clavulanate (if pt failed therapy with amoxicillin within the past month) Note: clindamycin or azithromycin can be used if the pt has a penicillin allergy

Answer 322

Tympanic membrane perforation Conductive gearing loss Mastoiditis Meningitis

Answer 323

- pts who have not had a booster in the past 10 years - pts who have not had a booster in the last 5 years and have visibly dirty or deep wounds - pts who have not completed the initial tetanus vaccination schedule or their vaccination status is unknown (these pts should also get tetanus immune globulin if their wound is visibly dirty)

Answer 324

Think about rhino-orbital-cerebral mucormycosis due to infection with rhizopus oryzae Confirm diagnosis with sinus endoscopy with biopsy and culture Treat with sinus endoscopic surgical debridement and IV liposomal amphotericin B followed by an oral anti fungal such as posaconazole once stabilized Note: Mucormycosis often spreads to the palate, orbit, and brain so prompt treatment is important

Answer 325

- diabetes (especially ketoacidosis) - hematologists malignancies - solid organ or stem cell transplant

Answer 326

1-4 weeks (Note: This means the test isn’t very sensitive for the first month after exposure and may miss some pts who have HIV that hasn’t built up in the body enough to be detected yet)

Answer 327

Less than 72 hours after possible exposure (ideally within 1-2 hours after possible exposure)

Answer 328

- Staging tests (CD4 count, viral load) - Drug resistance testing (HIV genotyping) - Screening tests (hep B serologies, tuberculosis, hep C, syphilis, and N. Gonorrhea) Note: Hep B is particularly important to screen for prior to initiation of antiretrovirals because some have dual activity against both HIV and hep B

Answer 329

Think tuberculous meningitis (CSF also usually has elevated adenosine delaminates) Confirm with serial lumbar punctures with SCF examination for acid fast bacteria via smear and culture Treat with 2 months of 4-drug therapy (isoniazid, rifampin, pyrazinamide, and fluoroquinolone/aminoglycoside) followed by 9-12 months of continuation therapy (with isoniazid and rifampin). Adjuvant glucocorticoid therapy should be given for the initial 2 months to prevent CNS inflammation (glucocorticoids significantly reduces morbidity and mortality)

Answer 330

Think pneumocystis jirovechii pneumonia (PCP) in this pt with hypoxia out of proportion to physical exam and renal transplant Collect induced sputum culture Treat with trimethoprim-sulfamethoxazole (pt should have been taking bactrim prophylactically)

Answer 331

Think viral meningoencephalitis likely due to the arbovirus West Nile virus (excoriated insect bites are likely from mosquitos) Collect CSF samples and viral serologies Treatment is mostly supportive

Answer 332

Enteroviruses (coxsackievirus, echovirus) Herpesviruses Arboviruses (west nile virus)

Answer 333

Right subphrenic abscess Confirm with abdominal ultrasound

Answer 334

14-21 days of amoxicillin or cefurixime Note: There does not appear to be any increased risk of fetal abnormalities if the mother is treated adequately

Answer 335

Pulmonary aspergillosis (imaging shows this halo sign or cavitations with air-fluid levels) Confirm with serum fungal biomarkers (galactomannan and beta-D-glucan assay) and sputum sampling for fungal staining and culture (may require bronchoalveolar lavage if inconclusive) Treat with voriconazole, reduction of any immunosuppression regimen, and surgery (if needed)

Answer 336

- stem cell or solid organ transplant - prolonged neutropenia - chronic corticosteroid use - immunosuppressive conditions (e.g. AIDS)

Answer 337

Myocarditis (a toxin-mediated complication)

Answer 338

Diagnose with toxin assay (to prove toxigenic strain) | Culture from respiratory secretions (C. Diphtheriae is a gram-positive bacillus)

Answer 339

``` Erythromycin or penicillin G Diphtheria antitoxin (if severe disease) ```

Answer 340

Early (not part of tertiary syphilis) - meningitis - posterior uveitis (most common) - decreases visual acuity - infectious CNS arteritis causing ischemia/infarction Late: - progressive dementia - generalized paresis - tabes dorsalis (uncommon)

Answer 341

Yes, unless the pt has a severe illness they can get vaccinated against anything

Answer 342

Tuberculin skin test or interferon-gamma release assay immediately after exposure and repeat testing 8-10 weeks after exposure

Answer 343

Ampicillin PLUS gentamicin or cefotaxime (if 28 days old or younger, when E. coli or Group B strep are the most common culprits) Ceftriaxone or cefotaxime PLUS vancomycin only if meninges involvement is suspected (if older than 28 days, when Strep pneumoniae or Neisseria meningitidis are the most common culprits)

Answer 344

``` CBC Blood culture Urinalysis Urine culture Lumbar puncture (with CSF cell count and CSF culture) ```

Answer 345

- all pts who have been symptomatic for less than 48 hours - all pts with severe disease requiring hospitalization (no matter how long ago their symptoms started) - all pts at high risk of having severe complications (no matter how long ago their symptoms started) Note: High risk pts include age 65 and up, women who are pregnant or within 2 weeks postpartum, pts with underlying chronic medical problems such as pulmonary/cardiac/renal/hepatic disease, immunosuppression, morbid obesity, native Americans, nursing home residents

Answer 346

Rocky Mountain spotted fever caused by rickettsia rickettsii transmitted by tick bite Clinical diagnosis (antibiotics should be started before confirmation as serologic tests remain negative early in the disease and delay can lead to encephalitis, pulmonary edema, and arrhythmia) Treat with doxycycline (even in children and pregnant women)

Answer 347

Chronic bacterial prostatitis (mostly due to the same bacteria common in UTIs such as E. Coli) Confirm diagnosis with urinalysis collected after prostate massage Treat with 6-weeks of ciprofloxacin or bactrim

Answer 348

Acute infective endocarditis Confirm with blood cultures and a TTE (IE is usually right-sided in IV drug users, so TTE is good whereas left-sided IE is more common in the general population and usually requires TEE) Note: Staph aureus is the most common culprit in IV drug users

Answer 349

- oral vancomycin OR oral fidaxomycin - discontinuation of any high-risk antibiotics (e.g. fluoroquinolones, cephalosporins, clindamycin) and replacement with low-risk antibiotics Note: Add IV metronidazole if pt has severe disease (hypotension, ileus, megacolon)

Answer 350

Intracolonic vancomycin PLUS IV metronidazole

Answer 351

Bactrim (TMP-SMX) Macrolides Tetracyclines Aminoglycosides

Answer 352

- PO vancomycin with prolonged 2-8 week pulse/taper course - PO fidaxomycin (unless fidaxomycin was used for primary) - PO vancomycin followed by rifaximin (if multiple recurrences) - fecal microbiota transplant (if multiple recurrences) Note: ANY episode associated with hypotension, ileus, or megacolon should be treated with PO/PR vancomycin AND IV metronidazole

Answer 353

Any of these high risk features: - Crush injury - bites in hands or feet - wounds on body > 12h or on face > 24h - cat bites (except on face) - human bites (except on face) - immunocompromised pt Note: Prophylaxis is with amoxicillin-clavulanate (and these pts wounds should be left open to heal by second intention)

Answer 354

Strep pyogenes (group A strep) Note: Cephalexin is a good choice for cellulitis

Answer 355

Acyclovir, vancomycin, and ceftriaxone (to treat for encephalitis) Note: Collect lumbar puncture CSF culture prior to antibiotics if possible

Answer 356

3-drug therapy (Isoniazid, rifampin and ethambutol) for 2 months followed by just isoniazid and rifampin for an additional 7 months. Pregnant women should also receive pyridoxine (vitamin B6) supplementation time help prevent isoniazid-induced neurotoxicity as in nonpregnant patients as well. Note: None of these drugs are teratogenic, but pyrazinamide (a component of the normal 4-drug therapy) isn’t that important and has uncertain safety in pregnancy

Answer 357

Strep pneumoniae (an encapsulated bacterium that is particularly invasive in HIV pts who have deficits in opsonuzation, humoral immunity, and macrophage/neutrophil function)

Answer 358

High-dose amoxicillin (usual culprit is Strep pneumoniae)

Answer 359

Azithromycin (usual culprit is Mycoplasma pneumoniae)

Answer 360

Acute rheumatic fever (clinical picture of Sydenham chorea and possible carditis) Treat with long-acting intramuscular penicillin until adulthood for secondary prevention and to eradicate the bacteria. Corticosteroids can also be used in severe cases of Sydenham chorea.

Answer 361

2 major OR 1 major and 2 minor ``` Major criteria (JONES criteria): Joints (migratory arthritis) ❤️ carditis Nodules, subcutaneous Erythema marginatum Sydenham chorea ``` ``` Minor criteria: Fever Arthralgias Elevated ESR/CRP Prolonged PR interval ```

Answer 362

Localized herpes zoster infection (shingles) Diagnosis is clinical Treat with oral acyclovir if pt has had symptoms for less than 72 hours (this reduces risk of transmission, new lesion formation, and possible postherpetic neuralgia)

Answer 363

Hospitalization for IV acyclovir (to reduce risk of complications such as ocular infection)

Answer 364

Standard precautions and lesion covering (for localized infection) Standard, contact, and airborne precautions (for disseminated infection) Note: precautions are only needed until the lesions crust over (indicating they are no longer infectious)

Answer 365

Think toxic shock syndrome due to nasal packing or tampons infected with Staph aureus that release a toxic shock syndrome toxin that acts as a superantigen to cause widespread T cell activation and massive cytokine release Treat with removal of source (nasal packing, tampon, etc), IV fluids, clindamycin (to prevent toxin production), and vancomycin/nafcillin (to eradicate the bacteria)

Answer 366

Urinary schistosomiasis (parasitic blood fluke) Confirm with the identification of eggs of urine sediment microscopy Treat with praziquantel

Answer 367

Carbon monoxide poisoning due to smoke inhalation Confirm diagnosis with an ABG for carboxyhemoblobin level (normal pulse oximetry can’t tell the difference between oxyhemoglobin and carboxyhemoglobin) Treat with high-flow supplemental oxygen, mechanical ventilation if needed, and hyperbaric oxygen if severe

Answer 368

Acute HIV infection Confirm with HIV screen AND viral load (pt may not have seroconverted yet, so antibody screening alone may be negative) Treat with combination antiretroviral therapy

Answer 369

Acute bacterial rhinosinusitis Clinical diagnosis with any of the following: - persistent symptoms for 10 days or more - severe symptoms (fever over 39, purulent nasal discharge, facial pain for at least 3 days) - “double sickening” (viral URI that resolves followed by clinical deterioration) Treat with 5-7 day course of oral amoxicillin-clavulanate (second line is doxycycline or fluoroquinolones)

Answer 370

Infantile botulism (due to ingestion of C. Botulinum spores in farm soil/honey that produces a neurotoxin that inhibits presynaptic acetylcholine release) Diagnosis is mostly clinical but can be confirmed with stool spore or toxin assays Treatment is with IV botulism immunoglobulin and admission to ICU to monitor for sudden respiratory decompensation (may take months to recover, but full recovery is likely with treatment)

Answer 371

Congenital rubella syndrome (cataracts, hearing loss, and patent PDA) Note: Mothers should be immunized with MMR vaccine prior to conception because they cannot receive the live-attenuated vaccine during pregnancy

Answer 372

Adult rubella Confirm with serology

Answer 373

Acute pharyngitis This pt has 3 Centor criteria so a rapid strep test should be ordered to see if they have group A strep pyogenes Treat with 10 days of penicillin V or amoxicillin (cephalexin can be used in pts with mild penicillin allergies and azithromycin can be used in pts with severe penicillin allergies)

Answer 374

3 or more centor criteria indicates someone should be tested for group A strep pyogenes with a rapid strep test: - tonsilar exudate - tender anterior cervical lymphadenopathy - fever - absence of cough

Answer 375

- anaphylaxic to neomycin - anaphylaxis to gelatin - pregnancy - immunodeficiency (long term immunosuppressive therapy, hematologists or solid tumors, severe HIV infection) Note: Household contacts of immunodeficiency people (e.g. transplant recipients) should get the vaccine but be monitored closely for a rash, which occurs in some people with this live-attenuated vaccine and can be contagious

Answer 376

Levels <45 don’t require treatment (normal is <5) Levels 45 and over should be treated with meso-2,3-dimercaptocuccinic acid (DMSA, succimer) Levels 70 and over or any level associated with encephalopathy are medical emergencies requiring hospitalization and should be treated with dimercaprol AND calcium disodium edetate (EDTA)

Answer 377

Organophosphate poisoning, usually from agricultural pesticides (leading to inhibition of acetylcholinesterase at the neuromuscular junction) ``` Diagnosis is clinical (DUMBELS): Defecation Urination Mitosis Bronchospasm/bradycardia Emesis Lacrimation Salivation ``` Treatment includes resuscitation (oxygen, fluids, intubation if needed), decontamination (removal of clothes), atropine AND pralidoxime (Note: only pralidoxime affects nicotinic symptoms such as muscle weakness/paralysis), activated charcoal (if within 1 hour of exposure)

Answer 378

An herbal supplement used for memory enhancement that also increases bleeding risk

Answer 379

An herbal supplement that improves mental performance and also increases bleeding risk

Answer 380

An herbal supplement used for BPH that can cause mild stomach discomfort and increases bleeding risk

Answer 381

An herbal supplement used for postmenopausal symptoms that can also cause hepatic injury

Answer 382

An herbal supplement used for depression and insomnia that can cause serotonin syndrome (if used with antidepressants), decreased INR (in pts on warfarin), decreased efficacy of OCPs, and can also cause hypertensive crisis

Answer 383

An herbal supplement used for anxiety and insomnia that can also cause severe liver damage

Answer 384

An herbal supplement used for stomach ulcers and viral infections that can also cause hypertension and hypokalemia (increases available cortisol)

Answer 385

An herbal supplement used to treat colds and the flu that can cause anaphylaxis (especially in asthmatics)

Answer 386

An herbal supplement used for the common cold, weight loss, and athletic performance that can cause hypertension, arrhythmias, strokes, and seizures

Answer 387

All at risk children: - history of pics - foreign-born children - homes built prior to 1978 - low socioeconomic status - use of painted toys made before 1978 or made outside of the US

Answer 388

Mild 32-35 C: tachycardia, tachypnea, ataxia, dysarthria, shivering (treat with passive external warming by removing wet clothes and covering with blankets) Moderate 28-32 C: bradycardia, lethargy, hypoventilation, atrial arrhythmias (treat with active external warming by using warm blankets, heating pads, and warm baths) Severe <28 C: coma, cardiovascular collapse, ventricular arrhythmias (treat with active internal rewarming with warmed pleural or peritoneal irrigation, and warm humidified oxygen) Note: Warmed IV fluids can be used for anyone with hypotension

Answer 389

Maximizing evaporative cooling by removing clothes from pt to maximally expose skin, spray pt with a tepid water mist or cover with wet sheet while using large fans to circulate air Note: Ice water gastric/rectal lavages can also be used as adjunctives, but only after augmenting evaporative cooling

Answer 390

Salicylate poisoning Treat with alkalinization of the plasma and urine with IV sodium bicarbonate (this deactivates the toxic effects of salicylic acid by making it a charged molecule that can not pass the blood brain barrier). Supplemental glucose and activated charcoal (if within 2 hours of ingestion) can also be used. Note: Dialysis is indicated if the pt has pulmonary edema, fluid overload limiting how much sodium bicarbonate can be infused, AMS, renal failure, cerebral edema, severe acidosis, or very high salicylate levels

Answer 391

Fomepizole (a competitive inhibitor of alcohol dehydrogenase)

Answer 392

Fomepizole (a competitive inhibitor of alcohol dehydrogenase)

Answer 393

Cat scratch disease due to bartonella henselae Treat with azithromycin (to speed recovery and avoid suppuration of lymph nodes)

Answer 394

Scombroid poisoning due to ingestion of improperly stored seafood (due to accumulated histamine because histidine can be decarboxylated to histamine at temperatures over 15C)

Answer 395

Tonsillectomy and adenoidectomy

Answer 396

SSRI/SNRI and/or cognitive behavioral therapy Note: Benzodiazepines can be used for acute distress

Answer 397

Precontemplation (not ready to consider change) Contemplation (considering change) Preparation (decision to change) Action (making the change) Maintenance (changes have been integrated, focus is on preventing relapse) Identification (changes are incorporated into sense of self, changes are automatic)

Answer 398

Catatonia (a syndrome of psychomotor disturbance that can happen in severely ill pts with psychotic disorders) Clinical diagnosis: - immobility or purposeless activity - mutism or decreased response to stimuli - negativism (resistance to instruction/movement) - posturing (maintaining positions against gravity when passively placed in them) - waxy flexibility (initial resistant of movement then maintenance of new posture) - echolalia, echopraxia (mimicking speech and movements) Can confirm diagnosis with lorazepam challenge test (1-2mg IV lorazepam often partially relieves symptoms, but not always) Treatment is with benzodiazepines or electroconvulsive therapy

Answer 399

- substance-induced psychotic disorder - psychosis due to another medical condition - schizophreniform - schizophrenia

Answer 400

At least 14 days, but fluoxetine has such a long half like it needs to be stopped for at least 5 weeks before starting an MAOi (this is to prevent serotonin syndrome)

Answer 401

Serotonin syndrome (due to excess SSRI, MAOi, linezolid, MDMA) Diagnosis is clinical: mental excitability, autonomic dysrefulation, and neuromuscular excitability (hyperreflexia, tremors) Treat by discontinuing all seritonergic medications, supportive care, sedation with benzodiazepines, and the serotonin antagonist cyproheptadine (if supportive measures fail)

Answer 402

- Ideation (wishing you die or wishing to not wake up are passive ideations, thinking about killing oneself is an active ideation) - plan (have you thought about how you would kill yourself) - Intent (how close have you come to acting on a plan)

Answer 403

Usually none necessary, will stop in 1-2 years Note: low-dose benzodiazepines can be used if episodes are frequent, distressing, and persistent

Answer 404

Usually either lithium or valproate (plus an antipsychotic if there are severe manic symptoms like aggression, psychosis, or high-risk behaviors) Note: lithium is preferred over valproate if pt is pregnant or suicidal

Answer 405

Neuroleptic malignant syndrome Treat with dantrolene

Answer 406

Acute dystonia (an extrapyramidal effect, in this case with torticollis and an oculogyric crisis) Treat with diphenhydramine or benztropine

Answer 407

Akathisia (an extrapyramidal symptom) Treat with propranolol Treat refractory cases with lorazepam or benztropine

Answer 408

Tardive dyskinesia Treat with valbenazine or deutetrabenazine

Answer 409

Drug-induced Parkinsonism Treat with benztropine or amantadine

Answer 410

Depressed mood or anhedonia PLUS 5/9 SIGECAPS symptoms for at least 2-weeks duration: ``` Sleep disturbance Interest loss Guilt Energy low Concentration impaired Appetite changes Psychomotor retardation Suicidal thoughts Depressed mood ```

Answer 411

SSRI (Sertraline and paroxetine can be used safely even when breastfeeding)

Answer 412

At least 6 months, then you can try tapering off

Answer 413

In order to be termed schizoaffective disorder the pt much have at least 2 weeks where they have psychotic features with no mood symptoms In mood disorder with psychotic features, the psychotic features only happen when the pt is experiencing mood symptoms

Answer 414

- loss of autonomy/control in the dying process - loss of dignity - loss of ability to engage in pleasurable activities

Answer 415

- low GFR (renal failure, elderly pts) - volume depletion - drug interactions (thiazide diuretics like chlorthalidone, ACE inhibitors, NSAIDs, etc)

Answer 416

Acute: -nausea, vomiting, diarrhea Chronic: -ataxia, confusion, agitation, tremor

Answer 417

-IV hydration -lithium levels every 2-4 hours Hemodialysis (if level > 4 or level > 2.5 with signs of renal failure or increasing levels despite IV fluids) Note: Bowel irrigation can be used for pts with an asymptomatic acute overdose

Answer 418

In somatic symptoms disorder pts have excessive anxiety and preoccupation with one or more specific symptoms, even if there have been many negative tests In illness anxiety disorder pts have a fear of having a serious illness despite few or no symptoms, even if there have been many negative tests

Answer 419

-regularly scheduled visits with a single provider (reduces healthcare use compared to symptom based appointments) -avoiding unnecessary testing and specialist referrals -legitimizing symptoms but making functional improvement the goal -focus on stress reduction Mental health referral once good relationship if pt will accept

Answer 420

Acute stress disorder has the same symptoms but happens within 1 month of the traumatic event (but symptoms must last at least 3 days) PTSD is diagnosed when these symptoms last more than 1 month

Answer 421

- Trauma-focused cognitive behavioral therapy - medication (in insomnia or intense anxiety) - follow up to see if it has progressed to PTSD

Answer 422

- nicotine replacement therapy (patch or short acting or both) - bupropion (contraindicated in pts with seizures or eating disorders) - varenicline (most effective, but may increase risk of cardiovascular events)

Answer 423

- cognitive behavioral therapy including sleep hygiene (first-line) - hypnotic medications (second line, with particular care in the elderly)

Answer 424

- reassurance, reorientation, safety watch | - low dose haloperidol (if pt presents a danger to themself or staff)

Answer 425

To treat depression, bipolar depression or mania, or catatonia in the following circumstances: - refractory to medications - psychotic features present - refusal to eat/drink - imminent risk of suicide - pharmacotherapy is not an option (poor tolerance, comorbidities, pregnancy) - history of ECT response

Answer 426

No absolute contraindications (relatively safe in pregnancy) NOTE: Pts with severe cardiac disease, recent MI, space occupying brain lesion, recent stroke, or unstable aneurysm are at increased risk for complications

Answer 427

- Dialectical behavior therapy - adjunctive mood stabilizers and antipsychotics as needed - antidepressants if comirbid mood or anxiety disorder

Answer 428

Refeeding syndrome (due to increased insulin from refeeding causing cells to take up phosphorus, potassium, magnesium, and thiamine and depletion’s intravascularly; pts can also have CHF symptoms due to weak strophic hearts) Monitor closely with frequent chem 8 and replete electrolytes and thiamine aggressively (phosphorus is especially important to replete as it is needed for ATP, oral supplementation is preferred to IV)

Answer 429

- SSRI - exposure and response prevention therapy (a type of cognitive behavioral therapy where they are exposed to obsessive stimuli but prevented from carrying out compulsive behaviors)

Answer 430

- Benzodiazepines (e.g. lorazepam) - Antipsychotics (e.g. haldol) can be used if benzodiazepines alone are not sufficient - physical restraints (if needed) Note: If pt has only mild symptoms of PCP overdose (detachment, withdrawal, dissociation) the first treatment should be providing a low stimulation environment

Answer 431

- later onset (peak onset is usually early 20s in med and late 20s in women) - female sex - acute onset with precipitation - predominantly positive symptoms (antipsychotics are more effective at treating positive symptoms) - no family history - short duration of active symptoms

Answer 432

Multiple motor and at least 1 vocal tic that persist for at least 1 year with an onset before age 18 (tics do not have to appear concurrently) Note: vocal tics include grunting, snorting, throat clearing, barking, yelling, and coprolalia Note: If the pt only has motor OR vocal tics but not both it’s considered chronic tic disorder. If the tics have not persisted for more than 1 year it’s considered provisional tic disorder.

Answer 433

- behavioral therapy (habit reversal training) - antidopaminergic agents (such as the dopamine depleting agent tetrabenazine or antipsychotics such as risperidone or aripiprazole) - alpha 2 adrenergic receptor antagonists (such as clonidine or guanfacine)

Answer 434

They can be suppressed voluntarily for brief periods of time but usually are preceded by irresistible urges that are only relieved by the tic

Answer 435

- reduce dose or number of antiparkinsonian medications to minimum necessary (reduce/discontinue the least potent medications first: anticholinergics, amantadine, MAO-B inhibitors, COMT inhibitors, dopamine agonists, then finally reducing carvidopa/levodopa only if possible) - second generation antipsychotic with few movement side effects such as quetiapine or clozapine (these can be added if the pt is still having psychotic symptoms while on the minimum treatments necessary to treat Parkinson’s symptoms) - pimavanserin is a serotonin 5HT-2A receptor reverse agonist that can also be used to treat psychotic symptoms in Parkinson’s patients

Answer 436

Calcium pyrophosphate dihydrate crystals seen in pseudogout and hereditary hemochromatosis

Answer 437

Distal radius fractures are usually caused by a fall on an outstretched hand (FOOSH) in a pt with osteoporosis Note: this fracture can usually be managed conservatively with sugar tong splinting +/- closed reduction, but may need surgical intervention (if severe displacement or angulation)

Answer 438

Kawasaki disease, a febrile vasculitis Workup includes CRP, ESR, and echocardiogram (at time of diagnosis and at 2 and 6 weeks after diagnosis to evaluate for the most concerning complication: coronary artery aneurysm) Treat with aspirin and IVIG

Answer 439

Live vaccines (e.g. MMR and varicella) should not be given for 11 months after receiving IVIG because it interferes with producing a robust immune response

Answer 440

The following make septic arthritis more likely: - unable to bear weight - leukocytosis - fever of 38.5 or more - ESR > 40 or CRP > 2 Note: Pts with 3 or more of these are very likely to have septic arthritis and should have immediate joint aspiration to confirm and decompress the joint and be initiated on IV vancomycin

Answer 441

- immediate joint aspiration for diagnosis confirmation and decompression - IV vancomycin (plus cefotaxime if < 3 months old due to risk for group B strep agalactiae and gram-negative bacilli) - surgical drainage and debridement of joint

Answer 442

>50,000 with > 90% neutrophils

Answer 443

Associated with Sjögren’s syndrome (not very sensitive, only 50% of cases test positive for one of these antibodies)

Answer 444

Think about B-cell non-Hodgkin lymphoma (Sjögren’s causes polyclonal B cell activation and infiltration of salivary glands which causes lymphoma in about 5% of patients)

Answer 445

A normal curvature of the legs that occurs between the ages of 2 and 5 where the knees are closer together than the feet when standing up (looks like “knock knees”), but is normal during development and resolves by age 7 Note: Radiographs should be taken if severe, progressive, persistent past age 7, unilateral, cause of medial thrust of knees while walking, or associated with short stature

Answer 446

Radial head subluxation (nursemaids elbow) Clinical diagnosis (radiographs not required) Treat with hyperpronation of forearm or supination of forearm with flexion of elbow

Answer 447

Scaphoid fracture due to forceful wrist dorsiflexion tenderness at the anatomic snuffbox is suggestive, but radiographs should be taken at time of injury and also repeat imaging 1-2 weeks later as xrays are often initially negative (if high suspicion can also do MRI at time of injury or bone scan 3-5 days post injury) Treat with a short arm thumb spica cast with serial xrays every 2 weeks to monitor healing (surgical management may be necessary if there is an associated tilt of the lunate, fracture displacement > 1mm, nonunion during follow up, osteonecrosis, or scapholunate dissociation)

Answer 448

Wrapped in gauze moistened with sterile saline and placed in a sealed sterile plastic bag The bag should be placed in an insulated cooling container filled with a 50/50 mix of ice and sterile saline or water

Answer 449

Reactive arthritis Synovial fluid aspiration will be inflammatory (elevated WBCs) but culture negative Treat with NSAIDs or intraarticular glucocorticoids (systemic glucocorticoids or DMARDs can be used for refractory cases) Note: Antibiotics should also be given in the case of chlamydia infection or non-self-limiting gastrointestinal infection)

Answer 450

Painless, shallow ulcers that appear on the glans of the penis as an extraarticular manifestation of reactive arthritis and may persist for months (unlike the painless ulcers of syphilis, which resolve in 3-6 weeks, and lymphogranuloma venereum, which resolve within days) Treatment is with topical steroids

Answer 451

- Ocular (uveitis, conjunctivitis) - Genital (urethritis, cervicitis, prostatitis) - Dermal (circinate balanitis, keratoderma blennorrhagicum) - Oral ulcers

Answer 452

DEXA scan showing T score of -2.5 or less OR History of a fragility fracture (any fracture occurring from a fall from standing height or less) Note: T score between -1 and -2.5 indicates osteopenia

Answer 453

- T score of -2.5 or less - History of low-trauma hip or vertebral fractures (regardless of T-score) - FRAX score showing 10-year probability of major osteoporotic fracture >20% or of hip fracture >3% Note: Bisphosphonates (e.g. alendronate) are first line treatments along with calcium and vitamin D supplementation

Answer 454

Carpal tunnel syndrome (caused by compression of median nerve as it passes under the transverse carpal ligament) Confirm diagnosis with a positive phalen test (reproduction of symptoms within 1 min of hyperflexion of the wrist) or tinel sign (tingling sensation elicited by tapping the median nerve in the carpal tunnel) Initial treatment is to use wrist splints, especially at night, to prevent excessive wrist flexion/extension. Surgery can be considered for pts with mod-sev symptoms that persist for more than 6 months or if there are associated neurological deficits (as determined by nerve conduction studies showing demyelination)

Answer 455

Monosodium urate crystals seen in gout Treat acute gout with NSAIDs, oral glucocorticoids, colchicine, or intraarticular glucocorticoids Use allopurinol or probenecid for prophylaxis against future attacks. Febuxostat can also be used unless there is high risk for cardiovascular disease

Answer 456

- Medications (diuretics, low-dose aspirin, immune suppressants) - recent surgery/trauma - CKD - volume depletion - obesity, high protein/high fat diet, excess alcohol

Answer 457

Ankylosis spondylitis Confirm diagnosis with xrays of the sacroiliac joint Monitor disease progression with serial xrays of the pelvis, lumbar spine, and cervical spine. These patients should also be monitored for restrictive lung disease due to limited costovertebral joint motion. Treatment with lifestyle modification (regular aerobic exercise, immediate smoking cessation) and NSAIDs for pain Note: These pts do not have decreased life expectancy

Answer 458

Back braces are helpful in preventing progression of scoliosis in patients who have not completed skeletal maturity (puberty is less than tanner stage 5) Surgical evaluation is indicated for pts with severe scoliosis (Cobb angle of 40 degrees or more) Note: No treatment for follow-up is necessary for pts who have completed puberty and have a Cobb angle less than 40 degrees

Answer 459

Posterior cruciate ligament injury (dashboard injury) due to forced posterior movement of the tibia in relation to the femur Note: Anterior cruciate ligament injuries usually occur after hyperextension of the knee and are often associated with a popping sound

Answer 460

Polymyalgia rheumatica Note: often associated with giant cell arteritis so look out for new headaches

Answer 461

3/5 of the following (94% sensitive and 91% specific): - age 50 or greater (greatest risk factor) - new onset localized headache with fever and visual disturbances - ESR > 50 - tenderness or decreased pulse of temporal artery - temporal artery biopsy showing necrotizing arteritis with mainly mononuclear cells

Answer 462

High-dose glucocorticoids (e.g. prednisone 40mg daily or more) while waiting for temporal artery biopsy

Answer 463

Lumbar spinal stenosis Confirm diagnosis with MRI of the lumbar spine Treatment is with physical therapy and oral pain medications. Surgical intervention (such as decompressive lamonectomy) can be considered for pts with severe refractory symptoms

Answer 464

Thompson test (have pt lie prone/belly down with feet hanging over table and squeeze the pts calf muscles; if there is no plantar flexion of the foot this indicated complete tear of the Achilles’ tendon) Note: If Thompson test is negative you can get an MRI, which is more sensitive and can also diagnose partial tendon tears

Answer 465

- RICE (rest, ice, compression, elevation) - oral analgesics - progressive return to activity as tolerated - surgical intervention (if severe or complete tear)

Answer 466

Meniscal tear

Answer 467

Femoral nerve injury

Answer 468

Patellofemoral pain syndrome (most common cause of knee pain in young adults) Confirm diagnosis with the patellofemoral compression test (pain elicited by extending the knee while compressing the patella against the knee joint) Treat with exercises to stretch and strengthen the thigh muscles and avoidance of activities that aggravate the pain (may take weeks to months to resolve, NSAIDs usually aren’t very effective)

Answer 469

Osgood-schlatter disease (pain at the insertion site of the patellar tendon, often happening after a growth spurt)

Answer 470

Prepatellar bursitis Note: Look out for secondary infection causing septic bursitis with staph aureus

Answer 471

Patellar tendonitis

Answer 472

Rotator cuff tear Note: if there was no weakness it would likely be simply rotator cuff tendonitis, and if there was stiffness and reduced range of motion it would likely be a frozen shoulder

Answer 473

Polymyalgia rheumatica Diagnosis is clinical with elevated ESR adding weight Treat with low-dose glucocorticoids (prednisone 10-20 mg daily), which usually cause rapid relief of symptoms Note: These patients should also be asked about symptoms of giant cell arteritis (headache, jaw claudication, scalp tenderness, visual changes) as these are often comorbid

Answer 474

- Indomethacin (unless history of GO bleed/ulcers or renal failure) - colchicine (unless advanced renal failure) - intraarticular corticosteroids (if contraindications to NSAIDs/colchicine and only one joint is involved; septic arthritis MUST be ruled out prior to injection) - oral prednisone (if contraindications to NSAIDs/colchicine and multiple joints are involved)

Answer 475

Chikungunya fever (caused by a mosquito-borne virus) Confirm diagnosis with PCR Treat with fluids, pain relief, and acetaminophen (most cases resolve within 2 weeks, but some progress to chronic joint pain)

Answer 476

More specific for SLE than anti-nuclear antibodies, but still fairly sensitive (66-95% sensitivity) Note: Anti-dsDNA antibodies can also be used as an indicator of disease activity while monitoring and are especially associated with the development of lupus nephritis

Answer 477

Sensitive for detection of CREST scleroderma

Answer 478

Sensitive to detect primary biliary cirrhosis

Answer 479

Highly specific for SLE, but not very sensitive (25% sensitivity)

Answer 480

This pt is having a lupus exacerbation with lupus arthritis and pleurisy causing a pleural effusion Treatment should be with hydroxychloroquine (effective at treating the arthralgias and serositis) and temporary low-dose prednisone (5-15 mg prednisone daily) until the hydroxychloroquin takes effect Note: If the kidneys or CNS were significantly involved, high-dose prednisone would be needed

Answer 481

Tibial stress fracture (due to repetitive tension/compression of the bone without adequate rest between) Clinical diagnosis (pain localized to a specific area of the tibia that increases with jumping/running and is associated with local swelling and point tenderness); initial xrays are usually negative and may take 4 weeks to show signs of fracture (sclerosis, cortical thickening, periostial elevation, visible fracture line). MRI should be used if confirmation of diagnosis is needed Treatment is with pneumatic splinting, reduced weight bearing (e.g. crutches), and a graduated exercise program over 8-12 weeks

Answer 482

Loss of sensation over the inner buttocks, perineum, and inner thighs that is often associated with causes equine syndrome

Answer 483

- saddle anesthesia (loss of sensation over buttocks/perineum/inner thigh) - acute urinary retention - motor deficits

Answer 484

- constitutional symptoms (fever, weight loss, etc) - age over 50 - higher risk for infections (IV drug use, immunosuppression, recent bacterial infection) - nocturnal pain - higher risk for malignancy (history of malignancy, smoker)

Answer 485

- suspicion for osteoporosis/compression fracture - suspicion for malignancy - suspicion for ankylosis spondylitis (insidious onset, nocturnal pain, better with movement)

Answer 486

- sensory/motor deficits - cause equine syndrome - suspected epidural abscess/infection or vertebral osteomyelitis - known malignancy Note: If pt has a contraindication to MRI they should get a bone scan instead

Answer 487

losartan (has a mild uricosuric effect) Note: Most diuretics decreased the fractional excretion of urate and should be avoided when possible

Answer 488

If there is spinal rotation of 7 degrees or more (or 5 degrees or more in children with obesity) in the forward bend test using a scoliometer or if there is an obvious deformity Note: If the Cobb angle on radiographs is 10 degrees or more the diagnosis of scoliosis is confirmed and a back brace can be considered if grown hasn’t completed (a Cobb angle of 40 degrees or more requires surgical evaluation)

Answer 489

Disease-modifying antirheumatic drugs: - methotrexate (common initial therapy when combined with temporary oral prednisone) - TNF inhibitors (more effective, but increased risk of opportunistic infections, must be screened for TB prior to treatment) - leflunomide - hydroxychloroquin - sulfasalazine

Answer 490

Pagets disease of the bone (a disease characterized by increased bone turnover common in older pts, usually asymptomatic) Confirm diagnosis with calcium (usually normal) and alkaline phosphatase (usually elevated) levels and a radionuclide bone scan to identify other affected areas Treatment is with bisphosphonates to reduce bone turnover (pts with bone pain or high risk areas such as the skull affected should be started on treatment) Note: Hearing loss is common in these pts but can be slowed with bisphosphonates and calcitonin

Answer 491

Polymyositis (an inflammatory myopathy often triggered by a viral infection or underlying malignancy) Confirm diagnosis with ANA, anti-Jo-1 antibodies, and a muscle biopsy Treat with systemic glucocorticoids +/- methotrexate or azarhioprine Note: Monitor for respiratory weakness vs interstitial lung disease with PFTs

Answer 492

Rheumatoid arthritis (ESR/CRP levels tend to correlate with disease activity) Confirm diagnosis with anti-citrullinated peptide antibodies (more specific specific) and rheumatoid factor (more sensitive) Treatment is with NSAIDs and DMARDs (initially methotrexate then biologics like the TNF inhibitor infliximab or etanercept if refractory)

Answer 493

- hepatotoxicity - stomatitis - bone marrow suppression Note: Folic acid supplementation should be given to pts on methotrexate to reduce these side effects

Answer 494

Adhesive capsulitis (“frozen shoulder syndrome” due to joint capsule contraction due to chronic inflammation of the joint from underlying conditions like rotator cuff tendinopathy) Treat by resting the shoulder and doing range of motion exercises. Glucocorticoid injections can be used in refractory cases

Answer 495

Concern for spinal cord tumor Get MRI spine

Answer 496

Fat embolism Can confirm with a VQ scan Treatment is mostly supportive Prevent from happening with early immobilization and operative fixation of fractures

Answer 497

Age 65 for women without risk factors Any postmenopausal women with risk factors (weight < 127lbs, chronic steroid use, smoking, malabsorption disorders, hip fracture or fragility fracture) Note: All postmenopausal women should be counseled in the importance of adequate calcium and Vit D intake

Answer 498

1200mg calcium daily 600-800mg vitamin D daily (sunlight for ~15 minutes twice a week)

Answer 499

Dermatomyositis (with grottons papules on the hands and a heliotrope rash on the eyes) Screen with ESR/CRP/CPK, an ANA titer, and other antibodies (anti-Ro, anti-La, anti-RNP, anti-Jo-1) and a muscle biopsy to confirm. Get a CXR to screen for interstitial lung diseases. If signs of pulmonary dysfunction, get PFTs and CT chest Treat with high dose glucocorticoids plus methotrexate or azothiaprine. Screen for underlying malignancy.

Answer 500

A progressive fibrosis of the palmar fascia with discrete nodules along the flexor tendons that prevent full extension of the digits Commonly seen in men over 50 with history of smoking, alcohol use, and/or diabetes Treat with occupational therapy adjustments (cushion tape, padded gloves), needle aponeurotomy, intralesional glucocorticoid injections, or surgical repair

Answer 501

ACL tear Confirm with anterior drawer test/Lachlan test (tibia is able to be pulled anteriorly relative to femur) and evaluate with MRI to determine the severity of the tear Treat with RICE (rest, ice, compression, elevation) and surgery (if needed)

Answer 502

- sacroiliitis - peripheral asymmetric oligoarthritis - dactylitis - enthesitis - reactive arthritis Note: These are more common in pts with HLA-B27

Answer 503

- Tightness in the area - Muscle weakness - Muscle pain with passive stretching - Paresthesias Note: paralysis, sensory deficits, loss of deep tendon reflexes, infection, diminished pulses, and necrosis occur later

Answer 504

Monitor compartment pressures If compartment pressure exceeds 20-30 mmHg, perform fasciotomy

Answer 505

Unstable slipped capital femoral epiphysis (SCFE) Xrays show displaced femoral head that looks like “ice cream slipping off a cone” Treatment of unstable (unable to bear weight) SCFE is with immediate surgical pinning (delay in treatment can lead to a vascular necrosis and femoroacetabular impingement with a greatly increased risk of degenerative arthritis)

Answer 506

Fibromyalgia Clinical diagnosis, but should get CBC and TFTs to screen for anemia and hypothyroidism, which can present similarly Treat with a progressive exercise regimen +/- pharmacotherapy (tricyclics antidepressants, SNRIs, cyclic skeletal muscle relaxants)

Answer 507

Avascular necrosis of the femoral head (osteochondritis dissecans) Early diagnosis with MRI is important to avoid bone collapse Treatment involves conservative management with avoidance of weight bearing, core decompression, osteotomy, and then joint replacement (if progression to stage 4: characterized by flattening of the femoral head with joint space narrowing)

Answer 508

Parvovirus infection Diagnosis is mostly clinical but can get parvovirus B19 serology Treatment is supportive with NSAIDs

Answer 509

Pulmonary sarcoidosis (a systemic inflammatory disorder characterized by the formation of noncaseating granulomas against an unknown antigen) CXR often has bilateral hilar lymphadenopathy, but biopsy is needed for definitive diagnosis Symptomatic patients should be treated with 12-24 months of oral glucocorticoids (most cases resolve over time and do not recur)

Answer 510

Complex regional pain syndrome (likely due to an injury causing increased sensitivity to sympathetic nerves) Confirm diagnosis with autonomic testing and/or MRI to look for edema/skin thickening/muscle wasting/bone demineralization Treat with a regional sympathetic nerve block or IV regional anesthesia

Answer 511

- AKI or CKD - CHF - Peptic ulcer disease - NSAID sensitivity - Currently on anticoagulation

Answer 512

PO captopril should be used to gradually lower the BP back to baseline over 72 hours (Note: ACE inhibitors should be used in scleroderma renal crisis to reverse angiotensin-induced vasoconstriction, even in the setting of renal failure ACE inhibitors will alleviate renal failure in the long run, though creatinine should be monitored as it may increase at first) Note: In the setting of hypertensive emergency a single dose of IV nitroprusside should be given to immediately bring down the BP while the captopril takes effect. Caution is needed to avoid compromising renal perfusion and causing acute tubular necrosis.

Answer 513

- confirmation of salivary dysfunction (e.g. Schirmer test) | - Autoantibody screen (Anti-Ro, anti-la, RD, ANA)

Answer 514

From birth to age 2 years (still considered pathological if associated with unilateral bowing, short stature, progressive, or associated with a lateral thrust during ambulation) Note: Genu varum is when the legs bow laterally so that the knees are more separated than the feet

Answer 515

Have the pt lie supine with legs straight and lifting one leg over 60 degrees upward; if this elicits a shooting or burning pain that radiates to the calf and foot it is suggestive of a herniated disc

Answer 516

Lumbosacral sprain No diagnostic imaging is needed Treatment escalation with conservative management (manning moderate activity, heat packs, massage, spinal manipulation), NSAIDs such as naproxen or acetaminophen if contraindication, muscle relaxants (cyclobenzaprine, tizanadine) Note: Opioids are not more effective than NSAIDs and should not be used

Answer 517

Any elderly person who was stable and ambulatory prior to hip fracture should have surgical correction within 48 hours (associated with lower mortality)

Answer 518

Occult supracondylar fracture (the posterior fat pad is an abnormal radiolucency posterior to the humerus that represents displaced fat due to traumatic elbow effusion) Treatment includes splinting for immobilization (displaced fractures on the other hand require open or closed reduction with percutaneous pinning)

Answer 519

- neurovascular compromise (brachial artery and median nerves are very easily injured by displaced supracondylar fractures) - compartment syndrome Note: Any possible elbow fractures check for distal pulses/perfusion/weakness

Answer 520

Juvenile myoclonic epilepsy Confirm with EEG showing bilateral polyspike and slow wave activity (if no classical findings on EEG, should get MRI to rule out mass lesions) Treat with valproic acid and avoidance of triggers (sleep deprivation, alcohol, etc)

Answer 521

- dose related thrombocytopenia (leukopenia and anemia can also be seen) - hepatotoxicity - pancreatitis - neural tube defects if pregnant Note: Monitor with CBC, LFTs

Answer 522

Major neurocognitive disorder (dementia) Note: Pseudodementia is treatable with SSRIs but pt should still be monitored for signs of full dementia

Answer 523

- cholinesterase inhibitors such as donepezil (for cognitive impairment) - carbidopa-levodopa (for Parkinsonism) - melatonin (for REM behavior disorder) Note: Antipsychotics can be used to treat functionally impairing visual hallucinations or delusions, but care should be taken as these pts are very sensitive and antipsychotics increase mortality in elderly pts with dementia (look out for worsening confusion, worsening Parkinsonism, and autonomic dysfunction such as orthostatic hypotension)

Answer 524

Psychogenic coma (caloric stimulation during oculivestibular testing cannot be voluntarily suppressed, so this pts normal response indicates that they are not in an actual coma)

Answer 525

Dropping eyelid

Answer 526

Unequally sizes pupils

Answer 527

- ptosis (levator palpebae superioris) - anisocoria (pupillary sphincter) - diplopia (4 of the extrinsic eye muscles)

Answer 528

Subarachnoid hemorrhage due to rupture of a posterior communicating artery aneurysm

Answer 529

- cold caloric testing (oculovestibular reflex) - pupillary light reflex - oculocephalic reflex (dolls eyes) - corneal reflex - gag reflex (e.g. on suctioning) Apnea test is performed after neurological exam confirms brain death Note: If pt is paralyzed or reflexes are difficult to interpret ancillary testing with EEG or brain angiography (CT/MRI/ultrasound) should be obtained

Answer 530

Parinauds syndrome due to a tumor of the pineal gland (headache is caused by obstructive hydrocephalus)

Answer 531

Nystagmus (a combination of fast-phase and slow-phase eye movements) in response to a visual stimulus Note: this allows us to track objects while keeping the head still (e.g. observing individual telephone poles on the side of the road while traveling in a car past them)

Answer 532

Clinical diagnosis based on the presence of essential features (bradykinesia, tremor, and rigidity on physical exam) Note: If there is suspicion for Parkinson’s but physical exam is not confirmatory, you can get a striatal dopamine transporter scan (DaTSCAN), which used the radiotracer ioflupane-123 to light up dopamine transporters in the striatum (low uptake of the radiotracer has the same diagnostic accuracy as physical exam)

Answer 533

- Dopamine agonists (e.g. bromicriptine, pramipexole, etc) | - Levodopa (if pt is over 65 with severe symptoms)

Answer 534

Subacute combined degeneration due to B12 deficiency

Answer 535

Tick paralysis (due to neurotoxins in the saliva of the tick) Perform a meticulous skin exam to try to find the tick. Symptoms should recover within hours of removing the tick Note: Guillain barre syndrome usually affects sensation and progresses more slowly over days and is preceded by a GI or respiratory illness

Answer 536

Bone marrow suppression (neutropenia, anemia, thrombocytopenia)

Answer 537

Elevated intracranial pressure due to: - mass lesions - increased CSF production - decreased CSF fluid outflow (e.g. venous sinus thrombosis) - idiopathic intracranial hypertension (psudotumor cerebri)

Answer 538

Spinal epidural abscess (usually due to Staph aureus) Evaluate with urgent MRI with contrast, ESR/CRP, and blood cultures Treat with emergent surgical decompression to avoid complications of cord compression and perform CT-guided aspiration and culture to direct antibiotic selection followed by empiric antibiotics Note: IV steroid are indicated for cord compression caused by malignant or traumatic injury but NOT for possible epidural abscess

Answer 539

Acute myelopathy, likely secondary to transverse myelitis (caused by cord compression from a tumor, trauma, herniated disc, epidural abscess) Get MRI spine with contrast Treat with 3-5 days high-dose corticosteroids once transverse myelitis is confirmed (can give empirically in the setting of high chance of malignant tumor) Note: Bladder dysfunction and well defined sensory level are not common in guillain barre syndrome

Answer 540

- MMSE (scow <24 suggestive of MCI/dementia) - lab work (CBC/Chem8/LFTs, B12/folate, TSH, vitamin D level, RPR for syphilis) - imaging (CT or MRI brain) - EEG (if atypical presentation) - lumbar puncture with CSF studies (if early onset)

Answer 541

- acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine, galantamine) - memantine, an NMDA receptor antagonist (can be used for moderate to severe cases) Note: All of these are likely only symptomatic treatments

Answer 542

Subarachnoid hemorrhage Get noncontrast CT head, but if negative may need lumbar puncture to completely rule out (Look for CSF with xanthochromia: a pink/yellow tint due to hemoglobin degradation products, elevated opening pressure, or persistently elevated RBCs in all tubes). Cerebral angiography can be used to identify the source of bleeding so that it can be stopped

Answer 543

- prostate - breast - lung - non-hodgkins lymphoma - renal cell carcinoma

Answer 544

Epidural spinal cord compression due to mass effect from tumor Immediately give dexamethasone to decrease edema and swelling around tumor and get an MRI spine to confirm diagnosis Note: If MRI reveals an unstable spine or tumor is found to be radioresistant, then urgent surgical evaluation is warranted for surgical decompression, otherwise radiotherapy alone may be sufficient

Answer 545

Nystagmus on far lateral gaze Note: If this happens get plasma drug levels and decrease dose of elevated or on the higher range of normal

Answer 546

Severe unilateral headaches localized to orbital, Supra orbital, or temporal area that last less than 3 hours each but occur 1-8 times per day for a period of weeks and are associated with autonomic symptoms (ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion)

Answer 547

Acute treatment with: - 100% oxygen via nonrebreather for at least 15 minutes - intranasal sumatriptan given contralateral to the side of the headache (second-line) preventative therapy given at the beginning of a cluster: -verapamil starting at 240mg and uptitrating (first-line)

Answer 548

- 5 min or more of continuous generalized convulsive seizure activity - two or more generalized convulsive seizures without recovery of consciousness between episodes

Answer 549

- Stabilize ABCs (intubate if needed) - IV benzodiazepine (lorazepam, diazepam, or midazolam) - Adjuvant IV agent (fosphenytoin, phenytoin, or valproic acid) - continuous IV infusion with midazolam, pentobarbital, or propofol Note: If IV access is taking too long, midazolam can be given intramuscularly or diazepam can be administered rectally

Answer 550

Blepharospasm (a form of focal dystonia provoked by external stimuli such as bright lights or irritants) Diagnosis is clinical Treatment is with botulinum toxin injections

Answer 551

This young female with neurological deficits disseminated in time and space likely has multiple sclerosis (optic neuritis cause of monocular vision loss is particularly common) Confirm diagnosis with an MRI of the brain and spinal cord (should show T2 hyperintense ovoid periventricular white matter lesions). Lumbar puncture with CSF analysis can can also be done to demonstrate oligoclonal IgG bands. Acute treatment with oral or IV corticosteroids (IV should be used if optic neuritis and plasmapheresis can be used in refractory cases). Disease modifying drugs (beta-interferon, glatiramer acetate) should be used for patients with the relapsing-remitting pattern of disease

Answer 552

- physical therapy and stretching - massage therapy - muscle relaxants (baclofen, tizanidine, etc)

Answer 553

- sleep hygiene and regular exercise - amantadine - stimulants (methylphenidate, modafanil, etc)

Answer 554

- timed voiding - fluid restriction - anticholinergics (oxybutynin, tolterodine, etc)

Answer 555

STOPBANG: - Snoring - Tiredness, excessive daytime - Observed apnea’s/choking/gasping - Pressure elevated (hypertension) - BMI > 35 (obesity) - Age > 50 - Neck size increased (men > 17, women > 16) - Gender male Note: 0-2 points low risk, 3-4 points intermediate risk, 5 or more points high risk

Answer 556

Vertibrobasilar insufficiency (reduces blood flow to the base of the brain often affecting the brainstem and labyrinth)

Answer 557

Neurofibromatosis with likely an acoustic scwannoma

Answer 558

Cerebral palsy Diagnosis is predominantly clinical but should be confirmed with an MRI brain (usually showing periventricular leukomalacia and basal ganglia lesions) Treatment is supportive with physical/occupational/speech therapy, nutritional support with G tube if needed, and antispastic medications (baclofen, botulinum, etc) as needed

Answer 559

Construction apraxia (usually due to a lesion in the nondominant/right parietal lobe)

Answer 560

A seizure that can occur during a high fever in children from age 6 months to 5 years with no signs of CNS infection This is benign and does not require treatment other than antipyretics, but does predispose to further febrile seizures and increases risk of epilepsy

Answer 561

- Transient post-trauma neurological disturbance (dizziness, disorientation, amnesia, etc) - No structural intracranial injury on imaging

Answer 562

- remove from same day physical activity - rest for at least 24 hours - gradual return to normal activity if symptoms do not worsen (light aerobic exercise to no contact sports to contact sports, limited screen time, school accommodations with frequent breaks and shortened days)

Answer 563

Sarcoidosis (extrapulmonary manifestations) Get a CXR to look for bilateral hilar or mediastinal adenopathy followed by biopsy of the most accessible affected site for confirmation (usually a lymph node showing noncaseating granulomas)

Answer 564

TIA due to symptomatic carotid artery disease (note right sided weakness is usually due to decreased flow to the left middle cerebral artery, a branch of the internal carotid) Get MR angiogram to confirm diagnosis and determine degree of stenosis Treat with carotid endarterectomy (if 70-99% stenosis and life expectancy greater than 5 years. Medical management for all patients includes aspirin and statin.

Answer 565

Wernickes encephalopathy due to thiamine deficiency Clinical diagnosis (MRI brain may show degeneration of mammillary bodies of pt also has korsakoff syndrome: amnesia and confabulation) Treat with IV thiamine (occulomotor dysfunction usually resolves quickly but confusion/ataxia take longer and may never fully resolve; once Korsakoff syndrome develops it rarely resolves)

Answer 566

Oral dopaminergic receptor antagonist (bromicriptine, capergoline, etc) Note: Transsphenoidal resection is rarely needed to treat prolactinomas as they are usually responsive to oral medications

Answer 567

Amaurosis fugax (retinal ischemia due to reduced retinal artery flow), usually due to carotid artery atherosclerosis

Answer 568

When presenting within 3-4.5 hours of last known normal as long as pt has no contraindications to fibrinolysis (active internal bleeding, bleeding diathesis such as platelets < 100000, CT showing intracranial hemorrhage, CT showing hypodensity in >33% of an arterial territory, intracranial surgery within past 3 months, blood pressure > 185/110)

Answer 569

- Carotid imaging (CT/MR angiography or duplex ultrasound) - ECG for arrhythmias or infarction - echocardiogram to evaluate for intracardiac thrombus

Answer 570

- RBCs > 6000 (decreasing in subsequent tubes with no xanthochromia) - elevated WBCs to approximately 1 WBC for every 1000 RBC - elevated proteins - elevated glucose

Answer 571

- clonidine - benzodiazepines - antiemetic - antidiarrheals - methadone (if pt will have good follow up in a detox program) Note: Buprenorphine can make withdrawal worse but if good for long term management of opioid use disorder

Answer 572

Any 1 of the following: - REM sleep latency of 15 min or less on polysomnographic multiple sleep latency testing - cataplexy (sudden transient loss of muscle tone associated with strong emotions or spontaneous abnormal facial movements without identifiable trigger) - CSF analysis showing hypocretin-1 deficiency

Answer 573

- lifestyle modifications (scheduled naps, good sleep hygiene) - modafanil (preferred over methylphenidate) - SNRI or SSRI, especially venlafaxine (to treat cataplexy) Note: Sodium oxybate can be used to improve nocturnal sleep and treat cataplexy but is rarely used due to abuse potential and restrictive regulations

Answer 574

Meralgia paresthetica due to entrapment of the lateral femoral cutaneous nerve as it courses from the lumbar plexus under the inguinal ligament and into the thigh Diagnosis is clinical Treatment involves weight loss and avoidance of tight fitting clothes

Answer 575

None, unless there are high risk features for intracranial structural injuries (AMS, LOC, severe headache/vomiting, severe mechanism of injury, signs of basilar skull fracture)

Answer 576

Carpal tunnel syndrome Treat with splint (surgery for refractory cases)

Answer 577

Carotid artery dissection (unilateral headache and associated Horner syndrome with transient loss of vision) Confirm diagnosis with CT angiography (Note: TIA or acute stroke are common complications) Treat with thrombolysis (if within 4.5 hours of last known normal) and antiplatelet therapy +/- anticoagulation Note: Theombolysis is used if possible because carotid artery dissections are associated with intramural thrombus formation causing luminal obstruction

Answer 578

Pseudotumor cerebri/idiopathic intracranial hypertension (due to chronically elevated intracranial pressures which usually occurs in obese females but can also happen in other cases such as with the use of isotretinoin for severe acne) Note: Headaches + papilledema think about pseudotumor cerebri

Answer 579

Myelomeningocele subtype of spina bifida due to maternal folate deficiency during pregnancy Elevated alpha-fetoprotein during pregnancy is suspicious and diagnosis is confirmed with prenatal ultrasound Treatment is with urgent surgical repair often complicated by hydrocephalus requiring ventriculoperitoneal shunt placement Note: Even with appropriate treatment, motor/sensory/autonomic function below the level of the lesion is usually impaired (neurogenic bladder with urinary retention/incontinence and frequent UTIs is nearly universal requiring intermittent catheterization and neurogenic bowel requiring laxatives/enemas is also common)

Answer 580

- hypocalcemia (perioral numbness, muscle cramps/spasms, Chvostek/Trousseau’s signs - severe hypocalcemia (AMS, seizures) Note: Hypocalcemia results from either relative hypoparathyroidism (due to chronic suppression of normal parathyroid tissue) or due to hungry bone syndrome (due to rapid influx of calcium to bone stores in states of higher bone turnover with post surgical decrease in parathyroid hormone, this happens 2-4 days post operation)

Answer 581

Injury to left hypoglossal nerve during surgery

Answer 582

Brainstem lesion

Answer 583

Wallenberg syndrome due to a lateral medullary infarction (often due to an occluded intracranial vertebral artery) Confirm diagnosis with MRI Treat with tPA (if within 4.5 hours)

Answer 584

Dysphagia, hoarseness, diminished gag reflex (due to CN IX and X involvement)

Answer 585

Weakness in the muscles of mastication, diminished jaw jerk reflex

Answer 586

Tongue deviation toward the side of the lesion

Answer 587

Contralateral ataxia and hemiparesis of the face, trunk, and limbs

Answer 588

Tabes dorsalis due to degeneration of posterior spinal columns in late neurosyphilis (Argyll Robertson pupils are characteristic) Confirm diagnosis with tests for treponema pallidum

Answer 589

Behavioral variant frontitemporal dementia Neuroimaging usually shows frontotemporal atrophy, often associated with autosomal dominant inheritance pattern Usually fatal within 8 years Note: Primary progressive aphasia is another type of frontotemporal dementia characterized by dementia that initially presents with isolated language impairment

Answer 590

Amyotrophic lateral sclerosis (progressive motor neuron disease that affects both lower and upper motor neurons, though usually starts with lower motor neuron defects) Treatment with riluzole (a glutamate inhibitor) can slow progression of the disease and prolong survival Note: Ocular motility, sensory, bowel, bladder, and cognitive functions are preserved (even in advanced disease)

Answer 591

Tuberous sclerosis complex (autosomal dominant mutation in hamartin or tuberin proteins that leads to the development of many benign tumors throughout the body) Confirm diagnosis with genetic testing Management is with frequent screenings: skin exams, eye exams, MRIs brain (screening for gioneuromal hamartomas), MRI kidneys (screening for angiomyolipomas), baseline echocardiogram with serial ECGs (screening for rhabdomyomas), baseline EEG, and neuropsychiatric screening Note: Antiepileptics should be started if EEG is abnormal as uncontrollable seizures are the most common cause of death)

Answer 592

- progressive symmetric muscle weakness - paresthesias - potentially life-threatening dysautonomia (tachycardia, urinary retention) - decreased or absent deep tendon reflexes Note: Usually occurs after a GI or respiratory infection

Answer 593

- Frequent measurement of vital capacity and negative inspiration force (30% of pts will require mechanical ventilation) - plasma exchange or IVIG can slow progression and speed recovery (give if nonambulatory or within 4 weeks of symptom onset) Note: 85% of patients regain the ability to walk after a year and nearly 60% of patients eventually have full neurologic recovery

Answer 594

- endocarditis - varicella zoster virus - meningovascular syphilis - bacterial meningitis - tuberculous meningitis Note: Also consider cocaine/amphetamine use, inflammatory arteritis as in Takayasu arteritis, or cerebral artery dissection

Answer 595

- Periorbital hematomas (raccoon eyes) - Mastoid or postauricular ecchymosis (battle sign) - clear CSF leaking from nose or ears

Answer 596

Absence epilepsy (petit mal seizures) EEG shows 3 Hz spike and wave discharges Treatment is effective with ethosuximide and disease usually spontaneously remits by early puberty (ethosuxomide can be stopped after child is seizure free for two years) Note: Often associated with anxiety/depression/ADHD

Answer 597

This pt has Cushings triad suggesting elevated intracranial pressure, likely due to intracranial hemorrhage Pt should be intubated and CT brain obtained to look for cause IV mannitol can be used to reduce intracranial pressure in emergency situations Note: Hyperventilation can be used to reduce intracranial pressure but is contraindicated one traumatic brain injury and stroke due to decreased cerebral blood flow

Answer 598

Diabetic neuropathy (peripheral neuropathy and neurogenic ED suggest neuropathy is significant enough to cause the cremasteric reflex to fail)

Answer 599

- AMS (fussy behavior) - Loss of consciousness - severe mechanism of injury (fall from more than 3 ft high, high impact, MVA) - scalp hematoma anywhere other than the frontal region - palpable skull fracture Note: These pts should get a noncon head CT

Answer 600

Diaphragmatic paralysis Note: Pt exhibits paradoxical abdominal wall motion during inspiration because the diaphragm isn’t contracting

Answer 601

Forehead sparing (ability to raise eyebrow and wrinkle forehead) suggests a central lesion, so brain imaging should be ordered If the forehead is not spared, this suggests a lesion of a peripheral nerve (Bell’s palsy of CN VII) and no other workup is needed unless there is suspicion for Lyme disease

Answer 602

Bell’s palsy of CN VII (if there was forehead sparing there would be concern for a brain lesion/infarction/mass) No workup is needed unless there is concern for Lyme (in which case an ELISA screening test should be ordered) Treatment is with corticosteroids (preferably within 3 days of symptom onset) and careful protection of the eyes with artificial tears and eye patching (eyes tend to dry out in Bell’s palsy due to inability to close fully predisposing to corneal abrasions) Note: Most patients recover within 1-6 months

Answer 603

Normal pressure hydrocephalus Neuroimaging should show ventriculomegaly out of proportion to sulcal enlargement with no identifiable cause of obstruction of CSF flow. Diagnosis can be confirmed with the lumbar tap/Miller Fisher test (gait and cognitive assessment before and after lumbar drainage of CSF) Temporary treatment with lumbar puncture and CSF drainage during confirmation of diagnosis. Definitive treatment is with a ventriculoperitoneal shunt

Answer 604

- hypertension (most important) - diabetes - smoking - dyslipidemia

Answer 605

If the pt is getting tPA, then maintain strict blood pressure control using IV antihypertensives to maintain a BP less than 185/105, but greater than 140/90 (to maintain perfusion if the penumbra) If the pt is not getting tPA, then allow permissive hypertension up to 220/120 Note: If tPA given IV antihypertensives such as labetalol, nicardipine, or sodium nitroprusside should be used

Answer 606

Headache, confusion, amnesia, difficulty concentrating, vertigo, photophobia, mood alteration, sleep disturbance, and/or anxiety that can persist for weeks to months after a concussion, regardless of the severity of the concussion Note: Most resolve within weeks but can persist for up to 6 months

Answer 607

Carpal tunnel syndrome Treat with splint (surgery for refractory cases)

Answer 608

Carotid artery dissection (unilateral headache and associated Horner syndrome with transient loss of vision) Confirm diagnosis with CT angiography (Note: TIA or acute stroke are common complications) Treat with thrombolysis (if within 4.5 hours of last known normal) and antiplatelet therapy +/- anticoagulation Note: Theombolysis is used if possible because carotid artery dissections are associated with intramural thrombus formation causing luminal obstruction

Answer 609

Pseudotumor cerebri/idiopathic intracranial hypertension (due to chronically elevated intracranial pressures which usually occurs in obese females but can also happen in other cases such as with the use of isotretinoin for severe acne) Note: Headaches + papilledema think about pseudotumor cerebri

Answer 610

Myelomeningocele subtype of spina bifida due to maternal folate deficiency during pregnancy Elevated alpha-fetoprotein during pregnancy is suspicious and diagnosis is confirmed with prenatal ultrasound Treatment is with urgent surgical repair often complicated by hydrocephalus requiring ventriculoperitoneal shunt placement Note: Even with appropriate treatment, motor/sensory/autonomic function below the level of the lesion is usually impaired (neurogenic bladder with urinary retention/incontinence and frequent UTIs is nearly universal requiring intermittent catheterization and neurogenic bowel requiring laxatives/enemas is also common)

Answer 611

- hypocalcemia (perioral numbness, muscle cramps/spasms, Chvostek/Trousseau’s signs - severe hypocalcemia (AMS, seizures) Note: Hypocalcemia results from either relative hypoparathyroidism (due to chronic suppression of normal parathyroid tissue) or due to hungry bone syndrome (due to rapid influx of calcium to bone stores in states of higher bone turnover with post surgical decrease in parathyroid hormone, this happens 2-4 days post operation)

Answer 612

Injury to left hypoglossal nerve during surgery

Answer 613

Brainstem lesion

Answer 614

Wallenberg syndrome due to a lateral medullary infarction (often due to an occluded intracranial vertebral artery) Confirm diagnosis with MRI Treat with tPA (if within 4.5 hours)

Answer 615

Dysphagia, hoarseness, diminished gag reflex (due to CN IX and X involvement)

Answer 616

Weakness in the muscles of mastication, diminished jaw jerk reflex

Answer 617

QALYs is way to measure the burden of a disease. The pt thinks about how many years with their current disease they would be willing to trade for 1 year of life at full health. If a pt states that 5 years in their current state is equivalent to 1 year at full health, then the time trade off is 1/5 or 0.2, which can then be used to calculate QALYs. If this pt was healthy until age 30, then had disease until present at age 40. The quality adjusted life years would be 32 (30 years at full health + 10 years at 0.2) Note: The goal is to maximize QALYs through treatments that increase the time trade off factor (treatments that increase quality of life)

Answer 618

DALYs are a way to measure disease burden that estimates the total number of years of life lost due to that disease. It can be calculated by adding the years of life lost due to decreased quality of life PLUS the years of life lost due to premature mortality If a pt develops depression at age 30 and commits suicide at age 50 (assuming life expectancy at age 50 is 84 and that the disability weight for depression is 0.35), then: DALY = years of life lost (84-50) + years of life with disability (30 + (20 x 0.35)) = 41 years (lost 7 years due to loss of quality of life during disability and lost 34 years due to premature mortality) Note: DALYs should be minimized. Disability weights are similar to time trade offs used for quality-adjusted years of life but are standard values used for populations, whereas TTOs are an individual pts self-reported number

Answer 619

- migraine with aura - at least 15 cigarettes/day PLUS age of 35 or greater - hypertension of 160/100 or greater - heart disease - diabetes with end organ damage - history of thromboembolic disease - antiphospholipid antibody syndrome - history of stroke - breast cancer - cirrhosis and liver cancer - major surgery with prolonged immobilization - less than 3 weeks postpartum

Answer 620

Penicillin or amoxicillin Of allergic to penicillin, then use a cephalosporins (if a mild reaction to penicillins) or azithromycin or clindamycin (if anaphylaxis to penicillins)

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