First line treatment for Impetigo
Leukocytosis w/ left shift indicates?
Dicloxacillin
Followed by Vanc if Beta-lactamase resistant
- Excess neutrophils ... essential a bacterial infection
Treatment:
Hot tub folliculitis
Impetigo by strep
Contact dermatitis
impetigo, abscess and folliculitis by staph
Fluoroquinolon, Ciprofloxacin
Cephalexin
Topical steroid
TMP-SMX
Difference between HIB and Influenzae
What's the pnuemococcal vaccine for?
HIB
- Cause lower respiratory infection
- HIB vaccine reduce incidence since 1990s
Influenzae
- high fever, runny nose, sore throat, muscle pains, headache, coughing, and feeling tired.
- Yearly vaccine
- Treat w/ neuraminidase inhibitors (oseltamivir and
Media
1) Chocolate agar
2) Thayer-Martin
3) Eaton agar
4) Charcoal yeast
1) H. Influenzae
2) N. Gonorrhea
3) Mycoplasma
4) Legionella
Stains
1) PAS
2) India ink
3) Silver Stain
1) Whipple diseae
2) C. neoformans
3) Fungi (e.g., Pneumocystis), Legionella,
Helicobacter pylori
___ antibiotics have better coverage than any other class
List them
Beta-Lactam
Penicillin, Cephalosporins, carbapenems, aztreonam
Which bacteria are covered by Amoxicillin
HELPS
H --> H. influenzae
E --> E. Coli
L --> Listeria
P --> Proteus
S --> Salmonella
Piperacillin, ticarcillin, azlocillin, mezlocillin
Cover what kind of bacteria
What are they useful for
Gram (-)
� Cholecystitis and ascending cholangitis
� Pyelonephritis
� Bacteremia
-All stuff that can climb up a tract
� Hospital-acquired and ventilator-associated pneumonia
� Neutropenia and fever
Ceftriaxone, Cefotaxime, Ceftazidime
- What class are these?
What is ceftriaxonde first line for?
Avoid ceftriaxone in ____ pt. Why?
3rd gen cephalosporin
- Meningitis
- Community-acquired pneumonia (in combination with macrolides)
- Gonorrhea
- Lyme involving the heart or brain
Avoid ceftriaxone in neonates because of impaired biliary metabolism.
Best therapy for community-acquired pneumonia, including penicillinresistant pneumococcus
Use ___ for cystitis and pyelonephritis.
____ can be used as a single
agent for diverticulitis and does not need metronidazole.
Fluoroquinolones (Ciprofloxacin, Gemifloxacin, Levofloxacin, Moxifloxacin)
* Macrolides and doxycycline also used
Ciprofloxacin
Moxifloxacin
Side effect of quinolones
Bone growth abnormalities in children and pregnant woman
Tendonitis and tendon rupture
Treatment for cystitis and pneumocystis treatment/prophylaxis
Side effects?
Trimethoprim/Sulfamethoxazole
Rash
hemolysis in G6PD
Bone marrow suppression (folate antagonist)
What do all these bugs have in common together?(E. coli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Citrobacter)
Treat them w/ (memorize this list)
All gram (-) and can cause infections of the bowel (peritonitis, diverticulitis); urinary tract (pyelonephritis); and liver (cholecystitis, cholangitis).
� Quinolones
� Aminoglycosides
� Carbapenems
� Piperacillin, ticarcillin
� Aztreonam
� Cephalosporins
Pt w/ fever, headache, neck stiffness (nuchal rigidity), and photophobia.
Most likely organism
Best initial test
Rash shaped like a target
Rash moves from arms/legs to trunk
Meningitis
S. Pneumonia (60%)
LP
- Unless there's possibility of space occupying lesion (Papilledema, Seizures, Focal neurological abnormalities, Confusion interfering with the neurological examination)
-In the above case, treat w/ empiric antibiotics fir
Thousands of neutrophils on CSF. Treat w/
If you find increase PMN in CSF, this means? What about increase lymphocytes CSF?
Add __ if immunocompromised, elder or neonates for Listeria.
___ meningitis requires respiratory isolation.
- Give details about th
ceftriaxone, vancomycin, and steroids
PMN--> indicate bacteria infection
Lymphocytes --> indicate fungal or TB infection
ampicillin
neisseria meningitis
- Give rifampin to close contacts (people in the same household or healthcare worker that intubate pt)
Acute onset of fever and confusion. Must consider ____
Most likely cause
First initial test
Most accurate test
What do you use for acyclovir-resistant form
Encephalitis
HSV
CT (because of the presence of confusion)
PCR of CSF (better than brain biopsy)
- Tzanck prep --> best initial on genital lesions
-Viral culture --> Most accurate for genital lesions
Foscarnet (has more renal toxicity than acyclovir thoug
Most sensitive physical finding for otitis media
Most accurate diagnostic test
best initial therapy
Most common cause of otitis?
immobile typmanic membrane
tympanocentesis
amoxicillin (add clavulanate if no response)
S. Pnuemoniae or Haemophilus influenzae
first-line therapy for both otitis and sinusitis
Amoxicillin/clavulanic acid
doxycycline
trimethoprim/sulfamethoxazole
Pt w/ pain on swallowing, enlarged lymph node, exudate on pharynx, fever, no cough
90% of cases are due to ____
- But can also be caused by
Best treatment
Why is treatment important
Pharyngitis
S. pharyngitis (Group A Beta-hemolytic)
- EBV or S. Pyogenes
*If EBV but you give amoxicillin accidentalyl for S. pyogenes, pt may present w/ rash
Amoxicillin or cephalexin (if penicillin allergic)
To prevent development of rheumatic fever
� Arthralgias/myalgias
� Cough
� Fever
� Headache and sore throat
� Nausea, vomiting, or diarrhea, especially in children
What is treatment protocol for these pt
Influenza (The Flu)
<48hrs of symptoms --> treat w/ neuraminidase inhibitors (oseltamavir and zanamivir)
>48 hrs of symptoms --> treat symptomatically
Blood and WBC in stool... Think
� __: poultry
� __: most common cause, associated with GBS
� __:H7-hemolytic uremic syndrome (HUS)
� __: second most common association with HUS. Pt can present w/ seizures too
� __: shellfish and cruise ships
� __: shellfi
Salmonella
Camplybacter
E. Coli 0157
Shigella
Vibrio parahaemolyticus
Vibrio vulnificus
Yersian
C. Diff
Hep B is dependent on Hep ___
Hep ___ is worst in pregnancy
Hep ____ is transferred by sex, blood and perinatal
Hep __ is associated w/ IVDU
What abnormalities would u see on lab values w/ acute hepatitis
Hep ___ disease activity is assessed w/ PCR for RN
C
E
- Typically found in E. Asian woman
B, C, D
C
increase direct bilirubin, ALT:AST (>2:1) and increase Alk Phos
C
surface antigen
antibody to surface antigen
Hep B panel
When would u see a positive e-antigen?
When would u see a neg core antibody w/ positive surface antibody
When is the only time you would see a positive surface antigen
What would show up first in Hep B infection
What is associated w/ the quant
Acute or chronic infection
Pt who is vaccinated for Hep B
Acute or chronic infection
Surface antigen
E- Antigen
E- Antigen
What's the different physical exam finding between urethritis and cystitis?
What's treatment for urethritis
Both have dysuria with urinary frequency and burning but cystitis does not have urethral discharge like urethritis
Gonorrhea --> Ceftriaxone, Cefixime
Chlamydia --> Azithro, Doxycycline
� Lower abdominal tenderness / Pain
� Fever / Leukocytosis
� Cervical motion tenderness
What's your diagnosis
What's your first initial test
Inpatient vs outpatient treatment
PID
Exclude pregnancy
Inpatient: Cefoxitin or cefotetan combined with doxycycline
Outpatient: Ceftriaxone and doxycycline (possibly with metronidazole)
Painless ulcer
Painful ulcer
Lymph nodes tender and suppurating
Vesicles prior to ulcer and painful
Also list treatment for each
Syphilis
- Single dose of penicillin or Doxycycline if penicillin allergic
- Usually multiple bumps
Chancroid (Haemophilus ducreyl)
- Single dose Azithro (1gram PO)
- Usually single or multiple bumps
Lymphogranuloma venereum
- Doxycycline
Herpes simplex
-
What are the presentation of different type of syphilis and their treatment
Primary
- Painless genital ulcer and adenopathy
- Treat w/ IM penicillin (oral doxy if penicillin allergic)
Secondary
-Rash on palms and sole, condylomata lata
- Same treatment as primary syphilis
Tertiary
- Neurosyphilis (menigovascular stroke, tabes dor
Treatment for
Condylomata acuminata
Pediculosis
Scabies
- How does this spread?
Genital warts
- Cryotherapy w/ liquid nitrogen, surgery.... Podophyllin or imiquimod
Crabs
- Permethrin
Scabies
- Permethrin
- Close skin to skin contact
- Treat close contacts as well
Best initial therapy for pyelonephritis
Presentation for cystitis
- How many WBC are you looking for on urinalysis
Treatment for cystitis
Ceftriaxone
- Use ampicillin and gentamicin until culture results are known
Suprapubic pain w/ mild fever
- 10 WBC
Nitrofurantoin, TMP/SMX, Cipro (try to reserve it though)
- Nitro for 3 days for uncomplicated cystitis/ Nitro 7 days if there's an anatomic
Most common bug for IVDU endocarditis
What do you find on presentation?
Best diagnostic test
If culture is neg but highly suspect endocarditis, treat w/
Treatment for endocarditis
- Strep
- Staph sensitive and resistant
-Enterococci
Prophylaxis for endoca
Staph A.
Fever w/ new onset murmur (endocarditis almost always occurs w/ abnormal valve)
Blood culture and TEE (look for vegetations).... Don't do EKG
Vanco and gentamycin
- Treat w/ ceftriaxone for HACEK group (most common cause of culture-neg endocardit
Lyme disease
Found in what region
Common presentations
Treatment
Caused by the ____, which is commonly carried by ___ on the white-tailed deer and white-footed mice
Northeast (rocky mountain)
-Rash (Erythema migrans "bull's eye)
-Joint pain (usually knee)
-Menigitis, encephalitis and cranial nerve palsy (Bell's, which is 7th cranial nerve)
-Transient AV block
Rash, joint paint and bell's palsy--> treat w/ doxy and am
HIV
Initial, confirmation and test for infected infants
When do you start treatment
What do you start treatment w/
What's the best test to assess treatment effectiveness
ELISA, confirme w/ Western, PCR or viral culture for infants
CD4 <350 or viral load >100,000
emtricitabine, tenofovir, and efavirenz (Atripla is the combination of the 3)
PCR-RNA for viral load. Not CD4 because CD4 changes lag behind viral load testing
Adverse effects of HIV Drugs
Zidovudine
Abacavir (HLA B5701)
Tenofovir
Anemia
Hypersensitivity, SJS
Renal insufficiency
Antiretroviral during pregnancy. When should you start treatment
-Patient on antiretrovirals at the time of pregnancy
-Not on antiretrovirals, CD4 low or viral load high
-Not on antiretrovirals, CD4 high and viral load low
Which antiretroviral should be a
Right away and continue for all 3 trimester
- Continue same medications, except switch efavirenz to a protease inhibitor
- Initiate antiretrovirals immediately; continue after delivery
- Antiretrovirals; immediately stop them in the mother after delivery
Blood and WBC in stool... Think
� Salmonella: poultry
� Campylobacter: most common cause, associated with GBS
� E. coli 0157:H7-hemolytic uremic syndrome (HUS)
� Shigella: second most common association with HUS
� Vibrio parahaemolyticus: shellfish and cr
...
What is the most common cause of osteomyelitis?
In those w/ sickle cell anemia
Diabetics and drug users
Staph
Salmonella
Pseudomonas
What is management for people w/ dog, cat or human bites
Amoxicillin/clavulanate should be given prophylactically
Tetantus vaccination booster if >5 yrs since last injection
What do these tell you on urinalysis?
-Leukocyte esterase test
- Nitrite test
___ is a vesicular eruption of the tonsillar region, soft palate, or posterior pharynx typically occuring in children 3-10 y.o.. It is most commonly as a result of infection by
Bacterial UTI
Gram negative bacterial UTI
Herpangina
- Coxsackie A virus
___ is localized anaphylaxis with a "wheal and flare."
Angioedema is swelling of ____
- Could be due to ____ or _____
-Treatment?
___ is sudden swelling of the superficial layer of the skin
Urticaria
Face, tongue, eyes, airway
- Recent start of ACE(-) or C1 esterase deficiency
-Ensure airway first. Acute therapy (FFP or Ecallanatide). Long term (androgen therapy).
.....GCT does not help in angioedema!
Urticaria
Pt presents w/ these symptoms. What is it?
� Watery eyes, sneezing, itchy nose, and itchy eyes
� Inflamed, boggy nasal mucosa
� Nasal polyps
How would there turbinates look like?
What is first line treatment?
Allergic rhinitis
� Pale or violaceous turbinates
Intranasal steroids
Pt present w/ recurrent sinupulmonary infection. Differential includes
Pt w/o AIDs presents w/ infections w/ PCP, Varicella and candida
Anaphylaxis to blood transfusion
Recurrent skin infection w/ staph
Immunodeficiency combined w/ thrombocytopenia and ec
CVID, X-linked (Bruton) agammaglobulinemia, SCID and IgA deficiency
SCID
IgA deficiency
Hyper IgE syndrome
Wiskott-Aldrich syndrome
Chronic granulomatous disease
- Nitroblue tetrzolium test
Individuals w/ CVID (common variable immunodeficiency) are at increased risk for
lymphoma
MI extremely rare in woman before age ____.
___ may improve LDL but does not help in CAD in woman
Worst risk factor for CAD?
Most common risk factor for CAD?
What age in man and woman do u start to worry about CAD
What are considered family risk factors
50
Estrogen replacement
DBM
HTN
45
55
1st degree relatives only. If family w/ CAD who are elderly, they don't count as family risk factor (most common wrong answer for risk factor assessment)
Physical exam finding of those w/ ischemic chest pain
Infarct symptoms
Pleuritic (changes w/ respiration), pain changes w/ POSITION, pain changes w/ touch of chest wall (tenderness)
Sharp / knife-life pain
Pain worse w/ lying flat, better when sitting up, young <40
Sudden-onset of SOB, tachycardia and hypoxia?
- What's the most accurate test
Pericarditis
PE
- Spiral CT or V/Q Scan
Stress testing is the answer
when __ and ___
What nuclear test are useful in assessing chest pain?
the etiology of chest
pain is uncertain and the
EKG is not diagnostic
Thallium and sestamibi
Ischemia gives ___
wall motion or thallium
uptake between rest and
exercise. Infarction is
___
Most accurate test of detecting CAD?
___is to evaluate stable
patients with chest pain whose diagnoses are not clear.
reversible
irreversible or "fixed."
Angiography
Exercise tolerance testing
Chronic angina, what drugs lower mortality?
Low ejection fraction / systolic dysfunction. Best drug to lower mortality
What drug increase mortality in CAD
Recent angioplasty w/ stenting. What drug do u give
pt w/ CAD, what is LDL goal
ASA, B-Blocker and NitroGlycerin
ACE-I/ARB
Ca++ channel blockers
clopidogrel
<100
Pt intolerant to both ASA and clopidogrel. Which drug can u give
Hydralazine should be used in association with ___ to dilate the coronary arteries so that blood is not "stolen" away from coronary perfusion when afterload is decreased with the use of hydr
Ticlopidine
nitrates
Pt on statin meds should be monitored for what?
___ w/ statins can increase risk of myositis
Liver dysfunction. Routinely monitor AST and ALT
Fibrates (such as gemfibrozil)
Adverse effects of lipid lowering meds
Statins
Niacin
fibric acid derivatives
Cholestyramine
Ezetimibe
Elevations of transaminases (liver function tests), myositis
Elevation in glucose and uric acid level, pruritus
Increased risk of myositis when combined with statins
Flatus and abdominal cramping
Well tolerated and nearly useless
Use CCBs (verapamil/diltiazem) in CAD only with
Adverse Effects of CCBs
� Severe asthma precluding the use of beta blockers
� Prinzmetal variant angina
� Cocaine-induced chest pain (beta blockers thought to be contraindicated due to unopposed alpha stimulation) (also use Benzo --> good for controlling chest pain and anxiety)
Indications for a CABG
Are artery or vein graph better?
___ is the best in acute coronary syndromes, particularly with ST segment elevation
� Three vessels with at least 70% stenosis in each vessel
� Left main coronary artery occlusion
� Two-vessel disease in a patient with diabetes
� Persistent symptoms despite maximal medical therapy
Artery graph (last 10 yrs)
Vein graph (last 5 years)
PCI
What is the S4 sound
What is the S3 sound
What is pulsus pardoxus and what is it associated w/
What is Kussmaul sign
Increase in wedge pressure is an indication of
Atrial pumping into a stiff ventricle
CHF
Decrease in BP >10mmHg on inspiration --> Pericardial tamponade
Inc in jugulovenous pressure on inhalation --> associated w/ constrictive pericarditis
pulmonary HTN
Leads V2-V4
Leads II, III, AVF
Leads V1, V2
Which is associated w/ worst mortality
Which leads are read backwards?
V1-V4
anterior wall
Inferior wall
Posterior wall
*present w/ reciprocal ECG changes
*Posterior descending from RCA
V2-V4 (anterior wall)
V1, V2 (therefore, ST depression is actually an infarct)
Ventricular aneurysm
In acute coronary syndrome, what drug decreases mortality?
After drugs what should u do?
When does CK-MB and troponin show up? How long until levels go down?
ASA. Morphine, O2, and Nitro should be given but they do not decrease mortality.
- B-blocker --> lower mortality but does not matter when you give it
- ACE-I --> lower mortality in those w/ EF <40%
- Statin --> Lowers mortality in those w/ LDL >100
Thromb
Q waves
Cannon A waves
Old infarcts
3rd degree AV block (atrial systole against closed tricuspid valve)
How do you decrease stent placement complications?
Contraindications to stent placement?
- Place a stent that is drug-eluting (inhibits local T-cell response). This reduces rates of restenosis
Any bleeding, recent surgery (<2 wks), HTN (>180/110)
When do you us Ca++ Channel blocker in heart disease?
Cocaine-induced pain or prinzmetal/vasospasctic variant angina (don't use b-blocker --> lead to unrestricted alpha stimulation which may further vasoconstrict coronary vessels)
Drugs used for stable angina
Drugs used for unstable angina / Non-ST elevation MI
ST elevation MI
ASA, B-Blocker and Nitrates
Drugs above and LMW Hep (non-ST elevation MI) and GPIIb/IIIa (Non-St elevation MI and about to undergo PCI and stenting)
Drugs above except for GPIIB/IIIa. Use thrombolytics if PCI is not available
RCA supplies
- R. Ventricle, AV node and inferior wall --> do not give nitro (will worsen MI)
*Nitro will decrease preload in inferior wall MI, which is preload dependent because it's not acting like a pump anymore. Good idea to give these pt fluids to increase preloa
Murmur at apex and radiate to axilla
Pt w/ Turner's present w/ what cardiac defect?
MR
Coarctation of aorta
- also aortic stenosis due to bicuspid aortic valve
Step up in O2 from RA to RV --> you should think of
septal rupture, post MI
Several days post MI --> sudden loss of pulse
What do you need to consider for pts before discharge
What drugs do you discharge them home on?
Pt, post-MI, present w/ erectile dysfunction. Most likely cause?
Tamponade/free wall rupture --> Emergency ECHO followed by pericardiocentesis
- Do a stress test
- ASA, B-blocker, ACE-I and statin
-Anxiety, however B-blocker can cause some erectile dysfunction
*Post MI, pt can reengage in physical activity including se
IWMI in history, clear lungs, tachycardia, hypotension with nitroglycerin
New murmur, rales/congestion
New murmur, increase in oxygen saturation on entering the right ventricle
RV infarct
Valve rupture
Septal rupture
Stress determines the need for ____. That determines the need for ____
Angiography
Revascularization, such as angioplasty and bypass surgery
*If pt are symptomatic --> Skip stress test and go straight to angiography
*Don't do angiography on infarcted heart (no point, tissue already dead)
Most likely diagnosis for dyspnea
1) Sudden onset, clear lungs
2) Sudden onset, wheezing, increased expiratory phase
3) Slower, fever, sputum, unilateral rales/rhonchi
4) Decreased breath sounds unilaterally, tracheal deviation
5) Circumoral numbness, caf
1) PE
2) Asthma
3) pneumonia
4) pneumo
5) Panic attack
6) Anemia
7) Tamponade
8) Arrhythmia of almost any kind
9) Pleural effusion
10)methemoglobinemia
11) CO poisoning
Most important test in CHF
ECHO
*CHF is a clinical diagnosis. Should be able to identify it w/o labs or imaging. Most common cause of SOB
What should you order in acute shortness of breath in whom the etiology of the dyspnea is not clear and you cannot wait for an echo to be done.
BNP
- Normal BNP excludes CHF and pulmonary edema
Pharm treatment for systolic dysfunction CHF
Which of these drugs show mortality benefits
Pharm treatment for diastolic CHF w/ preserved EF
1) ACE-I or ARB
2)B-Blocker
- Only metoprolol, bisoprolol and carvedilol
- Metoprolol and bisoprolol specific B1 antagonist
- Carvedilol non-specific beta and a-1 antagonist
3) Spironolactone
- Only effective in CHF stage III and IV
- Switch to eplerenone
When do you give
1) implantable defibrillator
2) Biventricular pacemaker
1) ischemic cardiomyopathy w/ EF <35%
2) Dilated cardiomyopathy w/ EF <35% and a wide QRS complex
*arrhthymia and sudden death are the most common cause of mortality in those w/ CHF
What's the most severe form of CHF
___ is ordered w/ the etiology of SOB is not clear
How do u distinguish between systolic or diasystolic CHF?
Engorged pulmonary veins indicate
Pulmonary Edema
BNP
ECHO
Pulmonary congestion (blood is backing up in the pulmonary system w/ often blood flow greater in the cephalad region because of pooling of pulmonary fluid in the base)
What is the best initial step for management of acute pulmonary edema
Loop diuretics -- remove large volume of fluid from vascular space --> reduces preload
- Afterward you can give them O2 and do an ECHO
Increase intensity w/ inhalation
Increase intensity w/ exhalation
Valvular heart disease
- Best initial test
- Most accurate
right side of the heart (triscupid or pulmonary valve)
Left side of the heart (Mitral or aortic valve)
- except for MVP and HOCM
-ECHO (TEE)
-Cath (can look into the chamber size and pressure gradient difference)
All forms of valvular heart disease will benefit from
___ is dilated w/ a balloon
Regurgitant respond best to
Rheuamtic fever can cause any valve dysfunction but the most common is __
diuretics
Mitral stenosis
Vasodilator therapy (ACEi/ARBs, nefedipine or hydralazine) --> all decrease venous return
Mitral stenosis
What are some unique presentation findings of mitral stenosis
Balloon valvuloplasty is not routinely done for ___
1) Dysphagia --> LA pressing on esophagus
2)Hoarseness --> LA pressing on largyneal nerve
3) A. Fib --> due to enlarge L. Atrium
4) Hemoptysis
AS --> because calcification doesn't improve much w/ a balloon
Diastolic murmur w/ opening snap
Systolic crescendo decrescendo.. Where does it radiate
Pansystolic that radiates to axilla
Diastolic, decrescendo murmur
More blood return increases all murmurs except ____
___ increases return
___ decreases return
Mitral stenosis
AS .... radiate to carotid A.
Mitral regurg
Aortic regurg --> heard best at L. LOWER STERNAL BORDER
MVP and HOCM
*In HOCM --> more blood dampens the sound of the mitral valve hitting the hypertrophic interventricular septum
squatting / han
Heart dilation will most likely result in what valve disorder
Mitral regurgitation or aortic regurg
What are some unique physical findings in aortic regurg
1) wide pulse pressure
2) Wide bounding pulse
3) Head bobbing
For MVP
____, which decrease venous return to the heart, will worsen MVP. Anything that increases left ventricular chamber size, such as___, will improve or diminish the murmur of MVP.
Valsalva and standing
squatting or handgrip
*MVP is essentially the opposite of what you would think intuitively... Don't forget this for the exam
*MVP is so common that it is at times considered a normal variant. Also rarely symptomatic
Cardiomyopathy
Present w/ ?
best initial test
Treat all of them w/ ?
edema, rales and JVD
ECHO
Diuretics (except for HOCM)
Hypertrophic cardiomyopathy
__ are the "best initial therapy" for both HOCM and ordinary HCM.
Diuretics & ACEi may help in ___, but they are contraindicated in___
___ should be used in any HOCM patient with syncope.
Beta blockers
HCM / HOCM
Implantable defibrillators
What are causes of restrictive cardiomyopathies
____improves HOCM
because the heart is
larger (more full), which
decreases the obstruction.
sarcodosis
amyloid
hemochromatosis
endomyocardial fibrosis
sceleroderma
Handgrip
Most common infection related to pericarditis?
Connective tissue disorder related to pericarditis
Pt presents w/
Viral (coxsackie B) followed by staph and strep
SLE, Wegener granulomatosis, Goodpasture, RA, polyarteritis nodosa, etc...
Pleuritic chest pain (worse when lying flat and better w/ sitting up). ST elevation in all leads and pulsus paradoxis
Hypotension, tachycardia, JVD and clear lungs
-Also w/ pulsus paradoxus
What would u see on EKG
what would u find on CATH
Pericardial tamponade
Electrical alternans, ST elevation in all leads, PR depression
Equalization of pressures in diastole
What causes constrictive pericarditis
Associated physical exam findings
Best initial test
Best treatment
Sufficient calcification and fibrosis that chronically prevents filling of the right side of the heart
Kussmaul sign
Knock--> Ventricular expansion hits a hard pericardium leading to a "knocking" sound
CXR --> shows calcification
Diuretics to relieve symp
____pain is worse when walking down hills, because of leaning back.
Spinal stenosis
Best initial test of PAD
Treatment
ABI (If <0.9 than considered positive for PAD)
-Not intuitive
ASA, smoking cessation and cilostazol (Phosphodiesterase 3-inhibitor)
What are key physical exam findings for aortic dissections
Best initial test
Most accurate test
Best initial treatment
Screening recommendations
- pain going back to scapula and difference in BP between the arms
CXR
Spiral CT angiography of the chest
-If ascending dissection that need to treat surgical right away before it ascends to the aortic valve
-If descending and pt stable, than give B-block
What is eisenmenger syndrome
What is peripartum cardiomyopathy
Development of R. to L. shunt due to severe pulmonary HTN (there must be a ventricular septal defect for this to occur)
AB develops against the myocardium after delivery. Subsequent pregnancy will provoke large antibody against myocardium again... This is
Someone presents w/ NS w/ tachycardia and no p-waves seen on ECG. What is the diagnosis
How do you treat?
SVT
Adenosine if pt is stable
Sync Cardioversion if pt is unstable
What is the NYHA classification of heart failure
Class I --> No limitation of physical activity, no symptoms on exertion
Class II --> slight limitations on physical activity and symptoms of heart failure with strenuous physical activity.
Class III --> symptoms such as angina, shortness of breath and pal
Prolactin deficiency leads to
LH &FSH deficiency
Inhibits lactation at birth
Women --> amenorheic, decrease libido
Men --> no testosterone or sperm, decrease libido, erectile dysfunction
Describe Kallman syndrome
Decrease FHS and LH from decrease GnRH
Anosmia (can't smell)
Renal agenesis (50% of people)
Panhypopituitarism
___ is common secondary to hypothyroidism and isolated glucocorticoid underproduction.Potassium levels remain normal because aldosterone is not affected and aldosterone excretes potassium.
Hyponatremia
The two products of posterior pituitary are
___ deficiency is called central diabetes insipidius
What can cause nephrogenic DI
What effect does SIADH have on volume and electrolytei What about on urine?
How can you tell the difference between nephogenic a
ADH and oxytocin
ADH
any damage to the kidneys. Hypercalcemia and hypokalemia. Lithium will do damage to the kidneys as well
-Volume depletion and hypernatremia
-Decrease urine osmolality and sodium concentration
Vasopressin challenge
- Central DI will co
What are some presentation of acromegaly
What is co-secreted w/ growth hormone
Best initial test for acromegaly?
� Increased hat, ring, and shoe size
� Carpal tunnel syndrome and obstructive sleep apnea from soft tissues enlarging
� Body odor from sweat gland hypertrophy
� Coarsening facial features and teeth widening from jaw growth
� Deep voice and macroglossia (b
What are some causes of hyperprolactinemia
Effects of hyperprlactinemia in men
Always exclude ___ in woman w/ high prolactin level
After prolactin levels are found to be high. What test do your run?
How do you treat it?
-Acromegaly (prolactin is co-secreted w/ GH)
-Hypothyrodism (high TRH stimulates prolactin secretion)
-Drugs such as verapamil
Erectile dysfunction and decrease libido
Pregnancy
Thyroid function test, pregnancy test, BUN/Creatinine
Give DA (Cabergoline is
In hypothyroidisms, all bodily processes are slowed down except for ___
What drug can cause hypothyrodism
When should you order antithyroid peroxidase/antthyroglobulin antibody and when should you start treatment
Is diarrhea and hypotension associated w/
Menstrual flow
Amiodarone
If TSH is more than double normal and T4 normal --> treat
If TSH is elevated but less than double normal and T4 normal --> order Antibody test
Hyperthyroidism
What's the TSH level, RAIU, Confirmatory test and treatment for each of the following
1) Grave's Disease
2) Subacute Thyroiditis
3) Painless "Silent" Thyroiditis
4) Exogenous thyroid hormone use
5) Pituitary adenoma
1) Grave's Disease
- Low / Increase / AB test / Radioactive iodine
2) Subacute Thyroiditis
- Low / Decrease / Tenderness / ASA
3) Painless "Silent" Thyroiditis
- Low / Decrease / None / None
4) Exogenous thyroid hormone use
- Low / Decrease / History & In
Treatment for thyroid storm
1) propanolol
2) Methimazole and PTU (PTU preferred)
3) Radioactive iodine
- Must wait at least an hr after PTU or else iodine will be used to make new thyroid hormone. Iodine in this case would prevent the release of thyroid hormone
4) Steroids (for Grav
Pt presents with a nodule in the neck. What are the steps for workup?
Which is worse, papillary or follicular carcinoma
What's another name for T4?
What's another name for TSH?
Order T4 and TSH
If normal, do a FNA
If hyperfunctioning, don't do FNA (may lead to thyroid storm)
Follicular
Thyroxine
Thyrotropin
What's the most common cause of hypercalcemia?
What are other causes of hypercalcemia?
What effect does hypercalcemia have on the cardiovascular system?
Treatment for hypercalcemia
What does calcitonin do?
Primary hyperparathyrodism
� Vitamin D intoxication
� Sarcoidosis and other granulomatous diseases
� Thiazide diuretics
� Hyperthyroidism
� Metastases to bone and multiple myeloma
Shorten QT
Saline hydration
Bisphonates such as pamidronate and zoledronic
What are some causes of hypocalcemia?
Pt w/ hypocalcemia present w/ ?
Prior neck surgery
Hypomagnesemia --> Mg+ is needed for PTH to be released from the gland
Renal failure --> Can't convert to active 1,25 hydroxy-D
Vit D Deficiency
Neural hyperexcitability (Chvostek sign)
Thyroid disorder
Increased T4 and T3 levels in asymptomatic person are due to increase ___
What is often depressed by glucocorticoids
___ when stimulated by TSH produced T4 and T3. Antibody to this is often found in ___
____ and ____ --> highly elevated i
Thyroxine Binding Globulin
- This is a carrier protein that binds both T4 and T3
- Increase seen in pregnancy
TSH
- Thyroglobulin
- Hashitmoto
anti-thyroid peroxidase antibody or anti-microsomal antigen
thyroxine binding globulin
CST
Physical presentation of Grave's disease includes
Hyperreflexia
Pretibial myedema (LLE edema)
Exothalmos (retroorbital fibrosis)
Someone comes w/ signs of Cushings. What is first initial test
If elevated, what's the next best test
How do you determine the origin of elevated cortisol
Hypercortisol will present w/ what electrolyte abnormality?
24 hr urine cortisol is best initial or else pick 1mg dexamethasone suppression test
ACTH levels
1) Adrenal tumor --> there will be low ACTH
2) Pituitary tumor --> High ACTH with SUPPRESSION of cortisol w/ dexamethasone
3) Ectopic tumor --> High ACTH no s
Primary adrenal insufficiency is AKA ___
Acute adrenal crisis presents w/
What's the best initial step in pt w/ adrenal crisis
How do you determine if adrenal insufficiency is due to pituitary or adrenal cause?
Addison's disease
profound hypotension, fever, confusion and coma... Oftentime will have eosinophilia as well
Treatment is more important than diagnosing.
- Measure cortisol levels and treat w/ hydrocortisone appropriately
Cosyntrophin stimulation test (t
Never start with a ____ in endocrinology. There are too many incidental lesions of the adrenal.
scan
- Do blood work first
HP BP and Hypokalemia --> think
Best initial test
Most accurate test
Treatment?
Primary hyperaldosteronism
Ratio of plasma aldosterone to renin
- In hyperadlosteronism --> will see depressed levels of renin
Venous blood sample from adrenals
If unilateral --> resect
Bilaterally --> suppress w/ eplernone or spironolactone
Episodic HTN w/ HA, sweating and palpitations. Think
Best initial test
What happens if imaging doesn't show anything?
Treatment
Pheochromocytoma
Free metanephrines followed by 24hr urine collection
Pheochromocytoma source most likely outside of adrenal gland so scan w/ MIBG scan
Phenoxybenzamine (a-blocker) followed by B-blocker or Ca+ channel blocker
- remove surgically for defin
What are the diagnostic criteria for BDM
What is the therapeutic goal of DBM
1) Random plasma glucose >200
2) Fasting plasma glucose >126
3) 2hr postpranial >200 (2 hr = 200)
- Give 75g of glucose for this one
4) A1C > 6.5%
A1C <7.0
First line treatment for diabetes?
- Need to watch out for what?
Which insulin is fast acting? Slow acting
What is a side effect of sulfonureas
- How do they work?
How does metformin work?
- What's the main side effect?
- What's a contraindication to use?
Metformin
- renal dysfunction --> may lead to metabolic acidosis
*does not cause hypoglycemia, therefore safe drug to start DBM pt
Fast acting --> lispro, aspart and glulisine, regular
Long acting --> Glargine or NPH (glargine is preferred)
Wt gain, hypog
Pt present w/ AMA, hyperventilation and increase glucose levels --> think
What's the most accurate measure of the severity of this disease
DKA
Bicarbonate levels
- If low, than it means the anion gap is increasing... Not good
Health maintenance exam for diabetics include
How do you treat gastroparesis?
1) pneumococcal vaccine
2) Yearly eye exam
3) If LDL >100 --> statin
4) ACEi or ARB if BP >130/80 or micoalbuminuria
-Don't give HCTZ --> may cause hyperglycemia
5) Regular foot exam
Metoclopromide and erythromycin
- Both will increase gastric motility
What are the numbers for metabolic syndrome
1) Obesity
2) TriG
3) HDL
4) BP
5) Fasting glucose
1) >40 inch in men and >35 inch in woman
2) >150
3) <40 in men and <50 in woman
4) >130/85
5) >100 or >120 according to book
What are the symptoms of hyperthyrodism
On scan, what would show these
-Diffuse toxic goiter
-Toxic multinodular goiter
insomnia, wt loss, anxiety, diarrhea, A. Fib, tremor, hyperreflexia, irregularly irregular heart rhythm
Grave's Disease
Plummer's Disease
What does radioactive iodine uptake tell you
___ is the first line therapy for diabetic neuropathy
It's a measure of the endogenous production of thyroxine (T4)
pregabalin
___ is asthma related to menstrual cycle
FEV1/FVC ratio is ____
- What kind of changes do you see in FEV1 and FVC?
Pulmonary function test indicating asthma
Catamenial
<0.8
- Both decrease but FEV1 decreases more
1) Decrease FEV1/FVC ratio
2) FEV1 increase >12% w/ albuterol
3) FEV1 decreaes >20% w/ metahcholine or histamine
4) Increase in DLCO
What are the 6 steps to asthma treatment
When is ipratropium and tiotropium used?
Someone presents w/ an acute asthma attack. How do you treat?
1) shorting acting beta agonist (albuterol)
2) Short acting ICS (beclomethasone, budesonide, fluticasone, etc..) + albuterol
3) Long acting beta agonist + Short acting ICS + Albuterol
4) Increase ICS to max dose + long acting beta agonist + albuterol
5) A
COPD presents w/ ____ FEV1:FVC
___ DLCO
___ response to albuterol
ECHO will show
What improves mortality in this disease?
When do you start O2 therapy?
What drug improves symptoms
decrease (<0.8)
decreased in emphysema
May be somewhat helpful but <12% in FEV1 (unlike asthma >12% increase in FEV1)
R. atrial and R. Ventricular hypertrophy
-Smoking cessation
- Influenza + Pneumococcal vaccine
- O2 therapy
PO2<55 or O2 Sat <88%
Ipratro
What is emphysema?
What is Chronic bronchitis?
- Treatment for acute exacerbation
What is bronchectasis
- What's the most common cause?
- What is the diagnostic test?
Permanent dilation due to alveolar damage
- Pink puffer --> pt is typically thin and leaning forward
Productive cough for 3 months duration for at least 2 yrs
- Blue bloater --> Pt typically overwt and cyanotic
Treat w/ antibiotics and O2 therapy (same cr
allergic bronchopulmonary aspergillosis presents w/ ___ and ___
Treat w/
Asthma and eosinophil
Inhaled steroid
Oral steroid, if severe case
Itraconazole for recurrent episodes
Cause of pneumonia associated
- COPD
- Hoarseness
- Birds
- Animals during the time of giving birth, veterinarians and farmers
- HIB
- Chlamydophila pneumoniae
- Chlamydia psittaci
- Coxiella burnetii
Which infections produce a dry, non-productive cough and show bilateral interstitial infiltrate on CXR
What is the criteria for diagnosing community acquired pneumonia?
What is the treatment for community acquired pnuemonia?
Mycoplasma
Viruses
Coxiella
Pneumocystis
Chlamydia
Symptoms before hospitilization or within the initial 48 hrs in the hospital
Outpt --> Macrolide or doxycycline. Treat w/ fluoroquinolone (levofloxacin or moxifloxacin) if there's comorbidities or recent
What are signs of empyema
what's the best treatment?
-LDH >60% of serum level
- Protein >50% of serum level
- WBC >1000
- pH <7.2
Should drain it with chest tube and treat w/ antibiotics
What is considered hospital acquired pneumonia?
Main bugs to worry about?
What antibiotics do you use?
Which antibodies are not acceptable?
More than 48 hrs after admission and up to 90 days post after hospitalization
Gram negative (E. Coli and Pseudomonas)
Antipseudomonal cephalosporins: cefepime or ceftazidime
or
Antipseudomonal penicillin: piperacillin/tazobactam
or
Carbapenems: imipenem,
Ventilator associated pneumonia treatment
1) Antipsuedomonal
- cephalosporin, penicillin (piperacillin/tazobactam), or carbapenem
2) Second antipsuedomonal agent
- Aminoglycoside (gentamycin or tobramycin)
- Fluoroquinolone (Cipro or Levofloxacin)
3) MRSA agent
- Vanc or linezolid
Which antibiotics would you use to cover someone w/ a bacteria lung abscess
clindamycin or penicillin
If pt is allergic to TMP/SMX, what other treatment can you give for PCP?
Clindamycin and primaquine
0r
Pentamidine
Treatment for TB
All of the TB meds cause ____
If pt has had BCG vaccine and test positive for PPD, what is treatment?
RIPE (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol)
- Stop ethambutol and pyrazinamide after 2 months
- Continue w/ Rifampin and Isoniazid for the next 4 months
* Total treatment time is 6 months
Hepatotoxicity
Isoniazide for 9 months, just like anyo
What is considered a positive PPD
What is recommendation for someone who's never had a PPD before?
Induration larger than 5 millimeters:
� HIV-positive patients
� Glucocorticoid users
� Close contacts of those with active TB
� Abnormal calcifications on chest x-ray
� Organ transplant recipients
Induration larger than 10 millimeters
� Recent immigrants
Pulmonary fibrosis
What's the FEV1/FVC ratio?
What's the DLCO?
Normal
Decreased
Pulmonary HTN is best treated w/
� Prostacyclin analogues (PA vasodilators): epoprostenol, treprostinil,
iloprost, beraprost
� Endothelin antagonists: bosentan
� Phosphodiesterase inhibitors: sildenafil
ARDs
What do you see on CXR
- Why does it look that way?
What lab abnormality would you see with this?
Best treatment?
White out w/ air bronchograms.
- Can look like CHF but with normal cardiac dynamics
- ARDs decreases surfactants which makes the lung cells leaky so that alveoli fill up with fluid
PO2/FIO2 = <300
- PO2 is measured on arterial blood gas
- FIO2 is usually
What's the difference between exudate and transudate
Blunting of costophrenic angle. When do you u use furosemide and when do you do thoracentesis?
Exudates are caused by infection and cancer
- High total protein and high LDH
Treatment regiment for PE
Heparin for 5 days to bridge warfarin therapy
- Warfarin for 3-6 months
- Treat w/ TPA if pt is hemodynamically unstable
- Put in IVC if there are recurrent PE or there's some contraindication to anticoagulation
Young pt present w/ arthritis, abd pain, hematuria, purpuric rash on buttochs and LE
What causes the rash
Treatment
henoch schonlein purpura (HSP)
IgA deposit small vessels. IgA also deposit in kidneys leading to nephritic syndrome
Supportive
osteoarthritis
What joints are affected
X-rays show
What is the order of treatment
DIP and PIP
� Joint space narrowing
� Osteophytes
� Dense subchondral bone
� Bone cysts
-Wt loss and moderate exercise
- Acetaminophen! (acetaminophen before NSAIDs)
-NSAIDs, second line due to renal toxicity and possible GI bleed
-Steroids
-Joint replace
What's the dose of EPI for IM? For IV?
IM--> 1:1,000
IV --> 1:10,000
Osteoarthritis affects which joint in fingers
Absense of ___ and normal ___ distinguishes OA from RA
Treatment order
DIP and MIP
inflammation and normal
1) Wt loss and moderate exercise
2) Acetaminophen (better side effects)
3) NSAIDs, if not controlled. Watch out for GI bleed
4) Intraarticular steroid
5) Joint replacement
Gout crystals on aspiration will show?
What abnormalities will u see on labs?
What is the order of treatment for acute attacks
What drugs are used for long-term management of gout?
Negative birefringence on polarized light
Increase uric acid levels, elevated ESR and elevated leukocytosis
1)NSAIDs
2)Steroid injection
3)Colchicine (not used much because of side effect profile)
allopurinol and febuxostat
For gout, ___ is used in acute attack for those who cannot use either NSAIDs or Steroids
What is the side effect of this drug?
What BP drug is contraindicated in gout? What drug should you use for HTN?
Colchicine (I C you need help)
Diarrhea and neutropenia (bone marrow suppression)
Thiazides
Losartan (controls BP and actually lowers uric acid levels)
What are risk factors for pseudogout?
Most affect which type of joints?
What would you see on synovial fluid?
What's the best initial therapy? Prophylaxis therapy?
Hemochromatosis and hyperparathyrodism
Large joint (knee and wrist)
2,000-50,0000 (positively bifringent rhomboids)
NSAIDs, intraarticular steroids (same as gout)
- Colchincine for prophylaxis (same as gout)
Point tenderness at the spine with percussion of the vertebra is highly suggestive of ___
cord compression
95% of disc herniation occur at?
What reflex and sensory area is affected by each nerve
Pt w/ low back pain --> when should you do imaging?
What's the first treatment if suspect cord compression. Why?
What's the treatment for disk herniation (sciatica)
L4/L5 and L5/S1
L4 --> Knee reflex, inner calf
L5 --> No reflex, inner forefoot
S1 --> Achilles reflex, outer foot
only when there are signs of sensory deficit (do MRI)
Steroids. Decrease presssure on the cord and prevents permanent paralysis
NSAIDs and c
How do you treat epidural abscess and endocarditis?
- First treatment
- Then what?
Use Vanc or linezolid
Switch to oxacillin if beta-lactam sensitive
Drain if is is large enough or resistant to treatment
Back pain worse w/ extension... Think?
Why?
Only test is?
Treatment?
Spinal stenosis
- Extension causes the spinal cord to press on the ligamentum flavum
MRI
Wt loss and pain meds (NSAIDs, opiates, ASA)
- Surgical correction to dilate spinal canal is needed in 75% of cases
The question will describe a young woman with chronic musculoskeletal pain and tenderness with trigger points of focal tenderness
Lab test will show?
Treatment?
Which treatment do you avoid?
Fibromyalgia
All test are normal (ESR, C reactive protein, RF and CPK
Amitripytline
- Milnacipran and pregabalin
- Milnacipran (Inhibitor of reuptake of 5HT and NE)
Don't treat fibromyalgia w/ steroid
What nerve is affected in carpal tunnel syndrome?
- What's the sensory distribution of this nerve
What test are used to confirm carpal tunnel?
- Most accurate test?
Treatment regiment?
Median nerve
- First 3 1/2 digits. Can present w/ thenar atropy
Phalen sign and tinnel sign (pain on tapping or percussion of median nerve)
electromyography and nerve conduction test are most accurate
Start w/ wrist splints than steroid injection than sur
Contracture of 4 and 5th digit, think?
what causes this?
Treatment?
Dupuytren contracture
Hyperplasia of palmar fascia
Triamcinolone, lidocaine, or collagenase injection may help. Surgical release is performed when function is impaired.
Patellofemoral syndrome and plantar fasciitis
Treatment and recommendation
� Pain and stiffness in shoulder and pelvic girdle muscles
� Difficulty combing hair and rising from a chair (proximal muscle weakness)
� Elevated ESR
� Normochromic, normocytic an
Pain control w/ NSAIDs, and steroids if necessary
Continue w/ activity --> symptoms improve w/ movement
* plantar fasciitis may improve w/ orthotics
Polymyalgia Rheumatica
For RA
1) What are some information that will help you establish diagnosis of RA
2) Which factors are specific for RA
3) which joint do you have to be particularly mindful of
4) Which joint of the finger is usually spared?
5) What is the best treatment?
1) A total of 6 or more points = RA.
- Joint involvement (up to 5 points)
- ESR or CRP (1 point)
- Duration for longer than 6 weeks (1 point)
- RF or anti-CCP (1 point) DIP Is spared in RA. DIP involvement happens in DJD.
2) RF and anti-CCP
3) Cervical jo
Adverse effect of RA meds
Anti-TNF
Hydroxychloroquine
Sulfasalazine
Rituximab
Gold salts
Methotrexate
Reactivation of tuberculosis
Ocular
Rash, hemolysis (G6PD), Bone marrow toxicity
Infection
Nephrotic syndrome
Liver, lung, marrow suppression
JRA
What's the two most important features
Treatment?
High fever (104) and rash (salmon color on chest and abdomen)
- Usually nothing else specific about this disease
ASA and NSAIDs. If no response than try steroids
SLE presents with what? 9 things
What markers are suggestive of SLE? What's the most specific? Sensitive?
In acute lupus flare, ___ drops and ___ rises
- Best treatment?
Most common cause of death in young pt? Old pt?
Malar rash, discoid rash, photosensitivity, oral ulcers, arthritis (90% of the time), serositis, renal (red cell cast and hematuria), hemolytic anemia
ANA (sensitive) (found in many rheumatologic disease)
Anti-dsDNA (extremely specific)
Anti-Smith (extrem
___presents with thromboses of both arteries and veins as well as recurrent spontaneous abortions. Think
What are the two main types
What abnormality do you see on hematology?
Best initial test? Most specific test
Treatment?
Antiphospholipid (APL) syndrome
Lupus anticoagulant
Anticardiolipin antibodies
elevated aPTT w/ normal PT
Mixing study (in APL the aPTT will remain elevated after mxing blood)
Russell viper venom is most specific
Treat for DVT and PE w/ heparin and warfar
Look for a young (20s to 40s) woman (3 times more likely than men) with fibrosis of the skin and internal organs such as the lung, kidney, and GI tract
Diagnostic test?
Treatment
Sceleroderma
ANA (nonspecific)
SCL-70 (anti-topoisomerase) --> most specific test
Anticentromere --> Indication of CREST
Methotrexate --> slow disease progression
- Treat renal crisis --> ACEi
- Esophageal dysmotility --> PPI
- Raynaud's --> CCB
- Pulmona
Inflammatory myopathies present with proximal muscle weakness leading to difficulty getting up from a seated position or walking up stairs.
What are some skin manifestations?
Diagnostic test
Treatment?
Polymyositis and dermatomyositis
For dermatomyositis
- Malar involvement, shawl sign (batman distribution), heliotrope rash and gottron papules
CPK and aldolase levels
- Muscle biopsy is most accurate
Steroids than use methotrexate if needed
____ is associated w/ cancer in 25% of cases
____ Antibody are associated w/ lung fibrosis
Dermatomyositis
Anti-Jo antibodies
In Sjorgen, why do you have to worry about the teeth?
Most dangerous complication of Sjorgen?
Best initial test? Most accurate test?
What rhuematologic factors are positive in this disease?
what can u use to stimulate production of saliva?
Need to worry about dental caries --> no saliva so nothing to neutralize acid
Lymphoma
Schirmer test (place filter paper on eye and see how much tears it collects
lip or parotid gland biopsy --> shows lymphoid infiltration of salivary gland
SS-A, SS-B AKA
Test all polyarteritis nodosa pt for ____
Which organ system is spared in this disease?
HEP B and HEP C
Lungs
Difficulty rising from a chair....
- If CPK and aldolase are positive then?
- If CPK and aldolase are negative then?
Polymyositis or dermatomyositis
Polymyalgia rheumatica
Look for a combination of upper and lower respiratory tract findings in association with renal insufficiency?
- What URT infections do you see?
Which is the most accurate place to biopsy?
Wegener Granulomatosis
- Sinusitis and otitis media
Lung
C-ANCA --> think
P-ANCA --> Think
Wegener
Churg-Strauss or microscopic polyangiitis
When the case describes leukocytoclastic vasculitis on biopsy, the answer is ____
Lab tests in____ show a positive rheumatoid factor and cold precipitable immune complexes
___ -->decreased C3
___ --> decreased C4
Henoch-Schonlein purpura.
cryoglobulinemia
(SLE) = C3
(Hep C)= C4
Describe pt w/ Behcet Syndrome
Look for an Asian or Middle Eastern person with painful oral and genital ulcers in association with erythema nodosum-like lesions of the skin. Also
with:
� Ocular lesions leading to uveitis and blindness
� Arthritis
� CNS lesions mimicking multiple sclero
What are the three seronegative spondyloarthropathies?
What do they have in common?
Ankylosing spondylitis, psoriatic arthritis, reactive arthritis (reiter syndrome
Typically male age 40
� Involvement of the spine and large joints
� Negative rheumatoid factor (hence the name seronegative)
� Enthesopathy (inflammation where tendons and li
Initial diagnostic test for anylosing spondylitis
- Treatment?
X-ray of sacroiliac joint (bamboo spine shows up later in disease)
- Exercise programs and NSAIDs, use anti-TNF drugs if necessary
initial test is an x-ray of the joint showing a "pencil in a cup" deformity. What disease?
What's the T-score for osteoporosis?
- What's the best initial therapy?
- What drug actually stimulates new bone formation?
Psoriatic arthritis
T score >2.5
- Vit D and Calcium. Also Bisphosphonates (remember to drink w/ water or it can causes esophagitis)
- Teriparatide
Best initial test for septic arthritis?
- What do you expect to see?
Empiric treatment?
When do you order imaging in septic arthritis?
What's the treatment for prosthetic joints?
- What's the most common organism?
aspiration
- 50,000-100,000 WBC (Predominantly neutrophils)
Ceftriaxone and Vanc
In septic prosthetic joints --> need to see if infection is limited to joint space only or has spread to surrounding bones
Remove joints, treat w/ antibiotics for 6-8 wks and
What's different from gonococcal arthritis from other arthritis?
Best treatment?
If recurrent gonorrhea infection is described, test for ___
Look for a history of STDs or a sexually active young person.
� Polyarticular involvement
� Tenosynovitis (inflammation of the tendon sheaths, making finger movement painful)
� Petechial rash
� More frequent during menses
Ceftrioxone, cefotaxime, or cefti
Look for a diabetic patient with an ulcer from peripheral neuropathy or vascular disease with warmth, redness, and swelling in the area. There may also be a draining "purulent sinus tract" in the lesion. Most patients are afebrile
Best initial test? most
Osteomyelitis. Don't ever culture drainage though
X-ray. Bone biopsy
*However, if X-ray is negative than you should a MRI before bone biopsy
to follow response to therapy
Staph
- Salmonella in those w/ DBM
Surgical debridement followed by 6 wks of IV anti
What are the four causes of microcytic anemia
TICS
Thalassemia, Iron deficiency, chronic disease and sideroblastosis
What is hematocrit?
Symptoms associated w/ hematocrit levels
1) >30-35%
2) 25-30%
3) 20-25%
4) <20%
Which hematocrit level do you transfuse w/ PRBC?
- What about which level of HGB?
- Each unit of PRBC should increase hematocrit and hemoglobin by how much
the volume percentage (%) of red blood cells in blood. It is normally 45% for men and 40% for women
1) none
2) Dyspnea (worse on exertion), fatigue
3) Lightheadedness, angina
4) Syncope, chest pain
25-30 or if pt is symptomatic
- HGB between 7-8
- 3 units
Causes of low MCV
Causes of high MCV
Results in both low and high MCV?
Normal MCV
� Iron deficiency
� Thalassemia
� Anemia of chronic disease
� B12 and folate deficiency
� Alcoholism
Sideroblastic anemia
Acute blood loss of hemolysis
When do you use FFP and cryoprecipitate?
When do u use whole blood?
Where is iron absorbed?
Where is B12 absorbed?
Where is Ca+ absorbed?
Celiac's disease causes deficiency in?
Gastric bypass, bypasses which part of the GI tract
FFP replaces clotting factors (intrinsic factors)
- So use in those w/ elevated PT, aPTT or INR
- Use in warfarin overdose
Cryoprecipitate (extrinsic factors)
- Use to replace fibrinogen, factor VIII, vWF
- Particularly useful in DIC
NEVER
Duodenum
Termin
What causes anemia of chronic disease?
What causes sideroblastic anemia?
Alpha-Thalassemia
- How many genes are deleted for pts to be symptomatic?
- Treat these pt w/
Deficiency of erythropoietin
- Therefore, inability to mobilize iron from liver
- Pt present w/ normal level of Iron, Low TIBC and high ferritin
EtOH suppressive effect on bone marrow
- 3 gene deletion
- 1 gene deletion is associated w/ increased hemoglob
1) Target cells
2) ringed sideroblast
3) hypersegmented neutrophils
4) Howell-Jolly Bodies
5) Basophilic stippling
6) Schistocytes
7) Bite cells / heinz body
8) Tear drop cell
9) Auer Rods
10) reed sternberg
11) rouleaux formation
1) Thalassemia
2) sideroblastic anemia
3) Megaloblastic anemia (particularly w/ B12 and folate deficiency. Not EtOH tho)
4) Sickle cell disease (those who do not have a spleen)
5) Sideroblastic anemia
6) intravascular hemolysis
7) G6PD
8) myelofibrosis
9)
Lab values for anemia
Look at page 387 in first aid
When do you see high iron levels?
Anemia of chronic disease. What do you expect to see for ferritin and TIBC
page 387 in first aid
Hemochromatosis and sideroblastic anemia
Ferritin is high / TIBC is low... Even tho this is a microcyctic anemia
What is needed for B12 absorption
Goat's milk can cause a deficiency in ?
How do you distinguish between folate and B12 deficiency?
Replacing B12 and folate can lead to?
Intact terminal ileum and pancreatic enzymes (intrinsic factor)
Folate
Both have ELEVATED homocysteine levels
- Only B12 will have elevated MMA levels
Hypokalemia --> bone marrow producing cells too quickly that they use up all the K+
Look for an African American patient with sudden, severe pain in the chest, back, and thighs that may be accompanied by fever... Think
These pt always have a high ___
They typically develop what kind of stones
Sickle cell crisis
Reticulocyte count
Bilirubin gallstones
Exchange transfusion is used if there is severe
____ presenting with:
What happens in aplastic crisis?
vasoocclusive crisis
� Acute chest syndrome
� Priapism
� Stroke
� Visual disturbance from retinal infarction
Parvo Virus B19 freezes growth of bone marrow
- typically occur in pt w/ sickle cell (reticulocyte normally high)
- aplastic crisis will present w
What's the treatment for hereditary spherocytosis?
Folic acid --> support RBC production
Splenectomy --> stops hemolysis
What's the best test for suspicion of autoimmune hemolysis?
- What are the two different types?
What would show up on peripheral smear?
Treatment?
Coomb's test --> detects IgG on surface of RBC
- Warm and cold agglutitin autohemolysis
Nothing abnormal. RBC destruction occurs in spleen or liver in these two cases
GCT, splenectomy, IVIG and rituximab for warm aglutining disease
Stay warm, rituximab an
what causes cold agglutinin disease?
What do you treat it with?
What other disease is also IgM mediated
EBV, waldernstrom macroglobulinemia and mycoplasma pneumoniae
Staying warm, rituximab
- Never treat w/ CST --> most common wrong answer
Cryoglobulin
- also don't treat w/ steroids
Look for African American or Mediterranean men with sudden anemia and jaundice who have a normal-sized spleen with an infection or are using one of the drugs previously listed... Think
what's genetic pattern in this disease
what do you see on peripheral s
G6PD
x-linked recessive
heinz body and bite cells
TTP and HUS are similar in which way
What do you see on coagulation test and coomb's test
How are they different?
Treatment?
� Intravascular hemolysis with fragmented red cells (schistocytes)
� Thrombocytopenia
� Renal insufficiency
� Deficiency in meatloproteinase ADAMTS 13
Low platelet w/ normal PT and aPTT
- neg Coomb's test
HUS --> more likely in kids. Associated w/ E Coli
CBC often shows pancytopenia in addition to anemia. The most accurate test is a decreased level of CDSS and CD 59. Think
Most common cause of death in these pt?
Treatment?
paroxysmal nocturnal hemoglobinuria
thrombosis
initial treatment --> Prednisone
Definitive treatment --> allogenic bone marrow transplant
Alternatives to decrease the need for steroids use generally are:
what age is too old for bone marrow transplant?
__ is pancytopenia of unclear etiology.
- What's the treatment?
� Cyclophosphamide
� Cyclosporine
� Azathioprine
� Mycophenolate mofetil
>50 y.o.
Aplastic anemia
- bone marrow transplant or antithymocyte globulin or cyclosporine
Unregulated production of all 3 cell lines leading to hematocrit > 60%... Think
Presents w/ ?
Most accurate test?
Polycythemia vera
Symptoms related to the hyperviscosity
- HA, HTN, Splenomegaly, bleeding, thrombosis and pruritus after warm showers (histamine release from increased number of basophils)
JAK2 mutation
What is essential thrombocytosis
Treatment?
Markedly elevated platelet count leading to both thrombosis and bleeding (From engorged blood vessels)
if asymptomatic than leave alone.
- Need treatment than give hydroxyurea
- ASA is used for erthromelalgia
Pancytopenia w/ fibrosis in bone marrow... Think
- What do you see on peripheral smear
What two drugs increase bone marrow production
myelofibrosis
- tear drop cells
Thalidomide and lenalidomide
What are the two types of acute leukemia?
These pt present w/
M3 is associated with ___ and ____ (two most tested point)
How do you treat ALL
Best test
what indicates prognosis
ALL and AML
Pancytopenia and mostly an infection
DIC and the need for all-trans-retinoic acid
add intrathecal methotrexate
blood smear showing blast
cytogenetics
Present with vague symptoms of fatigue, night sweats, pruritus after hot bat and fever. Pt also has high WBC (all neutrophil). Think?
How do you determine the cause of increased neutrophils?
What's the blast count in this disease?
Most accurate test?
Trea
CML
leukocyte alkaline phosphatase (LAP)
- LAP is decrease in CML
- LAP is increase in infection and stress
Elevated but <5%
PCR or FISH for BCR-ABL (Philadelphia chromosome)
Tyrosine kinase inhibitors, imatinib
- BMT, but shouldn't be first therapy
___ is a preleukemic disorder presenting in older patients (over 60) with a pancytopenia despite a hypercellular bone marrow.
- Usually complications like infection and bleeding lead to death before leukemia develops
Blood smear shows
Severity is based on
Myelodysplastic syndrome (MDS)
ringed sideroblast or pelger-huet cells
most common symptom is fatigue. Other symptoms include:
� Lymphadenopathy (80%)
� Spleen or liver enlargement (SO%)
� Infection from poor lymphocyte function
� Most common in those over 50
What do blood smear show?
CLL
Normal mature appearing B-cells
- However, these B-cells don't work
*Smudge cells are pathnognonmic
What shows tartrate resistance acid phosphatase
what's the treatment?
Hairy cell leukemia
Cladribine
o Painless lymphadenopathy
o May involve pelvic, retroperitoneal, or mesenteric structures
o Nodes not warm, red, or tender
o "B" symptoms: fever, weight loss, drenching night sweats
Best initial test?
How do you stage it?
How do you treat it
Non-hodgkin lymphoma
excisional biopsy
- Don't do needle aspiration (not enough and most common wrong answer)
Stage1: 1 lymph node
Stage2: 2 lymph node
Stage3: Both sides of diaphram
Stage4: Widespread disease
Stage 1 and 2 --> treat w/ local radiation an
Differences between hodgkin disease (HD) and non-hodgkin lymphoma (NHL)
What's the most common type of Hodgkin diseaes
HD usually in stage 1 and 2
NHL usually in stage 3 and 4
HD --> found in cervical area
NHL --> Disseminated
HD --> treat w/ ADVD (adriamycin, bleomycin, vinblastine and dacarbazine)
NHL --> treat w/ Rituximab and CHOP (cyclophosphamide, hydroxydaunorubici
Radiation increases risk of ____
Screening for ____ is recommended after __ years following radiation/chemo
adverse effect of chemo agents
Doxorubicin
Vincristine
Bleomycin
Cyclophosphamide
Cisplatin
solid tumors
Breast cancer, after 8 years of radiation/chemo
Cardiomyopathy
Neuropathy
Lung fibrosis
Hemorrhagic cystitis
Renal and ototoxicity
Pathologic bone fracture, hyperuricemia, anemia and renal failure.. think
Serum protein electrophoresis shows
What is seen on X-ray? What is the calcium level?
Just know that it's associated w/ bence jone protein on urinalysis and rouleaux formation in sm
Multiple myeloma
Monogammnopathy --> either IgG or IgA
Punched out lesion on x-ray and hypercalcemia (due to increase osteoclast activity due to stimulation from osteoclast activating factor)
A 23-year-old woman comes to the emergency department with markedly increased menstrual bleeding, gum bleeding when she brushes her teeth, and petechiae on physical examination. Physical examination is otherwise normal. The platelet count is 17,000. What'
ITP --> diagnosis of exclusion
1)No bleeding, count >30,000 --> no treatment
2)Mild bleeding, count <30,000 --> GCT
3)Severe bleeding (GI/CNS), count <10,000 --> IVIG, Anti-Rho (anti-D)
4)Recurrent episodes, steroid dependent --> splenectomy
Look for bleeding related to platelets (epistaxis, gingival, gums) with a normal platelet count. ____ markedly worsened after the use of aspirin.
What is the best test?
Treatment?
What do you find on hematology test for VWD?
what makes this disease worse?
Von Willebrand disease
*VWF normally protects factor VIII
Ristocetin cofactor assay --> detects VWF dysfunction
DDAVP (Desmopressin) --> increase release of VWF
- Increased bleeding time
- Increase aPTT (VWF normalyl protects Factor VIII degradation)
- No
Superficial bleeding disorder associated w/ ?
Deeper (joints) bleeding disorder associated w/ ?
PT is associated w/ with factor and pathway?
aPTT is associate w/ what factor and pathway?
Platelet disorder
Factor deficiency/disorder
Extrinsic pathway (Factor VII) (Involves Vit K)
Intrinsic pathway (all factors except VII and XIII)
What are the changes in PT and aPTT?
1) Hemophila
- Which factors are deficient?
2) Factor XI Deficiency
3) Factor XII Deficiency
4) DIC
1) PT normal / aPTT prolonged
- Factor 8 and 9
2) PT normal / aPTT prolonged
3) PT normal / aPTT prolonged
4) PT elevated / aPTT elevated
- also see low platelet count. Therefore prolonged bleeding time
Most common cause of hypercoagulable state?
- Treatment?
Factor V Leiden Mutation
- Warfarin and INR 2-3
Heparin induced thrombocytopenia occurs how many days after start of unfractioned heparin?
Diagnostic test?
Treatment regiment
Platelet will have low platelet. Should u replace platelet?
5-10 days
ELISA for platelet factor 4 antibodies
1) Stop all heparin products
2) Administer direct thrombin inhibitors: argatroban, lepirudin, and bivalirudin.
3) Than start warfarin
No, it would worsen the thrombosis
How can you distinguish between small and large bowel obstruction
Most common cause of large bowel obstruction
Most common cause of small bowel obstruction
X-ray. SBO (multiple air fluid levels). LBO (Dilated colon)
neoplasm, diverticular disease and volvulus
Adhesions (75% of cases)
Upper GI Bleed present w/?
Diagnostic test?
Bleeding proximal to ligament of treitz. Maroon color stool indicates high transit UGI bleed
Esophagogastroduodenoscopy is the gold standard
How do you treat tumor in the head of the pancreas.
what's all involved
Whipple procedure
Remove
- Head of pancreas
- All duodenum
- Distal stomach
- Proximal jejunum
___ presents w/ coffee bean sign on xray
- Describe this pt
Sigmoid volvulus
- Typically elderly, debilitated w/ history of dementia. Complains of constipation
� Young patient (under 50)
� Progressive dysphagia to both solids and liquids at the same time
� No association with alcohol and tobacco use
what's the treatment?
achalasia
1) pneumatic dilation
2) Botulinum toxin (require reinjection every 3-6 months)
3) Surgical sectioning or myotomy
� Dysphagia first for solids, followed later (PROGRESSING) to dysphagia for liquids
Need to check GERD pt how many yrs after diagnosis with GERD?
Treatment?
_ is a procedure used to treat complications of reflux such as hiatal hernia
esophageal cancer
Check them for esophageal cancer 5-10 yrs after diagnosis
Resection is the only cure
Nissen fundoplication
severe chest pain and the EKG and stress test will be normal. Symptoms precipitated by drinking cold water
Best Test
Best treatment
Intermittent dysphasia --> think
Esophageal spasm and nutcracker esophagus --> both are clinically indistinguishable
Manometry
Ca Channel Blockers
Schatzki ring
Zenker diverticulum is outpouching of what?
Best diagnositic test
What don't you do in these pt
People w/ sceleroderma have what esophageal problem? How do you treat it?
Posterior pharyngeal constrictor muscles
Barium study
Do not do NG tube or upper endoscopy --> may lead to perforation
decrease LES pressure --> treat w/ PPI as you would for any reflux symptoms
____ is the only way to truly understand the etiology of epigastric pain from ulcer disease.
In the esophagus, ___ may be a good place to start with testing, but in the stomach ___ is very poor
Endoscopy
barium studies
Barium studies
The patient also complains of sore throat, bad taste in the mouth (metallic), hoarseness, or cough . Think
When do you do endoscopy
GERD
� Signs of obstruction such as dysphagia or odynophagia
� Weight loss
� Anemia or heme-positive stools
� More than 5-10 years of symptoms to exclude Barrett esophagus
* Don't just do endoscopy if they have pyrosis (heartburn)... won't see anything
What kind of change is seen in Barrett's esophagus?
Management of Barrett's esophagus?
Metaplasia
- Stratified squamous epithelium becomes nonciliated columnar w/ globlet cells
scope 5-10 yrs after initial diagnosis
- barrett alone --> PPI and rescope ever 2-3 yrs
- Low grade dysplasia --> PPI and rescope every 6-12 months
- High grade dysp
___often presents with gastrointestinal bleeding without pain
Most accurate test for H. Pylori
- Treatment?
Stress ulcer prophylaxis is indicated in
____ (a drug) caues ulcers by inhibiting the production of ____ which produces mucus in the gastric mucosa
Gastritis
Endoscopic biopsy
- Triple therapy: 1 PPI and 2 antibiotics (usually penicillin and macrolide)
� Mechanical ventilation
� Burns
� Head trauma
� Coagulopathy
NSAIDs
Prostaglandins
PUD includes both
- which one is associated w/ cancer
What is treatment for PUD?
What delays the healing of ulcers?
How do you confirm eradication of H. Pylori?
What should you do 6-8 wks after initial diagnosis of PUD?
gastric and duodenal ulcers
- Gastric ( need to do repeat endoscopy after treatment to exclude cancer development) (happens in 4% of the time)
PPI with clarithromycin and amoxicillin
- If not responsive, use metronidazole and tetracycline
- Can add bismut
Most common cause of epigastric pain
Best initial treatment?
Should you scope them?
non-ulcer dyspepsia
PPI
No, unless they're >45 y.o. or present w/ alarm symptoms (dysphagia, wt loss and anemia)
What abnormality do you find on labs in gastrinoma
Best imaging
What drug increases gastric motility?
- what is it used for?
High gastrin levels
- Secretin does not decrease gastrin levels in gastrinoma
Somatostatin receptor scintigraphy combined w/ endoscopic ultrasound
- Gastrinoma is associated w/ massive increase in somatostatin receptors
Erythromycin and metoclopromide
- D
Treatment for GI bleed
Pt w/ variceal bleeding. what drugs should you give them?
When should CT or MRI be used for GI bleeds?
Take care of vitals first
- Fluid replacement (80% of GI bleeding will stop spontaneously if resusitation is appropriate)
- PRBC if hematocrit <30
- FFP if PT or INR elevated
Octreotide --> decrease portal pressure
Propanolol --> prevents esopageal varice
C. Diff is most commonly caused by what antibiotics
What is the treatment?
Clindamycin
Metronidazole
- Use vanc or fidaxomicin for resistant forms
What diseases can cause malabsorption
What are usually deficient in these people?
Celiac, pancreatitis, tropic sprue and whipple disease
Vit ADEK
What test do you do for celiacs? What's the most accurate
Most accurate test for pancreatitis?
� Anti-tissue transglutaminase (first test)
� Antiendomysial antibody
� IgA antigliadin antibody
- small bowel biopsy showing flattening of the villi
Secretin stimulation test --> normally, a pancreas will secret large amounts of bicarb into NG tube
Pt presents w/
� Flushing
� Wheezing
� Cardiac abnormalities of the right side of the heart
Best test
Treatment?
Carcinoid syndrome
5 HIAA
Octreotide
What is octreotide used for
What are the treatment options for IBS?
Acute variceal bleeds, acromegaly, VIPoma, and carcinoid tumors.
1. Fiber in the diet
2. Antispasmodic agents such as:
� Hyoscyamine
� Dicyclomine
3. Tricyclic antidepressants (e.g., amitriptyline or SSRis)
4. Antimotility agents such as loperamide for di
IBD extraintestinal manifestations include
What's the major difference between the two?
Both are always associated w/?
When should u screen them for colon cancer?
Treatment for both in acute and chronic state
If fistula forms than treat w/
� Arthralgias
� Uveitis, iritis
� Skin manifestation (erythema nodosum, pyoderma gangrenosum)
� Sclerosing cholangitis (more frequent in UC)
Crohn --> Skip lesions, transmural, fistula and abscess, rectal sparing, cobblestone
UC --> Continuous lesion, cur
Best test for diverticulitis
Best treatment
When should you consider surgery?
CT scan with contrast
- Avoid colonoscopy and barium enema --> increase risk for perforation
* Colonoscopy is the gold standard for diverticuLOSIS
Cipro combined w/ metronidazole
young pt with frequent recurrence of infection or perforation, obstruction,
Colon cancer screening in normal population
Screening if 1 family member has colon cancer
Screening if 3 family member has colon cancer
Screening if familial adenomatous polyposis
Previous adenmatous poly found
Previous history of colon cancer
begin at age 50 and repeat every 10 yrs
10 yr age before family member was diagnosed w/ colon cancer or age 40... whichever comes first
*repeat colonoscopy every 5 yrs
start at age 25 and repeat every 1-2 yrs
start at age 12 and repeat every year
repeat c
>90% of acute pancreatitis is caused by
___ is associated with the worst prognosis in pancreatitis
Best initial test
Most specific test
___ test is diagnostic. ____ test is therapeutic
If >30% necrosis found than treat w/
EtOH and cholelithiasis
Low Ca++ (Ca binds fat. Pancreatic insufficiency leads to more fat in the bowels and Ca binding to it)
amylase and lipase
CT Scan
MRCP
ERCP (can be used to place stents and remove stones)
Imipenem or meropenem --> decrease mortalit
All clotting factors except for ___ is made in the liver
___ factor is part of the extrinsic pathway
Haemophilia is a deficiency in
VIII
VII
Hemophilia A --> Factor VIII
Hemophilia B --> Factor IX
What's the significance of serum ascites albumin gradient (SAAG)? What does it tell you?
___ should be suspected in pt that present w/ liver failure w/ no obvious cause
It tells you what specific disease is associated w/ liver failure
- SAAG <1.1 --> due to infection and cancer
- SAAG >1.1 --> Portal HTN, CHF, Hepatic vein thrombosis
Budd-Chiari syndrome (hepatic venous outflow obstruction due to hepatic V. thrombosis)
Spontaneous bacterial peritonitis occurs when?
Most common bug
Best treatment
when there's an infection of the peritoneum w/o perforation of the bowel
E. Coli
Cefoxtaxime or ceftriaxone
what's the treatment
1) ascites and edema
2) Coagulopathy and thrombocytopenia
3) Encephalopathy
4) Varices
5) Hepatorenal syndrome
___ is the only cause of cirrhosis for which a biopsy is not the most accurate test
Anti-smooth muscle antibodies associate
1) Spironolactone and serial paracentesis
2) FF and platelet
3) Lactulose and rifaximin
4) Propanolol and banding
5) Somatostatin, midodrine
Primary biliary sclerosis
autoimmune hepatitis
� Woman in 40s or 50s
� Fatigue and itching
� Normal bilirubin with an elevated alkaline phosphatase
Unique features
Blood test to look for
Treat w/
Primary biliary sclerosis
� Xanthelasma/xanthoma
� Osteoporosis
antimitochondrial antibody
ursodeoycholic acid
� Pruritus
� Elevated alkaline phosphatase and GGTP as well as elevated bilirubin level
80% is associated w/
most accurate test?
Primary sclerosing cholangitis
- Elevated bilirubin distinguishes it from primary biliary scelerosis
IBD
ERCP
� Fatigue and joint pain (pseudogout)
� Erectile dysfunction in men, and amenorrhea in women (from pituitary involvement)
� Skin darkening
� Diabetes
� Cardiomyopathy
Mutation in which gene
Blood test shows
Treat w/
hemochromatosis
- Overabsorption in DUODENUM
C282Y gene
decrease ferritin and iron / increase TIBC
deferoxamine, deferasirox or deferiprone
� Neurological symptoms: psychosis/delusion, tremor, dysarthria, ataxia, or seizures
� Coombs negative hemolytic anemia
� Renal tubular acidosis or nephrolithiasis
what causes this?
best initial test
most accurate
Wilson's disease
Decreased copper excretion due to low levels of ceruloplasmin, which transport copper for excretion
slit-lamp --> looking for kayser-fleischer ring
increase urine output of copper after Penicillamine
- Not ceruloplasmin levels --> common
What are the signs of asecnding cholangitis
-what causes this
Stone located in cystic duct will lead to
What is courvoiser sign?
What is a porcelain gallbladder
Fever, RUQ pain and jaundice
- Dilated common bile duct
acute cholecystitis
Gallbladder becomes palpable due to an obstructive process. Most likely due to neoplasm from pancreas obstructing common bile duct
Abdominal X-ray image finding that is indicated
What do you do a breath hydrogen test for?
What's the preferred test for suspicion of hemorrhoid?
- What are the different grade of hemorrhoids and their treatment?
to test those that are lactose intolerant. 10ppm is normal. 10-20ppm is usually indeterminate. >20ppm is diagnostic of lactose intolerance
Anoscopy
- Grade 1 --> presence of hemorroid (treat w/ sitz baths, fiber and stool softener
- Grade 2 --> hemorrhoid
Pt present w/ burning sensation in outer arm and weakness in wrist extension unilaterally
Diagnosis?
What test do you perform
Cervical radiculopathy at C5/C6. Causing impingement of C6 nerve root
Spurling Test
What structures are contained in the carotid sheath
The tip of a central line should be placed at ___ and confirmed position w/ X-ray
Carotid artery
Jugular Vein
Vagus N
-Jugular vein is anterior to vagus nerve and lateral to carotid artery
SVC
Unilateral face paralysis w/ sparing of forehead. Most likely?
- Why is forehead spared
CVA or ischemic stroke
Forehead spared because of overlap between CN VII
Pt present w/ pain in the interdigital space in toes and no signs of callus or nodules. Most likely diagnosis
What causes this?
What's the treatment
Morton neuroma
entrapment of plantar interdigital nerve under tranverse metatarsal ligament in those that wear tight shoes
NSIADs and steroid injection. Consider shoe change or surgical decompression
Pt who present w/ continued pain out of proportion after an injury. Joint stiffness, increased hair growth and vasospasm. What's your diagnosis
Complex regional pain syndrome
- Type 1 --> no evidence of nerve damage
- Type 2 --> evidence of nerve damage
Initially dementia and visual hallucinations followed by parkinsonian features.
How is this different from Parkinson's
Pt present w/ Dementia, aphasia, parkinsonian aspects;
change in personality.
Lewy Body dementia
No dementia associated w/ Parkinson
Pick's disease (fronto-temporal neurodegeneration)
MCA stroke present w/
Which side does speech and handedness occur on
� Weakness or sensory loss on the opposite (contralateral) side of the lesions causing stroke.
� Homonymous hemianopsia: loss of visual field on the opposite side of the stroke.
� Aphasia if the stroke occurs on the same side as the speech center. This is
ACA stroke present w/
PCA stroke present w/
Treatment for stroke?
� Personality/cognitive defects such as confusion
� Urinary incontinence
� Leg more than arm weakness
� Ipsilateral sensory loss of the face, ninth and lOth cranial nerves
� Contralateral sensory loss of the limbs
� Limb ataxia
<3 hrs --> thrombolytics
>3
Identify each of these HA and list treatment for them
__: HA on both side of head
__: rare cases have aphasia, numbness, dysarthria, or weakness
__: red, tearing eye with rhinorrhea; Horner syndrome
occasionally
__: visual loss, tenderness of the temporal
Tension --> NSAIDs
Migraine --> Triptans or egotamine. Propanolol for prophylaxis
*triptans work on 5HT-1b and 5HT-1d
Cluster --> Triptan, ergotamine or 100% O2. Verapamil for prophylaxis
Giant cell (temporal) arteritis --> prednisone
Pseudotumor cerebri
Trigeminal neuralgia affects which nerve
Treat w/ ?
Definitive treatment is
5th cranial nerve --> feels like knife in face
Oxcarbazepine or carbamazepine
If medications do not control the pain, gamma knife
surgery or surgical decompression can be curative
Zoster vaccine should be given at which age?
Define epilepsy
any person >60 y.o.
seizure of unknown origin
Treatment for status epilepticus
When can you stop seizure medication
1) Benzo --> lorazepam or diazepam
2) Phenytonin or fosphenytoin (less side effect)
- More of seizure prophylaxis
3) phenobarbital
4) Succinylcholine or vecuronium to allow intubation and administration of general anesthesia
After 2 years of no symptoms a
Look for the sudden onset of an extremely severe headache with meningeal irritation (stiff neck, photophobia) and fever
Normal WBC to RBC on CSF is
What would LP show in this pt
Treatment?
Subarchnoid hemorrhage
*Fever is due to blood irritating the meninges
1 WBC per 500-1,000 RBC
Xanthochromia (yellow discoloration due to RBC breakdown)
1) Nimodipine (Ca channel blocker) --> prevent subsequent attacks
2) Embolization (coiling) --> this is
Anterior spinal infraction presents w/
Describe dysfunction found on PE for those w/ brown-sequard
- lost of all function except posterior column function (vibratory sensation and propioception)
- Flaccid paralysis below level of infarct
- Loss of DTR
Ipsilateral --> Position and vibration loss
Contralateral --> Pain and temperature loss
* Just remembe
Look for the loss of pain and temperature bilaterally across the upper back and both arms.
Most accurate test
Treatment
Syringomyelia --> cape-like distribution
MRI
Surgical removal of tumor or drainage of cavitation
Look for headache, nausea, vomiting, fever, seizures, and focal neurological findings
Treatment
This could be cancer or brain abscess
- Only way to tell is by biopsy. CT and MRI would both show a mass
Brain abscess
- Penicillin or Vanc + metronidazole + Ceftriaxone
- Need IV therapy for 6-8 wks followed by 2-3 months of oral therapy
Presents with cognitive impairment, epilepsy, and skin lesions (including facial angiofibromas, adenoma sebaceum)
Autosomal dominant disease characterized by caf� au lait spots, neurofibromas, CNS tumors (gliomas, meningiomas), axillary or inguinal freckl
Tuberous scelerosis
* no specific treatment
Neurofibromatosis
Sturge-Weber syndrome
Tremor at rest and exertion improved with a drink of alcohol is the key to the diagnosis
Fasciculations is a sign of what defect
What is considered a positive babinski
Essential tremor
LMN
Toes extend --> sign of UMN
gait disturbance with a history of repeated head trauma from boxing or the use of antipsychotic medications such as thorazine will help you establish the diagnosis
How do you treat restless leg syndrome
Parkinsonism
DA agonist, such as pramipexole
Treatment for parkinsonism in mild disease
Treatment for parkinsonism in severe disease
Does dementia part of Parkinsons?
1) Anticholinergic (benztropine) --> adverse effect of dry mouth, worsening prostate hypertrophy and constipation
2) Amantadine --> increase release of DA
1) DA agonist (pramipexole)
2) Levodopa/Carbidopa --> associated w/ on & off phenomenon
3) COMT inhi
� Choreaform movement disorder (dyskinesia)
� Dementia
� Behavior changes (irritability, moodiness, antisocial behavior)
� Onset between the ages of 30 and 50 with a family history
What do you see on CT and MRI?
Hungtinton's disease
Caudate nucleus degeneration
Look for multiple neurological deficits of the CNS affecting any aspect of CNS functioning. The most common presentation is focal sensory symptoms, with gait and balance problems.
Best test for this disease
Treatment
Multiple sclerosis
* Keep in mind that this is dysfunction exclusively of CNS (Brain and spinal cord)
MRI
High dose steroid
- Prevent relapse w/ glatiramer and beta-interferon
Look for weakness of unclear etiology starting in the 20s to 40s with a unique combination of upper and lower motor neuron loss.
What stays intact?
Most common cause of death
ALS
Sensory
Respiratory failure
What is pes cavus? What is it associated w/
high arch foot
- Associated w/ Charcot-Marie-Tooth disease
Neuropathies associated w/ these. Describe the deficit
1) Ulnar
2) Radial
3)Lateral cutaneous nerve
4) Tibial nerve
5) Peroneal N
6) Median N.
1) Wasting of hypothenar eminence, pain in fourth and fifth fingers
2) Wrist drop
3) Pain/numbness of outer aspect of one thigh
4) Pain/numbness in ankle and sole of foot
5) Weak foot with decreased dorsiflexion and eversion
6) Thenar wasting, pain/numbne
If the patient can wrinkle her forehead on the affected side, worry about ___ . If the patient cannot wrinkle his forehead on the affected side, it is ____.
stroke
Bell
What nerve is affected in bell's palsy?
What effect does it have
Treat w/?
7th cranial nerve
- Paralysis of one side of the face entirely
- Hyperacusis
- Taste disturbance
- Corneal ulceration (can't close eyes)
Nothing. 60% of cases resolve spontaneously
- Can use steroid or acycolovir to speed up recovery tho
Ascending weakness w/ loss of reflexes --> think
Treatment?
GBS
IVIG or plasmapharesis
- Not steroid, they do not help in this case
Look for a question describing "double vision and difficulty chewing," "dysphonia,"or "weakness oflimb muscles worse at the end of the day."
What causes this disease
Best initial test
Most accurate
Acute treatment
Long term treatment
Myasthenia gravis
Antibody against acetylcholine receptors at NMJ
ACH receptor antibody
- Not edrophonium test
Electromyography
IVIG or plasmapharesis
Neostigmine or pyridostigmine
Staggering gait, frequent falling, nystagmus, dysarthria, pes cavus, hammer toes, hypertrophic cardiomyopathy (cause of death).. Think
Which part of the neural system does it affect
Friedreich's ataxia
Progressive degenerative disease affecting the dorsal columns and spinocerebellar tracts
First line treatment for AD
This drugs is an NMDA receptor antagonist; helps prevent excitotoxicity (mediated by Ca2+).
Cholinesterase Inhibitors --> donepezil, rivastigmine, and galantamine
Memantine --> actually is a disease modifying drug for AD
what is comlex regional pain syndrome
- What's the difference between type 1 and type 2
Complex regional pain syndrome is a disorder that is chracterized by continued pain, allodynia, or hyperalgesia.
- Type 1 --> no definitive nerve lesion
- Type 2 --> definitive nerve lesion
The best initial therapy for a nonhemorrhagic stroke is:
Isolated LMN signs, perineal paresthesia, bowel/bladder incontinence --> think
- What's the treatment for this?
� Less than 3 hours since onset of stroke: thrombolytics
� More than 3 hours since onset of stroke: aspirin
� Hemorrhagic stroke: nothing
Cauda equina syndrome
- Immediate surgical consultation
What's the difference between C. botulinum, lambert-eaton, myasthenia gravis, GBS, MS, and ALS?
C. botulinum caused by bacterial toxin that prevent the release of presynaptic NT
Lambert-Eaton --> autoimmune disorder which AB attack Ca++ channels, preventing release of NT
Myasthenia Gravis --> Autoimmune disorder which autoAB attack ACH receptors
GBS
Difference between primary, secondary and tertiary prevention
Primary (Screening to avoid development of disease. Using sun screen)
Secondary (Screening to detect disease early. Ex, checking a mole. Disease is already there. We're just diagnosing it early)
Tertiary (Aim to reduce impact of already established diseas
Pt w/ type II DBM
BP goal?
A1C goal?
Screening exam recommendations?
130/80
- Start treatment when BP is > 140/90
<7%
yearly --> dilated retinal exam, foot exam and exam for microalbinuria
What is the pneumococcal vaccine recommendation
When do you start screening w/ DEXA?
AAA screening recommendation
- When should you repair it?
When should smoker be screened for lung cancer?
Give to every >65 yrs
- If recieved before 65 than a second shot should be given 5 yrs after the first shot
- Give to DBM, alcoholics, AIDs and corticosteroid users
- Those who are asplenic
WOMAN >65 y.o.
MEN >65 w/ smoking history and 65-75 w/ family his
what is the recommendation for bone densitometry?
What do the T-scores mean?
Woman above the age >65 y.o.
T score -1.0-2.5 --> Osteopenia
T score <-2.5 --> Osteoporosis
When do you need antibiotic prophylaxis prior to procedure to prevent infective endocarditis
What's the most common bug
What's the antibiotic of choice?
Prophylaxis is only inidcated for high-risk cardiac conditiosn in pts w/ presthetic cardiac valves, pt w/ history of infective endocarditis, pt w/ forms of congenital heart disease and pt w/ history of cardiac transplantation
S. Viridans
Amoxicillin 30 mi
Person undergoing Chemo
- What do you need to worry about?
- What can you give prophylactically?
Tumor lysis syndrome leading to renal damage
Allopurinol, hydration, and rasburicase
What does positive BRCA indicate?
- What do you do for these pt?
Increase risk of breast cancer and ovarian cancer
- We don't know... No current indication on what to do for those that are BRCA positive
When should you start lipid screening for healthy pt?
Screening for HTN should start at
When do you start screening for DBM?
When should you use INACTIVATED flu vaccine?
What's the pneumococcal vaccine recommendation
Zoster vaccine for those with what age
Men (>35) and woman (>45)
Every clinical visit starting at age 18
When pt has HTN or hyperlipidemia
Age >50 or with chronicmedical illness
� One vaccine above 65 only
� Single revaccination after 5 years if the patient is immunocompromised or the first in
What's the tetanus vaccine recommendation
Tetanus
Never vaccinated, <3 boosters, or unsure:
Dirty wound:
Clean wound:
What's the Tdap recommendation?
� Td (toxoid) every 10 years
� One Tdap (tetanus with acellular pertussis) as one of the boosters
� Tetanus immune globulin in those never vaccinated
- Immune globulin
- Booster after 5 years
- Booster after 10 years
*So someone w/ a dirty wound and >5 yr
Recommendation for meningococcal vaccine
routinely vaccinate at age 11 and in those w/
� Asplenia
� Terminal complement deficiency
� Military recruits
� Residents of college dormitories
� Travelers to Mecca or Medina in Saudi Arabia for the Hajj (pilgrimage)
SERMs act on what receptors
Which cancer does it decrease risk
- Which cancer does it increase risk
What side effect can you expect from it?
Acts on estrogen receptors on the bone
* acts as an antagonist of estrogen receptors on the breast and uterine tissue
Breast and endometrial cancer
- Uterine cancer
Exacerbation of postmenopausal symptoms (ie hot flashes and vaginal dryness)
What's the order for treatment of constipation?
Chronic constipation should be treated in a step-wise fashion as follows: 1) Education 2) Increasing fiber 3) Bulk-forming laxatives (psyllium and methylcellulose) 4) osmotic (PEG, lactulose), surfactant (docusate sodium), or stimulant (bisacodyl) laxativ
What's the first line treatment for HTN?
HCTZ
Different layer of skin and associated infection
Impetigo --> most superficial (epidermis)
-Most likely strep
Erysipelas --> Upper dermis
- Most likely staph
- raised, sharply demarcated area of erythema w/ slowly advancing margins
What's the best initial test for melanoma
What's the best test to confirm melanoma
Melanoma most likely metastasize to __
Excisional biopsy
Wide surgical biopsy
Brain
an ulcer that does not heal or continues to grow and associated w/ organ transplant and lont term use of CST
waxy lesion that is shiny like a pearl.
- Diagnose w/
- Treat w/
SCC
BCC
- shave biopsy
- Mohs micrographic surgery
What's the most common cause of Kaposi Sarcoma
Kaposi sarcoma is due to ___
treat kaposi with?
AIDS
HHV 8
treat underlying disease.... Aids
Skin lesion extremely common in elderly w/ "stuck on" appearance
- Treatment?
Seborrheic keratoses
- Non necessary. These are benign
- Can have them removed w/ cryotherapy for cosmetic purpose
� Asthma
� Allergic rhinitis
� Family history of atopic disorders
� Onset before age 5, very rare to start after age 30
pruritus and scratching is the most common presentation because of __
Scratching can lead to ___
- Treat w/
Home treatment
Pharm Treatm
Atopic dermatitis (Eczema)
premature and idiosyncratic release of transmitters such as histamine
Superficial skin infection (staph)
- ephalexin, mupirocin, retapamulin
-Skin care, moisturize, Avoid (bathing, soap and washcloth)
- Topical steroids for flar
What's the difference in presentation between eczema and psoriasis?
What's the treatment for psoriasis?
They are both scaly types of plaques; however, eczema is itch and psoriasis is not itchy (most of the time)
-Topical steroid
-Vit A and D --> can replace steroids
- Coal tar
- Pimecrolimus and tacrolimus --> used on more delicate areas
- UV, TNF-I and met
What is seborrheic dermatitis
What presents w/ positive Nikolsky sign?
Which one does the bullae stay intact?
Dandruff
- Hypersenitivity reaction ot a dermal infection
Pemphigus vulgaris
Bullous pemphigoid
What's the etiology of Pemphigus vulgaris
Best diagnostic test
Obviously treat w/ steroids but what can u use to wean them off steroids?
autoimmune or drug induced disease (ACEi)
Biopsy --> showing autoantibodies
Azathioprine and mycophenolate
Porphyria cutanea tarda (PCT) is a blistering skin disease of sun-exposed areas in those with a history of:
Most accurate test
� Liver disease (HEPATITIS C, alcoholism)
� Estrogen use
� Iron overload (hemochromatosis)
increased uroporphyrins in a 24-hour urine collection.
___ is a much more severe disease than ___ because it occurs at a deeper level in the skin.
- What are the most likely bug for each of these disease
Treatment of all skin infections are pretty much the same. What are the treatments?
Erysipelas --> Strep pyogenes
*treat w/ pencillin
impetigo --> Staph
Mild disease with topical agents:
� Mupirocin
� Retapamulin
� Bacitracin
Severe disease with oral agents:
� Dicloxacillin or cephalexin
Community-acquired MRSA with:
� Doxycycline
� Clin
Based on size, what's the naming of infections surrounding hair follicles
Define cellulitis
Folliculitis < Furuncle < Carbuncle
Skin infection
- no weeping or purulent materia
- Superficial antibiotics don't work because the infection is below the dermal/epidermal junction
What does tinea mean
Best initial test
Most accurate test
Best initial therapy for skin infection, not involving hair and nail?
If hair and nail are involved, than what?
Superficial fungal infection
KOH
Fungal culture
Topical antifungal (ketoconazole, nystatin,
- If involving hair and nail --> terbinafine, itraconazole
Rash due to drug reaction. List by severity of them
� (+) Nikolsky sign
� Hypotension
� Renal dysfunction (elevated BUN and creatinine)
� Liver dysfunction
� CNS involvement (delirium)
- Think?
What's the similarity and difference between scalded skin syn
Morbilliform rash < Erythema Multiforme < Stevens Johnson < Toxic Epidermal Necrolysis (ten times worst! haha)
Staphylococcal Scalded Skin Syndrome (SSSS)
They are both associated w/ nikolsky sign
- SSS does not involve mucus membrane, but TEN does
- SSS
Questions regarding rash associated w/ adverse drug reaction
What's the treatment for morbilliform rash
How does erythema multiforme present?
- Treatment
How does SJS present
- Treatment?
How does TEN present
- Treatment?
Supportive
Target lesion with no mucus membrane involvement
- Steroid
Mucus membrane involvement
- IVIG
Mucus membrane involvement and Nikolsky sign
- IVIG
Treatment order for acne
Mild --> Benzoyl peroxide, topical antibiotics (Clinda and Erythro
Moderate --> Topical Vit A (tretinoin), oral antibiotics (Minocycline or doxycycline)
Severe --> Oral Vit A (isotretinoin)
- Can cause hyperlipedemia
What rash occurs on palms and soles
CARS
- Coxsackie A
- Rocky Mountain Spotted Fever
- Syphilis (secondary)
- Also HSV
� Ejection fraction below___: increased risk for
noncardiovascular surgery
� Recent myocardial infarction: must defer the surgery __ and stress the patient at that interval
� Congestive heart failure (JVD, lower extremity edema): Medically optimize the pa
35%
6 months
ACE inhibitors, beta blockers, and spirinolactone
� EKG
� Stress testing to evaluate for ischemic coronary lesions
� Echocardiogram for structural disease and to assess ejection fraction
Need to do a pulmonary function test
- Also quick smoki
What's the best way to maintain airway?
- What if there are signs of facial trauma?
- What if there's cervical injury
Orotracheal tube
- Cricothyroidotomy
- Give orotracheal entubation but under the guidance of a flexible bronchoscopy
How do you diagnosis SIRS
How do you diagnosis sepsis, severe sepsis and septic shock
2 criteria needed:
-Body temperature <36�C or >38�C
-Heart rate >90 BPM
-Tachypnea >20 breaths per minute, or PC02 <32 mm Hg
-WBC <4,000 cells/mm3 or >12,000 cells/mm3
Sepsis --> SIRS + source of infection
Severe sepsis --> Sepsis + Organ dysfunction
Sept
Pseudocysts develop later, __ postpancreatitis
- How do patient's present?
What's the difference between incarcerated and stragulated hernia?
6 to 8 weeks
- Epigastric pain with normal lab values
Incarcerated hernia --> nonreducible
Strangulated hernia --> pt typically much more ill, with fever and lactic acidosis
List what each of these signs look like and what they're associated with
1) Cullen sign
2) Grey Turner sign
3) Kehr sign
4) Balance sign
5) Seatbelt sign
6) Hamman sign
1) Bruising around the umbilicus --> Hemorrhagic pancreatitis, ruptured abdominal aortic aneurysm
2) Bruising in the flank --> Retroperitoneal hemorrhage
3) Pain in the left shoulder --> Splenic rupture
* due to irritation of phrenic nerve
4) Dull percuss
__ pushes the trachea away from the involved lung, and __ pulls the trachea toward the involved lung.
What requires chest tube placement?
What requires needle decompression prior to chest tube placement?
Which one allows air into the lungs but not out (on
Tension pneumothorax
atelectasis
-Pneumothorax
-Tension pneumothorax
Tension pneumothorax
Tension pneumothorax
Blood at the urethral meatus and high-riding prostate --> diagnosis?
Best initial test?
What's the best test to assess for ureter damage?
Urethral disruption
KUB x-ray followed by retrograde urethrogram followed by foley to aid in urination
IV indigo carmine administration
* This test injects dye which will enter kidney and than ureter (not urethra)
A 75-year-old man with a history of atrial fibrillation, coronary artery disease (CAD), and dyslipidemia presents with severe abdominal pain that is worsened with eating. He states the pain is 10/10 but no peritoneal signs are present.
- diagnosis?
First
acute mesenteric ischemia
get angiography
- This test will guide therapy and it also avoids the risk of perforation that you would get with other invasive procedures
What's the best initial test for suspicion of ischemic bowel
- Most accurate
-Treatment?
___are contraindicated in diverticulit is due to an increased incidence ofperforation
CT scan
- Angiography
- IV hydration and surgical removal of necrotic tissue
Barium enema and colonoscopy
Where does peptic ulcer, sigmoid volvulus, duodenal ulcer pain present?
Acute, progressive worsening abdominal pain that radiates to the right shoulder due to acid irritation of the __
What's the most accurate test for appendicitis? Cholecystitis? Pancrea
Midepigastrium, LLQ and RUQ, respectively
phrenic nerve
CT Scan
HIDA Scan
CT scan
What's the most common cause of gastric perforation?
- Best initial test
- Most accurate test
Treatment
ulcer disease
- Abdominal x-ray --> free air under diaphragm
- CT
- PT NPO
- NG tube and suction out 4L of gastric juices
- Start IV NS
- Surgically repair perforation
* This is also the same treatment regiment for bowel obstruction
RLQ in female of childbearing age
- Differential
What test should you do
appendicitis , ectopic pregnancy, cysts, and torsion
Get B-HCG and U/S of pelvic
- remember to avoid radiation in possible pregnancy
What are signs of pancreatitis
1) Rovsing sign: palpation of the left lower quadrant causes pain in theright lower quadrant
2) Psoas sign: pain with extension of the hip
3) Obturator sign: pain with internal rotation of the right thigh
Pt present w/ GI pain --> An elevated lactate with marked acidosis is a hallmark sign of
- What's the best initial test? Most accurate
- How do you treat
bowel obstruction
- Xray --> multiple air fluid level
- CT Scan
- Same step as in pancreatitis
What's the difference between open and closed reduction
What are the types of fractures. Describe them
- Open reduction --> severe fracture w/ displacement
- Closed reduction --> mild fracture w/o displacement
1) Comminuted fractures --> bone broken into multiple pieces
2) Stress fractures --> repetitive insults
- x-ray may not shot it initially
- most lik
How will the pt present w/ anterior and posterior shoulder dislocation
What's the treatment for clavicular fracture? Scaphoid fracture?
- Anterior dislocation --> Externally rotated
- Posterior dislocation --> Internally rotated
Simple arm sling
Thumb spica cast
___ is caused by a stenosis of the tendon sheath leading to the finger in question
___ is when the palmar fascia becomes constricted and the hand can no longer be properly extended open
What is the treatment for each
Trigger finger
- Steroid injection
Dupuytren contracture
- Surgery is only treatment
The onset of symptoms in fat embolism after bone fracture is
What will they present w/
Treatment
5 days
� ABG will show P02 under 60 mm Hg.
� Confusion
� Petechial rash on the upper extremity and trunk
� Shortness of breath and tachypnea with dyspnea
Keep O2 sat >95%
How do you definitively diagnose someone w/ compartment syndrome
The unhappy triad in knee injury includes
Measure delta pressure
- Delta pressure = diastolic BP - compartment pressure
- <30 mmHg --> get that patient some fasciotomy
ACL, MCL and medial/lateral meniscus
A AAA occurs when....
What is the best test to determine triple AAA
Surgery is indicated when AAA reaches ___
Who should you screen for AAA
Most important risk factor?
portion of the aorta in the abdomen grows to 1.5 times its normal size or exceeds the normal diameter by more than 50 percent through dilation
U/S
*3-4cm --> monitor with U/S annually
5cm
Former or current smoker >65 y.o.
Smoking, not HTN
List the postoperative fever assessment
POD 1-2 --> Atelectasis or pneumonia
- Vanc and Tazobactam-Pipercillin for hospital acquired form
POD 3-5 --> UTI
POD 5-7 --> DVT and PE
- Heparin for 5 days as a bridge for coumadin 3-6 months
POD 7 --> Wound infection + cellulitis
POD 8-15 --> Drug feve
What do you find on imaging of someone w/ acute cholecystitis?
U/S will reveal pericholecystic fluid, gallbladder wall thickening and stones in the gallbladder. HIDA scan is the most accurate test
Explain the different types of Lefort Fractures
-Type I the palate is separated from the maxilla
-Type II the maxilla separates from the face
-Type III involves craniofacial disjunction.
What's considered age for immature lungs
How do you diagnose it
24-34 weeks
lecithin:Spnhingomyelin ration <2:1
Fetal alcohol syndrome presents w/
retardation, microcephaly, holoprosencephaly, facial abnormalities, (smooth philtrum, thin upper
lip, small palpebral fissures, hypertelorism), limb dislocation, and heart defects.
What is considered a term baby
When do you send cord blood for ABG
Normal RR and HR in baby
38wks or more
ONLY if the child is not breathing or in respiratory distress
40-60 and 120-160
Causes of conjunctivitis in children based on date
What eye treatment does every neonate get?
1 day --> Chemical irritation
2-7 days --> N. Gonorrhoeae
>7 days --> C. tachomatis
>3 wsk --> herpes infection
-Erythromycin or tetracycline
-Silver nitrate solution
What prophylactic treatment should a child get right after birth
- Single IM injection of Vit K
- Erythromycin/tetracycline + Silver nitrate
- Hep B vaccine --> Add HBIG if mother is HBsAg-Positive
G6PD genetic pattern
PKU
- Genetic pattern and treatment
Galactosemia
- genetic pattern and treatment
Congenital adrenal hyperplasia
- Genetic pattern and treatment
Congenital hypothyroidism leads to
X-linked recessive
Autosomal recessive
- Diet low in phenylalanine for 16 yrs
Rare
- Avoid lactose-containing products
Autosomal recessive
- errors in steroidogenesis --> therefore replace glucocorticols and mineralocorticoids
cretinism
In new born, if tachypnea last more than ___ hrs, it's considered sepsis
- What do you do to work them up
why is there transient jaundice in 60% of newborn?
4 hrs
- Blood and urine cultures
Spleen is breaking down hemoglobin F --> increase bilirubin
- Splenomegaly is a normal finding in newborns
Caput succedaneum is a swelling of the ___ of the scalp that ___ cross suture lines.
Cephalohematoma is a __ that __ suture lines
soft tissues.... does
subperiosteal hemorrhage... does not
What are the two most common brachial plexus injury in infants. Describe their presentation and treatment
Duchenne-Erb Paralysis: C5-C6
� "Waiter's tip" appearance; secondary to shoulder dystocia
� The infant is unable to abduct the shoulder or externally rotate and supinate the arm
Klumpke Paralysis: C7-C8+/- T1
� "Claw hand" due to a lack of grasp reflex
�
What's the difference between omphalocele and gastroschisis
Large abdominal mass palpated.
- most likely diagnosis
- ___ is highly associated w/ this
- Best initial and most accurate diagnostic test
- Treatment?
Most common cancer in infancy
- What is thi
Imphalocele --> outpouching of intestinal content w/ a peritoneal sac covering
Gastroschisis --> Outpouching of intestinal content lateral to the midline w/ no sac covering (covered in green layer)
- Need gradual introduction of bowel and silo formation
W
Elevated AFP indicates what
Most likely incorrect dating or neural tube defect or abdominal wall defect
What's the difference between hydrocele and varicocele
What's the treatment for cryptorchidism?
Hydrocele --> painless, remnant of tunica vaginalis
Varicocele --> Dull ache and heaviness, Bag of worm, dilation of pampiniform plexus
- Need to U/S both sides
If testes hasn't descended by 1 yr than orchipexy is indicated
What's the difference between hypospadias and epispadias?
- What are they associated w/
Hypospadias (ventral surface)
- Associated w/ cryptorchidism and inguinal hernias
- Avoid circumcisions
Epispadias (dorsal surface)
- Associated w/ bladder exstropy and urinary incontinence
Both need surgical correction
The history of exercise intolerance and squatting while playing outside (tet spells) is pathognomonic for ___
- what is this condition associated w/ on cardiac exam
- What is it associated w/ from genetic standpoint
What are the holosystolic murmurs
Trans
tetralogy of Fallot
� Overriding aorta
� Pulmonary stenosis
� Right ventricular hypertrophy
� Ventricular septal defect (VSD)
� Boot shaped heart
- Chromosome 22 deletion
VSD, MR, TR
PDA, ASD, VSD
___ is the most common cyanotic condition in children after the neonatal period. ___ is the most common cyanotic lesion during the neonatal period
What closes and keeps open the PDA
Tetralogy of Fallot
Transposition of the great vessels (TOGV)
PGE-1 --> opens PDA
NSAIDS (indomethacin) --> close PDA
Explain each
� Pulsus alternans:
� Pulsus tardus et parvus:
� Pulsus paradoxus:
� Irregularly irregular:
___is defined as the process in which a left-to-rightshunt caused by a VSD reverses into a right-to-left shunt due to hypertrophy of theright ventricl
� Pulsus alternans: sign of left ventricular systolic dysfunction
� Pulsus tardus et parvus: aortic stenosis
� Pulsus paradoxus: cardiac tamponade and tension pneumothorax
� Irregularly irregular: atrial fibrillation
Eisenmenger syndrome
� Absent pulses with a single S2
� Increased right ventricular impulse
� Gray rather than bluish cyanosis
Pulmonary veins drain into right heart circulation (SVC, coronary sinus, etc.); associated with ASD and sometimes PDA to allow for right-to-left shun
Hypoplastic L. heart syndrome
Total anomalous pulmonary venous return (TAPVR)
Fixed wide splitting of S2 indicates
PDA is a normal finding in the first ___of life. After __ it is considered pathologic.
- Best initial and most accurate test for PDA
ASD
12 hours
24 hours
- ECHO than cardiac cath
combination of hearing loss, syncope, normal vitals and exam, and family history of sudden cardiac death is all you need to clinch the diagnosis of
� Severe CHF and respiratory distress within the first few months of life
� Differential pressures and puls
Long QT Syndrome
Coarctation of the aorta
- Rib Notching
- Cardiac Cath
Hyperbilirubinemia is considered pathological when:
On the USMLE, ___ is almost alwayscaused by vomiting
Double bubble sign of CXR indicate
� It appears on the first day of life.
� Bilirubin rises more than 5 mg/dL!day.
� Bilirubin rises above 19.5 mg/dL in a term child.
� Direct bilirubin rises above 2 mg/dL at any time.
� Hyperbilirubinemia persists after the second week of life.
hypochlore
Child will turn blue when feeding and then pink when crying
- What is it?
- What causes it?
- List CHARGE syndrome
In choanal atresia, the infant is born with a membrane between the nostrils and pharyngeal space that prevents breathing during feeding. This condition is associated with CHARGE syndrome.
C: coloboma of the eye, central nervous system anomalies
H: heart d
Hirschsprung disease is a congenital lack of innervation of the distal bowel by the __
- Commonly associated w/
- Manometry will show
Auerbach plexus
- Down syndrome
- High pressures in the anal sphincter (for some reason these kids have tight anal sphincter, often presenting w/ failure to pass flatus)
What does the VACTERL Syndrome stand for.
- What's the common association
V: vertebral anomalies
A: anal atresia
C: cardiovascular anomalies
T: tracheoesophageal fistula
E: esophageal atresia
R: renal anomalies
L: limb anomalies
All part of the mesoderm (muscle, bone, connective tissue)
Infant w/ non-bilious vomiting
Infant w/ bilious vomiting
__ presents with colicky abdominal pain, bilious vomiting, and currant jelly stool.
- U/S will show?
- Treatment?
- what position do the pt present w/ ?
Pyloric stenosis
dudoenal atresia
Intussusception
- doughnut sign and target sign (due to telescoping of bowels)
- Do barium enema (both diagnostic and therapeutic)
- Typically lie in a position w/ their knee drawn to their chest
Painless rectal bleeding in a male child <2 y.o. --> think
Is this a true or false diverticulum?
Diagnostic test?
Treatment?
Distance from ileocecal valve?
Meckel's diverticulum
True
Technetium 99m scan
Surgery
2 feet
*about 2 inches long
Abdominal x-ray will reveal the pathognomonic "pneumatosis intestinalis" or air within the bowel wall and CT will reveal air in the portal vein, dilated bowel loops, and pneumoperitoneum if a perforation has occurred
- Diagnosis?
Best first step? Which on
Necrotizing enterocolitis
Start antibiotics (Vanc, gentamicin and metronidazole)
1. Feeding must be discontinued for bowel rest.
2. IV fluids must be started immediately.
3. NGT must be placed for bowel decompression.
4. If medical management does not lea
congenital adrenal hyperplasia are diagnosed by
what are the electrolyte abnormality associated w/ this disease
serum electrolyte abnormality and increase 17-OH Progesterone
Hyponatermic, hypocholoremic, hypoglyemic and hyperkalemic
- Due to lower levels of aldosterone and steroids
What are the three main etiologies to rickets
1. Vitamin D-deficient rickets caused by a lack of enough vitamin D in the child's diet.
2. Vitamin D-dependent rickets is the inability to convert 25-0H to 1,25(0H)and therefore the infant is dependent on vitamin D supplementation.
3. X-linked hypophosph
What's the most common cause of neonatal sepsis
What's the most common organism
Treatment?
Pneumonia & meningitis
Group B strep
E. coli
S. aureus
Listeria monocytogenes
Ampicillin and gentamicin
Chorioretinitis, hydrocephalus, and multiple ring-enhancing lesions on CT caused by Toxoplasma gondii
Week 1: shock and DIC
Week 2: vesicular skin lesions
Week 3: encephalitis
Rash on the palms and soles, snuffles, frontal bossing, Hutchinson eighth nerve
Toxoplasmosis
Herpes
Syphilis
- VDRL /RPR
- FTA ABS or Darkfield
CMV
Rubella
best initial test is tzanck smear showing multinucleated giant cells; most accurate test is viral culture
Cough, coryza and conjunctivitis w/ kopliks spots
Fever, URI, rash and slapped cheek
Fever and URI progressing to diffuse rash
Fever precedes classic
Varicella
Rubeola or measles
Parvo B19
Roseola
Mumps
Supportive treatment
(1) fever, (2) pharyngitis, (3) sandpaper rash over trunk and extremities, (4) strawberry tongue, and (5) cervical lympadenopathy.
Caused by what bug
Treatment
Scarlet Fever
S. Pyogenes
penicillin, azithromycin, or cephalosporins
Barking cough, coryza and inspiratory stridor
- Diagnosis
- Caused by
- CXR shows
- Treatment
� "Hot potato" voice
� Fever
� Drooling in the tripod position
� Refusal to lie flat
- Diagnosis
- Caused by
- CXR show
- Treatment
- Treatment for unvaccinated
- Croup (laryngotracheobronchitis)
- Parainfluenza Virus (type 1 and 2) / Also caused by RSV
- Steeple sign
- Mild symptoms (steroids) / severe symptoms (racemic EPI)
- Epiglottitis
- Used to be HIB before vaccine, now Strep and nontypable influenza
- Thu
Whooping cough associated w/ which bug
Treatment / management
Bordetella pertussis
- Erythromycin or azithromycin
- Isolation
- DTaP vaccine (which has decreased incidence of this disease)
Congenital hip dysplasia
- Age
- Diagnosis
- Treatment
Legg-Calve-Perthes
- Age
- Diagnosis
- Treatment
Slipped capital femoral epiphyisis
- Age
- Diagnosis
- Treatment
- Infant
- Ortolani and Barlow
- Pavlik harness (flex hip and ext rotate femur)
- 2-8 y.o.
- Xray show joint effusion and widening
- Rest and NSAIDs / Follow with surgery on BOTH hips
- Teenager (fat ones)
- Xray show widening joint space + painful limp..
Name these vitamin deficiencies
1) Beriberi and Wernicke's encephalopathy
2) Angular chelosis
Stomatitis
Glossitis
3) Pellagra (4 D's: diarrhea, dermatitis, dementia, death)
4) Peripheral neuropathy and must be given with INH
5) Folate is which vitamin
6)
1) Thiamine
2) Vitamin B2 (Riboflavin)
3) Vit B3 (niacin)
4) B6 (pyridoxine)
5) B9
6) Vit C
7) Increases PT and INR
Infant w/ blood in diaper
- What's your two differential and how to distinguish them
HUS
- Caused by E. Coli 0157:H7
- Shigga toxin causes bleeding
- Associated w/ microangiopathic hemolytic anemia, renal failure and thrombocytopenia
Shigella
- Transmitted by fecal oral route
- Shigella toxin just causes GI bleeding, that's it
- May progr
Kid with fever and seizes
- What's most likely diagnosis
- What's the next best test
Reye's syndrome causes ___that has been associated w/ ___ use in children
Febrile seizures (common in kids 6 months to 5 y.o.)
- If the <12 months --> Do LP
- If >12 months --> give antipyretics and supportive care
encephalopathy and liver failure
aspirin
Describe tanner stages
*A Tanner stage is assigned independently to genitalia, pubic hair, and breast (e.g., a person can
have Tanner stage 2 genitalia, Tanner stage 3 pubic hair).
I. Childhood (prepubertal)
II. Pubic hair appears (pubarche); breast buds form (thelarche)
III. Pubic hair darkens and becomes curly; penis size/length ; breasts enlarge (age 13 y.o.)
IV. Penis width , darker scrotal skin, development of glans; raised are
___ is caused by mutation in the dystrophin protein and results in muscle breakdown with normal muscle usage. ____ can be used to rule out muscular dystrophy
- What sign is associated w/ this?
Duchenne musculuar dystropy
Serum creatine kinase
- Gower sign --> walking with hands up the legs in order to rise to a standing position
The patient in this scenario has prolonged fever, conjunctival injection, strawberry tongue, rash, and extremity involvement. Think
- Treatment?
What are the characteristics of this disease?
what's a serious complication of this disease?
- How do you avoi
Kawasaki disease
- IVIG and aspirin
Change in extremities, conjuncitivis, rash, cervical adenopathy, changes in oral cavity
coronary artery aneurysm
- Treat w/ ASA and intravenous immunoglobulins
1
1
1
1
Best treatment for pregnant w/ UTI
____ has one indication: cystitis, especially in pregnant women.
Beta-Lactam AB such as penicillin or amoxicillin
Nitrofurantoin
Pt is 36 week and present w/ signs of HELLP syndrome. What is should you do first?
What is definitive treatment?
What is treatment if <32 wks
Antihypertensive meds and magnesium sulfate
Induction of labor. No need for C-section
Give bethamethasone w/ expectant management (no need for immediate delivery)
Pregnant pt w/ hyperthyroid. How do you treat?
A thickened or enlarged nuchal translucency is an indication of ___
PTU if in the first trimester
methimazole if in the second trimester (this is the preferred choice of drug in normal population. However, it has been shown to be teratogenic in the first trimester)
Down syndrome.
What are the folic acid recommendations for pregnancy
0.4mg folic acid --> all reproductive age woman
4.0mg folic acid --> All woman w/ history of neural tube defect
Someone come w/ cervical bleeding. What do you do first?
What do you do if you find high grade squamous intraepithelial lesion
What is the last step in treatment?
Pap smear
Do colposcopy
If CIN 2 or 3, than do LEEP procedure (regardless of whether they're pregnant). Repeat HPV testing in 6-12 months
- CIN 1 will regress spontaneously
Pregnant female comes in w/ elevated AFP. What should u be concerned about
What should you do initially?
Neural tube defect
ultrasound to confirm gestational age
- Most common cause of inaccurate AFP
Order ___ to rule our preterm labor in woman 22-34 wks gestation.
Does this have a strong sensitivity or specificity?
The viral load cut off requiring cesarean deliver is ______ in an HIV positive pregnant patient
Fetal fibronectin
Sensitive
1000
Pap smear shows high-grade squamous intraepithelial lesion on pregnant woman. What should u do next?
Colposcopy to examine the lesion further (current recommendations say to not do biopsy on cervix of pregnant woman)
Repeat cervical cytology and colposcopy should be performed on all pregnant woman postpartum as well
Triad of missed period, vaginal bleeding and abdominal pain makes you think.....
What is definitive treatment
what should u do first
What's definitive treatment for barholin gland cyst
Ectopic pregnancy
Surgery
*Methotrexate if ectopic pregnancy is <4cm
U/S to rule out intrauterine pregnancy
I&D and eventual marsupialization, if necessary
Pt presents w/ complaint of amenorrhea. What is the first thing to consider.
Workup for primary amenorrhea
Workup for secondary amenorrhea
is this primary or secondary amenorrhea (Have they ever had a period?)
Check FSH/LH levels
Check B-HCG (most common cause)
- If normal, check thyroid
- If normal, check prolactin level
- If normal, progestin challenge test
Remember the importance of assessing __ production when choosing an agent for the medical induction of pregnancy. Patients who are noted to have adequate production of __ should undergo medical therapy with ___, as in the case above. Patients who are foun
estrogen
estrogen
clomiphene citrate
hypoestrogenic
human menopausal gonadotropin (hMG)
combination of LH and FSH.
What's the diagnostic criteria for hyperemesis gravidarum?
- How do you treat it?
Persistent vomiting past the 1st trimester
- Hydration and B6 (pyridoxine) & doxylamine (H-1 receptor blocker)
Difference between PMS and PMDD
What are the hormonal changes associated w/ menopause?
- Explain why these changes occur
Hormone replacement therapy is contraindicated in what? HRT can lead to what?
PMDD is a more severe version of PMS
- PMDD is associated w/ disruption in daily activities (both are associated w/ disruption in daily activities)
estrogen and progesterone decrease
LH and FSH increases
- Decrease estrogen production by the ovaries drive
Name this type of bleeding
1) Heavy and prolonged menstrual bleeding
2) Light menstrual flow
3) Intermenstrual bleeding
4) Irregular bleeding
5) Menstrual cycles >35 days long
6) Bleeding after intercourse
1) Menorrhagia
� Endometrial hyperplasia
� Uterine fibroids
� Dysfunctional uterine bleeding
� Intrauterine device
2) Hypomenorrhea
3) Metrorrhagia
- Cancer or polyps
4) Menometrorrhagia
- Cancer or polyps
5) Oligomenorrhea
6) Postcoital bleeding
- Cervic
Explain physiology behind dysfunctional uterine bleeding (DUB)
Need to rule out
In DUB --> pts are anovulatory but bleeding. Ovary produces estrogen but there's no corpus luteum to produce progesterone (because there's no ovulation). Therefore, endometrium will continue to grow due to stimulation by estrogen. Bleeding will occur when
Contraception.
Explain each
1) Vaginal diaphragm
2) OCP --> increase and decrease the risk of what?
3) Transdermal patch
4) Depot injection
5) IUD
1) circular ring w/ contraceptive jelly
- Need to place 6 hrs before and keep in 6 hrs after sex
2) Usually a combination pill
- Increase risk of thromboembolism / decrease risk of ovarian cancer, endometrial cancer and ectopic pregnancy
3) New patch plac
Labial problems
Labial fusion is caused by ___. This is usually due to ___
white, thin skin extending from labia to perianal area
- treatment?
- Associated w/ increased risk of
Violet, flat papules
- Treatment?
Excess androgens. 21-hydroxylase deficiency
Lichen sclerosus
- Steroids
- SCC
Lichen planus
Steroids
Normal vaginal pH?
Gardnerella
- What symptoms present
- What do you see on wet mount
- Treatment
Trichomonas
- What symptoms present
- What do you see on wet mount
- Treatment
Which one do you need to treat both partners?
<4.5
Vaginal discharge w/ fishy oder,
- Clue cells
- Metronidazole or Clinda
Profuse, green, frothy vaginal discharge
- Motile flagellates
- Treat both partners w/ metronidazole (considered an STD)
___ presents with vulvar soreness and pruritus appearing as a red lesion with a superficial white coating. Looks like eczema on vulva
- How do you diagnose it
- How do you treat it
What's the most common form of vulvar cancer?
- how do these pt present?
Paget disease
- biopsy
- radical vulvectomy
*paget's disease of the breast present w/ chronic, eczematous rash on nipples too
SCC
- It presents with pruritis, bloody vaginal discharge, and postmenopausal bleeding.
___ is the invasion of endometrial glands into the myometrium. This usually occurs in women between the ages of 35 and 50
___presents with cyclical pelvic pain that starts 1 to 2 weeks before menstruation and peaks 1 to 2 days before menstruation
- Diagno
Adenomyosis
Endometriosis
- Lapraoscopy for direct visualization
- Danazol (androgen derivative) --> cause acne, oily skin, wt gain and hirsutism
- Leuprolide (GnRH agonist) (given continously suppresses estrogen) --> causes hot flashes and decrease bone
� Amenorrhea or irregular menses
� Hirsutism and obesity
� Acne
� Diabetes mellitus Type 2 (increased insulin resistance)
- Think
How do you diagnose it
Treatment options
PCOS
U/S show bilaterally enlarged ovaries w/ multiple cyst
- Free testosterone will be elevated secondary to androgen
- LH:FSH ratio >3:1
* high testosterone and obesity leads to increase estrogen formation --> this in turn increases LH levels but suppre
Define
1) Embyro
2) Fetus
3) Infant
Nagele's Rule
1) Preterm
2) Term
3) Postterm
1st physical sign of pregnancy
-what is blue discoloration of vagina and cervix called?
1) Fertilization to 8 wks
2) 8 wks till birth
3) Birth to one year
LMP - 3 months + 7 days
-25-37 wks
-38-42 wks
->42 wks
Goodell sign --> softening of cervix
- Chadwick sign
Beta-HCG is produced rapidly in the first trimester, doubling every ___ for the first __. At __ of gestation, the beta-HCG peaks, and levels will typically drop in the second trimester
When can you do U/S to confirm pregnancy?
48 hours
4 weeks
10 weeks
5 wks or BHCG level of 1000-1500
Physiologic changes in pregnancy
1) Cardiology
2) GI
3) Renal
4) Hematology
1) Increase in CO / and lower BP
2) Morning sickness (caused by increase in BHCG)
- GERD and constipation
3) Increase in GFR (Decrease in BUN/Creatinine)
4) Anemia due to 50% increase in plasma volume
- Hypercoagulable state w/ normal PT and aPTT
Prenatal care during 1st trimester
Prenatal care during 2nd trimester
Prenatal care during 3rd trimester
- Clinic visit every 4-6 wks
- U/S at 14 wks to determine gestational age (most accurate way of doing it)
- Fetal heart sound can be heard towards the end of 1st trimester
- Blood test, pap smear, gonorrhea/chlamydia test
- Triple or quad screen
- Experie
When are triple and quad screen performed.
- What do they test for
When do you perform amniocentesis and CVS?
What's the best initial diagnostic test for ovarian torsion?
15-20wks
- MSAFP, BHCG, estriol / Add in Inhibin A for quad screen
-Amniocentesis --> 15-20 wks
- CVS --> 10-12 wks
BHCG>U/S>Laparoscopy
Vaginal bleeding w/ increase BHCG and no fetus. U/S shows snowman pattern
- Think
Pt comes in w/ signs of ectopic pregnancy
- What baseline exams do you do
- What's the treatment regiment?
Hydatidiform mole
Order CBC, Blood type, transaminase to see if you can give methotrexate later, and BHCG
Give methotrexate
- If <15% decrease in BHCG in 4-7 days than give another dose of methotrexase
- If BHCG still high than surgery
- Follow BHCG till
What are exclusion criteria for methotrexate usage in ectopic pregnancy
- Immunodeficiency --> methotrexate has immune suppressive effects
- Noncompliant pt --> need them to f/u
- Hepatotoxicity
- Ectopic pregnancy >3.5cm
- Ectopic pregnancy has a heart beat
Different type of abortions
1) No products of conception found
2) Some products of conception found
3) Productions of conception intact, but intrauterine bleeding present and dilation of cervix
4) Production of conception intact, intrauterine bleeding, no
1) Complete abortion
2) Incomplete abortion
3) Inevitable abortion
4) Threatened abortion
5) Missed abortion
6) Septic abortion
- Misoprostol (PGE1 analog)
- Oxytocin
- Amnitomy (mechanical rupture of amniotic sac)
What is considered preterm labor
Pt present w/ preterm contractions
- When should you deliver
- When should you stop delivery?
- What do you stop delivery with?
When do you go ahead and deliver even if fetus is not within the recommended wks?
Contraction and cervical dilation must both be present at 20-37 wks
- Deliver if 34-37 wks
- Stop delivery --> 24-33 wks
- Betamethasone, tocolytics (Mg sulfate or CCB or terbutaline)
*Tocolytic should be given so that steroids have 24-48 hrs to mature th
Preterm infant w/ premature rupture of membrane w/o chorioamnionitis should be treated with
- Betamethasone and a tocolytics
- Ampicillin and 1 dose of azithromycin --> prevent development of chorioamniotis while in utero
� Painless vaginal bleeding in 3rd trimester. Think
- what's the diagnostic test?
What are the different forms of this disease
Treatment recommendation
Placenta previa
- Tranabdominal U/S... DO NOT do transvaginal U/S, may further separate placenta from uterus
1) Complete --> Completely cover internal cervical os
2) Partial --> Partially cover internal cervical os
3) Marginal --> Placental is adjacent to
What are the different types of placental invasion
Placental abruption can lead to
1) Placenta accreta --> Superficial uterine wall
2) Placenta increta --> Attaches to myometrium
3) Placenta percreta --> Invades all the wall through to bladder or rectal wall
* REMEMBER --> A-I-P
If the separation is large enough and life-threatening ble
� Sudden onset of extreme abdominal pain
� Abnormal bump in abdomen
� No uterine contractions
� Regression of fetus: fetus was moving toward delivery, but is no longer in the canal because it withdrew into the abdomen
- Think
Treatment?
Effects on future
Placental rupture
immediate laparotomy --> no C-Section because fetus may no longer be in the uterus
All future pregnancies will be delivered at 36wks via C-section
Prenatal screening for Rh immunoglobulin occurs at ___
What's the recommendation for unsensitized mom
What's the recommendation for a sensitized mom
28 wks
Unsensitized mom should recieve Rhogam at 28 wks and one more after pregnancy if the child is Rh+
- Give RhoGAM anytime fetal blood may cross into the mom (ie amniocentesis, abortions, vaginal bleeding, etc...)
Sensitized mother
- Do a titer --> if
What's the treatment for pregnant woman w/ HTN
What's considered gestational HTN
What's the difference between mild and severe preeclampsia
How do you manage/treat someone w/ eclampsia
What's HELLP syndrome
- Treatment
methyldopa, labetalol, or nifedipine
*Don't use ACEi or ARBs
HTN (>140/90) that starts after 2owks gestation (no proteinuria or edema)
Mild --> >140/90 with proteinuria between 1-3 grams
Severe --> >160/110 with proteinuria >3 g
Prevent eclampsia w/ magne
When do you screen pregnant woman for DBM
How do you it?
___ are most commonly implicated in the development of gestational DBM
24-28 wks
1) Nonfasting ingestion of 50g glucose --> >140 than need a glucose tolerance test
2) Glucose tolerance test --> Injgest 100 mg of glucose followed by 1,2,3 hr glucose measurement
-If any of the 2 are observed
Fasting (>95), 1 hr (>180), 2hr (>1
What's the difference between symmetric and asymmetric intrauterine growth restrictions?
For macrosomic babies
- C-section is indicated when?
Symmetric
- before 20 wks gestation
- Brain in proportion w/ rest of the body
Asymmetric
- After 20 wks gestation
- Brain wt is not decreased/ abdomen is smaller than head
When the fetus is >4500 g (9.9lbs)
Nonstress test
- when should you do them
- What is considered a reactive NST
When do you do a biophysical profile
- What does it consist of
- what's considered a good score
the presence of ___ on fetal monitor represent an active, well-oxygenated
weekly between 32-36 wks
- detection of 2 fetal movements
- acceleration of fetal heart rate >15BPM lasting 15-20 sec over a 20 min period
>36 twice weekly
- NST
- Fetal chest expansion
- Fetal movement
- Fetal muscle tone
- Amniotic fluid index
8-10 is c
Normal fetal heart rate is
What are the different types of decelerations and what do they mean
110-160
Early deceleration --> contractions lead to head compression
Variable deceleration --> decrease in HR but return to normal w/o pattern. Cause by umbilical cord compression
Late deceleration --> Decrease in HR after contraction indicating fetal hyp
What are the different stages of labor?
What are the steps in fetal descent?
Stage 1 --> labor to full cervical dilation
- Latent phase --> 4cm of dilation
- Active phase --> 4-10cm of dilation
Stage 2 --> Full dilation and delivery of fetus
Stage 3 --> Delivery of placenta
Engage, descend, flexion, int. rotation, extension, exter
Prolonged latent stage occurs when the latent phase lasts longer than __ for primipara and longer than ___ for multipara.
- Treat w/
___ are a set of 4 maneuvers that estimate the fetal weight and the presenting part of the fetus.
20 hours
14 hours
- Rest and hydration --> most will convert to spontaneous delivery in 6-12 hrs
Leopold maneuvers
CXR are usually in which position
Abdominal xray is only good for ___
Abdominal perforation, you should get
PA (posterior/ anterior)
Ileus
Upright CXR
What are CT w/ contrast good for
- What are contraindications to the use of contrast
This study should be performed with both intravenous and oral contrast
Detection of cancer or infection
*Both CT and MRI can't distinguish between the mass of cancer or an abscess
- Don't use contrast w/ renal failure
- d/c metformin before using contrast
- Hydrate pt and treat w/ bicarb or N-acetylcysteine prior if they hav
abominal CT w/ contrast is the most accurate test for what
___ is the most accurate test of all central nervous system diseases with the exception of looking for hemorrhage
Gallbladder disease is best imaged w/
nephrolithiasis and diverticulitis
MRI
* also the most accurate test for osteomyelitis
U/S
Endoscopic ultrasound (EUS) is the most accurate method of assessing?
� Pancreatic lesions, particularly in the head
� Pancreatic and biliary ductal disease
� Gastrinoma localization (Zollinger-Ellison syndrome)
Best test
1) only functional test of the biliary system that allows detection of cholecystitis.
2) Fever of unknown origin
3) Assessment of PE
4) Most accurate way to measure ejection fraction
1) HIDA
2) Gallium scan --> follows iron metabolism
*you can also used indium scan which follows WBC
3) Spiral CT most accurate (used to be V/Q scanning)
4) Multiple-gated acquisition scan (MUGA)
Pt presents visual changes including blue halos in his visual field. What new drug caused this
sildenafil
Difference between bacterial conjunctivitis and viral conjunctivitis
When do you consider gonococcal conjunctivitis? What's the presentation?
Bacterial usually produce thick mucopurulent discharge that is unilateral
- Treat w/ topical sulfacetamide or erythromycin
Viral is usually a thin, watery discharge
Young, sexually active people and infants born to mothers w/ N. Gonorrhea
- Presentation i
Difference between periorbital and orbital cellulitis
How do you treat it
Perioribital --> infection of eyelid and area around the eye. EOM should not be affected. No change of vision or pain.
- Supportive measures only
Orbital cellulitis --> Usually cause by previous sinusitis. Presents w/ redness and swelling, fever, pain. EO
What's the difference between viral and bacterial conjunctivitis?
Viral --- Bacteria
Bilateral --- Unilateral
Watery discharge --- Purulent, thick discharge
Easily transmissible --- Poorly transmissible
Normal vision --- Normal vision
Itchy --- Not itchy
Preauricular adenopathy --- No adenopathy
No specific therapy ---
What is uveitis
- Etiology
- Eye finding
- Most accurate test
- Treatment
Gluacoma
- Presentation
- Eye finding
- Most accurate test
- Treatment
inflammation of uvea (iris, ciliary body and choroid)
- Autoimmune
- Photophobia
- Slit lamp finding
- Topical steroids
-Pain
- Fixed midpoint pupil
- Tonometry
- Acetazolamide, mannitol, pilocarpine, laser trabeculoplasty (These are all for acute angle-c
How often should diabetics get their eyes examed?
How does renal artery and vein occlusion present?
- How do they look different on retinal examination?
What's transient monocular blindess called?
- Most common cause?
- Best test?
__ presents with the sud
annually
Monoocular visual loss
- Artery occlusion will make the retina look pale
- Vein occlusion leads to extravasion and the retina will look red
Amaurosis fugax
- Carotid emboli occlude opthalmic A. (most commonly from carotid A)
- Carotid duplex U/S
� Far more common in older patients
� Bilateral
� Normal external appearance of the eye
� Loss of central vision
Best treatment?
Macular degeneration
*Most common cause of blindness in older person
VEGF inhibitor such as ranibizumab, bevacizumab, or aflibercept.
Depressed pt who complains of HA and palpitations after going out to eat
Difference between conduct disorder and antisocial personality disorder?
MAO-I therapy exacerbated by tyramine ingestion (wine, cheese, etc...)
Both involve breaking rules and harming others
- conduct disorder is in those <18 y.o.
- antisocial personality disorder is in those >18y.o.
Tachycardia, sweating, increase BP, shivering, dilated pupils and myoclonus
treat w/
Serotonin syndrome
cyproheptadine (5HT antagonist)
Progressive encephalopathy, microcephaly, hand-wringing, loss of speech, ataxia and psychomotor retardation
- More common in boys or girls?
Normal development for 2 yrs, then marked regression in functioning. This includes loss of language, social interac
Rett's syndrome
- Girls
Childhood disintegrative disorder
- Boys
How do you diagnose MDD?
Patient with depression and neuropathic pain --> treat w/
Patient with depression who is fearful of weight gain or sexual side effects --> treat w/
- Also effective for treatment of smoking cessation
- What's a side effect of this
Symptoms for 2 weeks but usually last 6-12 months w/ 5 of the following 9
SIG E CAPS:
Sleep disturbance
Loss of Interest (anhedonia)
Guilt or feelings of worthlessness
Energy loss and fatigue
Concentration problems
Appetite/weight changes
Psychomotor reta
what's the difference between Bipolar I and II
What's the difference between hypomania and mania?
Bipolar I --> Mania + depression
Bipolar II --> Hypomania + depression
Hypomania --> Does not affect function, usually last <1 wk
Mania --> Affects functioning, usually last >1 wk and requires hospitalization
How do you diagnose dysthymia
How do you diagnose cyclothymia
Atypical depression is best treated w/
___ is used in the treatment of depression w/ significant insomnia
Depressed mood w/ symptoms present for >2yrs
Hypomanic episodes and mild depression
Trazodone
Timeline for postpartum blues and postpartum depression
Blues --> Up to 2 wks after birht
Depression --> within 1-3 months after birth (treat w/ antidepressants)
Medication side effect
1) Tricyclic antidepressants (amitriptyline, nortriptyline, imipramine
2) Monoamine oxidase inhibitors (phenelzine, isocarboxazid, tranylcypromine)
3) Serotonin selective reuptake inhibitors (fluoxetine, paroxetine, sertraline,cital
1) dry mouth, sexual side effects, wt gain and GI disturbance
2) Tyramine will produce HTN
3) HA, wt changes, sexual side effects, GI disturbance
4) HTN, blurry vision, sexual side effect
5) Bupropion --> inc risk for seizures / Trazodone --> Priapism / M
Common symptoms include:
� Cognitive effects: agitation, confusion, hallucinations, hypomania
� Autonomic effects: sweating, hyperthermia, tachycardia, nausea, diarrhea, shivering
� Somatic effects: tremors, myoclonus
Treatment
Serotonin syndrome
� Stop SSRI medication.
� Symptomatic treatment of fever, diarrhea, hypertension
� Cyproheptadine (serotonin antagonist)
___ is a thought disorder that impairs judgment, behavior, and the ability to interpret reality.
- What drug screen is important to rule out in this population?
In emergency situation where intramuscular medication is needed, consider __
If noncompliant w
Schizophrenia
- Cocaine and amphetamine
olanzapine or ziprazidone
risperidone
Clozapine
What are the different types of schizo?
Characterized by delusions or hallucinations, mostly of the persecutory or grandiose type
Characterized by psychomotor disturbances, ranging from retardation to excitation. Mutism is common
Characterized by marked r
Paranoid
Catatonic
Disorganized
Residual
Undifferentiated
Disorganized
Name the side effect of the antipsychotic drug
1) Olanzapine
2) Risperidone
3) Quetiapine
4) Ziprasidone
5) Clozapine
Which medication should you use to prevent wt gain?
1) Greater incidence of diabetes and weight gain; avoid in diabetic and obese patients
*Olanzapine --> "O" for obesity
2) Greater incidence of movement disorders
3) Less incidence of movement disorders
4) Increased risk of prolongation of QT interval; avo
When do these occur and what are the symptoms
1) Acute dystonia
2) Akathisia
3) Tardive dyskinesia
4) Neuroleptic Malignant Syndrome (NMS)
- What's the treatment for this one?
1) hrs to days
- Muscle spasms, such as torticollis, laryngeal spasms, occulogyric crisis
2) Weeks
- Generalized restlessness, pacing, rocking, inability to relax
3) Rare before 6 months
- Abnormal involuntary movements of head, limb, and trunk. Perioral
___ is characterized by the prominence of non-bizarre delusions for more than one month and no impairment in level of functioning
What's the treatment for phobias (specific and social)
What's the difference between acute stress disorder and PTSD?
- Treatm
Delusional Disorder
Behavioral modification and relaxation techniques
- B-blocker are only used for performance anxiety (give 30-1hr before performance)
Acute stress disorder --> symptoms for 2days to 1month from onset of stressful event
PTSD --> symptoms
Pt w/ panic disorder --> treat w/
Pt w/ panic attack --> treat w/
Pt w/ single panic attack --> treat w/
SSRI
Alprazolam
Benzodiazepine
What's the difference between obsession and compulsion
- Treatment?
Obsession --> Thoughts that are intrustive and distressing
Compulsion --> Rituals which are preformed to neutralize thoughts
* often both are part of OCD
SSRI
Side effect of antianxiety meds
1) Used frequently in emergency situations because it can be given IM
2) May be used if addiction is a concern given it has a longer half-life
1) Lorazepam
2) Clonazepam
___ is a benzodiazepine antagonist
- What's a major side effect of this drug?
- What situation will u use this drug?
What's the treatment for amphetamine and cocaine intoxication
- What do you use for withdrawal symptoms?
Flumazenil
- Seizures
- Only in acute overdose. Don't use for chronic dependence (can lead to tremors or seizures)
Antipsychotic or benzo
- Bupropion and/or bromocriptine
Name these disorder
1) Patients must have at least 4 pain, 2 gastrointestinal, 1 sexual, and 1 pseudoneurological symptom.
2) Patients believe that they have some specific disease despite constant reassurance.
3) Typically affects voluntary motor or senso
1) Somatization disorder
2) Hypochondriasis
3) Conversion
4) Body dysmorphic disorder
5) Pain disorder
What's the difference between somatization, factitious and malingering disorder?
Involuntary constriction of the outer third of the vagina preventing penile insertion. This is known as?
Somatization --> Physical symptoms w/o a medical explanation
Factitious disorder --> Individual fakes an illness to get attention and emotional support (can be factitious disorder by proxy too)
Malingering --> Conscious production of signs and symptoms fo
Identify these type of personality disorder
1) Suspicious, mistrustful, and questioning of loyalty of family and friends
2) Choice of solitary activities, lack of close friends, emotional coldness
3) Ideas of reference and magical thinking, brief psychoti
1) Paranoid
2) Schizoid
3) Schizotypal (so typical to do magical thinking)
4) Histrionic
5) Antisocial
6) Borderline
Borderline and schizotypal
Characterized by excessive daytime sleepiness and abnormalities of REM sleep
- Treatment?
What are some specific features of narcolepsy?
Narcolepsy
- Forced daytime naps. Modafinil and methylphenidate to maintain alertness
1) Sleep attacks --> Irresistible sleepiness and feeling refreshed upon awakening
2) Cataplexy --> Sudden loss of muscle tone
3) Hypnogogic and hypopompic hallucinations
What's the difference between masochism and sadism
Masochism --> Sexual arousal involving acts of humiliation
Sadism --> sexual arousal involving acts of physical or psychological suffering of victim
Pt undergoing surgery and develops high fever. What happened?
How do you treat it?
- What is BP goal?
____ is defined as encephalopathy or nephropathy in combination w/ papilledema on exam
Malignant hyperthermia
Dantrolene and cooling body w/ ice and water
- BP goal of 160/100 --> can only decrease BP by 25% in first 1-2 hrs
malignant hypertension
Pt present w/ scrotal pain and fever. Positive Phrehn's sign. Think
Most common cause
What do you do when a child ingest battery?
Epididymitis
<35 and sexually active --> chlamydia
>35 --> most like E. Coli
- If it's in the esophagus, remove right away
- If it's in the small or large intestine, observe and monitor mercury level. If pt become symptomatic, than surgery
GLASGOW COMA SCALE
What score indicates intubation
https://www.withfriendship.com/images/b/9984/Glasgow-Coma-Scale-image.jpg
<8
A patient who is suicidal ingests an unknown substance and develops renal failure 3 days later. Her calcium level is also low and the urinalysis shows an abnormality. What did she take?
Ethylene Glycol
- Will see calcium oxalate crystals (enveloped shaped)
- Ca+ is low because Ca+ precipitates as oxalate crystals
What does prehn sign indicate?
- Most common cause?
Up to what time can you do gastric lavage?
Indicates epidymitis
- Lifting of scrotum relief pain
- N. Gonorrhea
Up to 2 hrs after ingestion of drug
- Typically only useful in first hr after ingestion
The best initial management of altered mental status of unclear etiology is an ____
When you don't know what to do in toxicology, give __
opiate antagonist and glucose
Charcoal --> not always effective, but it is not harmful in any case
1. If a clearly toxic amount of acetaminophen has been ingested (more than 8-10 grams), the answer is ____
2. If the overdose was more than ____, there is no therapy.
3. If the amount of ingestion is unclear, ___.
4. ___ is not contraindicated with N-acet
1) N-acetylcysteine.
2) 24 hours ago
3) get a drug level
4) Charcoal
_____ are the key to diagnosing aspirin overdose.
- Acidosis is due to?
Treatment for ASA overdose?
How do you treat aspirin related respiratory disease?
Tinnitus, respiratory alkalosis, and metabolic acidosis
- metabolic acidosis --> ASA interefers w/ oxidative phosphorylation
Alkalinizing the urine
leukotriene receptor antagonist such as montelukast, zileuton or zafirlukast
__toxicity can cause seizures and arrhythmia leading to death. A ___ will tell who is about to have an arrhythmia.
What's the treatment?
Tricyclic antidepressant (TCA)
wide QRS
Sodium bicarb
Pt w/ CO poisoning
- What effects does it have on pH, CO2 and Bicarb
- What's the most accurate test?
Best initial therapy?
When do you treat w/ hyperbaric O2
___ is oxidized hemoglobin that is locked into the ferric state. Oxidized hemoglobin is ____ and
- Metabolic acidosis (Decrease pH, Decrease CO2 (compensation) and decreased bicarb)
- Look for levels of carboyhemoglobin
-100% O2
-Presence of
� CNS symptoms
� Cardiac symptoms
� Metabolic acidosis
Methemoglobin
brown
- get a methemoglobin level (most a
Organophosphate and nerve gas does the same thing. What effect does it have?
- What's the treatment for each?
Increase in ACH levels lead to
� Salivation
� Lacrimation
� Polyuria
� Diarrhea
� Bronchospasm, bronchorrhea, and respiratory arrest if severe
- Organophosphate (not as severe) --> treat w/ pralidoxime (reactivates acetylcholinesterase)
- Nerve gas (more
Hypokalemia predisposes to ___ toxicity
- why?
These pt presents w/
- What do you see on their EKG?
- Treatment?
digoxin
- Digoxin and K+ compete for the same binding site
* Digoxin toxicity will lead to hyperkalemia
Primarily GI symptoms and rhythm disorder
- Downsloping of all ST segments
- Control K+ levels and give Digoxin-specific antibodies
Lead poisoning
- Best initial test
- Treatment?
What kind of lab test abnormality will a black widow spider bite produce?
Dog, cat and human bites are managed with
- when do you give rabies vaccine?
increased level of free erythrocyte protoporphyrin .
- Succimer (oral form). EDTA and demercaprol (BAL) are parenteral form
Hypocalcemia
� Amoxicillin/clavulanate
� Tetanus vaccination booster if more than 5 years since last injection
� Animal has altered
What's some of the difference between methanol and ethylene glycol toxicity?
- What's the best initial treatment? Ultimate treatment?
- Ethylene glycol is from antifreeze, produces oxalic acid metabolite, cause renal toxicity
- Methanol toxicity is due to paint thinner and cleaning solution, produces formic acid metabolites, presents w/ ocular toxicity
Treat w/ fomepizole and ultimately
What will a concussion and contusion show on CT scan?
- What's the treatment?
What presents w/ lucid intervals?
- What type of bleeds are these?
- Treatment?
Associated w/ A-V malformation and berry aneurysms?
Most likely nothing
- Nothing really besides observation
Subdural and epidural
- Subdural --> Concave venous bleed
- Epidural --> biconcave arterial bleed
1. Intubation and hyperventilation
*Hyperventiliation increases CO2 which cause vasocontriction
2. M
In burn victims, when do you intubate?
How does the rule of 9 work?
What fluid do you use to replace burn victims? How much?
� Stridor
� Hoarseness
� Wheezing
� Burns inside the nasopharynx or mouth
Adult one side: Head (4.5), Body (18), arm (4.5), leg (9)
Kids one side: Head (9), Body (18), arm (4.5), Leg (7)
Ringer lactate is better than NS
- 4ml x %BSA x Kg
Heat disorders
What's the difference between Heat cramps/exhaustion and heat stroke
- Treat w/?
How do you treat NMS?
What causes malignant hyperthermia?
- what causes it?
- Treatment?
What's the most common cause of death in those w/ hypothermia? What do
- Heat cramps/exhaustions --> Body temp, CPK and K+ are normal. Treat w/ oral fluids
- Heat stroke --> Body temp, CPK and K+ are elevated. Treat w/ IV fluids and evaporation
Dantrolene or DA agonist (bromocriptine or cabergoline)
Anesthetics and succinylc
What's the difference in presentation of those w/ fresh and salt water drowing
Salt water drowning --> Similar to CHF w/ wet, heavy lungs
Fresh water drowning --> Hemolysis from absorption of hypotoninc fluid into the vasculature
Don't do chest compression on someone w/ a pulse. idiot
The best initial management of all forms of pulselessness is ___.
What do you do for asystole?
What do you do for V. Fib?
Only ____ without a pulse get unsynchronized cardioversion (AKA defribillatio
CPR
CPR and EPI or vasopressin
Unsynchronized cardioversion followed by EPI or Vasopressin
VF and ventricular tachycardia (VT)
How do you manage V. tach?
Hemodynamically unstable means?
Totally based on hemodynamic status
� Pulseless VT: Defib w/ EPI or vasopressin afterward
� Hemodynamically stable VT: Amiodarone > Lidocaine > Procainamide > Cardiovert if necessary
� Hemodynamically unstable VT: Cardiovert several times before Amiodaron
What is pulseless electrical activity?
- What causes it?
An irregularly irregular rhythm suggests __ as "the most likely diagnosis" even before an EKG is done.
What are the CCBs that are specific for the heart
Heart has electrical activity but there's no mechanical activity
� Tamponade
� Tension pneumothorax
� Hypovolemia and hypoglycemia
� Massive pulmonary embolus (PE)
� Hypoxia, hypothermia, metabolic acidosis
� Potassium disorders, either high or low
atrial
A fib and A. flut
- What's the difference
- Treatment for hemodynamically unstable pt?
What about treatment for chronic
- A flut --> regular rhythm
- A fib --> irregular rhythm
- Synchronized cardioversion
- First --> slow the rate w/ b-blocker of Ca++ Channel blocker (verapamil and diltiazem)
- Second --> Anticoagulate w/ ASA or warfarin based on CHAD score
What is the CHAD score and what is it used for?
CHAD
C: CHF or cardiomyopathy
H: hypertension
A: age >75
D: diabetes
S: stroke or TIA = 2 points
- Score <1 --> Use ASA in chronic atrial fib
- Score >1 --> use warfarin in chronic A fib
Treatment for nose bleeds
Treatment for SVT?
- What's the rate of SVT?
The most accurate test for WPW is ___
- What is the acute therapy for WPW?
- What is the chronic therapy for WPW?
____ are dangerous in WPW. They block the normal AV node and force con
1) continuos pressure 2) Packing 3) Cauterization
1) Vagal maeuvers 2) Adenosine 3) BB, CCB or digoxin
- Syn Cardiovert if hemodynamically unstable
- > 160 BPM
cardiac electrophysiology (EP) studies.
- Acute --> Procainamide or amiodarone
- Chronic --> Ra
Pt present w/ heart rate of 40 and hemodynamically stable.
- What do you do?
- What if they brady and symptomatic?
Difference between Mobitz I and II
- What's the treatment for each?
- Get EKG to rule out 3rd degree heart block (will need a pacemaker if there is 3rd degree). If EKG is normal, than do nothing
- Give atropine (best initial) or pacemaker (most effective)... Do not give EPI, dangerous and can lead to cardiac ischemia
Mobi
__ are done if there are short runs or ventricular tachycardia or unexplained syncope and you want to see if you can induce sustained ventricular tachycardia.
What does a swan-ganz cath do?
EP studies
Swan-Ganz is a right heart catheter that assesses intracardiac pressure and cardiac output.
Describe the glascow coma scale
Eye Response (4 grades)
1) No eye opening
2) Opens to pain
3) Opens to voice
4) Opens spontaneously
Verbal Response (5 grades)
1) No verbal response
2) Incomprehensible sounds
3) Inappropriate words
4) Confused
5) Oriented
Motor Response (6 grades)
1) No
Myxedema coma/crisis present w/
severe hypothyroidism leading to altered mental state, profound hypothermia, and respiratory depression
Pt present w/ nonspecific shoulder pain and difficulty with overhead activity. Pain illicited when forward flexing arm while stabilizing scapula.
Diagnosis
Treatment
Subacromial bursitis
NSAIDs first
Subacromal steroid injection second
Surgicagl subacromial decompression third
Where is the angle of scapula?
Pt presents w/ fibromyalgia --> What OMT should you do?
At the spinous process of T7 but at the transverse process of T8
An indirect technique, but counterstrain is the best.
*Counterstain balances the overactive sympathetic system and allows it to rest
Radial head subluxation present w/
What's the treatment
Elbow flexed and pronated w/ tenderness on lateral aspect of elbow joint
Closed reduction via supination (60 degrees) and flexion
- Physician's thumb pushes subluxed radial head back in place after supination
What dysfunction correlate w/ each axis of the sacram
Superior transvere --> respiratory and cranial
Middle transverse --> Postural motion
Inferior transvse --> Innominate rotation
Oblique --> Ambulation
Which muscle is used for ME on anterior and posterior innominate
Anterior innominate --> Uses hamstring muscles to pull innominate posteriorly
Posterior innominate --> uses Quads to pull innominate anteriorly
Nontender midline mass that moves w/ tongue protrusion
Thyroglossal duct cyst
Pain in anterior medial section of proximal tibia is most likely ___
Pain in anterior medial section of distal tibia is most likely ___
Pes anserine bursa
medial tibial stress syndrome (Shin splints)
Vault hold finger placement
Index --> Greater wing of sphenoid
Middle --> Preauricular portion of temporal bone
Ring --> mastoid process of temporal bone
Pinkie --> Squamous portion of occipital bone
Which muscle do you treat for each rib dysfunction?
First rib
Second rib
Ribs 3-5
Ribs 9-10
Ribs 12
Anterior and middle scalenes
Posterior scalenes
Pect Minor
Lattisimus dorsi
Quadratus lumborum
Patellar reflex involves which nerve?'
Acute onset of sharp back pain exacerbated by forward flexion... what should you be thinking?
herniation at which level would cause a decrease patellar reflex
Which reflex do these correspond to
C5
C6
C7
L4
Intervertebral disc herniation
L3/L4 Hernation
C5 --> biceps reflex
C6--> brachioradialis reflex
C7--> triceps reflex
Abnormal strain patterns at the SBS and cervical or thoracic spine dysfunction are commonly associated w/ _____
- These most likely also ___ CRI
Which four bones comprise the pterion?
Migraine
-Decrease
Frontal, parietal, temporal and sphenoid
Explain the significance of L5 in sacrum dysfunction
L5 will sidebend to a certain side --> this will be the side of axis of rotation
L5 will rotate to a certain side --> the sacrum will rotate in the opposite side
Treatment regiment for scoliosis?
<20 Cobb's angle --> observation
20-40 Cobb's angle --> Brace to prevent further progression
*Only brace before skeletal maturity (male 13-15 and female 15-17).
>40 Cobb's angle --> surgery
* Try OMT first. If pt symptomatic than treat w/ surgery
Knee pain in adolescent with negative exam test and irregular ossification of the proximal tibial tuberosity and calcification on x-ray
treatmetn
Osgood-Schlatter
NSAIDs, ice and rest
Ankle injuries commonly lead to fibular fratures. The ____ supplies sensation to the dorsum of the foot and can be injured in distal fibular factures
What supplies sensation to the dorsum of the foot?
Superficial Peroneal N.
Tibial N.
What's the difference between the seated and standing flexion test?
Seated
- Sacraliliodysfunction
- Indicates sacral dysfunction
Standing
- iliosacral dysfunction
- Indicates innominate dysfunction
*I Stand Bitches.
Child w/ nonsymmetric gluteal fold, think
Developmental dysplasia of the hips
What technique increases the rate and amplitude of CRI
What's the normal CRI rate
CV4 (compression of 4th ventricle)
10-14
Viscerosomatic
Heart
Lung
Upper GI
Middle GI
Lower GI
Head and neck
Stomach, gallbladder, spleen, pancreas and liver?
T1-5
T2-7
T5-9
T10-11
T12-L2
T1-4
T5-9
What findings on physical exam indicate a acute problem
PE reveals the talus is internally rotated on the right and the right foot is inverted and plantarflexed w/ ease. What is the most likely diagnosis
Boggy, warm, edematous and increased moisture
Posterior fibular head
Explain what happens in movement of midline bone and paired bones during SBS flexion
What does the sacrum do when SBS flexes?
- What happens to the AP and transverse diameter in SBS Flexion?
The articular mobility of the cranium has two major phases, which are flexion and extension. The primary motion occurs at the articulation between the sphenoid bone and the occipital bone, termed the sphenobasilar synchondrosis (SBS). When the flexion pha
What's the order of the lateral ankle ligament tears?
The movement of the sacral base into the motion of nutation and counternutation occurs around a ___ axis in a ___ plane of motion
anterior talofibular and calcaneofibular and posterior talofibular ligmaments
transverse
sagittal
Restricted forearm supination and tenderness over the radial head indicates a ___
Name the four muscles of the rotator cup and their motion
posterior radial head
1) Supraspinatus --> Abduct and flex
2) Infraspinatus --> Ext rotation
3) Teres minor --> Ext Rotation
4) Subscapularis --> Int Rotation
When should you treat leg length discrepancy w/ heel lift?
- When do you treat it with surgery?
- What height of hill lift should you use?
What's the best method for measuring leg length discrepancy?
Short leg on the right
- What happens to the sacral bas
<2CM --> heel lift
>2CM --> surgery
- Elderly pt use 1.5 mm (1/16 inch)
- Young pt use 3.2 mm (1/8 inch)
Determined by drawing a straight line from the ASIS to the medial malleolus of the same extremity
- Sacral base lower on the right
- Anterior innomina
Tennis elbow is pain on which side of the elbow?
- It's due to a microscopic tear of what?
What's the anterior and posterior chapman points for appendicitis?
Lateral side of the elbow
- due to a tear in the extensor carpi radialis brevis
Anterior --> tip of 12th rib
Posterior --> tip of transverse process of T11
__ is a common cause of low back pain during pregnancy and after delivery
What is the thompson test?
bilateral sacral flexion
Squeeze the calf to see if it plantar flexes --> If it doesn't, than this is an indication of achilles tendon rupture
Anterior knee pain. Think
- What causes this
What's the treatment for trigger finger?
Patellofemoral snydrome (AKA chondromalacia)
- Caused by weakness in the vastus medialis obliquus which allows the vastus lateralis to dominate and pull the patella laterally
Order is stretching, splinting and ice followed by CST if that doesn't work
Indications:
radionucleotide urethrogram
voiding cystography
retrograde urethrogram
evaluation of vesicouretheral reflux and frequent UTI
type of x-ray performed during urination. Useful for diagnosing tumors or defects in bladder wall, vesicoureteral reflux and renal calculi
Used for evaluation of urethral injury. Pt presents w/ blood a
Pt present w/ trauma to perineum and blood at urethral meatus. What is best initial management
Suprapubic cathether
This allows time for pelvic hematoma to go away.
Eventually these pts will need surgical intervention of course
Men age 20-35 w/ firm, fixed tunica albguinea w/ rubbery enlargement
gradual onset of pain, fever and chills w/ warmth and swelling of scrotum. Most likely causative agent?
Painless scrotal mass that transilluminate
Aching scrotal pain, heaviness, bag of
Testicular cancer
Epididymitis
Hydrocele
Variocele
Pt w/ nephrotic syndrome are at an increase risk of ____ infection
- What should u do for for these people
encasulated infection (particularly strep)
Give them 23-polyvalent pneumococcal vaccine
CT scan of kidney show staghorn calculi
Most likely what kind of stone
Most likely cause of stone
Magnesium ammonium phosphate (10% of kidney stones)
Urease producting organism
- Proteus, Klebseilla, Serratia, Staph Saprophyticus
Side effect of HCTZ
hyperuricemia
Hyponatremia
Hyperglycemia
Hypercalcemia
Hypokalemia
*Causes all sorts of stones and decrease electrolytes but increase glucose
severe proteinuria means
Urine dipstick only detects
Normal protein per 24 hrs
How can you tell how much protein is excreted in 24 hrs
What determines the cause of proteinuria?
What is considered microalbuminuria?
- What population is this important in
-
Glomerular damage
Albumin
<300 mg
Collect urine for 24 hrs or better method is the protein to creatinine ratio ( ratio of 2.5 indicates that 2.5 g of protein is excreted in 24 hrs)
Biopsy
30-300 mg/24 hrs of protein
- DBM
- ACEi
eosinophils on urinalysis indicate
- What stain identifies eosinophils?
What's the best test for detecting Kidney stones
What's the most accurate test of the bladder?
- when do you do this test?
allergic or acute interstitial nephritis
- Wright and Hansel stains
Renal CT
- Intravenous pyelogram is always the wrong answer --> slower an contrast is renal toxic
Cystoscopy
- when there is hematuria without infection or prior
trauma
� The renal ultras
1)Red cell
2) White cell
3) Eosinophil
4)Hyaline
5) Broad, waxy
6) Granular "muddy-brown"
7) Fatty Cast
1) Glomerulonephritis
2) Pyelonephritis
3) Acute (allergic) interstitial nephritis
4)Dehydration concentrates the urine and the normal Tamm-Horsfall protein precipitates or concentrates into a cast.
5) Chronic renal disease
6) Acute tubular necrosis; they
What does BUN/Creatinine ratio tell you
What's the best way of preventing contrast-induced nephrotoxicity?
>20 --> Could be prerenal or post renal azotemia
<10 --> Intrinsic renal damage due to ischemia or toxins
Saline hydration
___is usually a clear diagnosis with the question describing:
� BUN: creatinine ratio above 20:1 and
� Clear history of hypoperfusion or hypotension
___ is usually a clear diagnosis with the question describing:
� BUN: creatinine ratio above 20:1 and
� Di
Prerenal azotemia
Postrenal azotemia
� Acute (allergic) interstitial nephritis (commonly from medications such as penicillin)
� Rhabdomyolysis and hemoglobinuria
� Contrast agents, aminoglycosides, cisplatin, amphotericin, cyclosporine, and NSAIDs: most c
What does urine sodium and FeNA tell you?
When do you expect to see a urine Na+ >20?
What does urine specific gravity tell you?
Basically they tell you the same thing, the function of the kidney
In acute tubular acidosis --> tubular cells are damaged, therefore they can't reabsorb Na... Their osmalality will be similar to what you would find in blood (300 mOSM)
It correlates w/ ur
ASA is ___ toxic
Acetaminophen is __ toxic
NSAIDs is __ toxic
renal
Hepato
Renal
What causes immediate renal toxicity
What causes renal toxicity in 5-10 days
Contrast media. Tumor lysis syndrome after chemo
aminoglycoside antibiotics, amphotericin, cisplatin, vancomycin, acyclovir, and cyclosporine
In rhabdo
- what lab abnormalities do you see
Treatment?
BUN/Creatinine <10
Hyperkalemia --> Release from damaged cells
Hyperuricemia --> release of nucleic acid from damaged cells
Hypocalcemia --> Ca++ bind damaged muscles
Saline, mannitol and bicarb (decrease hyperkalemia)
Hepatorenal syndrome presents w/
� New-onset renal failure with no other explanation
� Very low urine sodium (less than 10-15 mEq/dL)
� FENa below 1%
� Elevated BUN: creatinine ratio (greater than 20:1)
� Severe liver disease (cirrhosis
Why does someone develop livedo reticularis?
Atheroemboli plaques can be dislodged during catheter procedure and end up in the kidney causing acute tubular damage
- Livedo reticularis --> is a purplish skin lesion that results due to cholesterol crystals depositing there
It can also be caused by pol
___ dilate afferent arteriole
___ constrict afferent arteriole
What effect does this have on filtration fraction?
Best test for renal artery stenosis?
- Treatment?
Prostaglandins
NSAIDs
Duplex U/S
- This does not do any damage to kidneys
- Do CT w/ contrast if there is clear sign that kidney is not damaged
Treat w/ statin to prevent further development of atherosclerotic plaques
- Use ACEi if there's unilateral arte
How can you tell someone has suffered from papillary necrosis?
Difference between papillary necrosis and pyelonephritis?
They will have acute onset of symptoms w/ UA showing red and white blood cells
- CT scan will show bumpy contour of interior where papillae were lost
Pyelonephritis --> infection of bladder w/ positive urine culture and diffusely swollen kidney on CT scan
Summary of Tubular Disease
� Generally, tubular diseases are ___.
� Tubular diseases are caused by ___.
� None of them ever cause___ or give massive proteinuria.
� __ is not needed to establish a diagnosis.
� They are not treated with ___ (like all drug a
acute
toxins (drugs, myoglobin, hemoglobin, oxalate, urate, NSAIDS, contrast)
nephrotic syndrome
Biopsy
steroids / AIN
hypoperfusion and removing the toxin.
� Glomerular diseases are generally ___.
� Glomerular diseases are generally not caused by__ or __
� All of them can cause __
� ___ is the most accurate test to establish a diagnosis (though not always needed).
� They are often treated with ___
� Addition
Chronic
toxins or hypoperfusion.
nephrotic syndrome.
Biopsy
steroids (several resolve spontaneously).
What is a glomerular disease that involves lung and kidney?
- How is this different from Wegener's?
Best initial test for this disease
What's the best test
Best treatment?
Goodpasture
- Wegener's prsent w/ URT infection in addition to a vasculitis
Antiglomerular basement membrane antibodies
Kidney biopsy --> shows linear deposits
Plamapheresis and steroids
Look for an Asian patient with recurrent episodes of gross hematuria 1 to 2 days after an upper respiratory tract infection (synpharyngitic).
- What do you find on electron microscopy?
___ follows pharyngitis by 1 to 2 weeks
- Which population does it pri
IgA Nephropathy (Berger's disease)
- Mesangial deposition of IgA and C3 are seen on electron
microscopy
Poststreptococcal glomerulonephritis
- Children (age 2-6)
� Dark (cola-colored) urine
� Edema that is often periorbital
� Hypertension
� Oliguria
- Think
Treatment for this disease?
Postinfectious glomerulonephritis
Supportive
Describe Alport syndrome
Stroke or Ml in a young person suggests
- Likely associated w/ ___
Biopsy is the most accurate test. You will see green birefringence with Congo red staining.
- Think
Alport is a congential defect of TYPE IV collagen that leads to sensorineural hearing loss and visual disturbances
- No specific therapy or treatment
Polyarteritis nodosa (PAN)
- Hep B
Amyloidosis
- Treat w/ steroids and melphalan
___is a systemic vasculitis of small and medium-sized arteries that most commonly affects the kidney.
- Spares what organ?
What kind of symptoms do they present w/?
How do you diagnose it?
Treatment
Polyarteritis nodosa (PAN)
- Lungs
fever, malaise, weight loss, myalgias, and arthralgia developing over weeks to months
- Pain can be worsened by eating because of mesenteric vasculitis
- Livedo reticularis
angiography showing aneursymal dilation
Prednis
Individuals w/ Nephrotic syndrome present w/
Treatment for nephrotic syndrome
- Edema everywhere , unlike CHF where edema is only in LE. Periorbital edema is characteristic fo nephrotic syndrome
- hyperlipidemia. Understand why?
- Infection --> because urinary loss of immunoglobulin
- Proteinuria >3.5 g/ 24 hr
- Hypoproteinemia
GCT
1) Effacement of foot process
2) Spike and dome / lumpy bumpy
3) Tram track
4) Diabetic glomerulonephropathy
1) Could be focal segmental or minimal change (seen more in children)
2) Membranous
3) Membranoproliferative
4) Mesangial
These indicate uremia and indications for dialysis
� Metabolic acidosis
� Fluid overload
� Encephalopathy
� Hyperkalemia
� Pericarditis
Manifestation and treatment of end stage renal failure
1)Anemia--> Erythropoietin replacement and iron supplementation
2) Hypocalcemia and osteomalacia --> Replace vitamin D and calcium
3) Bleeding --> DDAVP increases platelet function; use only when bleeding
4) Pruritus --> Dialysis and ultraviolet light
5)
When vitamin D is replaced to control hypocalcemia, it is critical to also give ___ otherwise vitamin D will increase GI absorption of ___
phosphate binders;
phosphate
� Intravascular hemolysis
� Renal insufficiency
� Thrombocytopenia
- Think
What do you see on blood smear
TTP and HUS --> both present similiarly
schistocytes, helmet cells, and fragmented red cells.
What causes TTP?
What causes HUS?
What's the PT and aPTT values for these two?
Treatment
HIV, cancer, and drugs such as cyclosporine, ticlopidine, and clopidogrel
- Somehow these things lead to TTP (a platelet consumption disease)
E. Coli 0157:H7 and shigella
They are normal in both disease
1) HUS typically resolve on its own but can use plas
What are the two forms of diabetes insipidus?
- What do they have in common
What makes them different?
What's the opposite of this disease?
Central and nephrogenic DI
- Some abnormality involving antidiuretic hormone
- Both have polyuria and nocturia
- high volume urine output w/ low urine osmolality
- Both present w/ hypernatremia (due to free water loss)
1) Water deprivation is the first in
Hypernatremia corrected too quickly leads to
Hyponatremia corrected too quickly leads to
- What fluid should u use to correct
Cerebral edema
* makes sense, think about it
central pontine myelinolysis and seizures
* 0.5 to 1 mEq per hour or 12 to 24 mEq per day.
Use saline for moderate hyponatremia
Use hypertonic saline for severe hyponatremia
What are hypervolemic, hypovolemic and euvolemic causes of hyponatremia
Which drugs are ADH antagonist?
Hypervolemic
- CHF, Nephrotic syndrome and Cirrhosis
Hypovolemic
- Sweating
- Pneumonia
Euvolemic
- Hyperglycemia --> high glucose produces an osmotic draw which decrease Na+ concentration
- Hypothyroidism --> thyroid hormone is needed to excrete water
-
What can cause hyperkalemia
Presentation
Treatment options
- Hemolysis
- Renal failure
- Decrease in aldosterone due to addison's or ACEi
- tissue destruction (rhabdo, tumor lysis syndrome)
- Beta-blocker
- decrease insulin level
- Acidosis --> cells will absorb H+ and exchange it for K+
weakness, paralysis, ileu
What causes hypokalemia
Treatment?
- Alkalosis
- Insulin abuse
- B-adrenergic agonist
- Conn syndrome (Primary hyperaldosteronism)
- Hypomagnesemia
Replace K+ orally
- Must do it very slowly to prevent fatal arrhythmia
- Make sure magnesium levels is not low --> will cause increase urinary
EKG findings of hyperkalemia
EKG findings of hypokalemia
Hypomagnesium will lead to
Acidosis will lead to
B-agonist will lead to
Peak T waves, wide QRS, PR prolongation
U waves, flattened T-wave
Hypokalemia --> cause increase urinary excretion of K+
Hyperkalemia
Hypokalemia
How do you calculate anion gap
what is the normal anion gap
Renal tubular acidosis causes the urine to become
- what's the problem w/ this?
Na - ( Cl + HCO3)
6-12
alkalotic
- alkalkine urine increase formation of kidney stones from calcium oxalate
Cause of anion gap acidosis
Vomiting leads to
Diarrhea leads to
MUDPILES:
Methanol (formic acid)
Uremia
Diabetic ketoacidosis
Propylene glycol
Iron tablets or INH
Lactic acidosis
Ethylene glycol (oxalic acid)
Salicylates (late)
Metabolic alkalosis
- Increase Bicarb levels due to vomiting out all acids
Metabolic acidos
The most common cause of kidney stones (nephrolithiasis) is ___, which forms more frequently in an __ urine. The most common risk factor is the __ in the urine.
What's the most accurate test for nephrolithiasis
Stones __ pass spontaneously
Stones ___ get
calcium oxalate
Low Ca++ diet does not help
alkaline
overexcretion of calcium
Spiral CT w/o contrast
- Don't do IVP because it requires contrast
<5mm
5-7mm
2-3 cm
surgery
*conservative treatments include straining stones --> this could detect what kind of
What BP is considered hypertensive
Cause of HTN
- UE BP > LE BP
- Episodic HTN w/ flushing
- Weakness from hypokalemia
What's the best initial drug therapy?
- If this drug doesn't work then try what?
140/90 --> normal people
130/80 --> DBM or renal disease
- Coarctation of aorta
- Pheochromocytoma
- Hyperaldosteronism
Thiazide
� ACE inhibitor
� Angiotensin receptor blocker (ARB)
� Beta blocker (BB)
� Calcium channel blocker (CCB)
Special circumstances require a different HTN drug... What drugs are indicated in each case
1) Coronary artery disease
2) Diabetes mellitus
3) Benign prostatic hypertrophy
4) Depression and asthma
5) Hyperthyroidism
6) Osteoporosis
BB, ACE, ARB
ACE, ARB (goal <130/80)
Alpha blockers
Avoid BBs
BB first
Thiazides
How do you diagnose HTN crisis
Best initial therapy?
If you lower BP too fast than what can happen?
End organ damage must be involved
Labetolol or nitroprusside
* Any drug IV is acceptable
provoke a stroke
What cancer can GERD lead to
How do you determine the type of cancer
What is a important clue in the history to distinguish the two
Barrett's esophagus and Adenocarcinoma
Biopsy
- Barrett's esophagus --> simple stratified is changed to metaplastic columnar cells
Adenocarcinoma
- Progressive wt lost
- Progressive dysphagia w/ solids and then liquid
Pt w/ FAP. What is screening guideline
Begin flexible sigmoidscopy beginning at age 10-12.
- Repeat yearly
- If genetic test is positive, consider colectomy
Skin lesion on sun exposed area of the face
- Most likely
- ___ is the cancerous form that would be concerning
BCC
SCC
http://www.veteranstoday.com/wp-content/uploads/2011/06/Squamous-Cell-Carcinoma-VS-Basal-Cell-Carcinoma.jpg
What's the difference between a FNA and core needle biopsy
At what age do you start screening w/ mammography?
- How often do you repeat it?
- When do you stop
FNA --> this is the best initial test to do for biopsy however, it cannot test for estrogen or progesterone receptors
Core needle biopsy --> more deforming but can test for Her 2/ NEU receptor
50 y.o.
- Every 2 yrs
- 75
When do you want to do an U/S for breast cancer
When do you want to do PET scan for breast cancer
When do you do a sentinel node biopsy
When do you need adjuvant chemotherapy?
- to determine whether lesion is cystic or solid in nature
- Is painful
- Varies in size or pain with menstruation
To determine if there is cancer in hard to reach lymph nodes
when breast cancer is confirmed and you need to determine if you need to do a a
Estrogen or progesterone positive breast cancer, treat w/
HER2/NEU positive treat w/
Pt w/ multiple first degree relatives w/ breast cancer
- What is most likely to benefit an asymptomatic person?
- What about symptomatic person?
What is stage O, 1 and 2
tamoxifen, raloxifene, or one of the aromatase inhibitors (anastrazole, letrozole, exemestane
Trastuzumab
- Tamoxifen and raloxifene (SERM
- test them for HER2/NEU and
Stage o --> no breast cancer
Stage 1 --> no lymph node involvement
Stage 2 --> 1-3 lymp
What's the best initial test for prostate cancer
Complications of prostatectomy include
What helps control size and progression to metastasis in prostate cancer
PSA corresponds to what?
biopsy
� Erectile dysfunction
� Urinary incontinence
Flutamide, GNRH agonists, ketoconazole, and orchiectomy
Volume of cancer
- Does not indicate anything about mortality
When is surgery not an options for lung cancer
� Bilateral disease
� Malignant pleural effusion
� Heart, carina, aorta, or vena cava is involved
� Small cell cancer
What's the initial test for ovarian cancer? Most accurate test
treatment?
U/S or CT scan
- Biopsy
Removal of ovaries plus any visible cancer and all other pelvic organs
Painless lump in scrotum that does not transilluminate could indicate
Diagnostic test
What is usually elevated in those w/ scrotal cancer
testicular cancer
Just remove the testicle through the inguinal cancer --> don't cut the scrotum or do needle biopsy because it can cause it to spread
HCG
HPV vaccine is given during what ages?
When do you start Pap smear and end it?
- How often should you repeat?
___ on Pap smear is followed up with a colposcopy for a biopsy.
If ___ is present, perform HPV testing. If HPV is found, ___ is performed
11-26 y.o.
21-65 y.o
- Repeat every 3 yrs.
- If you combine PAP w/ HPV testing than you can repeat a pap every 5 yrs
Low-grade and high-grade DYSPLASIA
- ASCUS (atypical squamous cell of undertermined significance)
- colposcopy
What marker is used to follow granulosa cell tumors
Inhibin
Bone cancer
- Which ones occur at the diaphysis
- Which one at the metaphysis
- Which one at the epiphysis
Which one is associated w/ codman's triangle (lifting of periosteum)
Xray finding described as onion ring
- Ewing and Chondrosarcoma
- Osterosarcoma (AKA Paget's disease of the bone)
- Giant cell tumor
Osteosarcoma (lifting of periosteum)
Ewing sarcoma (Ewing goes good w/ onions)
*Neuro origin
unilateral large, smooth, firm, multinodular mass that has been expanding over the past several months. Think
- Treatment?
phyllodes tumor
- Wide-excisional biopsy
Suspect ___ in a woman w/ a pelvic mass and virilizing symptoms
Suspect ___ in a female with early puberty and hyperplastic endometrial lining or abnormal vaginal bleeding
Sertoli-leydig cell tumor
Granulosa cell tumors (this will secrete excess estrogen)
Faulty collagen synthesis causing hyperextensible skin, tendency to bleed (easy bruising), and hypermobile joints. Think
Connective tissue disorder affecting skeleton, heart, and eyes. Findings: tall with long extremities, pectus excavatum, hypermobile jo
Ehler's Danlos
Marfan's
Pain in front of the knee or under patella. Associated w/ runners... Think
- What muscle is weak in this disease?
"Anterior" and "posterior" in ACL and PCL refer to sites of __ attachment.
patellofemoral syndrome
- Vastus medialis
tibial
advance directives is the same thing as healthcare proxy
When is the ethics committee useful?
When is court useful
the family can refuse organ donation even if the patient has an organ donor card.
You can report elder abuse without consent of pt. However,
FYI
The ethics committee is important when a patient has lost capacity to make decisions and the advance directive is missing or unclear. The ethics committee is also important on issues of medical futility. This is when the patient or healthcare proxy is
Freiberg's infarction
Kienbock's diseaes
Kohler's disease
Panner's disease
Sever's disease
Osteochondrosis of the 2nd metatarsal head
Avascular necrosis and collapse of the lunate
Osteonecrosis of the tarsal navicular
Osteochondrosis of the capitellum
Osteochondrosis at the insertion of the achilles tendon on the calcaneal tuberosity
Irreversible state of confusion, confabulation, mammillary body atropy, ataxia and anterograde/retrograde amnesia
Traide of ataxia, enceophalopathy and ophthlmoplegia. Think
what causes both of these?
Korsakoff
Wernicke
Thiamine deficiency
*usually wernicke will progress to korsakoff if it gets to that point
infection of the skin extends through the dermis into the fascial layers and becomes limb thereatening. Think
Most common bugs
Antibiotics of choice
Necrotizing fascitis
S. Pyogenes (GAS), S. Aureus, and C. Perfringens
vancomycin, penicillin and clindamycin
Formula for Filtration fraction
What effect does NSAIDs have on FF?
What effect does ACEi have on FF?
FF= GFR/ RPF
NSAIDs --> constrict afferent arteriole
- This leads to decrease GFR and decrease RPF --> therefore, no change in FF
ACEi --> Dilate efferent arteriole. This leads to an increase in RPF and consequently decrease in FF
Airborn precaution for?
Droplet precaution for?
Contact precaution for
TB and SARs
Influenza, Group A Strep, epiglottis, mumps, rubella and meningocococcal infections
diarrhea, pneumonai, C. Difficle and presumed meninigitis after 24 hrs of symptoms
Most common complication for those w/ sickle cell trait?
- Why?
Transient cerebral function manifesting as alterations in cognitive function and consciousness. Usually due to med side effect
___ is an underlying depression presented as cognitive impairmen
Hematuria
- Due to renal papillary necrosis
Delirium
Psuedodementia
recurrent laryngeal nerve branch of ____ that supplies motor and sensory function to ___. ___ is the only muscle that opens the vocal cord
Compresses ipsilateral CN III (blown pupil, "down-andout" gaze), ipsilateral PCA (contralateral homonymous hemianops
Vagus
Larynx
posterior cricoarytenoid muscle
Uncal herniation
Polycystic kidney disease --> what type of genetic pattern?
- What's the most likely outcome
Staggering gait, frequent falling, nystagmus, dysarthria, pes cavus, hammer toes, hypertrophic cardiomyopathy (cause of death).
Autosomal dominant
- Dialysis by age 60 due to kidney failure
friedreich ataxia
how does thiazolidinediones such as pioglitazone and rosiglitazone work
how does sulfonylureas work?
increase insulin sensitivity by binding PPAR
Encourages insulin release from pancreas by blocking K+ channels
cervical disc hernation will typically affect the nerve root exitign at the level ___ its vertebral body. e.g. herniation at C5-6 will typically affect the___ cervical nerve root
above
6th
What drug should you use emergently in NSTEMI and unstable angina
LWM heparin