PANCE (part 1)

ACE-inhibitors: MOA? Drugs? ADRs? CI?

"-prills" = lisinopril, enalipril, captopril MOA: Inhibit ACE enzyme = prevents conversion of angiotensin 1 --> angiotensin 2 ADRs: -hypovolemia (MC = 1st dose) -HYPERKALEMIA (K+) -LOW: Na, Cl, Mg, Ca -chronic "dry" cough -angioedema -rash CI: -H/o angioedema -BL renal artery stenosis -Pregnancy (X)

ARBs: MOA? Drugs? ADRs? CI? Main indication for use?

"-sartans" = losartan MOA = inhibit angiotensin-2 from binding to its receptors ADRs (similar to ACE-i): -hypovolemia -HYPERKALEMIA -LOW: Na, Cl, Mg, Ca CI (SAME as ACE-i) **MAINLY used for patients who don't tolerate ACE-i (i.e. chronic cough) **must remember that ARBs are slightly less effective than ACE-i alone

Acute Bronchitis: Etiologies? MC? Symptoms? PE? CXR? Treatment?

"Acute inflammation/infection of BRONCHI" VIRAL (90%) = adenovirus (MC) **Bacterial etiologies are more common in patients with underlying lung disease (same pathogens as PNA) SXS (last < 3 weeks): (+) Fever (+) Cough (dry or productive) (+) SOB PE: (+) decreased BS (+) Rhonchi DX = clinical ** only obtain CXR if suspicious for pneumonia CXR = NORMAL (hallmark) TXT (supportive): a) decongestants b) cough suppressants c) analgesics (tylenol)

Ankle Strain/Sprain: Grades? Symptoms suggestive of each? PE?

"Ankle pain + swelling" (all) PE = (+) drawer test (+) tarsal tilt test GRADE 1 ("stretching" of ligaments): (-) ecchymosis (+) NORMAL ROM (+) Able to bear weight GRADE 2 (partial tear): (+) ecchymosis (+) limited ROM (+) Able to bear weight GRADE 3 (complete tear): (+) ecchymosis (+) SEVERE limited ROM (+) INABILITY TO BEAR WEIGHT

Aortic Stenosis: Symptoms? PE findings? EKG? What is the appropriate workup? DEFINITIVE diagnosis?

"Aortic Stenosis Complications" (symptoms): -Angina -Syncope -CHF PE: (+) SYSTOLIC crescendo-decrescendo murmur (@ RUSB + XRT carotids; best heard sitting & leaning forward) (+/-) S4 (if LV strain or LVH) (+/-) Pulses Parvus Et Tardus (weak carotid pulse) (+/-) Narrowed pulse pressure (diastolic pressure rising) (+/-) Paradoxical split S2 (during expiration) EKG (may show LVH) = R+S > 30-35mm Workup: a) ECHO b) Cardiac cauterization (DEFINITIVE DX)

MALIGNANT bone tumors: Breakdown differences between: a) Multiple Myeloma b) Osteosarcoma c) Ewing sarcoma d) Chondrosarcoma Detail: -Epidemiology -MC sites -MC metastasis -Symptoms -XR -Gold standard -TXT

"BONE pain" (MC symptom) (+) limping (+) night pain (+) weight loss MULTIPLE MYELOMA: -bone marrow cancer w/ main manifestation (bone tumors) -OLDER AA males (> 65 yo) -Bones "BREAK" symptoms = bone pain, recurrent infection, elevated Ca, anemia, kidney failure. -Urine = (+) Bence Jones protein -XR = (+) punched out "lytic lesions" -DX = bone marrow biopsy -TXT = autologous stem cell transplant OSTEOSARCOMA (MC type): -bone tumor -ADOLESCENTS or > 60yo -If older = (+) h/o Paget's or repetitive radiation exposure -MC = long bones (femur > humerus > tibia) -MC metastasis = lungs -XR = (+) Sunburst pattern (+) "Hair on end" pattern (+) Codman angle -TXT = resection +/- chemo/XRT EWING SARCOMA: -giant cell tumor -CHILDREN (MC = males) -MC = femur, pelvis -MC metastasis = bones -XR = (+) Onion Skin appearance (periosteal reaction) or "Codman angle" -TXT = resection +/- chemo/XRT CHONDROSARCOMA: -cancer of cartilage -ADULTS (MC = ages 40-75) -XR = "Punctate Ring" or "Arc" appearing (mineralization/calcification of chondroid matrix) -TXT = SURGICAL RESECTION (always)

Ganglion cyst: Also called? What is this? MC location? Symptoms? PE? TXT?

"Bible Cyst" Synovial fluid cyst MC = Dorsal surface (wrist) RF = DM, hypothyroidism, pregnancy Firm, PAINLESS, well-circumscribed fixed mass PE = (+) TRANSILLUMINATES TXT = watch / wait (surgical if large, symptomatic)

Takotsubo Cardiomyopathy: Also known as? Cause? Symptoms? Diagnostic studies? Usually mistaken as? Prognosis? TXT?

"Broken Heart" syndrome Idiopathic (BUT theorized to be 2/2 sudden catecholamine surge) **why we see it usually associated with SUDDEN life stressor [STEMI] + [cardiomyopathy] (+) chest pain (+) ST elevation (+) troponin increase (+) HF-type symptoms **usually accidentally taken to cath lab for STEMI Diagnosis = angiography (+) apical left ventricular ballooning Prognosis = 95% will spontaneously resolve within 4-6weeks (treat symptoms)

Thromboangitis Obliterans: Also called? Pathophysiology? Cause? Epidemiology?

"Buerger's Disease" ("young male smoker") Distinguishing features: -NON-ATHEROSCLEROTIC -Autoimmune mediated -VASCULITIS (small & medium vessels) -Affects BOTH arteries & veins Cause = idiopathic (but STRONG association w/ tobacco use) MC = males

Squamous Cell Lung Cancer: Defining Features? TXT?

"CCCP" (+) Centrally located (+) Cavitary lesions (necrosis) (+) HyperCALCEMIA (+) Pancoast syndrome (common) **This type of lung cancer is MC associated with hemoptysis TOC = resection

Solitary Pulmonary Nodule: Also called? What are these most commonly?

"COIN" LESIONS ( < 3cm) MC = benign MC (either caused by): -Infectious granuloma (MC) = prior TB or fungal infection -FB reaction

Strabismus: What is this? 2 types? MCC? Gold standard test? TXT? Prognosis?

"CROSS eyes" "LAZY eyes" Esotropia = inward gaze Exotropia = outward gaze MCC = EOM weakness (but may be a early sign of Retinoblastoma) Diagnostic test = Hirschberg corneal light reflex testing ("cover & uncover test") **always get MRI r/o retinoblastoma TXT : a) Eye patching (frontline) b) Surgery (refractory cases) **MUST be corrected by age 2 or it may become permanent.

ABG: What is the "rule" regarding PaCO2 & PaO2 levels.... Discuss what the result is of: a) high PaCO2 b) high HCO3-

"Can't drive 55" **just remember that 55mHg is your dangerous cut off for NORMAL values of PaO2 (should be >55mmHg) and PaCO2 (should be < 55mmHg) --> when outside these normal ranges = (+) give supplemental O2 CO2 (acts like acid) --> converted to carbonic acid.... (HIGH PaCO2 = pH < 7.35 = acidosis) HCO3- (acts like base) (HIGH HCO3 = pH > 7.45 = alkalosis)

Cubital Tunnel Syndrome: What is this? MOI? Symptoms? PE? TXT?

"Carpal Tunnel" @ elbow MC = repetitive use injury Compression of ULNAR nerve (+) pain/paresthesias along ulnar nerve distribution (BUZZ = 5th digit (pinky) affected) PE: (+) Tinel sign (@ elbow) (+) Fromet's sign (pinching paper) TXT: -Rest -Wrist immobilization -NSAIDS -Steroid injections

Alpha blockers: 2 types? MOA? Drugs? Indications?

"Catecholamine inhibitors" (block activity of Epinephrine / Norepinephrine) Alpha-1 blockers (HTN, BPH): -"post-synaptic" inhibitors (prevent Epi/NorEpi from binding to receptors) -"-zosins" = doxazosin, terazosin, tamulosin CENTRAL Alpha-2 blockers (HTN urgencies/emergencies): -more potent -"pre-synaptic" inhibitors (prevent the release of Epi/NorEpi) -clonidine, methyldopa, moxonidine

Eosinophilic Esophagitis: MC in who? Hallmark of diagnosis? TXT?

"Children" with atopic disease (allergies, asthma, eczema) EGD = normal (hallmark) (+) multiple corrugated rings TXT = removal allergen (i.e. food)

Hypertrophic Cardiomyopathy: Explain the pathophysiology behind why these kids classically "just suddenly fall dead on football field" ?

"Commotio Cordis" Underlying HCM predisposes these children to QT prolongation --> which in rare cases can be induce by a sudden trauma to the chest

Pulmonary Embolism: What is the "S1Q3T3" pattern? What does it indicate?

"Cor Pulmonale" (sudden right sided HR that results from PE) S1Q3T3: (+) "deep" s-wave (lead 1) (+) pathologic Q-wave (lead 3) (+) inverted T-wave (lead 3)

Anti-arrhythmics (class I): What is the breakdown of these? Differences? Drugs? Uses?

"Double Quarter Pounder" "Lettuce Mayo" "Fries Please" Class 1a "Intermediate acting" : -Drugs = Disopyramide, Quinidine, Procainimide -Uses = Supraventricular + ventricular arrhythmias -3RD line (d/t intolerability) Class 1b "short acting" : -Drugs = lidocaine, mexiletine -Uses = VENTRICULAR arrhythmias only Class 1c "long acting" (FRONTLINE): -Drugs = Flecanide, Propafenone -DOC for wolffe-parkinson-white syndrome -PREFERRED Class 1 drugs (best tolerability) -Uses = atrial & ventricular arrhythmias (broad)

Esophageal Spasm: 2 types? Main symptom? Defining features? Treatment?

"Dysphagia to LIQUIDS" Types: 1. Diffuse esophageal spasm (DES) = multiple, uncoordinated spasms of NORMAL strength ("corkscrew") 2. Nutcracker esophagus = SINGLE, coordinated spasm of increased strength *manometry can tell the difference between these* (measure pressure) TXT = same as Achalasia

Achalasia: Pathophysiology? Symptoms? Diagnostic tests? Gold standard? TXT options? Preferred TXT?

"Dysphagia to SOLIDS + LIQUIDS" Pathophysiology: -Impaired peristalsis -Impaired relaxation of LES Barium swallow study = (+) "bird-beak" appearance (BUZZ) Gold standard = Manometry study (LES pressure > 40mmHg) TXT: a) CCB / Nitrate before meals b) Botox injection c) Heller myotomy (preferred)

Esophageal Stenosis: Types? MCCs? Main symptom? Gold standard (DX)? Treatments?

"Dysphagia to SOLIDS" Types: a) Stricture (MC) = asymmetric, associated with chronic inflammation (i.e. GERD) b) Ring = symmetric, congenital (MC = Schatzki Ring) c) Web = asymmetrical, associated with chronic anemia Gold standard = Barium Swallow (MORE sensitive then EGD) TXT: -fix underlying cause -surgical dilatation -surgical resection

Cerumen Impaction: Presents as? TOC?

"Ear fullness" "CONDUCTIVE hearing loss" Cerumen softening (TOC): -Hydrogen peroxide 3% -Carbamide peroxide (Debrox)

Antibiotic Review List Macrolides.... Coverage? Usage?

"Eats Cheeseburgers Allday" -erythromycin -clarithromycin -azithromycin MAINLY GM(+): -ENT, respiratory infections -GREAT alternative in cases PCN allergy

Infertility: Defined as? MC male or female? MCC? Workup? TXT?

"FAILURE to conceive after 1 YEAR of active trying" MC = female cause MCC = anovulation Workup: -sperm analysis (1st) -RH status -hormonal workup -pelvic u/s -HSG TXT: -Clomiphene (Clomid) -Intrauterine insemination (IUI) -In-vitro fertilization (IVF)

What meds should be avoided in PREGNANCY?

"FATS" 1. FQ (increased risk abnormal fetal bone development) 2. "A -drugs" a) Aminoglycosides (AG) = gentamycin, tobramycin, neomycin, streptomycin. b) ACE-inhibitors 3. Tetracyclines = tetracycline, doxycycline, minocycline 4. "S-drugs": a) Sulfa-drugs (i.e. BACTRIM) b) Sulfazalazine (if don't combine with folic acid)

Scarlett Fever: How does this present? Treatment? Why is this concerning?

"Fever + Sore throat + RASH" (+) STRAWBERRY tongue (+) RASH (superficial, "blanchable," "sandpaper," "sunburn w/ goodbumps" TREAT GABHS infection = Amoxicillin

Mitral Valve Prolapse: Cause? Epidemiology? Symptoms? PE? Diagnosis? Treatment?

"Floppy non-compliant" valve Cause = underlying connective tissue disorder: -Marfan's -Ehlers-Danlos -Osteogenesis imperfecta MC = younger females (15-35yo) Symptoms (vary depending on stage) a) Asymptomatic (MC) b) May have autonomic dysfunction (palpitations, anxiety, panic attacks, syncope) b) Late stage --> can progress to MR & Pulmonary HTN / CHF PE: (+) Mid-late systolic "EJECTION CLICK" + murmur (+) Chest wall deformities (narrow AP diameter, pectus excavate, etc.) Diagnosis = ECHO (+ "posterior bulging leaflets") TXT: a) NO surgical intervention is indicated (good prognosis) b) MAY give (+) BB (to alleviate autonomic "dysfunction symptoms)

Cholelithiasis: What is this? Risk factors? Symptoms? PE? Diagnostic test of choice? Treatment?

"GALLSTONES" Risk factors: a) 5Fs = Forty, Female, Fat, Fertile, Filippino/feather (asian, Indian) b) OCP use c) Rapid weight loss d) Fibrate use (TG lowering meds) Symptoms: (+) asymptomatic (MC) (+) "Biliary colic" = intermittent colicky epigastric/RUQ pain (worsened after fatty, greasy, spicy foods) PE: normal RUQ u/s (test of choice) Treatment: a) Diet modification b) Consider prophylactic cholecystectomy (to prevent cholecystitis)

Atherosclerosis: Risk factors? Worst prognosis? Most important modifiable risk factor?

"HAS LIPIDS" -hereditary -age -sex (males >> females) -lipidemia -inactive lifestyle -pressure (high = HTN) -increased weight (obesity) -DM (WORST prognosis) -smoking (MOST important modifiable risk factor)

HIT: Pathophysiology? MC complication?

"Heparin Induced Thrombocytopenia" Pathophysiology: Heparin "over-activates" platelets = causing them to aggregate & form excessive clots (resulting in observed "low PLTE") MC complication = thromboembolic events (DVT, PE, MI, TIA, CVA)

SHOCK: Pathophysiology.... Common symptoms?

"Hypo-profusion" to organs EITHER d/t: -decreased CO -decreased SVR **remember that: -vasodilation = decreased SVR -vasoconstriction = increased SVR Symptoms: -hypotension -tachycardia (MC) -cool clammy skin -AMS -decreased urine output/anuria

IFA vs. DFA tests: Recall the general rule regarding these....

"ID is most important" = IFA "before" DFA IFA/ELISA = serum test to look for ANTIBODIES (initial test) DFA = serum test to look for specific ANTIGENS (confirmatory test = 2nd)

SHOCK (cardiogenic): Pathophysiology? Etiologies? Treatment?

"Impaired cardiac function" (pump isn't working) Decreased CO Increased SVR Increased PCWP Etiologies (damage to heart): -MI -CHF -Arrhythmias -BB overdose Treatment (do NOT give IVF): -Fix underlying cause -Inotropic agents (dopamine, dobutamine, etc.)

Acute Otitis Media: MCC? Risk factors? Diagnostic criteria? Treatment?

"Inner ear infection" MCC = BACTERIAL -s. pneumoniae (MC) -m. catarhalis -h. influenzae Risk factors: a) ET dysfunction (MC = after URI) b) Cranio-facial abnormalities (classic = Down Syndrome) c) prolonged pacifier or bottle DIAGNOSIS (must have all 3): 1. Acute onset 2. Inner ear inflammation (erythema, TM retraction) 3. Inner ear effusion (air-fluid level, bubbles) TXT = Amoxicillin (frontline) **may consider "watch/wait" principal with older children (mild symptoms)

Rheumatic Fever: Diagnostic criteria?

"JONES criteria" a) 2 Major b) 1 Major + 2 Minor MAJOR criteria ("JONES") a) "J" = joint (MIGRATORY polyarthritis) b) "O" = oh my heart (carditis) c) "N" = nodules (subcutaneous) d) "E" = erythema marginatum (rash) e) "S" = Sydenham's CHOREA MINOR criteria: -elevated CRP -elevated ESR -REVERSIBLE PR prolongation -polyarthralgias -fever

Osgood-Schlater Disease: What is this? Also called? Pathophysiology? MC in who? Symptoms? PE? DX? TXT?

"JUMPER's KNEE" MC = young male athletes Osteochondritis of patellar tendon @ insertion point (Tibial Tuberosity) MC = repetitive contraction of QUAD muscle on patellar tendon (i.e. repetitive jumping) (+) Anterior knee pain / edema (worse w/ activities = "jumping" "running") PE: (+) PROMINENT + tender tibial tuberosity XR (lateral view best): (+) ossification @ tibial tuberosity TXT (usually resolves with time) = REST + NSAIDS + PT

Aldosterone Antagonists: Also called? MOA? Drugs? Main usage? Unique ADRs?

"K-sparing Diuretics" = Aldosterone Antagonists MOA: -Aldosterone (increases Na/H20 retention + K excretion) -By inhibiting Aldosterone you INCREASE K+ levels ("K sparing") Meds: -Spironolactone -Amiloride -Eplerenone Uses: -Adjunctive therapy w/ Thiazide diuretic (to correct the low K+ levels) -Treat fluid overload (CHF/cirrhosis pts) -Treat hyperaldosteronsim -Treat sex hormone imbalances (i.e. hirsutism, acne) Spironolactone (ADR): a) gynecomastia- b) PREGNANCY CATEGORY

Mononuceleosis: MC caused by? Distinguishing features? Initial test? Gold standard? Treatment?

"Kissing Disease" Cause = EBV **DIFFICULT to distinguish from simple pharyngitis (WHY the "amoxicillin rash" is so common) Distinguishing features: (+) PROFOUND FATIGUE (+) Pharyngitis (+) "shaggy purple-white" exudates (+) Posterior cervical LAD (+) hepato-splenomegagly Initial test ("monospot") = rapid AB **may take up to 4 weeks to become (+) GOLD STANDARD = Throat culture + peripheral smear (+ "atypical lymphocytes") TXT: a) supportive b) avoid contact sports (for at least 1 month)

Labyrinthitis vs. Vestibular Neuritis: What are these? Differences? MCC? How does it present? Treatment?

"LABRYINTH" (ear) = cochlea (hearing) + semilunar canals (balence) (+) CONTINUOUS vertigo MCC = post-URI Vestibular Neuritis = inflammation of semilunar canals only (NO hearing loss) Labyrinthitis = inflammation of BOTH cochlea + semilunar canal (+ hearing loss) TXT: a) CCS (1st line) b) Antihistamines / Vestibular suppressants (2nd line) = Meclizine c) BZD (3rd line; severe cases)

Pleural Effusion: What is the "LIGHT" criteria?

"LIGHT" criteria is used to distinguish EXUDATE pleural effusions.... When you suspect effusion, you use thoracentesis to obtain a pleural fluid sample for analysis (protein, LDH levels) EXUDATE effusion ("light criteria") if any of the following are true: 1. Pleural fluid protein/serum protein > 0.5 2. Pleural fluid LDH/serum LDH > 0.6 3. Pleural fluid LDH > 3xULN

Thiazide Diuretics: What must you remember when dosing these?

"LOW CEILING AFFECT" Thiazide diuretics reach their MAXIMUM efficacy @ 1/2 max dose (never any need to max out these medications)

Croup: Pathophysiology? MC pathogen? Epidemiology? Symptoms? CXR? Treatment?

"Laryngotracheitis" (inflammation / infection of UPPER airways = larynx, subglottis, trachea) MC = parainfluenza virus MC = children (3mo-3yrs) Symptoms (hallmark): (+) HARSH "barking" cough (+) stridor (+) fever DX = CLINICAL (MC) CXR (AP) = (+) steeple-sign (subglottic narrowing) TXT: a) Mild (no stridor) = (+) humidified O2 b) Moderate/Severe (stridor) = consider (+) steroids (PO/IM) and nebulized racemic epinephrine

Primary HTN: What cardiac auscultation findings may you hear? What do these indicate?

"Left heart strain" (+) LOUD S2 (+) S4

Aortic Regurgitation: Symptoms? PE? What is the MOST sensitive PE sign?

"Left-sided" HF symptoms PE: (+) Diastolic "descrescendo" "blowing" murmur @ LUSB (+) Displaced PMI (d/t LVH) (+) BOUNDING pulses (+) WIDE pulse pressure (+) Double "thready" carotid pulse ("pulses bisferiens" = usually indicates mixture AR/AS) PE Signs: (+) Hill's sign (MOST sensitive) = popliteal SBP > brachial SBP by > 60mmHg (+) Water Hammer pulse = bounding radial pulse that shows a rapid fall with wrist elevation

Olecranon Fracture: Classic symptom? What nerve are you worried about? TXT?

"Limited extension of elbow" ULNAR NERVE TXT = Reduction (must)

Discuss a good way at evaluating EKGS to distinguish between: a) AFIB b) AV heart blocks

"Look up" and then "Look down" LOOK UP = evaluate for the R'R' interval a) regular = NSR, 1st degree AV block b) irregular = AFIB, 2nd-degree or 3rd degree AV block LOOK DOWN = evaluate for p:QRS a) normal p:QRS = NSR (normal PR) vs. 1st degree AV block (prolonged PR) b) irregular p:QRS = 2nd, 3rd degree AV block b) indiscernable p:QRS = AFIB

Gestational Trophoblastic Disease (Hydatidiform Moles): Pathophysiology? Also known as? Symptoms ("clues")? U/S findings? Concern? TXT?

"MOLAR pregnancy" NON-viable egg that ends up getting fertilized --> leads to non-viable pregnancy BUT placenta continues to grow..... Types: a) Partial b) Complete (MC, higher risk choriocarcinoma) Symptoms: (+) HIGH b-HCG (>100,000) (+) Enlarged uterus (compared to predicted size according to gestational age) (+) Hyperemesis gravidum (+) PAINLESS vaginal bleeding Pelvic U/S = (+) "cluster of grapes" (+) "snowstorm" pattern Concern = 20% progress to CHORIOCARCINOMA (cancer) Management: a) SURGICAL evacuation b) Consider (+) Methotrexate if complete or presents with choriocarcinoma

Discuss differences between: a) Galezzai Fracture b) Monteggia Fracture Concerns? TXT?

"MUGR" MU = Monteggia = ULNAR fracture (proximal) w/ radial head dislocation. (r/o radial nerve injury) GR = Galeazzi = RADIAL fracture (distal) w/ ulnar dislocation. (r/o ulnar styloid avulsion fracture) TXT (unstable) = ORIF (immediately)

Small Cell Lung Cancer: Also called? Defining features? MC site of metastasis? Treatment?

"Oat carcinoma" -WORST prognosis -MOST aggressive -HIGHEST rate of metastasis (MC = lymph nodes) -HIGHEST rate of paraneoplastic syndromes TOC = chemotherapy (not amendable to surgery)

Incompetent Cervix ("cervical insufficiency"): MCC? Clinical picture? Concern? DX? Workup? TXT?

"PAINLESS cervical dilation & shortening" (increased risk miscarriage and/or preterm labor) MCC = prior cervical trauma (surgery, LEEP, etc.) Workup (evaluating & r/o premature labor): (+) fetal fibronectin (fFN) (+) U/S (cervical length) TXT: a) Vaginal Progesterone (until 36W) to stabilize uterus b) cervical cerclage

Pulmonary Embolism: What criteria is used to determine the "LIKELIHOOD" of PE?

"PERC" (pulmonary embolism rule out criteria) LOW suspicion of PE if: a) Age < 50 b) Pulse < 100bpm c) Pulse Ox > 95% d) No history DVT/PE e) No recent surgery/trauma f) No hemoptysis g) No exogenous estrogen h) No UL leg swelling

Benign Positional Vertigo: Cause? Presentation? Treatment?

"POSITIONAL" vertigo MCC = otolith (inner ear) DX = Dix-Hallpick manuever (+) Will see (+) horizontal nystagmus with this maneuver TXT = Epley Manuever **allows you to get "otolith" out of the ear

Trigger Finger: What is this? RF? Symptoms? DX? Frontline treatment?

"PULLY" issue Inflammation of flexor tendon sheath --> entrapment of flexor tendon. RF = DM, RA Finger gets "STUCK" in flexed position ("clicking" sound when trying to extend finger) DX = clinical FRONTLINE = steroid injection (relax tendon sheath)

Zenker Diverticulum: What is this? Classic symptoms? Diagnosis? Treatment?

"Pharyngoesophgeal pouch" (outpouching of esophagus) Pathophysiology: false diverticulum that results from WEAKNESS of cricopharyngeal muscle (+) Dysphagia (+) Regurgitation ("undigested food') (+) halitosis DX = Barium swallow TXT : a) mild/asymptomatic = watch &wait b) symptomatic = surgical correction (diverticulectomy, cricopharyngeal myotomy)

Torsades De Pointes: Also known as? Potential causes? What should you always check? TXT?

"Polymorphic VTACH" ("ribbon") (+/- QT prolongation) Potential causes: a) Low Mg (MCC) b) Low K c) Low Ca d) Ischemic heart disease e) Elevated ICP f) Hypothermia g) Congenital TXT = (+) add class Ib drug to prevent recurrence (MC = lidocaine) TXT = fix underlying cause (MC = give IV magnesium sulfate)

Macular Degeneration: Types? Discuss natural disease course..... Treatment?

"Progressive CENTRAL vision loss" (+/- color vision loss) (+/- metamorphopsia "wavy" vision) Types: 1. "DRY" (MC): -age related -slow onset, progressive -(+) drusen deposits (which lead to macular destruction) -TXT = NONE (vitamins may slow progression) 2. "WET" (rarer but more severe): -neovascularization around macula (new blood vessels) which bleed, causing progressive damage to macula. -sudden, rapidly progressing -(+) serous leaks & hemorrhages & mottling (neovascularization) -TXT = no cure, BUT anti-VEGF agents may slow progression (Bevacizumab) TXT = no EFFECTIVE treatment **can use vitamins & antioxidants to SLOW progression

Esophageal Cancer: MC type (worldwide)? MC type (USA)? Risk factors for both? "Alarm" symptoms? Gold standard DX? TXT?

"Progressive dysphagia (solids)" "Weight Loss" SQUAMOUS cell carcinoma (MCC worldwide): a) RF = ETOH, tobacco ADENOCARCINOMA (MCC USA): a) RF = chronic GERD Gold standard = EGD + biopsy TXT = resection +/- chemo/XRT

Beta-Blockers: What MUST you counsel patients about when initiating therapy?

"REBOUND HYPERTENSION" -occurs if beta blocker is abruptly discontinued -can cause adverse effects -EDUCATE patients that if they wish to discontinue to notify office so they can be titrated down slowly!

TB: Treatment modalities? ADRs? What labs should be monitored? Recommended treatment for: a) Latent TB b) Active TB

"RIPE" drugs: a) Rifampin: hepatitis, "flu-like" syndrome, thrombocytopenia, orange urine/tears. b) Isoniazid: hepatitis, SLE syndrome (rash), peripheral neuropathy. c) Pyrazinamide: hepatitis, hyperurecemia d) Ethambutol: optic neuritis (vision changes/loss, difficulty with red/green vision), peripheral neuropathy. **MONITOR = LFTs** LATENT TB (either): a) Rifampin x 4 months b) Isoniazid x 9 months OR Rifampin + Isoniazid x 3 months ACTIVE TB: Initial "RIPE" x 2 months --> followed by additional 4 months of "tailored" therapy

SVT: MC symptom? Treatment?

"Racing heart" (MC) **realize this differs from sinus tachycardia (SA node) vs. SVT (atria) STABLE: a) Vagal maneuvers b) Rapid IV push Adenosine (frontline) c) try BB or CCB (if adenosine fails or they have severe asthma/COPD) UNSTABLE = synchronized cardioversion **consider ICD placement if recurrent

Nursemaid elbow: What is this? MOI? Classic presentation? TXT

"Radial head dislocation" MOI = parent pulling on their child's arm (upwards traction), swinging of child by arms. Presentation: "child presents holding arm in fixed flexed position" (REFUSES TO USE ARM) TXT (manually reduced) = supinating + flexing forearm

Reactive Arthritis: Also known as? Etiology? Symptoms? Labs? Diagnosis? Treatment?

"Reiter's Syndrome" Possible autoimmune response to a recent GU / GI infection (self limiting): a) MC = chlamydia b) GU (others) = gonorrhea c) GI = campylobacter, salmonella, shigella "Can't see, can't pee, can't climb a tree" Symptoms ("tetrad") -conjunctivitis -urethritis -arthritis (ASYMMETRIC; below waist) -mucocutaneous ulcers Labs ("seronegative arthritis"): (+) HLAB27 (-) Synovial culture Diagnosis = CLINICAL Treatment = NSAIDS + PT **consider (+) Doxycycline if pathogen is chlamydia.

Asthma: Discuss the classification system....

"Rule of 2's"

SHOCK: Discuss the different types & common causes...

"S-H-O-C-K-D" a) Septic shock b) Hypovolemic shock c) Obstructive shock d) Cardiohenic shock e) "K" = Cortisol (Addison's crisis) f) Distributive shock Realize that Distributive shock includes: -septic -anaphylactic -neurogenic -endocrine (Addison's)

Lung Cancer: Recall how to remember which types of Lung Cancers are found centrally vs. peripherally?

"SC" = if it begins with "S" then its CENTRALLY located (small cell, squamous) **All others are peripheral (adenocarcinoma, large cell, mesothelioma)

When there is a pathology in either the RUQ (liver/gallbladder/pancreas) or the LUQ (spleen) what type of referred pain can be seen?

"SHOULDER PAIN" (d/t irritation of phrenic nerve) RUQ --> R shoulder (+Boas sign) (liver, gallbladder, pancreas) LUQ --> L shoulder (+Kerr sign) (spleen)

Rotator cuff: What are the 4 muscles that make this up? MC injured?

"SITS" muscles: -supraspinateous (MC injured) -infraspinateous -tres minor -subscapularis

Allergic Rhinitis: Symptoms? PE findings (BUZZ)? Treatment?

"Seasonal Allergies" "Watery eyes + runny nose + sneezing" (+) allergic shiners (+) allergic salute TXT (supportive): -inhaled mast cell stabilizer (Cromolyn) -nasal corticosteroid spray (Fluticasone) -nasal decongestants (Afrin) -oral antihistamines (Benadryl, Allegra, Claritin) **for young children (less <6 months) = inhaled mast cell stabilizer is preferred (best safety profile)

(+) HLA-B27: What conditions fall into this?

"Seronegative Spondyloarthropathies" (arthritis, BUT (-) ANA and (-) RF) Psoriatic arthritis Ankylosing spondylitis Reactive (Reiter) Arthritis

Ankylosing Spondylitis: Classified as? Also called? Pathophysiology? Epidemiology? Symptoms? PE? Labs? Imaging? TXT?

"Seronegative Spondyloarthropathy" ((-) RF)) "BAMBOO" SPINE Chronic inflammatory condition --> leads to destruction of the intervertebral disk space--> leads to progressive loss of ROM & eventual "fusion" of the spine MC = Males (30s-40s) Symptoms (100% starts @ SI joint): -SI joint +/- back pain/stiffness -gradual & progressive -WORSE in AM & with inactivity -BETTER with exercise (buzz) -May have systemic manifestations (eyes, heart, lungs) PE: (+) decreased ROM "stiffening" (+) Schober Test (loss flexion) (+) hyperkyphosis Labs: (+) HLA-B27 (**) (-) ANA (-) RF Imaging: (+) Sacroiliitis (early finding) (+) Loss of normal curvature (+) "squaring" of vertebra (+) Spinal fusion "Bamboo spine" (late finding) TXT: a) EXERCISE/PT (frontline) b) NSAIDS c) TNF-alpha inhibitors (Infliximab) or DMARDS

HMG-CoA reductase inhibitors: MOA? Most potent? Max doses?

"Statins" HMG-CoA enzyme = catalyzes the "rate limiting" step in cholesterol synthesis MOA: -Inhibit HMG-CoA -Reduce peripheral lipolysis Potency (most --> least): a) Rouvastatin (crestor) = MAX 40mg QD b) Atorvastatin (lipitor) = MAX 80mg QD c) Simvastatin = MAX 80mg QD (but most abide by max 40mg QD d/t evidence that shows increased risk of myalgia/RHABDO with Simvastatin 80mg)

Otitis Externa: Also know as? MCC? Symptoms? PE? Treatment?

"Swimmer's Ear" (RF = repetitive H20 exposure) Bacterial (MCC) -S. aureus -Pseudomonas (immunocompromised) (+/-) Ear pain, pruritus, discharge (+/-) external canal erythema (-) NORMAL TM BUZZ = "Pain OUT OF PROPORTION" (touch their pinna / tragus) TXT = ear drops [AG/FQ + steroid]

Sick Sinus Syndrome: Also called? Pathophysiology? MCCs? Symptoms? Treatment?

"Tachy-Brady Syndrome" SA node dysfunction (leads to cardiac arrhythmia): -sinus bradycardia -sinus pause -sinus arrest -alternating bradycardia & tachycardia Causes: -aging (MC) -underlying heart disease -underlying disorders that cause cardiac fibrosis (SLE, sarcoidosis) -medication induced (BB, CCB or digoxin) Symptoms (stem from chronic bradycardia): -asymptomatic -fatigue -lightheadedness/dizziness -syncope ("Stoke-Adams Attack") -CP -SOB Treatment: a) Atropine (MC) b) ICD placement

Trichomonas: Pathogen? Risk factors? Symptoms? DX? TXT?

"Trichimonas Vaginalis" (flagellated protozoa) "sexually transmitted disease" a) MEN = asymptomatic carriers b) WOMEN = vaginitis -Vaginal itching -Vaginal burning -Malodorous, thick "green/yellow dc" -Strawberry cervix -Dysuria -Dyspareunia -Vaginal pH > 4.5 DX: a) Wet mount = (+) motile flagellated protozoa b) Culture = (+) PMNs TXT (same as BV): a) Metronidazole 2g x 1 b) Metronidazole 500mg BID x7d **can use Tinidazole (resistant)

GOUT: Symptoms? What is the MC INITAL presentation? What symptoms indicate CHRONIC gout?

"UNILATERAL joint redness, swelling & pain" MC initial presentation = 1st metatarsal-phalageal joint ("podagra") CHRONIC gout (indicated by) = "TOPHI" on x-ray (calcified uric acid crystals within soft tissues)

ESOPHAGEAL VARICES: What are these? MCC? MC underlying pathology? Symptoms? DX?

"VARICOSE" veins (esophagus) MCC = portal HTN MC underlying pathology = liver cirrhosis Symptoms: -asymptomatic (MC) -hematemesis (LARGE volume) +/- hemodynamic instability DX = EGD

Achilles Tendon Tear: MOI? MC in who? Symptoms? PE? GOLD standard? TXT?

"Weekend Warrior" injury MC = athletes MOI = Forceful plantar flexion (SUDDEN "pushing off") **sudden pulling of gastrocsoleus muscle "snaps" the achilles tendon "Felt a POP" or "Felt like someone kicked me in the heel" --> followed by SEVERE heel pain, swelling & reduced ability to bear weight. PE = (+) Thompson test (weak plantar flexion when gastrocnemius is squeezed) Gold standard = MRI TXT: -Initially splint in slight plantar flexion -refer to ORTHO (serial castings vs. surgery)

Pertussis: Also called? Pathogen? Epidemiology? Clinical course? DX?

"Whooping Cough" (cough, cough, cough, WHOOP...) Pathogen = Bordetella Pertussis (GM (-) coccobaccilus) MC = young children Course (3 stages): a) Catarrhal Stage (1-2 weeks): vague "URI" symptoms b) Paroxysmal Stage (2-4 weeks): chronic cough, INSPIRATORY WHOOP, post-tussive emesis c) Convalescent Stage (up to additional 6 weeks): slow resolution of cough DX = Nasopharyngeal swab (GOLD standard)

ACS: What are the different options for Thrombolytic (Fibrinolytic) Therapy? Indications for use?

"clot busters" (dissolve clots) **used if PCI is not an option (MAY be used within 12 hrs of symptom onset) Types: 1. Plasminogen Activators (tPA, TNKase, RPA) 2. Streptokinase **streptokinase is LESS EFFECTIVE, but carries LESS risk of intracranial hemorrhage & is usually CHEAPER

Post-partum hemorrhage: MCCs? Treatment?

"drop in H/H by 10% or more" Causes: a) Uterine atony (MCC) = failure of uterus to contract properly s/p delivery to coagulate blood b) Retained contraceptive products (+/- endometritis) TXT: (+) UTERINE massage (frontline) (+) IV oxytocin + IV misoprostol (to stimulate uterine contractions & aid in coagulation) (+/-) blood transfusion (+/-) ABX

Alpha-blockers: MOA? Why aren't these frontline?

"fight or flight": -NorEpi or epinephrine bines to alpha receptors -increased HR -vasoconstriction -bronchodilation -slowed GI motility BLOCKING the ability of Epi/NorEpi to bind to these receptors results in: -lowered HR -vasodilation (lowers BP) -bronchoconstriction -increased GI motility (diarrhea) **NOT FRONTLINE for HTN because has a lot of unintended side effects (GI, lungs, etc.)

AFIB: Causes? Nicknamed ? Why? EKG finding?

"irregularly irregular" (buzz): -no discernible p-waves -irregular 'R-R" (not consistent) Causes: -Age -underlying cardiac disease -underlying pulmonary disease -endocrine (thyroid issues) -electrolyte imbalances -ETOH abuse / withdrawal (nicknamed "Holiday heart"

PROM / PPROM: What is the difference between these? DX? What is our major concerns?

"water breaking" Described as either: (+) MAJOR gush fluid (MC) (+) "slow continuous trickle" PROM = premature ruptured membranes (after > 37weeks) PPROM = preterm premature ruptured membranes (BEFORE < 37 weeks) DX = NITRAZINE test ((+) blue = amniotic fluid) Major concerns: -increased risk infection -increased risk cord prolapse -delivery usually occurs within 24 hours

Fecal Impaction: What is the "classic" symptom? Who is at highest risk? Recommended f/u?

"watery stools" (leakage around impaction) MC = elderly **get colonoscopy to r/o colon cancer**

Hospital Acquired Infections: What are the TOP 2 ?

#1 = UTI #2 = Pneumonia (HAP)

Mitral Stenosis: Causes? Outcome (if untreated)?

#1 MCC = Rheumatic Heart Disease MS (untreated) --> increased LA pressure (increased in back flow of blood) --> eventually leads to further back flow into the lungs --> PULMONARY HTN **if problem is not corrected, chronic pulmonary HTN can then lead to --> r-sided heart failure

Mitral Regurgitation: Causes? Outcome (if untreated)?

#1 cause = MVP Other potential etiologies: a) Infectious (Rheumatic HDz, endocarditis) b) Papillary/Chordae Tendinae damage (ischemia, infarct or cardiomyopathy) OUTCOME: MR --> LVH (initially) --> LA hypertrophy --> pulmonary HTN + CHF -Initially you have back-flow from LV into the LA -MOST of that blood will flow back to the LV upon atrial contraction --> leads to increased LV strain & LVH (initial manifestation) -As the disease progresses, the LV will no longer be able to comply with the increased volume & more & more blood will flow back into the LA & pulmonary circuit = eventually also leading to LA hypertrophy & pulmonary HTN.

R-sided HF: What is the #1 cause of RHF? Symptoms? PE?

#1 cause right HF = LEFT HF (if pt presents with sudden onset, consider PE) Right HF (results in): a) systemic congestion Symptoms/PE: (+) peripheral edema (MC) (+) portal HTN/esophageal varices (+) JVD (+) Hepatojugular reflex (+) ascites (+) S3 or S4

Pancreatic Cancer: #1 risk factor? Types? (MC?) MC location? Symptoms? (MC?) PE? Diagnostic test of choice? TXT? Prognosis?

#1 risk factor = SMOKING (ETOH abuse, chronic pancreatitis are also important risk factors) MC type = Adenocarcinoma (exocrine) MC location = pancreatic head Types: a) Exocrine (adenocarcinoma) b) Endocrine (insulinoma / glucagonoma) CLASSIC symptoms / PE: (+) PAINLESS jaundice (+) weight loss (+) Courvoisier sign (non-tender enlarged gallbladder) Other potential symptoms: (+) steatorrhea ("clay colored" stools) (+) pruritus (liver dysfunction) (+) refractory hypoglycemia (insulinoma) (+) refractory hyperglycemia (glucagonoma) Diagnostic test of choice = CT TXT = WHIPPLE procedure (resection) **prognosis = poor

Septic Arthritis: Symptoms? Diagnosis? Treatment?

(+) "UNILATERAL hot, red, swollen & painful joint" (+) Constitutional (F/C) DX (gold) = arthrocentesis + culture (+) Start initial EMPIRIC THERAPY (IV) x 2 weeks (+) followed by "tailored" therapy (PO) x 4 additional weeks. Regimens: a) STAPH = IV Naficillin (+/- VANCO) b) Gonorrhea = IV Ceftriaxone c) (+) Rifampin (prosthetics) d) wash out joint (if necessary)

Scleroderma (systemic sclerosis): Discuss diagnostic labs? How do these differentiate 2 forms?

(+) ANA (all forms) Limited / CREST form = (+) Anti-centromere Ab Diffuse form = (+) Anti-SCL 70 Ab

Cervical Cancer (Squamous Cell): Discuss how to interpet: a) ASC-US b) CIN1 c) CIN2 d) CIN3 e) Carcinoma-in-situ

(+) Atypical Squamous Cells (ASC-US) = just means you have abnormal cellular changes (UNK significance) **warrants further workup** BREAKDOWN / PROGRESSION: normal --> CIN1 --> CIN2 --> CIN3 --> CIS --> Cervical CA CIN1 ("LGIL" = mild dysplasia) = 1/3 thickness CIN2 ("HGIL" = moderate dysplasia) =2/3 thickness CIN3 ("HGIL" = severe dysplasia) = > 2/3 thickness (but not full thickness) Carcinoma-in-situ = FULL thickness dysplasia

Acute Gastroenteritis (AGE): Defining features? MCC? 2 best ways to break down the possible etiologies?

(+) Epigastric pain (+) N/V/D (+) constitutional (F/C) MCC = Viral Etiologies: a) Non-inflammatory/Non-invasive ("secretory"): -profuse WATERY diarrhea -VOMITING (usually main sign) -no blood -no WBC (stool) b) Inflammatory/Invasive (hemorrhagic): -bloody diarrhea (FEVER more pronounced) -Vomiting rare -(+) WBC (stool)

AGE: What makes food poisoning a little different from just infectious diarrhea?

(+) PREFORMED toxins (so the onset of symptoms is much QUICKER, but also resolves faster)

Acute Pancreatitis: What (+) signs are more concerning with hemorrhagic pancreatitis?

(+) Turner sign = PERIUMBILICAL ecchymosis = indicates bleeding into peritoneum. (+) Grey Turner sign = FLANK ecchymosis = indicates bleeding into retroperitoneum

Discuss the difference between: a) Threatened abortion b) Inevitable abortion c) Incomplete abortion d) Complete abortion e) Missed abortion

(+) Vaginal bleeding: 1. Threatened = (closed cervix, no passing CP) 2. Inevitable = (OPEN cervix, no passing CP) 3. Incomplete = (open cervix, partial passing CP) 4. Complete abortion = (open cervix, complete passing CP) (-) Vaginal bleeding: 1. Missed abortion (closed cervix, no passing CP) **fetal demise inutero

Achalasia: In what population would giving CCB/Nitrate be less preferable?

(+) concomitant GERD **remember these meds are smooth muscle RELAXERS (so this could make GERD worse)

Bacterial Vaginitis: Symptoms? Diagnosis? Treatment?

(+) copious watery "grayish white" dc (+) "fishy odor" (+) vaginal irritation (pruritus, etc.) Diagnosis (Amsel Light Criteria): 1. Homogenous discharge 2. Vaginal pH > 4.5 3. "CLUE" cells (Wet Mount) = "glittery squamous epithelium" / "epithelial cells covered by bacteria" 4. (+) WHIFF test (amine) **MUST have at least 3 criteria TXT: a) Metronidazole 2g x 1 b) Metronidazole 500mg BID x 7d c) Clindamycin (if allergic to METRO)

Acute Pancreatitis: What labs would you expect to be elevated? Which is considered the MOST SPECIFIC?

(+) elevated Amylase (+) elevated Lipase (most specific) (+) high glucose (+) LOW calcium If pancreatitis is secondary to gallstone: (+) LFT (+) Alk Phos (+) Bilirubin

Primary Amenorrhea: In cases of pure anovulation, what is should you give?

(+) give gonadotropins (to stimulate ovulation)

Glycoprotein IIb/IIIa Inhibitors: MOA? Drugs? Indications? Dosing requirements?

(Abciximab) Integrillin, Reopro, Aggrestat MOA = inhibit the final pathway for platelet "cross-linking" by blocking fibrinogen from binding to GPIIb/IIIa receptor Indication = prior to PCI Dosing = MUST be used in combination with "ASA + UFH/LMWH"

How does the secretin test work? Educational point for patients?

**MUST d/c H2B or PPI before test** Secretin --> stimulates pancreas to release more [bicarb] = which inhibits gastrin (which produces acid in the stomach) (+) give Secretin = should see a FALL in [gastrin] levels (+) give Secretin = elevated [gastrin] (Zollinger Ellison Syndrome)

Orthostatic Hypotension: What is the BEST way to distinguish whether the issues is "autonomic dysfunction" vs. "hypovolemia"?

**NATURAL way our body deals with a drop in BP is to INCREASE CO (increase HR) Autonomic Dysfunction = -low BP -LOW HR (normal response is not initiated) Hypovolemic: -low BP -HIGH HR

Acute Pancreatitis: MCCs? Symptoms? Diagnostic test of choice? Treatment?

**NOT USUALLY INFECTIOUS** Causes: -Gallstone pancreatitis (MCC) -ETOH pancreatitis (2nd MC) -Hypertriglyceremia (TG > 500) -Iatrogenic (2/2 ERCP) -Scorpion bites -Mumps (kids) Symptoms: (+) epigastric pain (better leaning forward) (+) fever (+) N/V Diagnostic test of choice = CT TXT ("rest the pancreas"): -NPO + IVF -Analgesia -Treat underlying condition (if applicable)

Ventricular Arrhythmias: Breakdown the different types? What are these usually associated with?

**Usually associated with ELECTROLYTE abnormalities... Breakdown: 1. Tachycardia: a) PVC b) VTACH c) Torsades 2. V. flutter 3. Pulseless VTACH 4. VFIB

TB: Discuss the pros & cons of: a) PPD test b) Quantiferon gold assay

-BOTH are screening tests -BOTH ONLY indicate prior "exposure" to TB (do not differentiate between active vs. latent TB) PPD test: a) May take 2-8 weeks to become positive (+) after initial exposure b) May yield FALSE (+) = patients who have received BCG vaccine c) May yield FALSE (-) = immigrant from country w/ TB (boosting effect), immunocompromised (anergy effect) Quantiferon Assay: Major benefit is that this is UNAFFECTED by prior BCG vaccine.

PNEUMOCOCCAL VACCINE: Who is considered "high risk"?

-Chronic cardiac diseases -Chronic lung diseases -Chronic liver disease -Immunocompromised (HIV, DM) -ASPLENIC (BUZZ) = classic sickle cell anemia patient -Alcoholism -Smokers

Asthma: When would a Leukotriene Inhibitor (Singulair) be a good option?

-Excercise-induced asthma -ASA sensitivity

Chlamydia: Complication if untreated?

-PID / infertility (MC) -Premature labor -Ectopic pregnancy -Reactive Arthritis (Reiter's syndrome)

ACS: Why do we give Morphine?

-Pain -Vasodilation (decreases PRELOAD)

Temporal ("Giant Cell") Arteritis: What MUST you r/o?

-Polymyalgia Rheumatica (50% co-occurrence) -Aortic aneurysms (higher risk)

Candidiasis: Symptoms? Diagnosis? Treatment?

-Vaginal itching/burning -THICK "cottage cheese" discharge -Erythematous vagina w/ "satellite" lesions -Dysuria -Dyspareunia -Vaginal pH = normal (MC) Diagnosis: (+) Buds/hyphae/spores (wet mount) (+) White plaques (vaginal wall) Treatment: a) OTC = Miconazole (Monistat) b) RX = Clotrimazole (cream), Fluconazole (PO)

PAD/PVD: Discuss the appropriate management of NON-HEALING ulcers?

-Wet-to-dry dressing -Unna boots -Hyperbaric O2 -Edema control (PVD) -Amputation (if severe)

What is the MOST COMMON cause of fever in postpartum period?

0-24 hrs s/p delivery (MC) = 5Ws (water, wind, walking, wound, wonder drug) > 24 hrs (MC) = endometritis

HF: Breakdown differences between: a) Acute vs. Chronic b) Systolic vs. Diastolic

1. Acute HF: -usually systolic HF -usually d/t acute cardiac damage (MI) 2. Chronic HF: a) Systolic HF (MC): -Causes = CAD, Dilated cardiomyopathy -Features = LOW EF, thin ventricular walls, dilated LV, S3 b) Diastolic HF: -Causes = HTN/Valvular abnormalities (--> lead LVH), Hypertrophic cardiomyopathy -Features = normal EF, thick ventricular walls, small LV, S4

Tertiary syphilis: List some of the MC manifestations?

1. Bone pain 2. Aortitis (MC) - increased risk of aortic rupture 3. NEUROSYPHILLUS: (+) recurrent meningitis (+) TABES-DORSALIS (demyelination --> loss of proprioception + coordination) (+) ARGYLL-ROBINSON pupil ("small irregular pupils that do NOT constrict to light")

Acute Bronchitis: Main differentials? Main distinguishing factors?

1. Bronchitis vs. URI: a) MC = viral (both) b) CXR (-) in both c) URI = will have more NASAL symptoms and lungs will be CTA d) Bronchitis = (+/-) Rhonchi, wheezes, decreased BS 2. Bronchitis vs. Pneumonia (symptoms very similar): a) Bronchitis (MC = viral): CXR (-) b) Pneumonia (MC = bacterial): CXR (+)

AGE (inflammatory diarrhea): List the main causes and: a) tranmission b) BUZZ associations c) Concerns d) DX e) TXT

1. Campylobacter (GM (-)) -MCC enteritis (USA) -undercooked chicken -can mimic "acute appendicitis" -associated w/ Guillian-Barre or Reactive Arthritis -DX = stool culture -TXT = Erythromycin (if severe) 2. Salmonella (GM(-)): -undercooked chicken -usually only seen in IMMUNOCOMPROMISED patients (if healthy = need a large inoculation to become sick) -"TYPHOID Fever" (most severe form) -Association w/ Reactive Arthritis -TXT = FQ (if severe) 3. Shigella (GM (-)): -fecal-oral transmission -SEVERE presentation -WBC >50,000 with HIGH FEVER -Increased RF = toxic megacolon -Associated with Reactive Arthritis -TXT = BACTRIM (if severe) or FQ 4. E.coli (GM(-) (hemorrhagic form): -undercooked "red" mean (classic is hamburgers)

What are the MCCs of "Secondary HTN"? Treatment?

1. Cardiovascular: -coarctation of aorta -sleep apnea 2. Renal: -renal artery stenosis (RAS) -chronic kidney disease (CKD) 3. Endocrine: -hyperaldosteronsim (MCC) -pheochromocytoma -cushing (high cortisol) 4. Meds/substances: -chronic NSAIDS (Cox-2 inhibitors) -chronic ETOH -Smoking -chronic OCP -chronic steroids TXT = treat underlying cause

Cardiomyopathy: List different types... MC? Most worrisome?

1. Dilated (95%) 2. Hypertrophy (4%) = most severe 3. Restrictive (1%) Other less common: 1. Takotsubo cardiomyopathy

Pleural Effusion: Classifications? MCCs?

1. EXUDATE = "leaky" capillaries (THICK fluid): a) Infection: pneumonia (MCC), TB b) Trauma c) Autoimmune (SLE, RA) d) Malignancy 2. TRANSUDATE = "intact" capillaries (THIN fluid) that occurs due to "third spacing": a) CHF (MCC) b) Liver cirrhosis c) Renal dysfunction 3. Empyema (pus) = infection 4. Hemothorax (blood) = trauma, malignancy

1st TRIMESTER Bleeding: MCCs? Some important distinctions?

1. Ectopic Pregnancy 2. Miscarriage (SAB) Both Ectopic Pregnancy & Abortions will have abnormally LOW B-hCGs, but the Abortions will have (+) Cervical Opening and the Ectopic Pregnancy will NOT!

Colorectal Cancer: Risk factors?

1. Familial Adenomatous Polyposis (genetic APC gene mutation) **100% will develop colon CA by age 40 2. Familiar NON-polypsis colorectal cancer ("Lynch Syndrome") **40% risk of colon cancer **also associated with increase risk for reproductive, intestine, brain and skin cancer 3. Peutz-Jegher Sydnrome (autosomal dominant): -hamartomatous polyps (GI track) -hyperpigmentation (lips, oral mucosa, hands) 3. IBD (UC >>> Cronh's) 4. Lifestyle: -excessive ETOH -tobacco -low fiber diet -diet high in red/processed meat

Hyperlipidemia: Causes?

1. Familiar = (genetic) 2. Lifestyle = (obesity, sedentary, ETOH) 3. Endocrine = (hypothyroidism, DM) 4. Induced = (pregnancy, steroids, estrogen, BB)

Rheumatoid Arthtiris: What are some other syndromes associated with this?

1. Felty's syndrome = [RA] + [Splenomegaly] + [Recurrent infections] 2. Caplan Syndrome = [RA] + [Pneumoconiosis]

HMG-CoA reductase inhibitors: What medications are NOT recommended to be combined with a "statin" ? Explain...

1. Fibrates (contraindicated use w/ statins) **severely increases risk of RHABDO & muscle damage 2. CCB (Amilodipine) **not contraindicated, just warning **CCB increase the serum [concentration] of statins, which increases risk of muscle damage **if you are going to use together, make sure statin is low-dose

Vasculitis: Breakdown the different causes... a) Granulomatous Polyangitis ("Wegners") b) Henoch-Schonlein Purpura c) Polyarteritis Nodosa (PAN) d) Kawaskai Disease e) Takayasu Arteritis

1. Granulomatous Polyangitis (Wegners) -3 main features: upper airway (nose = necrotic), lower airway (lungs), acute GN (kidneys) -"Saddle Nose" deformity -(+) C-ANCA -TXT = CCS 2. Henoch-Schonlein Purpura: -KIDS -IgA mediated vasculitis -[URI] --> (purpura, arthritis, abdominal pain, hematuria) -(+) HIGH IgA / normal coags -DX = kidney biopsy (IgA deposition) -TXT = none (self limiting) +/- CCS 3. Polyarteritis Nodosa (PAN): -Necrotizing vasculitis -"ANCA negative vasculitis" -High association = HepB, aneursyms -Skin, CNS, Renal (spares lungs) -BUZZ = (+) livedo reticularis, neuropathy, renal HTN -DX = Angiogram -TXT = CCS 4. Kawasaki Disease: -"Asian KIDS" -"FEVER + cream" -"FEVER, FEVER, FEVER, FEVER, RASH" -CREAM = conjunctivitis, rash, extremities (arthritis), adenopathy (cervical LAD), mucosal (oral lesions, cracked/fissured lips, "strawberry" tongue" -DX = clinical -TXT = IV IMG + high dose ASA 4. Takayasu Arteritis: -Asian females -"Pulseless disease" -MC affects = aorta/aortic arch -MC presents: MI, TIA, CVA, LE claudication -DX = angiography -TXT = high dose CCS +/- Methotrexate

Asthma: What agents are used for "maintenance" therapy? Frontline?

1. ICS (frontline) = fluticasone, beclamethasone, tramcinolone (Flovent, QVAR, Asmanex) 2. LABA (2nd line adjunct) = salmeterol (Servent) **NEVER use alone (always w/ ICS) 3. Leukotriene Inhibitor (3rd line) = montekulast (Singulair) Other options (less common) 1. Inhaled Mast Cell Stabilizer (Cromolyn) 2. Theophylline

Hepatitis: Causes? MCC? Discuss how LABS can help tell these apart?

1. Infectious Hepatitis: a) Viral (MCC) b) Parasitic/Protozoa (i.e. Amebiasis) 2. Toxic Hepatitis: a) ETOH (2nd MCC) b) Medication induced (i.e. acetaminophen, statins, TB drugs, warfarin). 3. Biliary Hepatitis 4. Autoimmune Hepatitis ________________________________________________ Lab distinctions: 1. Infectious Hepatitis (MCC): (+) Elevated LFTS (ALT > AST) (+) Elevated indirect bilirubin 2. ETOH Hepatitis (2nd MCC): (+) AST > 2x ALT (classic) (+) Elevated indirect bilirubin 3. Biliary Hepatitis: (+) Elevated LFTS (ALT>AST) (+) Elevated Alk Phos (+) Elevated GGT

ABG: Discuss the appropriate way of interpreting an ABG?

1. Look at pH (decide whether it is normal, acidosis, alkalosis) 2. Look at RR & pCO2 levels (decide whether you have normal, hypo or hyperventilation) 3. Look at HCO3 levels (decide the kidneys involvement) Based upon this information you should be able to determine whether its: a) Respiratory Acidosis / Alkalosis (ventilation is compensatory mechanism) b) Metabolic Acidosis / Alkalosis (kidneys are the main compensatory mechanism)

CAP (atypical): What organisms cause atypical CAP? MC? BUZZ associations with each?

1. Mycoplasma Pneumoniae (MCC) -"walking pneumonia" -MCC pneumonia (ages < 40) -college students / military recruits ("dorm style living") -Bullous myringinitis -Cold agglutinins (hemolytic anemia) -Classically CXR is MUCH WORSE than symptoms/PE suggest (DIFFUSE consolidation) 2. Legionella Pneumoniae: -Transmitted via contaminated H20 (AC, hot tubes, showers) = NOT person to person -2 phases (viral prodrome "Pontiac Fever" --> Pneumonia) -BRADYCARDIA (MC early finding) -Pontiac fever = F/C, NV, HA, "diarrhea" (BUZZ), hyponatremia 3. Chlamydia Pneumoniae: -Parasite -h/o close contact w/ BIRDS -Hoarseness / URI symptoms -common to see lots of EXTRAPULMONARY symptoms (meningoencephalitis, reactive arthritis, guillain-barre, etc.) 4. Pseudomonas: -Cystic fibrosis patients (BUZZ) -Immunocompromised pts -ICU/ventilator patients (HAP) 5. FUNGAL etiologies: -Always #1 cause in immunocompromised pts -AFEBRILE 6. VIRAL etiologies: -Infants/children (MCC) = RSV or parainfluenza -Adults (MCC) = influenza

Colon Polyp: Types? MC? Highest association w/ CA?

1. Pseudopolyps (not cancer) = 2/2 IBD 2 Hyperplastic polyps (MC = 90%) = low risk for cancer 3. Adenomatous polyps "precancerous" (10%): a) Tubular Adenoma = least risk for cancer b) Tubulovillous (mixture) = intermediate risk c) Villous adenoma = HIGHEST risk

EKG Review: What is the proper way of evaluating these?

1. Rate (normal, brady or tachy): a) (+) NSR = count #R waves (300,150, 100, 75, 60, 50, 40...) b) (-) NST = [#QRS] x 10 2. Rhythm (NST?): a) NST = 1p:1QRS + R'R intervals (same) + correct p-wave orientation (+ in all leads, EXCEPT (-) AVR). 3. Axis: a) Look at leads 1 & AVF b) lead 1 (+) & AVF(+) = normal c) lead 1 (-) & AVF (+) = R-axis deviation d) lead 1 (+) & AVF (-) = L-axis deviation --> MUST then check lead 2 (if + = normal; if (-) = true L-axis deviation) 4. P-wave & PR-inteval (Leads 1, 2, AVR): a) P-wave morphology b) PR-interval length & consistency 5. QRS complex (shape, wide? narrow?) = look @ leads V1 + V6 6. ST-segment (elevated? depressed)? 7. T-wave (shape, peaked? inverted?)

CAD: Treatment approach for someone who has CHRONIC stable angina?

1. Rescue therapy = NTG (sublingual, patch) 2. Preventative therapy (should be placed on): a) Anti-platelet (ASA, plavix) b) BB or CCB c) Statin d) ACEi/ARB (protect kidneys)

Asthma: What agents are used for "rescue" therapy? Frontline?

1. SABA inhalers (frontline) = albuterol, levalbuterol (ProAir, Ventolin, Xopenex) 2. Inhaled Anticholinergics = ipratropium (Atrovent); tiotropium bromide (Spiriva) **mainly used either in adjunction to SABA for poorly controlled or in patients who have a SABA intolerance (these medications have more of a use in COPD patients)

Pharyngitis: What are the potential complications if "GABHS" is untreated.... Which ones are HELPED by giving Abx?

1. Scarlett Fever --> Rheumatic Fever (Jones criteria) --> Rheumatic heart disease 2. Peritonsillar abscess 3. Glomerulonephritis Giving (+) ABX reduces the risk of all of these EXCEPT glomerulonephritis

Pneumothorax: 3 types (& their features)? MCCs?

1. Spontaneous Pneumothorax (occurs d/t ruptured "bleb"): a) PRIMARY (no underlying lung disease): "tall, thin male" (i.e. Marfans) b) SECONDARY (+ underlying lung disease = COPD, asthma) 2. Traumatic Pneumothorax (MCC = iatrogenic): -CPR -Thoracentesis -Subclavian line placement -MVA 3. Tension Pneumothorax (MEDICAL EMERGENCY): -occurs d/t trauma that results in a "one-way valve" allowing air to ENTER pleural space (but not exit) --> eventually leading to collapsed lung.

CAP (typical): Pathogens? MCC? Gram stains? BUZZ associations?

1. Streptococcus Pneumoniae (MCC): -Gram (+) dipilococci -Rust colored sputum -LOBAR consolidation 2. Haemopilus influenzae (2nd MCC): -Gram (-) rod -Underlying lung disease (COPD, CF) 3. S. aureus -Gram (+) cocci clusters -Common complication = ABSCESS FORMATION 4. Moraxella Catarhallis -Gram (-) rod 5. Klebsiella Pneumonia -Gram (-) rod -Currant jelly colored sputum ("necrotizing pneumonia" = cavitation lesions) -ETOH abuse patients

Colon Polyps: What is the average time it takes for a adenomatous polyp to progress to CANCER?

10-20 YEARS

SHOCK (hypovolemic): At what level of blood loss would you expect to see tachycardia?

15-30% blood loss = results in tachycardia

PCOS: What is the daily dosing of Metformin for PCOS? BBW? CI?

1500-2000mg/day BBW = Lactic Acidosis (increased risk in patients with impaired renal function) CI = GFR < 30 (pregnancy category B)

HTN: 1st & 2nd line agents in PREGNANCY?

1ST LINE = Methyldopa (alpha-2 inhibitor) 2nd LINE = Hydralazine (vasodilator)

Prenatal Care: WHEN is ultrasound the most accurate at determining EDC / due date?

1ST TRIMESTER (becomes less accurate the further into pregnancy)

Prenatal Screening: Discuss recommended screening? Abnormal results? Recommended f/u for "abnormal" result?

1st trimester screen (10-13W): -PAPP-A -free B-HCG -U/S -Nuchal translucency 2nd trimester screen (15-20W): -AFP -unconjugated estriol -free B-HCG -inhibin A ANEUPOLIDY suggested by: -LOW PAPP-A -HIGH B-HCG -HIGH NT (enlarged) -LOW AFP -LOW estriol -HIGH inhibin A Neural tube defects (folic acid deficiency) suggested by: -HIGH AFP If you have a patient whose screenings are suggestive of aneuploidy, you should over "invasive prenatal testing" to as confirmatory test (either): a) Amniocentesis (sampling amniotic fluid) b) Chorionic villi sampling (CVS) (sampling placental cells)

Otitis Externa: MC use drops? Discuss their appropriate usage?

2 MC drops: 1. CORTISPORIN drops = neomycin (AG) + Polymyxin B (ABX) + hydrocortisone (steroid) 2. OFLOXACIN drops = ciprofloaxin (FQ) + dexamethasone (steroid) The choice all depends on TM ! **AG (neomycin) are OTOTOXIC and contraindicated if their is a possible TM perforation ! (-) TM perforation = Cortisporin (+) TM perforation = Ofloxacin

Superficial Thrombophlebitis: If your patient has (+) MIGRATORY thrombophlebitis, what is your concern? Appropriate workup?

2 MCCs: a) TROUSSEAU'S syndrome = migratory thrombophlebitis that occurs SECONDARY to malignancy! b) Thromboangitis Obliterans Must r/o cancer: -CEA -PSA -mammography -colonoscopy -CT scan

Cervical Cancer Screening: Discuss the appropriate management of a patient > 30yrs who shows (-) cytology BUT (+) HPV co-test....

2 initial options: a) Repeat cytology/co-test 12 months -if both are (-) @ 12 month = resume normal testing -if either are (+) @ 12 months = COLPOSCOPY b) HPV DNA testing (which strains) -if HPV 16, 18 (high risk) = COLPOSCOPY -if HPV 6, 11 (low risk) = repeat in 12 months

Discuss how to interpret: a) Alkaline Phosphatase levels b) Gamma-glutamyltransferase (GGT) levels Which is more specific? How can they be used to differentiate between: -cholecystitis -cholangitis

2 labs: a) Alkaline phosphatase = elevation indicates EITHER skeletal or biliary pathology. b) Gamma-glutamyltransferase (GGT) (MORE SPECIFIC than Alk phos for biliary pathology) = elevation indicates hepatobiliary pathology. Cholecystitis (infection is ONLY of the GALLBLADDER): (-) normal Alk Phos (-) GGT Cholangitis (infection is of the BILIARY TREE): (+) elevated Alk Phos (+) GGT BONE pathology: (+) elevated Alk Phos (-) normal GGT

Psoriatic Arthritis: What is this? Looks like what? Distingushing features? BUZZ? TXT?

20% of patients with psoriasis develop arthritis (seronegative spondyloarthropathy) Asymmetric OR Symmetric arthritis (+) signs psoriasis (pitting nails, erythematous rash w/ "thick silvery scales") Can look a lot like RA, BUT this affects DIPJ (RA spares DIPJ)!!! XR = (+) "pencil in cup" deformity (lytic lesions @ distal phalangeal) TXT = NSAIDS (frontline)

Mitral Stenosis: What is the usual timeframe between progression of Rheumatic Fever --> to Rheumatic Heart Disease?

20-40 years

Prenatal Care (2nd trimester): Discuss screening for gestational diabetes: a) recommended time b) protocol c) normal cute-offs

24-28 weeks 1hr GTT (screening): a) Measure fasting b) Give 50g glucose & repeat blood glucose 1-hr later c) If elevated, conduct 3hr GTT 3hr GTT (diagnostic test): a) Measure fasting glucose b) Give 100g glucose c) Measure serum glucose 1, 2 and 3 hours later d) Elevation 2+ readings confirms diagnosis of gestational diabetes 1 hr GTT NORMAL ranges: -Fasting < 95 -1hour < 140 3 hr GTT NORMAL ranges: -Fasting < 95 -1hour < 180 -2hour <155 -3hour < 140

Thromboangitis Obliterans: What is the classic patient that presents to clinic....

25 year old male, smoker, complaining of calf pain when he walks....

ASD: Types? (MC?) Pathophysiology? Symptoms? PE? Diagnostic test of choice? Treatment?

2nd MC congenital abnormality Like VSD, results in Left--> Right shunting (non-cyanotic) MC etiology = Ostium secundum (enlarged foramen ovale) HOWEVER, unique in that MOST patient remain ASYMPTOMATIC until 30-40s, where they may report: (+) decreased exercise tolerance (+) excessive fatigue (+) idiopathic thromboembolic events (TIA, CVA) PE: (+) Systolic ejection crescendo/decrescendo murmur (best @ LUSB) (+) widely FIXED S2 ECHO (best) TXT: consider surgical correction if large or symptomatic

Trisomy 21 (Down Syndrome): Pathophysiology? BUZZ prenatal findings? EARLIEST sign? Symptoms? TXT?

3 copies of Chromosome 21 ("trisomy") PRENATAL screenings ("soft markers"): -"echogenic" foci (calcium deposits in heart) -"linear" MV / TV -short femur -short humerus -hydronephrosis EARLIEST symptom = (+) hypotonia @ birth ("floppy baby") Signs/symptoms: -FLAT facial profile -low set ears -open mouth, protruding tongue -small head (bradycephalic) -epicanthic folds -single palmer (Simian) crease -hypotonia -intellectual difficulties

Cervical Cancer Screening: Discuss appropriate management of pap that comes back as (+) ASC....

3 initial options: a) Repeat cytology 6, 12 months b) Get HPV co-testing c) Go straight to colposcopy Repeat cytology 6, 12 months: a) if both NEGATIVE = resume normal testing b) If either POSITIVE = COLPOSCOPY Get HPV testing: a) NEG HPV = repeat 1 year b) POS HPV = COLPOSCOPY COLPOSCOPY: a) NEG CIN --> get HPV testing (-) HPV = repeat 1 year (+)HPV = repeat cytology 6, 12 months (go above) b) POS CIN -CIN1 = repeat cytology + HPV contesting 6, 12 months -CIN2, 3 = LEEP, cone biopsy, ablation

ACUTE HF exacerbation (inpatient): Discuss management?

3 main components: 1. O2 saturation: -CPAP vs. BiPAP -Best if started early -Intubation (+ PEEP) if needed 2. Reduce preload: -NTG (best) -Diuretics -Morphine -Synthetic BNP (Nesiritide) = inhibits RAAS system 3. Reduce afterload: -NTG -ACEi -Nitroprusside OPTIONAL components: a) Treat any unstable dysrhythmias (if applicable) b) Positive inotropic agents (Dopamine, Dobutamine) = only use in severe hemodynamic instability (i.e. shock)

Umbilical cord anatomy: What is considered normal? What should you be thinking if you see a "two-vessel cord?"

3 vessel cord (normal) = 2 arteries, 1 vein 2 vessel cord (ABNORMAL) = 1 artery, 1 vein Abnormal cord (suggestive of): -higher association with CV, GI and renal abnormalities -higher association with chromosomal issues (MC = Trisomy 18 "Edwards Syndrome")

ACS: What is meant by "silent MI" ? Who is MOST at risk?

30% patient with acute MI have NO CHEST PAIN = ("silent MI") = presents with "atypical" symptoms (angina-equivalents) Highest risk (can order annual "CRP" labs to screen for CVD in these patients): -DM -women -elderly examples: -Women = (+) right shoulder/back pain -Elderly = (+) non-specific sxs (fatigue, weakness, syncope, AMS) -Diabetics / Obese = (+) dull epigastric pain

Colorectal Cancer: ____ leading cause of cancer death (USA) MC type? Is this fast or slow growing? High rate of metastasis? Prognosis?

3rd leading cause of death MC = Adenocarcinoma SLOW growing LOW rate of metastasis GOOD prognosis (if caught early)

H. pylori: Which tests can be used to confirm "cure" after treatment? Indicated timeframe?

4 weeks after completion of TXT (obtain either): -urea breath test -stool antigen **serology (testing for antibodies) = ONLY good at detecting initial infection & will remain (+) for months after eradication of organism (therefore not a good confirmation test)

Sarcoidosis: Treatment?

40% will spontaneously resolve within 2 years... Corticosteroids (TOC) when treatment is needed (may reduce duration & increase changes of resolution) Adjunctive TXT: a) Hydroxycholorquine (for skin lesions) b) NSAIDS (for erythema nodosum) c) Methotrexate (for severe or refractory cases)

Chlamydia / Gonorrhea: What is the recommended timeframe of abstinence?

7 days after completion of TXT

CAD: At what level of stenosis do we usually see "pain @ rest"?

> 90% occlusion

EKG: What is meant when we say "contiguous leads"? "Reciprocal changes?

A "contiguous" lead is ones that surround a single area of the heart..... **Leads 1, AVL, V5, V6 = contiguous b.c. they surround the lateral area of the heart..... STEMI = (+) ST elevation in 2+ contiguous leads **ST-elevation (leads 1, AVL) = contiguous **ST-elevation (leads V1, AVL) = not contiguous "Reciprocal changes' refers to the face that when their is ischemia/infarct, if you see (+) ST elevation in a few leads, the remainder of the leads will have ST-depression (reciprocal effect)

Lung Function: What is the "A-a" gradient" How to interpret this?

A = pO2 (alveoli) a = pO2 (blood) In healthy individual A = a (meaning all the O2 entering the alveoli would diffuse into the blood) However, if there is something blocking that diffusion there will be a "A-a mixmatch" EXAMPLES: a) Pneumonia = fluid in lungs blocking this diffusion b) Pulmonary embolism (PE) = blocks blood from reaching alveoli (disrupting diffusion)

AFIB & A.Flutter: What cardioversion "setting" (joules) is used to treat: a) A.flutter b) AFIB

A. Flutter = 50J AFIB = 200J

Primary HTN (JNC8): WHY are ACEi/ARBs not recommended as frontline therapy for AA patients?

AA naturally produce less renin (ACEi/ARB are theoretically less effective) AA are at greater risk for ANGIOEDEMA if given an ACEi/ARB

ABG: What does this reflect? Normal pH? Normal PaO2, PaCO2, HCO3? What 2 physiologic systems primarily regulate this? Explain...

ABG reflects: pH, PaO2, PaCO2 pH (normal) = 7.35 - 7.45 PaO2 (normal) = 80-100mmHg PaCO2 (normal) = 35-45mmHg HCO3 (normal) = 22-26mmHg pH < 7.35 (acidotic) pH > 7.45 (alkalotic) When our pH gets off balanced, the body tries to compensate it either via: a) Respiratory system (changes to PaCO2 levels) b) Kidneys (changes to bicarbonate HCO3- levels)

Paget's Disease: Pathophysiology? Epidemiology? Symptoms? Labs? XRAYs?

ABNORMAL bone remodeling: -INCREASED osteoclastic activity -Abnormal trabecular bone formation -Leads to LESS DENSE/WEAKER BONES MC = older (>40 yo) Presentation: a) Asymptomatic (MC) b) Bone pain c) Atypical fractures (**) Labs: (+) ELEVATED Alk Phos (buzz) (-) normal Ca (-) normal phosphate XRAYS: (+) lytic lesions (blade of grass) (+) coarsened trabeculae

GOUT: Pathophysiology? Epidemiology? Risk factors?

ABNORMAL purine metabolism leads to elevated uric acid levels (from either): a) overproduction b) increased intake c) decreased excretion (90%) MC = males (ratio equalizes to 1:1 after menopause) Risk factors: a) excessive ETOH b) excessive purine intake (diet) = red meat, fish c) dehydration

ACS: What are the CONTRAINDICATIONS of using Plasminogen Activators (tPA, TNKase)?

ABSOLUTE contraindications: -Previous intracranial hemorrhage -Non-hemorrhagic stroke within 6 months -Facial trauma within 3 months -Intracranial neoplasma -ANY active internal bleeding -Suspected aortic dissection RELATIVE contraindications: -SBP > 180mmHg -INR > 2 -PLTE < 100,000 -UFH/LMWH within 48hrs -trauma or surgery within 2 weeks -internal bleeding within 2 weeks -pregnancy

Acute Bronchitis: When is ABX therapy indicated? Frontline? 2nd line?

ABX are indicated if: a) symptoms fail to improve within 7-10 days (more suggestive of bacterial etiology) b) elderly c) Immunocompromised patients (HIV, DM) d) underlying lung disease (COPD, CF, etc.) FRONTLINE = cephalosporin 2nd line = macrolide, BACTRIM

Endocarditis: What are 2 NEW changes to the recommendations?

ABX prophylaxis NO longer recommended prior to GU/GI procedures. ABX prophylaxis is NO longer recommended for MVP.

Endocarditis prophylaxis: Indications? Abx of choice?

ABX prophylaxis indicated in: -high risk patients -high risk procedures High risk patient criteria: -history of endocarditis -prosthetic valve -congenital heart disease -heart transplant High risk procedures: -invasive dental (not cleanings) -invasive skin procedures (i.e. I&D) -respiratory procedures (ex: lung biopsy) ABX (choices): -Amoxicillin 2g PO/IV/IM -Ceftriaxone Ig IV **should be given within 1-2 hours prior to procedure.

Knee Ligament Tears: ACL, PCL, MCL, LCL injuries discuss: a) MOI b) PE findings c) TXT Symptoms suggestive of this? MC injury?

ACL (MC knee injury overall) MCL >> LCL (+) Sudden "POP" --> followed by severe KNEE PAIN (+) instability (inability to bear weight) (+) knee buckling ACL: (+) INJURY = "pivoting" injury (no trauma) (+) Anterior drawer (+) Lachman test TXT (controversial): PT vs. surgical PCL: (+) INJURY = Anterior blow to flexed knee (common w/ MVA) (+) Posterior drawer TXT = surgical (MC) MCL: (+) INJURY = Lateral blow to knee (extreme valgus stress) (+) Instability w/ valgus stress TXT (depends) = PT vs. surgical LCL: (+) INJURY = medial blow to knee (extreme varus stress) (+) Instability w/ varus stress TXT (depends) = PT vs. surgical

ACL tears: What should you always r/o? (commonly occurs together)

ACL tear MEDIAL meniscus tear MEDIAL collateral ligament Avulsion fracture (lateral tibial condyl)

Esophageal Spasm: What can patients mistaken this as?

ACS (strength of the spasm is so heightened that patient may thinks it is an MI)

ACS: Discuss the different etiologies & their pathophysiology?

ACS occurs either d/t: a) Atherosclerosis (MC) b) Coronary vasospasm Atherosclerosis: pre-existing coronary plaque --> ruptures --> acute coronary thrombosis (blockage) Coronary Vasospasm (2 etiologies): -Prinzmetal Angina -Cocaine-induced

ESOPHAGEAL VARICIES: Discuss management of ACUTE BLEED? Treatment of choice? What treatment should be considered in those at high risk of re-bleeding? Prophylaxis?

ACUTE BLEED: a) Medical management (vasoconstriction) : IV Octreotid (best), IV Vasopressin b) Endoscopic ligation (TOC) **consider blood transfusion / FFP / vitamin K (if needed) AFTER acute bleed, everyone should be placed on PROPHYLAXIS: a) Beta-blocker (preferred) = propanolol b) Isosorbide **For those patients who continue to bleed despite above treatment and/or are at HIGH risk of re-bleeding (Child Class C Cirrhosis), consider: (+) Trans-jugular Intrahepatic Portosystemic Shunt (TIPS) (works to reduce portal HTN)

Cholecystitis: What is this? Symptoms? PE? Test of choice? Treatment?

ACUTE INFECTION (gallbladder): -pt has h/o cholelithiasis (stones) -stone gets impacted in cystic duct -biliary stasis predisposes you to infection (MC = e.coli) Symptoms: (+) RUQ/epigastric tenderenes (constant) (+) Fever (if infectious) (+) N/V PE: (+) Murphy's Sign RUQ (initial test of choice) HIDA scan (gold standard ) (+) gallbladder wall thickness (>4mm) (+) Sonographic murphy's sign TXT: (+) NPO + IVF (+) IV ABX (+) cholecystectomy

Fulminant Hepatitis: What is this? Causes? MCC? Presentation? TXT?

ACUTE LIVER FAILURE Anything that can cause hepatitis can cause this (viral, meds, etc.) MCC = acetaminophen "Hepatic Encephalopathy" (+) Asterixis (+) Hyperrflexia (+) AMS --> seizures --> coma Labs = (+) HIGH ammonia TXT: a) Lactulose (initially) = neutralizes ammonia b) Liver transplant (definitive)

Hepatitis B: Discuss what markers you would see in: a) ACUTE infection b) CHRONIC infection c) Recovered infection

ACUTE infection: (+) HBsAg (+) HBcAb (IgM) CHRONIC infection (elevation > 6 months): (+) HBsAg (+) HBcAb (IgG) Recovered infection (HBsAg = negative): (+) HBsAb (+) HBcAb (IgG)

Nitrates: ADRs? What are some counseling points? CI?

ADRs (similar to CCB): -HA -Flushing -Rebound tachycardia Patient should have at least 12 hour "nitrate free" period/day to avoid developing TACHYPHYLAXIS (diminished sensitivity & bodily response to medication) Nitrates (contraindicated): -hemodynamtically unstable -suspected RV infarct -PDE-5 inhibitor (Viagra) within 48 hrs

Dihydrapyridine CCB: ADRs? MC? CI?

ADRs (think sudden vasodilation): -Constipation (MC) -HA -Flushing -peripheral edema -REFLEX TACHYCARDIA CI / precautions: -concomitant use with BB -CHF -AV heart blocks -Sick Sinus Syndrome

Beta-Blockers: ADRs? CI?

ADRs: -fatigue (MC) -bradycardia, sexual dysfunction (i.e. impotence in men) -orthostatic hypotension -hypertriglyceremia -"MASKED hypoglycemia" CI: -concomitant use w/ CCB -preexisting bradycardia -uncontrolled asthma -uncontrolled HF -2nd/3rd degree heart block -pregnancy (D)

HMG-CoA reductase inhibitors: MC ADR? CI? Counseling points?

ADRs: a) Myalgias (MC) b) Myositis c) Hepatitis d) Rhabdo CI: -concomitant use with Fibrates (too high risk of RHABDO) -pregnancy (X) Counseling: -take at night for maximum efficacy (cholesterol synthesis is MAINLY at night) + regularly monitor LFTS

HTN: Discuss what the BEST med would be to treat a patients HTN who ALSO has: a) AFIB b) Angina c) s/p MI d) HF e) DM f) osteoporosis g) BPH h) AA i) gout

AFIB = BB or CCB (non-dihydropyridines) Angina = BB or CCB s/p MI = BB or CCB HF = ACEi/ARB or BB DM = ACEi/ARB Osteoporosis = Thiazide BPH = Alpha-1 blocker AA = Thiazides Gout = CCB **remember that: a) thiazides = high Ca + glucose + uric acid b) AA = ACEi/ARB have higher risk of angioedema when used in this population c) A1B have additional indication to treat BPH

AFIB: Discuss HOW to choose which anticoagulant is appropriate?

AFIB d/t valvular abnormality = always COUMADIN! AFIB d/t non-valvular (may use): a) Direct thrombin inhibitors (Dabigatran) b) Antifactor-Xa (Rivaroxiban, Apixiban)

BREAST CANCER: Single most important RF? What percentage of patients are (+) BRCA1/2?

AGE !!!! ONLY 5-10% of all breast cancer patients will have (+) BRCA 1 or 2 testing

Osteoarthritis: Pathophysiology? MC risk factor? Defining features? MC areas affected?

AGING DISORDER NON-FLAMMATORY ASYMMETRIC arthritis Risk factors: a) age (MC) b) obesity c) overuse Pathophysiology: Aging --> progressive destruction of the joint space --> leads to "bone-on-bone" reactive changes--> resulting in pain & swelling. MC areas = hands, hips, knees

PLACENTA Accreta vs. Increta vs. Percreta: What is the difference in these? Which is most common? Management?

ALL 3 TYPES INVOLVE ABNORMAL ADHERENCE OF PLACENTA TO THE MYOMETRIUM: a) Accreta (MC) = firm adherence (no penetration) b) Increta = invasion of placenta into the myometrium c) Percreta = PENETRATION of the placenta through the myometrium Management = c-section (hemorrhage risk)

REALIZE: Discuss the pathogens for: -Croup -Acute bronchitis -Acute bronchiolitis

ALL 3 conditions CAN be caused by: -RSV -Adenovirus -Rhinovirus -Parainfluenza virus -Influenza virus HOWEVER the most common associations are: a) Croup = parainfluenza (MC) b) Acute Bronchitis = adenovirus (MC) c) Acute Bronchiolitis = RSV (MC)

Anticoagulation: What are the major DDI associated with Warfarin?

ALL INCREASE BLEEDING RISK (increase INR): a) G's (ginger, ginko, green tea, garlic) + DARK GREEN LEAFY VEGGIES b) Anti-fungals c) ABX (lots) d) NSAIDS e) Antiplatelets f) SSRIs e) Amiodarone

Corneal Abrasion: What should be avoided?

ALL the following RETARD healing (do not prescribe): -analgesic drops (i.d. lidocaine) -steroid drops -eye patching > 24 hrs IN GENRAL eye patching is NOT recommended & contraindicated in CONTACT lens wearers! (if you are going to patch = LESS 24hrs)

HTN: What drugs are used to treat severe or refractory HTN?

ALPHA BLOCKERS BB

Pulmonic Stenosis: Cause? Outcome?

ALWAYS YOUNG CHILD / congenital (#1 cause = congenital rubella syndrome) Outcome: Pulmonic stenosis --> back flow into the RV --> right-sided HF

ACS: Classic symptoms?

ANGINA (hallmark): (+) CRUSHING "pressure" (+) lasts > 30 min (+) NOT relieved by rest/NTG (+) LEVINE sign Other common symptoms: -SOB -Diaphoresis -Weakness or syncope -N/V

Post-menopausal bleeding: Defined as? Potential etiologies? Appropriate workup?

ANY bleeding that occurs 6+ months after cessation of periods (menopause). MC = bengin Etiologies: -Atrophic endometrial bleeding (MC) -Endometrial /Cervical polyps -Fibroids -Endometrial cancer -Cervical cancer 1st = pelvic exam 2nd = pap smear + pelvic u/s 3rd = endometrial biopsy (if indicated) EMB indicated if pelvic u/s = (+) Endometrial thickness > 4mm

ARDS: Main differentials? How to distinguish?

ARDS vs. pleural effusion: a) ARDS = "spares" costophrenic angles b) Effusion = (+) blunting of costophrenic angles ARDS vs. Cardiogenic Pulmonary Edema (i.e. HF): a) ARDS = PCWP (normal) < 18mmHg (b.c. the issue ISN'T fluid overload) b) Cardiogenic Pulmonary Edema = PCWP (high) > 18mmHg (b..c. in this issue the edema is coming from back-flow of blood into pulmonary circuit d/t heart failure)

Which murmur classically can present as "nitroglycerine-induced syncope"? Explain....

AS (answer) -remember that NTG reduces preload/afterload -AS patients already have decreased CO (which includes a decreased blood flow to carotids/brain) -so if you give a patient who has severe AS + NTG, the further decrease in CO results in sudden SYNCOPE

Aortic Stenosis: What medications should be avoided in these patients? Why?

AS = results in INCREASED afterload (therefore they rely on the preload pressure for their CO) AVOID meds that are known to DECREASE pre-load: diuretics, ACEi, nitrates, morphine

What are some known ototoxic agents?

ASA Loop diuretics AG (neomycin, gentamycin, tobramycin)

GOUT: What meds are known to predispose patients to this?

ASA Thiazide diuretics ACEi/ARB TB drugs (PYZ, ETH)

Rheumatic Fever: What test should you order initially?

ASO titer test (this test measures Abx against Streptolysin O, a substance produced by GABHS) (+) ASO titer = indicates a PRIOR or current GABHS infection

Osteoarthritis: Classic symptoms? PE? Labs? XRAY results? TXT?

ASYMMETRIC joint pain + stiffness: -intermittent -lasts < 1 hour -worse in morning / cold weather -BETTER w/ rest PE: (+) crepitus (+) "Bouchard" nodes (PIPJ) (+) "Heberden" nodes (DIPJ) Labs = normal XR = (+) asymmetric joint space narrowing (+) sub-condral bone thickening (+) bony osteophytes Treatment: a) 1st line = Acetaminophen +/- P T b) 2nd line = NSAIDS c) 3rd line = steroid injections DEFINITIVE TXT = joint replacement

Any time a patient presents with a NEW ONSET of acute red, painful, swollen joint, what should your differentials be? Workup?

ASYMMETRIC: a) osteoarthritis b) reactive arthritis c) septic arthritis d) gout e) pseudogout SYMMETRIC: a) rheumatoid arthritis b) SLE (or other autoimmune)

Hyperlipidemia: Symptoms? General lipid level GOALS?

ASYMPTOMATIC (MC) TC < 200 TG < 150 LDL < 100 HDL > 60

Scleroderma (systemic sclerosis): Pathophysiology? Epidemiology? Hallmark symptom? 2 types? DX? TXT?

AUTOIMMUNE Inappropriate collage deposition MC = skin MC = females "Tight, shiny, thickened skin" (MC) Types: 1. Limited Scleroderma (better prognosis): a) "CREST" syndrome (10%) = calcinosis cutis, RAYNAUD'S, esophageal dysmotility (MC = GERD), sclerodactyly, telangiectasias. **usually SPARES trunk 2. Diffuse Scleroderma (worse prognosis) a) Widespread involvement (usually concentrates in trunk) DX = labs (+) ANA (all) (+/-) Anti-centromere Ab --> indicates LIMITED form (+/-) Anti-SCL-70 Ab --> indicates DIFFUSE form TXT (no cure; symptom management): (+/-) Raynauds = (+) CCB (+/-) Steroids (+/-) DMARDs (Methotrexate)

Oral Lichen Planus: What is this? Association? Presentation? DX? TXT?

AUTOIMMUNE MC associated with hepatitis C (HCV) white "LACY" reticular leukoplakia (oral cavity) DX = clinical (r/o HCV) TXT = CCS

Sjogren Syndrome: Pathophysiology? Presentation? PE finding? Labs? Gold standard DX? TXT?

AUTOIMMUNE Body attacks EXOCRINE glands MC = lacrimation / salivation glands "Dry eyes" "Dry mouth" PE = (+) parotid gland enlargement Labs: (+) ANA (60%) (+) RF (70%) (+) Anti-Ro Ab (+) Anti-La Ab GOLD STANDARD = salivary biopsy (lymphocyte infiltration + gland fibrosis) TXT (symptomatic): (+) artificial tears (+) Pilocarpine (cholinergic agent)

Rheumatoid Arthritis: Pathophysiology? Epidemiology? Defining features?

AUTOIMMUNE (inflammatory) SYMMETRICAL Arthritis Chronic synovitis (inflammation) --> leads to synovial hyperplasia --> leads to "pannus" formation which eventually encroaches on the blood supply to the joint, leading to progressive joint space destruction. MC = younger women (40-60yrs)

Primary Sclerosing Cholangitis: Pathophysiology? Cause? Symptoms? Labs? Diagnostic test of choice? TXT?

AUTOIMMUNE disorder Leads to chronic inflammation & fibrosis of hepatobiliary tree --> progressive "cholecstasis" [gall bladder] + [liver pathology] (+) biliary colic (+) jaundice (+) pruritius (+) hepatomegaly/splenomegaly Labs (elevated): (+) AST/ALT (+) Alk Phos (+) conjugated (direct) bilirubin (+) GGT (+) P-ANCA (***) Diagnostic test of choice = ERCP TXT: a) Stricture dilation (temporary) b) Liver transplant (definitive)

Temporal ("Giant Cell") Arteritis: Pathophysiology? Cause? Classic symptoms? PE? Labs?

AUTOIMMUNE granulomatous vasculitis!! Features: -idiopathic (but MC occurs following viral infxn) -affects medium / large vessels -usually affects cranial arteries (MC = temporal artery) Classic symptoms: (+) new onset HA (usually unilateral) (+) jaw claudication/trismus (w/ mastication) (+) visual changes (amaurosis fugax, diplopia, etc.) (+) constitutional sxs PE: (+) scalp tenderness (esp. along temporal artery) Labs: (+) VERY VERY high ESR (+) high CRP

Lupus (SLE): What is this? Epidemiology? Classic presentation? Diagnostic criteria?

AUTOIMMUNE, multisystem Body attacks CONNECTIVE tissues "Child-bearing female" MC initial symptoms = fatigue + joint pain "RELAPSING/REMITTING" symptoms: -Joint pain (90%) -Fever -Rash (malar "butterfly" vs. discoid) -Serositis (pleuritis, pericarditis, GN, oral lesions) -photosensitivity -Alopecia Diagnosis (requires): [4 above] + INCLUDING (+) ANA MUST r/o drug induced lupus

Neurofibromatosis: What is this? Types? MC? Manifestations? TXT?

AUTOSOMAL dominant disorder with mutation of either NF1 or NF2 gene leading to growth of benign & malignant tumors. Types: NF1 (MC) vs. NF2 1. NF 1 (MC): -mainly cutaneous (skin) involvement. -"cafe-au-lait" spots -FRECKLING (axillary, inguinal) -neurofibromas ("skin tags") -optic pathway gliomas 2. NF2: -ADDS (+) CNS involvement -MAINLY CN 8 (acoustic) -BILATERAL vestibular (acoustic) neuromas -Meningiomas TXT (general) = a) Bevacizumab (may shrink tumors) b) Don't remove anything unless causing issues.

Wilson's Disease: What is this? Presentation? DX? TXT?

AUTOSOMAL recessive (rare) Inappropriate metabolism of copper --> leads to copper disposition (organs) Presentation = [Parkinson's] + [liver failure] (+) bradykinesia, rigidity, tremor (+) ELEVATED LFTs BUZZ = (+) Kayser-Fleischer Rings (copper deposition in eyes) DX: (+) INCREASED urinary copper (+) DEFINITIVE = genetic testing (ATP7B gene) TXT = chelation therapy

What drugs should you never given patients with: a) WPW b) AV heart block

AVOID "ABCD" drugs: -A = adenosine -B = BB -C = CCB -D = Digoxin **all of these drugs block AV node, which worsens WPW or AV heart blocks = can lead to VFIB !

Hypertrophic Cardiomyopathy: What meds should be avoided? What is one very important counseling point?

AVOID the following as they can worsen condition: -digoxin -nitrates -diuretics Counsel patient to avoid dehydration & extreme exercise = increases risk of VFIB (sudden cardiac death)

Mallet Finger: What is this? MOI? Symptoms? PE? Concern? TXT?

AVULSION of extensor tendon ("cannot extend finger") MOI = direct blow to finger while it was hyperflexed Finger will be held in FLEXED position @ DIPJ ("cannot straighten finger") Concern = (+/-) avulsion fracture of distal phalanx TXT = Extension split x 6 weeks

AAA: Defined as? MC location? Risk factors?

Abdominal aorta > 3cm MC = infrarenal MC risk factor = atherosclerosis Other risk factors: -Caucasian -Male -Smoker -uncontrolled HTN -Connective tissue d/o (i.e. Marfan)

GI Pathology: Recall the common ADRs with anticholinergic drugs?

AcH effects = "SLUD" -salivation -lacrimation -urination -diarrhea Anticholinergic drug: -dry mouth -dry eye -urinating difficultly -constipation

TB: Discuss the different diagnostic tests & how they are used.... GOLD STANDARD?

Acid-Fast-Bacillus (AFB) smear & culture (GOLD STANDARD): **3 samples (minimum 8 hrs apart) Screening tools (if either are (+), obtain CXR): a) PPD test b) Quantiferon Gold Assay Diagnostic tests: a) CXR (used to confirm ACTIVE infection) b) Nucleic amplification testing (confirmatory test) c) Lung Biopsy (BUZZ) = (+) caseating "necrotizing" granulomas

Shoulder separation (AC Injury): Symptoms? Classifications? Diagnostic test (gold)? TXT?

Acromioclavicular Joint Injury (involves injury to 1 or BOTH): -acromioclavicular (AC) ligament -coracoclavicular (CC) ligament "Difficulty lifting" (+/- "step-off" deformity with CLASS 3) CLASS 1 = AC/CC strain = normal XR CLASS 2 = AC rupture = "minor" widening (XR) CLASS 3 = BOTH AC & CC rupture = significant widening (XR) CLASS 4 / 5 = (above) + displacement GOLD STANDARD = weighted XR TXT = immobilization (sling) + RICE (consider surgery Class 3 & higher)

Peripheral Arterial Disease: Discuss the symptoms associated with: a) Acute Arterial Embolism ("acute limb ischemia") b) Gangrene

Acute Arterial Embolism ("Acute Limb ISchemia") = SUDDEN occlusion (presents with 6Ps): -Pallor (decreased) -Pulselessness -Paresthesias -Pain OUT OF PROPORTION -Paralysis -Poikilothermia Gangrene = represents when a occlusion is so severe that the lack of distal blood flow results in tissue NECROSIS (skin turns blue/purple --> black): A) Dry gangrene = mummification of digits b) Wet gangrene = non-healing ulcers (malodorous, purulent discharge)

Pericarditis: What are the 2 forms? Causes? MCC?

Acute Pericarditis (MC) Constrictive Pericarditis (chronic/milder form) 2 MCC both: -idiopathic -viral (MC = coxsackie) Other potential causes: -infectious (other) = bacterial, fungal -autoimmune (i.e. SLE, etc.) -post-MI ("Dressler Syndrome") -malignancy -TB -drug-induced (MC = XRT/chemo related)

Osteomyelitis: Breakdown the the following for both Acute & Chronic Osteomyelitis: a) Epidemiology b) MC transmission c) MC organism What are some other BUZZ etiologies you should know ?

Acute osteomyelitis: -MC = kids -MC RF = recent URI -MC = hematogenous apred -MC = staph aureus Subacute (chronic) osteomyelitis: -MC = adults -MC = trauma (direct inoculation) -MC = staph aureus Sickle Cell = salmonella Puncture wound = pseudomonas IVDU = pseudomonas

Gastric Cancer: Types? MC? Risk factors? Most important risk factor?

Adenocarcinoma (MC) Non-hodgkin lymphoma Risk factors: a) H. pylori (most important) b) pernicious anemia c) diet high in nitrates (cured meats )

CAD: Discuss the MOA & use of the following: a) ASA b) Clopidogrel (Plavix) c) Prasugrel (Effient) Most potent? Least potent? Which agent should you always pick on the boards?

All 3 agents inhibit PLATELET aggregation (sticking together)...... Visualize a platelet having 2 "hooks" that allow it to aggregate or stick together with other platelets (form clots): a) Thromboxane A2 b) Adenosine Diphosphate (ADP) ASA = inhibits COX + Thromboxane A2 Clopidogrel/Prasugrel = inhibit ADP Prasugrel (strongest) >>> Clopidogrel >>> ASA **always pick the STRONGEST agent on boards**

Asthma: What are some "combination" products for maintenance therapy?

All of the below contain "ICS + LABA": -Advair -Dulera -Symbicort

Conjunctivitis: Etiologies? MC? How does each present differently? Treatment?

Allergic (MCC): (+) BILATERAL red, itchy, watery eyes (+) "stringy discharge" (+) "cobblestoning" (inner eyelid) **TXT = antihistamine, mast cell stabilizer, steroid drops (all will end in = "-ine" = olopatidine) Viral (picture) = "PINK EYE" = MCC (swimming pools): (+) Ul/BL red + painful eyes (+) copious WATERY discharge (+) ipsilateral pre-auricular LAD **TXT = daily NS lavage + warm-to-cool compress Bacterial (MC = staph) (+) UL/BL red + painful eye (+) copious amounts of PURULENT discharge **TXT = ABX (PO vs. drops)

GOUT: Discuss HOW each of the following aid in preventing acute gouty flares: -Allopurinol -Probenecid

Allopurinol = gets ride of "ALL" of it (stops metabolism) a) Xanthine Oxidase Inhibitor b) MOA = inhibits the enzyme that converts purines --> uric acid Probenecid = is "proactive" at getting rid of it. a) MOA = INCREASES uric acid excretion @ kidneys

Orthostatic Hypotension: What are some medications that are known to cause this?

Alpha-1 blockers ACEi/ARB Diuretics BB

Amiodarone: When prescribing this, what drugs does it have significant DDI with?

Amiodarone will INCREASE concentrations of: a) warfarin b) statins c) digoxin **need to remember to [1/2 doses] of these when prescribed in combination with Amiodarone

PCI: Discuss the restenosis rates of angioplasty (alone)? What is usually done in combination to reduce this rate?

Angioplasty alone = 30% restenosis rate (within 3 months) **today most people place a BMS/DES to reduce this restenosis rate.

Anovulatory bleeding: Discuss the pathophysiology behind this and how it leads to menorrhagia...

Anovulation = UNOPPOSED estrogen -ovum isn't released, so we don't produce any progesterone -leads to continual thickening of endometrial lining -usually leads to menometrorrhagia because the lining continues to grow and sheds a heavy volume @ random

ANTERIOR Epistaxis: MC location? RF? Treatment approach?

Anterior (MC) >>> Posterior MC = "Kesselbach plexus" RF = trauma, low humidity DIRECT PRESSURE (frontline) If continues to bleed consider: a) topical vasoconstrictors (liquid cocaine) b) topical decongestants (oxymetazoline = Afrin) c) cauterization (electrical vs. silver nitrate)

ACS: Discuss the LOCATION of the MI if ST-elevation is observed in: a) septal (posterior wall) MI b) anterior wall MI c) lateral wall MI d) inferior wall MI What vessels does this correspond to?

Anterior Wall MI (V1-V4): a) septal (V1, V2) = septal branch of LAD b) anterolateral (V4, 1, AVL, V5-V6) = LAD or CFX Lateral Wall MI (1, AVL, V5, V6) = Left CFX Inferior "posterior" MI (2, 3, AVF) = RCA

LMWH: What CAN you monitor? When is this necessary?

Anti-factor Xa Recommended to be monitored: -severely obese -pregnant women -renal dysfunction **all of these instances have UNPREDICTABLE volumes of distribution

Lupus (SLE): What concomitant condition should you r/o in childbearing female? Lab? Why?

Anti-phospholipid Syndrome = predisposes you to arterial & venous thrombosis LABS = (+) Lupus Anticoagulant Classic = (+) "recurrent miscarriages" (or DVT/PE, TIA, CVA, MI)

Discuss anticoagulation options?

Anticoagulants: a) UFH (IV) b) LMWH (IV vs. SQ injection) Indirect Thrombin Inhibitors: a) Bivalirudin (IV) b) Dabigatran (Pradaxa) (PO) Factor Xa Inhibitors: a) Fondaparinux (IV) b) Rivaroxaban (Xarelto)(PO) c) Apixaban (Eliquis)(PO) Vitamin K Antagonists (PO): a) Warfarin / Coumadin Antiplatelets: a) ASA b) Plavix Thrombolytic Therapy (CVA/MI/PE): a) Plasmogin activators (tPA, TNKase) b) Streptokinase

Pneumoconioses: What are associated with: a) Asbestos b) Coal Worker's c) Berylliosis

Asbestos = high risk for Malignant Mesothelioma (MC = pleura) Coal Workers = high association with concomitant Rheumatoid Arthritis ("Caplan syndrome") Berylliosis = increased risk of lung, stomach and colon cancer

Pneumoconioses: For each of the major types list: a) risk factors b) CXR c) Diagnostic test

Asbestosis: -inhalation of insulation material -RF = destruction/renovation of older homes, ship builders, pipe fitters -MC affects = lower lobes & pleura of lung -CXR = (+) pleural plaques ("calcifications") or lower lobe nodules -DX = Lung biopsy ("linear asbestos bodies") Silicosis: -inhalation of silica dusk -RF = quarry/stone workers, sandbasting, pottery -MC affects = upper lobes -CXR = (+) upper lobe nodules -DX = lung biopsy Coal Worker's Lung ("black lung"): -inhalation of coal or carbon dust -RF = coal miners -MC affects = upper lobes -CXR = (+) upper lobe nodules -DX = lung biopsy Berylliosis: -RF = electronics, aerospace, tool or dye manufacturing, FLUORESCENT light bulbs -CXR = normal (50%), hilar LAD -DX = lung biopsy (+beryllium lymphocyte proliferation / noncaseating granulomas) Byssinosis ("Monday Fever"): -Also called "brown lung" -Inhalation of cotton fibers -RF = textile workers -CLASSIC = symptoms are WORSE at the beginning of the week (Monday) & slowly get better throughout the week.

Cirrhosis: In late disease, what are the most severe complications? Evident by?

Ascites (+/- bacterial peritonitis) Portal HTN (+/- esophageal varices) Hepatic encephalopathy

Cardiology basics: WHO is contraindicated to relieve any "Pharmacologic Stress Testing" ? Why? How do these drugs work?

Asthmatics (drugs used cause bronchospasm) Commonly used drugs: a) Adenosine b) Dobutamine **these work by either INCREASING cardiac O2 demand or they cause vasodilation of NORMAL arteries (but not diseased ones)

Osteoporosis: Symptoms? MC sites of pathologic fractures?

Asymptomatic (MC) "Loss of Height" Pathologic fractures Post-menopausal type (MC) = vertebral or wrist fractures Senile type (MC) = hip & pelvis fractures

OPEN angle glaucoma: Disease course? Treatment?

Asymptomatic --> LOSS of peripheral vision --> blindness Treatment is aimed at decreasing IOP (by either): a) decreasing aqueous humor production b) increasing outflow of aqueous humor TXT (combination of): -BB -Carbonic anhydrase inhibitor (Acetozolomide) -Alpha2Blocker (Brimonidine)

Asthma: What TRAIDs should you be aware of with asthmatic patients?

Atopic TRAID: -asthma -atopic dermatitis (eczema) -allergic rhinitis Samter's TRAID: -asthma -nasal polyps -ASA/NSAID allergy

ACS: Which statin has been the ONLY one shown to reduce death and ischemic events after ACS?

Atorvastatin 80mg QD

Amiodarone: Main usage? Unique ADRs?

Atrial Flutter AFIB VTACH VFIB ADRs: -Torsades De'Poines -Pulmonary fibrosis (BBW) -QT prolongation (BBW) -Hepatotoxicity (BBW) Amiodarone specific ADRs (because has iodine component): -thyroid disturvances -bluish skin discoloration

Antibiotic Review: Discuss the difference between Amoxicillin & Augmentin?

Augmentin = Amoxicillin + clavulanic acid **clavulanic acid = anti-betalactimase (helps fight resistance)

Aortic Regurgitation: Also called the "________" murmur?

Austin Flint murmur

Syphillis: What concomitant conditions can complicate testing?

Autoimmune disorders (SLE, Lyme, etc.) **usually leads to FALSE (+) results

SHOCK (Neurogenic): Pathophysiology? Etiologies? Treatment?

Autonomic dysfunction --> leads to impaired cardiac & vascular function..... Low CO Low SVR Low PCWP Etiologies: -Spinal cord injury -Anesthesia Treatment: -ABCDEs -IVF -Vasopressor -Inotropic agents

Discuss how the autonomic nervous system regulates the heart function.... How do we use these principals in treating arrhythmias?

Autonomic nervous system: a) Sympathetic ("fight or "flight") b) Parasympathetic ("rest & digest") SYMPATHETIC (Epi/NorEpi) cause: -increase in heart contractibility (HR) -increase in "force" of heart contraction PARASYMPATHETIC (acetylcholine via vagus nerve) causes: -decrease in heart contractibility (HR) -decrease in "force" of contraction IN PRACTICE: a) Dopamine, Dobutamine = serve as "sympathetic" analogs b) Anticholinergic drugs or vagal maneuvers can serve as "parasympathetic" system stimulators

Cystic Fibrosis: Cause? Pathophysiology? MC organs affected? Symptoms? MC INITAL symptom?

Autosomal Recessive Defect in the "Cystic Fibrosis Transmembrane Receptor (CFTR)" gene = leads to impaired Chloride/H20 movement = leads to overproduction of thick, purulent mucus... MC organs affected: -lungs -pancreas -GI tract -reproductive tract MC initial symptom = meconium illeus (failure to pass 1st stool after birth) Other symptoms: a) Lungs = recurrent lung infections, bronchiectasis b) Pancreas = digestive enzyme/vitamin deficiencies, "STEATORRHEA," failure to thrive (infant), weight loss, new onset DM c) GI tract = meconium ileus, constipation d) Reproductive tract = infertility

Discuss how to interpret (+) "axis deviation"

Axis deviation is: a) TOWARDS hypertrophy b) AWAY from infarction EXAMPLE: (+) Left-axis deviation MAY represent LVH or a right-side infarct

PREGNANCY: Discuss B-HCG trajectory? Peaks? What "low" indicates? What "really high" indicates? At what level should a gestational sac be observed?

B-hCG (produced by placenta): -Begins to rise @ Day 9 post-conception -DOUBLES every 48hrs -Peaks @ Day 65 -Normalizes D24 post-partuum NOT pregnant < 5.0 Peak (@ D65) = 300,000 b-HCG 1500 = (+) should be able to see "gestational sac" in uterus LOW or falling levels: a) Ectopic pregnancy b) SAB Really HIGH levels: a) Molar pregnancy

HF: Discuss why "BNP" lab test is helpful in identifying CHF?

B-type Natriuretic Peptide (BNP): -ventricles release this when under stress (volume vs. pressure) -helpful in distinguishing between "pulmonary SOB" vs. "CHF SOB" BNP > 100 = indicates CHF

PNEUMONIA (diagnosis): Discuss the rule of thumb.... Specific diagnostic tests for: a) Mycoplasma pneumonia b) Legionella pneumonia c) Chlamydia pneumonia

BASIC RULES: a) bacterial = culture b) viral = IFA (1st), DFA (2nd), PCR (definitive) Mycoplasma Pneumonia: a) BEST initial test = sputum culture + acid fast bacillus b) DEFINITIVE test = PCR Legionella (doesn't grow well): a) Best INITAL test = urine antigen b) DEFINITIVE tests = IFA/DFA Chlamydia pneumonia (parasite): a) Nucleic Acids Amplification Tests (NAATs)

Beta-Blockers: Explain HOW to counsel patients about distinguishing between BB ADR & true hypoglycemia....

BB cause VERY similar symptoms to hypoglycemia d/t possible hypotension/bradycardia (weakness, lightheaded, dizzy) So for diabetic patients you MUST counsel them that "SWEATING" is the one symptom that is specific to true hypoglycemia....

CAD: What are some alternative agents if a Beta-Blocker is contraindicated or not well tolerated?

BB contraindicated: -pregnant -uncontrolled asthma -uncontrolled HF -bradycardia -heart block (2nd/3rd degree) Alternatives: -CCB -Ranolozine (Ranexa) -Long acting nitrate **remember CANNOT use CCB + BB

Ovarian Cysts: Types? MC? Symptoms? Best test? TXT?

BENIGN -follicular cysts -corpus luteal cysts -hemorrhagic cysts MC = ASYMPTOMATIC (unless large or rupture): (+) severe UL pelvic pain (+) painful intercourse (deep penetration) (+) problems defecating (if pushing on colon) DX = pelvic U/S Management: GIVE NSAIDS FOR PAIN most people do not require treatment 1. Cyst < 5cm (no symptoms) = nothing 2. Cyst >5cm (or highly symptomatic) = remove cyst +/- suppress ovulation with OCP (prevent recurrence). 3. Recurrent cysts (symptomatic) = Oophorectomy or Hysterectomy

Intraductal Papilloma: Benign or malignant? What is this? Symptoms? TXT?

BENIGN breast tumor that develops in the milk ducts **HOWEVER has been shown to possibly harbor DCIS" (+) UL breast mass (near nipple) (+) UL "bloody" nipple discharge TXT = biopsy + excision

Fibroadenoma: What is this? Epidemiology? Symptoms? Diagnosis? TXT?

BENIGN mass (very common) MC = younger females (teens, etc.) Symptoms (NOT cyclic): UNILATERAL "discrete, firm, non-tender, MOBILE nodule(s)" **usually MORE difficult to distinguish from cancer Diagnosis: a) clinical (MC) b) consider FNA/Bx if suspicious or in females < 25 yrs TXT = none (can resect if bothersome)

Solitary Pulmonary Nodule: Discuss how a nodule that was benign vs. malignant may present or appear on CT? Appropriate workup....

BENIGN nodule: -single nodule -size < 3cm -well-defined borders -unchanging (size/character) -surrounded by NORMAL lung tissue MALIGNANT nodule(s): -usually > 1 nodule -size > 3cm -ill-defined borders -changing (either in size/character) -NOT surrounded by normal lung tissue Workup: a) LOW-risk lesion ("watch & wait") = serial CT imaging for 3 years (q3months for 1st year & q6months for 2 additional years). b) Moderate-high risk lesions = BIOPSY ! Biopsy: a) Central lesion = sputum culture and/or bronchoscopy b) Peripheral lesion = Transthoracic needle biopsy

Boxer Fracture: What is the proper way of splinting a boxer fracture? Concern?

BEST = wrist slightly flexed NEVER set with wrist straight or HYPEREXTENDED (--> can lead to collateral ligament SHORTENING --> lead to limited MCP flexion)

Rheumatoid Arthritis: BEST "initial" test? BEST diagnostic test? Which medication has GREATEST bearing on prognosis?

BEST initial test = RF Best diagnostic (most specific) = Anti-CCP DMARD = reduces PERMANENT joint damage (most important for prognosis NSAID = analgesia

Sepsis: Recall how the presentation changes with time? What is the diagnostic criteria?

BIMODAL presentation: classic presenation (fever, high WBC) --> followed by a "normalization" period (no fever, normal WBC) --> followed by RAPID DETERIORATION DIAGNOSTIC CRITERIA (must have 2+): -Temperature (EITHER >100.4F or <96.8F) -HR > 90bpm -RR > 20 or PCo2 < 32mmHg -WBC > 12,000, <4,000 or > 10% bands -High Lactic Acid -Hypotension despite adequte fluid resusitation -Known or suspected source of infection

Hepatocellular carcinoma: What is AVOID in these patients?

BIOPSIES (high risk of seeding)

Hyphema: What is this? MCC? What should you always perform? Treatment?

BLOOD collection (anterior chamber) MCC = trauma **ALWAYS measure IOP** TXT = OPTHAL REFERRAL !

Pinguecula vs. Ptyergium: Discuss similarities & differences?

BOTH ARE: -overgrowth of conjunctiva -caused by excessive sun, wind or dust exposure! (classic = farm worker) Pinguecula = does NOT cross onto iris Ptyergium = (+) extends onto iris TXT = none (cosmetic only)

Palsies: Discuss differences between: a) Erbs Palsy b) Klumpkes Palsy Appropriate workup?

BOTH are Brachial Plexus injuries (OBTAIN MRI) Erb Palsy (MC = C7) -usually occurs during births (shoulder dystocia, forceps / vacuum usage) -Baby's arm will "HANG LOOSELY @ side" (paralysis) Klumpke's Palsy (C7, C8, T1) -"Limp hand" -HIGH association w/ HORNER'S syndrome (--> think Pancoast Tumor) -Obtain CXR r/o lung cancer

Polymyositis / Dermatomyositis: Discuss the defining differences between these?

BOTH will have: (+) high CK (+) high Aldolase (+) Anti-Jo Ab PM: (-) skin involvment (+) Anti-SRP Ab DM: (+) skin involvement (+) Anti-Mi-2 Ab

HTN EMERGENCY: a) What is this? b) Symptoms? c) Treatment?

BP > 180/120 (WITH evidence of end organ damage) Symptoms: a) NEURO = TIA, CVA, hemorrhage, encephalopathy, seizure b) RETINAL = vision loss, papilledema, hemorrhages c) HEART = MI, aneurysm rupture d) RENAL = anuria, hematuria, proteinuria, AKI Treatment = LOWER MAP by 25% (first 1 hr) with addition lowering 5-15% over next 24-48 hours (USING IV AGENTS) -Labetalol (IV) -Nitroprusside (IV) -Hydralazine (IV) -Nicardipine (IV) -NTG (IV)

HTN Urgency: a) What is this? b) Symptoms? c) Treatment?

BP > 180/120 (WITHOUT end organ damage) ASYMPTOMATIC (MC) **but may have a dull HA Usually from non-compliance with antihypertensive meds....(ie. abrupt discontinuation of BB, etc.) Treatment = SLOWLY bring MAP down by 25% over 24-48hrs (ORAL meds) Options: -restart their prior med -increase dosage of prior med -ADD labetalol, clonidine, nicardipine, hydralazine (ORAL forms may be temporarily used in hospital setting)

Orthostatic Hypotension: a) Defined as? b) Etiologies? c) Treatment?

BP taken (supine after 5 min) --> BP re-taken (sitting or standing) DEFINITION (either): a) Fall SBP > 20mmHg upon standing b) Fall DBP > 10mmHg upon standing Etiologies: a) Hypovolemia (dehydration, blood loss, fluid loss "electrolyte issues") b) Autonomic Dysfunction c) Medication induced Treatment: -Fix underlying cause -Can give mineralocorticoids to raise BP (Fludorcortisone)

Mastodynia: When is this considered normal & not pathologic?

BREAST pain is usually not pathologic if it "cyclic" (occurs during LUTEAL phase of menstruation)

Diphtheria: Classic patient? Classic presentation? PE? TXT?

BUZZ = Farmers Infection (MC) --> leads to laryngeal infection --> SWOLLEN NECK ("Bull's Neck") PE = (+) "greyish" membrane @ posterior pharynx ("pseudomembrane") **when scrapped off the membrane BLEEDS DX = culture TXT (always start ASAP; do not wait for culture): a) Antitoxin b) ABX (TOC = erythromycin)

Corneal Ulcer (Keratitis): 2 MCCS? Symptoms? DX? Treatment?

BUZZ causes: -Pseudomonas (i.e. Contact lens) -HSV Stars out like corneal abrasion [red, painful eye] --> progresses to corneal ulcer ["haziness"] DX = Fluorescein stain (HSV = (+) dendritic ulcers) TXT = (+) FQ drops (best) ***always cover for pseudomonas If viral (HSV) = (+) PO acyclovir + ganciclovir drops

Gastric Cancer: Classic symptoms? Signs of metastasis? Gold standard (DX)? TXT?

BUZZ symptoms: -refractory PUD -early satiety -postprandial vomiting -weight loss -NEW iron-deficiency anemia Signs of metastasis: (+) Virchow's Node (L supraclavicular LAD) (+) Sister Mary Joseph node (umbilical LAD) EGD + biopsy (gold standard) TXT = RESECTION (poor prognosis)

Gestational Diabetes: How does the prenatal care CHANGE for these patients?

Begin NST & BPP @ 34 weeks Considered induction: a) well-controlled @ 40W b) poorly controlled @ 38W

Alpha-blockers: What is a potential benefit of these? Main limitation to use (counseling point)

Benefit: -lower LDL -increase HDL Main limitation (downside) = "ORTHOSTATIC HYPOTENSION" (syncope) -1st dose phenomemon -should decrease & eventually resolve -titrate slowly to reduce risk.

Osteochondroma: Benign vs. malignant? Epidemiology? MC location? XR? TXT?

Benign cartilaginous tumor (MC benign bone tumor) **but may be precursor to chondrosarcoma YOUNGER MALES (ages 10-20yo) MC = knee XR = (+) pedunculated tumor growing AWAY from growth plate TXT = watch/wait

Celiac Disease (Sprue): Initial test? Gold standard? Treatment?

Best INITIAL tests (serology): -IgA endomysial antibody -IgA tissue transglutaminase antibody Duodenal biopsy (gold standard): (+) villous atrophy TXT: a) avoid gluten (wheat, rye, barley) b) consider CCS (flares)

Beta-Blockers: Recall the difference between: a) Beta-1 receptors b) Beta-2 receptors Which BB are better to use? Which BB is the MOST B1-selective? Which BB is the LEAST B1-selective?

Beta-1 = heart only Beta-2 = lungs, GI, peripheries **BEST to use "Beta-1 specific" beta-blockers = less unwanted ADRs!!! B1-selective BB = "NAMEEBBA" a) BEST agents = metoprolol, atenolol a) MOST B1-selective = metoprolol Propranolol = LEAST B1-selective (commonly used to treat anxiety, etc.)

Anti-arrhythmics (class II): What are these mainly used for? Which should be used?

Beta-blockers (use beta-1 selective agents) -HTN -Angina -Supraventricular arrhythmias (SVT, A.Flutter, AFIB)

Coarctation of Aorta: What other congenital abnormalities should you always r/o? (high con-incidence)

Bicuspid Aortic Valve (80%) Turner Syndrome (15-20%) Cerebral aneursyms

Gastrectomy procedures: Describe the Billroth II procedure? What is the #1 reported complication?

Billroth II procedure = gastrojejunostomy -portion of stomach (removed) -remaining stomach in anastomosed to the jejunum "Dumping Syndrome" (10%) = patients will report early satiety & feelings of "weakness, sweating, tachycardia" 30 min after eating

Aortic Stenosis: If you have a patient who is contraindicated to receive anticoagulation, WHICH TYPE of valve replacement is preferred?

Bioprosthetic (less thrombotic risk)

Hepatitis C: Transmission? Labs? Prognosis? Treatment?

Bodily fluid transmission (MC = blood) -IVDU -Blood products (transfusions) Labs = (+) Anti-HCV (IgM) TXT = Interferon + Ribavirin Prognosis: -80% become CHRONICALLY infected -20% clear infection

Thyroid disturbance (pregnancy): Recall the NATURAL change in our thyroxine (T4) production during pregnancy? Why do we care so much about this during pregnancy?

Body naturally INCREASES thyroid hormone production during pregnancy (which exacerbates any underlying thyroid conditions) For those women who have preexisting thyroid condition it is recommended they achieve EUTHYROID state PRIOR to pregnancy.... Why do we care: -Thyroxine (T4) plays a very important role in fetal brain development -Imbalances in T4 lead to not only fetal development issues, but overt OB complications

Recall the "Renin-Angiotensin" pathway?

Body senses LOW BP!! STEP 1: -liver releases angiotensinogen -kidneys releases RENIN enzyme -RENIN converts angiotensinogen --> Angiotensin 1 STEP 2: -lungs release "ACE" enzyme -ACE converts angiotensin 1 --> angiotensin 2 STEP 3: angiotensin 2 causes: a) increase Aldosterone (increases NaCL retention) b) increase in ADH (vasopressin) release (pituitary gland) c) vasoconstriction

Imaging: Recall the appropriate use of each of the following: a) XR b) CT without contrast c) CT WITH contrast d) MRI

Bone = XR Soft tissue: a) CT without contrast (initial) b) MRI (best) Soft tissue (WHEN also evaluating for vascular and/or infection): a) CT with contrast **example = appendicitis b.c. we must r/o RUPTURE (infection) we get CT + contrast....

Liver disease & menstruation issues: Explain why we see this?

Both estrogen & progesterone exist in: a) free "active" forms (2%) b) protein bound forms (98%) Liver is responsible for producing the majority of our body's proteins (albumin) Therefore if liver isn't working = LOW proteins = MORE ACTIVE forms of estrogen / progesterone = leads to menstrual irregularities

If you see the formation of a new "neck mass" following a acute URI, what it is most likely?

Brachial Cleft Cyst

ACE-i vs. ARBs: Discuss WHY we see certain ADRs with ACE-i but not ARBs?

Bradykinin = vasodilator + bronchoconstrictor ACEi MOA (leads to): -ACE enzyme normally breakdown bradykinin -inhibiting ACE = "bradykinin" excess = vasodilator and broncoconstriction (edema, rash and cough) **ARBs only block Angiotensin 2 from binding to it's receptors (therefore doesn't affect ACE / bradykinin levels)

Adenocarcinoma: What type is typically found in NON-SMOKERS?

Bronchoalveolar carcinoma ("Adenocarcinoma In-Situ"): -subtype of adenocarcinoma -"female non-smoker" -best prognosis

Bilirubin: So when you see "JAUNDICE" what are your top etiologies?

Buildup of UNCONJUGATED (indirect) bilirubin indicates (either): a) Excessive breakdown of RBC (hemolysis process) b) Liver issue (not conjugating) c) Familial bilirubin disorder

CAP (Mycoplasma pneumonia): Recall what "bullous myringitis" is? Recall what "cold agglutinins" is?

Bullous Myringitis = "TM blister" (bullous = blister, myringitis = TM inflammation) **C/O = (+) ear pain Cold agglutinins = hemolytic anemia (d/t autoantibodies against RBC)

Mononucelosis: What does this increase your risk for later on in life?

Burkitt's Lymphoma Oral Hairy Leukoplakia

Murmurs: What are "innocent' or "functional" murmurs? Types? (MC?) Epidemiology? Recommended workup? Treatment?

By definition a "functional" (innocent) murmur: (-) NO symptoms (-) normal tests (i.e. EKG, ECHO) MC = children / adolescents (usually resolves by adulthood) Causes = UNK Types: 1. STILLS "vibratory" murmur (MC type): -systolic murmur (best @ left sternal border) -worsens with any increase in CO = fever, exercise, PREGNANCY 2. Venous "HUM": -diastolic murmur (best heard @ BL infraclavicular region) 3. Pulmonary "ejection" murmur: -systolic murmur (best heard @ ULSB) Workup = should get ECHO to r/o valvular abnormalities TXT (all) = NOTHING (usually self resolves)

Ovarian Cancer: What lab can be used to monitor treatment response?

CA-125

Esophageal Stenosis: What is the main differential you MUST r/o?

CANCER

Aphthous ulcers: Also known as? Features? Diagnosis? Treatment?

CANKER SORES (cause UNK; may be HSV6) (+) PAINFUL "yellow/grey" ulcers with "red halo" DX = clinical TXT: a) supportive (magic mouthwash) b) oral steroids or cimetidine can be used (recurrent ulcers) "MAGIC MOUTHWASH" = lidocaine + steroid + antihistamine + nystatin

VFIB: What is this? Treatment?

CARDIAC ARREST (no pulse) TXT: a) 1st line = DEFIBRILLATION (120-200J) + CPR (30:2) b) 2nd line = epinephrine

Otitis Media: In a child with RECURRENT otitis media what workup may be warranted?

CBC --> r/o Fe-deficiency anemia

Anti-arrhythmics (class IV): Drugs? Main usage? CI?

CCB (Non-dihydrapyridine): a) verapamil b) ditalizem Uses (supraventricular arrhythmias): -SVT -Atrial Flutter -AFIB CI: -HF -2nd/3rd degree heart block

AV Heart Blocks: What medications are contraindicated?

CCB (all) BB (2nd/3rd degree) Amiodarone (2nd/3rd degree)

HIV patients: When is it appropriate to place these patients on PROPHYLACTIC Bactrim (TMP/SMX)?

CD4 count < 200

Vertigo: Discuss the different etiologies and the main difference between them...

CENTRAL vs. PERIPHERAL Central (CNS etiology): a) (-) NO auditory symptoms (tinnitus, hearing loss) b) (+) Vertical nystagmus c) MCC (issue in brain) = migraine, multiple sclerosis, acoustic (vestibular) neuroma, CVA Peripheral (EAR etiology) a) (+) Auditory symptoms b) (+) HORITZONAL nystagmus c) MCCs = BPV,Meniere, Labyrinthitis, Vestibular Neuritis

What are the MCC of "Meconium Ileus" ?

CF Hirschsprung disease

AFIB & A.Flutter: Discuss how to use the CHADS2 / CHA2DS2-VASC scoring system?

CHADS2/CHA2DS2 VASC scoring: a) Score 0 = none or ASA only b) Score 1 = ASA or AC c) Score 2+ = AC

Mesenteric Ischemia: Discuss the differences between "chronic" vs. "acute": a) MCC b) Presentation c) Diagnostic study of choice d) TXT

CHRONIC mesenteric ischemia: a) MCC = atherosclerosis b) "chronic diffuse abdominal pain, WORSE after meals" ACUTE mesenteric ischemia (EMERGENCY): a) MCC = embolism (clot) b) (+) "Acute Abdomen" = SEVERE, DIFFUSE abdominal pain ("pain out of proportion") Best DX study (both) = Angiogram TXT (both) = revascularization (angioplasty, stenting, bypass) **may need to resect necrotic bowel in acute ischemia

Infective Esophagitis: What are the typical endoscopy findings if the etiology is: a) CMV b) HSV c) Candida Treatments for each?

CMV = large "shallow" ulcers TXT = ganciclovir HSV = small "deep: ulcers TXT = acyclovir Candida = "white plagues" TXT= fluconazole (PO)

Lung Function: What is considered the MAIN DRIVER of ventilation? How does this affect pH?

CO2 levels (PaCO2) = MAIN driver of ventilation. There are receptors in the body that detect PaCO2 levels & adjust respiration rate accordingly (via phrenic nerve). CO2 --> carbonic acid (high CO2 = acidosis)

ACS: In addition to classic BB contraindications, what "ACS scenario" is it 100% contraindicated to give a BB? Why?

COCAINE USE (cannot give BB) cocaine blocks reabsorption of NorEpi @ post-synpatic ALPHA terminal = which leads to MORE free NorEpi (leads to vasoconstriction & vasospasm) "Cocaine" induced ACS: -Giving a BB would result in "unopposed alpha" effect = leads to uncontrolled vasoconstriction/spasm (can lead to CVA & death)

BIRTH CONTROL: List the main forms and whether they are combo vs. progesterone only?

COMBO options (estrogen + progesterone): a) OCP b) Transdermal patch c) Nuvaring PROGESTRONE only: a) Depo shot q3months b) Implannon/Nexplanon c) IUD (hormonal) NON-hormonal options: a) Copper IUD

PCOS: Concerns? TXT goals? TXT options?

CONCERNS: -risk infertility -risk endometrial CA (unopposed estrogen) TXT GOALS: Get them to either spontaneously ovulate or invoke monthly ovulation to keep endometrial lining thin & reduce risk of endometrial cancer TXT options: 1. Provoke ovulation (TOC): -weight loss + exercise (best) -Metformin -OCP 2. Androgen excess (all inhibit "activation" of sex hormones): -Sprinolactone -Dexamethasone -Finasteride

Hearing Loss: What are the MCCs of: a) Conductive hearing loss b) Sensorineural hearing loss

CONDUCTIVE: -cerumen impaction -OM/OE -TM perforation -Otosclerosis SENSORINEURAL: -Presbycusis (MCC = "old age") -Acoustic (Vestibular) Neuroma

Hirschsprung Disease: Pathophysiology? Risk factors? MC location? Presentation? BEST initial test? Definitive DX test? TXT?

CONGENITAL disease MC = males MC = Down Syndrome MC = distal colon / rectum Pathophysiology: Lack of GANGLION cells --> impaired relaxation of GI tract --> leads to OBSTRUCTION MC presentations: -Meconium ileus (neonate) -chronic constipation -TOXIC MEGACOLON INITAL test = anorectal manometry (+) lack of relaxation BEST test = rectal biopsy (+) absence of ganglion cells TXT = RESECT diseased bowel

Meckel Diverticulum: Pathophysiology? Epidemiology? Symptoms? DX? TXT?

CONGENTIAL (persistent vitteline duct) "Rule of 2s" -ONLY 2% population -2 types (gastric or pancreatic) -2 yo (MC) -2x more common (males) -2" inches long -2 ft from ileocecal valve -2% symptomatic Symptoms: a) Asymptomatic (MC) b) "PAINLESS rectal bleeding" DX = "Meckle Scan" (looking for ectopic gastric or pancreatic juices) TXT = resection (if symptomatic)

Ehler's Danlos Syndrome (DES): Pathophysiology? Features? MC CAUSE OF DEATH? TXT?

CONNECTIVE TISSUE disorder Overproduction of COLLAGEN --> leads to: (+) super stretchy skin (+) extreme flexibility (joints) BUT, the concern is that this disorder also affects collagen BLOOD VESSELS --> leading to compromised integrity #1 cause of death = ANEURSYMS TXT = none

Marfan Syndrome: Pathophysiology? Features? #1 cause of death? TXT?

CONNECTIVE tissue disorder (autosomal dominant) Main manifestations: a) SKELETAL (MC) = super "tall, thin male" with chest wall deformities (pectus carinatum "pigeon chest") b) CVS = MVP, aneurisms c) Eyes = lens dislocation (myopia) #1 CAUSE OF DEATH = aneurysms TXT = none

ACUTE Hepatitis A: Route of transmission? Contagious? BUZZ symptom? Labs? Treatment (active infection)? Prophylaxis (potential exposure)?

CONTAGIOUS Fecal-oral transmission RF = international travel Only hepatitis associated with = (+) "SPIKING FEVER" Labs = (+) anti-HAV (IgM) **antibodies** TXT = none (self limiting) Prophylaxis (if potentially exposed): (+) Give HAV Immunoglobulin IgG (IV) within 2 weeks of exposure (+)

Compartment Syndrome: In the ER setting, if you suspect developing compartment syndrome, would it be appropriate to elevate the affected limbs above the heart?

CONTRAINDICATED!! -affected limbs should ONLY be elevated to heart level -elevating above the heart actually reduces arterial blood flow to the area & and can WORSEN the ischemia

Bronchiectasis: What is considered the CORNERSTONE of treatment? MC infections? Best ABX choice?

CORNERSTONE = treating any lung infections (w/ ANTIBIOTICS) to reduce progression Bronchiectasis + CF = always need to cover for pseudomonas (Frontline ABX = FQ) Other infections: a) H. influenza (2nd MC) b) S. pneumoniae (3rd MC) c) Staph aureus (4th MC)

HMG-CoA reductase inhibitors: At what CPK level should you DISCONTINUE statin therapy?

CPK > 1500 u/L (highest risk of rhabdo)

In a patient with RUQ pain, what is the BEST test to rule OUT pancreatitis?

CT

Recall the CURB-65 criteria....

CURB-65 = -confusion (1pt) -uremia, BUN <19 (1pt) -RR > 30 (1pt) -BP < 90/60 (1pt) -Age > 65 (1pt) Score 2+ = admit Score 3+ = ICU

Pleural Effusion: CXR? DX? TXT? (gold standard?)

CXR (screening): a) AP view = (+) blunting costophrenic angles b) Left Lateral Decubitus view (BEST for seeing small effusions) = (+) layering GOLD standard (DX / TXT) = thoracentesis Full drainage (indicated): a) large effusion b) severely symptomatic c) UNKNOWN cause Chest-tube (indicated): a) empyemia Pleurodesis (Talc vs. Doxycycline): a) recurrent effusions

HF: Discuss common diagnostic test findings... What is the diagnostic test of choice?

CXR: a) cardiomegaly b) cephalization --> "Kerly-B lines" c) peri-hilar infiltrates ("Bat wings" "Butterfly infiltrates) d) Pleural effusions (transudative) ECHO (diagnostic test of choice):

Prenatal Care: How do you calculate the expected date of confinement (EDC) "due date." What gestational age is considered "full term"?

Calculation of due date: a) Nagele's Rule (LNMP - 3mo + 7days) = DUE DATE b) Ultrasound **generally as long as these are within 7 days of each other it is okay FULL TERM = 40W

What is the MOST COMMON cause of bacterial enteritis (USA)?

Campylobacter jejuni

Acute Epiglottis: When performing laryngoscopy and/or intubation, what is your main concern?

Can cause severe larynx spasm (which would close off the airway)

UTIs (pregnancy): If a patient continues to have recurrent bacteremia despite initial Abx course, what it the appropriate next step?

Can continue on ABX for remainder of pregnancy (need to prevent risk undecided UTI --> which could progress to pyelonephritis and cause OB complications)

Trisomy 21 (Down Syndrome): What are these kids at higher risk for? (associated conditions)

Cardiac abnormalities (ASD, VSD, CoA, PDA, TOF) Hirschsprung disease ("meconium ileus") Leukemia (later on in life)

What are some examples of COMBINATION Alpha/Beta-blockers? Mainly used for what?

Carvediolol Labetalol Indications (mainly): -refractory HTN -HTN urgencies -HTN emergencies

PCOS: Cause? #1 risk factor? Diagnostic criteria? Labs? DX?

Cause = UNK (however insulin resistance) #1 risk factor = OBESITY ROTTERDAM Criteria (must have 2/3): 1. Menstrual irregularities +/- infertility 2. Androgen excess (either evident clinically (acne, hirsutism, deepened voice) or lab values) 3. Evidence of polycystic ovaries (pelvic U/S) Labs: (+) High free testosterone (+) Low sex hormone binding globulin (+) High LH (+) Normal estrogen (+) Low progesterone (+) Hyperlipidemia U/S = (+/-) string of pearls ovaries

Fetal Alcohol Syndrome: Main manifestations? BUZZ findings?

Cause = mothers who consume ETOH during pregnancy Main manifestations: a) GROWTH restrictions (small baby, small adult) b) Intellectual difficulties BUZZ: (+) small head (microcephaly) (+) thin upper lip (+) small palpable fissures (+) small distal phalanges

Lymphogranuloma venereum: What is this? Cause?

Cause = untreated CHLAMYDIA -spreads to inguinal lymph nodes (inguinal bubos) -can lead to draining sinus tracks, etc.

OLECRANON bursitis: MCCs? Symptoms? Workup? TXT?

Causes: -Repetitive injury (MC) -Gout Symptoms: (+) Limited ROM (+/-) Painful vs. painless (painful higher suspicion for septic bursitis) Workup: (+/-) synovial aspiration + culture (if suspect septic bursitis) TXT = compression + NSAIDS (steroid injections if refractory)

Ludwig angina: 2MCCs? Classic presentation? Test of choice? TXT?

Causes: 1. Dental infection (MCC) 2. Retropharyngeal peri-tonsillar abscess (untreated) "posterior neck swelling" (+) PUS on floor of mouth Gold standard = CT + contrast TXT (same as peritonsillar abscess): (+) IV ampicillin/sulbactam (unasyn) (+) IV amoxicillin/clavulanic acid (augmentin)

TM Perforation? MCCs? Presentation? Treatment? Avoid?

Causes: 1. Trauma (barotrauma, Q-tip) 2. Recurrent infection (OM) (+) ear pain / discharge (+) CONDUCTIVE hearing loss (+/-) tinnitus or vertigo TXT (MC) = will heal spontaneously! (+) Avoid AG (+) Avoid H20 exposure (i.e. swimming) (+/-) surgical repair (tympanoplasty)

Pharyngitis: Causes? MC? Main Symptom? PE? Diagnosis? Treatment?

Causes: 1. Viral (MCC) 2. Bacterial (GABHS, chlamydia, gonorrhea) Symptom (main)= "Sore Throat" (+) pharyngeal erythema (+/-) pharyngeal exudates Diagnosis: a) CLINICAL (viral cases) b) Obtain rapid-strep test if suspect GABHS (use CENTOR criteria) Treatment: a) Viral = supportive b) Bacterial = Amoxicillin PCN allergy = macrolide, clindamycin

Laryngitis: MCC? Hallmark symptom? Treatment?

Causes: 1. Viral (MCC) --> usually following a URI 2. Overuse (2nd MC) 3. Bacterial (rare) HALLMARK symptom: (+) Hoarseness TXT: a) vocal rest b) supportive therapy

Esophagitis: Common causes? MCC? MC symptom?

Causes: a) GERD (MCC) b) Infectious c) Eosinophillic d) "Pill esophagitis" "odynophagia" (sore throat)

Aortic Regurgitation: Causes? Outcome if untreated?

Causes: a) Idiopathic (80%) b) Congenital = bicuspid aortic valve, Marfans c) Infection damage = rheumatic HDz, endocarditis d) Fibrosis = CAD, s/p MI, SLE, sarcoidosis, RA e) Increase in aorta pressure = HTN Outcome: Untreated AR --> decreased CO + increased back-flow into the LV --> chronic LV strain (increase diastolic pressure) --> LVH --> CHF

Dilated Cardiomyopathy: Causes? Defining features? Symptoms? Diagnostic test of choice? Treatment?

Causes: a) Idiopathic (MCC) b) Viral myocarditis (MC = endoterovirus "Coxsackie") c) Induced (ETOH, DM, pregnancy, thyroid disturbances, cocaine) d) Takotsubo Features: -SYSTOLIC dysfunction (low EF) -Dilated ventricles -Thin ventricular walls Symptoms = HF symptoms TTE (test of choice): (+) ventricular dilation (+) systolic dysfunction (low EF%) Treatment: a) reduce risk factors (i.e. ETOH) b) treat HF symptoms c) prophylactic AC d) consider heart transplant

GERD: 2 MCCs? MC reported symptom? Other possible symptoms?

Causes: a) LES dysfunction (MCC) b) Hiatal hernia "HEARTBURN" (MCC) (+) worse after meals (+) worse with lying down (+) relieved by antacids (tums) Other potential symptoms: (+/-) dyspepsia (+/-) chronic cough (+/-) sore throat (-->esophagitis) (+/-) halitosis (+/-) dental erosion

Vitamin B12 deficiency: MCCs? BUZZ presentation?

Causes: a) Lack of intrinsic factor (pernicious anemia) b) Lack of absorption (Crohn's) c) MEDS = H2B, PPI, METFORMIN "Megaloblastic anemia" + NEURO symptoms: (+) peripheral neuropathy (+) paresthesias (+) psych issues

Pelvic Inflammatory Disease: MCCs? Manifestations? Symptoms? DX? TXT?

Causes: a) MC = poly-microbial b) BUZZ = untreated chlamydia, gonorrhea MC Manifestations: a) Salpingitis (MC) b) Pelvic cellulitis --> pelvic abscess c) Tubo-ovarian abscess Diagnosis (exclusion) but MUST have the following to meet criteria: (+) pelvic pain (+) cervical motion tenderness ("Chandelier Sign") TXT (treat underlying cause): [gonorrhea + chlamydia] = [DOXY + Ceftriaxone]

Tonsillitis: Causes? MC?

Causes: a) VIRAL (MCC) b) Bacterial (GAS)

Antibiotic Review: List the different generations of cephalosporins.... Can you prescribe these to patients with "PCN allergy"?

Cephalosporins (generations 1-5): -1st generation = ONLY GM(+) -as you move up in generations, you get LESS GM(+) and more GM(-) coverage MOST COMMONLY USED: a) 1st generation = Cefazolin (Ancef), Cephalexin (Keflex) b) 3rd generation = Cephtriaxone (Rocephin) c) 4th generation = Cefepime (antipseudomonal) d) 5th generation = Ceftaroline (ONLY MRSA coverage) THESE ARE NOT a good option for PCN allergy patients (5-15% cross-reactivity)

Fibrocystic Breast Disease: Pathophysiology? Epidemiology? Symptoms? DX? TXT?

Changes in breast in response to HORMONAL changes during menstrual cycle (i.e. estrogen) MC = pre-menopausal women Multiple "mobile" breast lumps: -cyclic (come & go) -TENDER -usually bilateral DX = clinical (However, U/S +/- FNA usually obtained to r/o abscess vs. cancer) (+) straw colored fluid (no blood) TXT (supportive); -supportive bras -Danazol (FDA approved; reduces estrogen) -AVOID OCP/HRT

Acute Bronchiolitis: MC pathogen? Epidemiology? Symptoms? CXR? DX? TXT?

Children < 2 yo (MC) RSV (MC) Symptoms: Starts as "URI" symptoms (fever, rhinorrhea) --> progresses to SEVERE respiratory distress (grunting, nasal flaring, retractions, cyanosis, apnea) CXR = (+) peribronchial cuffing DX = "nasal wash" (RSV Ab testing) TXT (supportive): a) Neb humidified O2 (mainstay) b) Ribavirin In severe cases, consider (+): -nebulized racemic epi -nebulized albuterol

Cervicitis: Etiologies? MCC? General symptoms?

Chlamydia (MCC) Gonorrhea HSV Trichimonas SYMPTOMS: -asymptomatic -vaginal irritations (pruritus, dysuria, discharge)

Chlamydia: Pathogen (GYN)? Symptoms? Best test? TXT?

Chlamydia trachomonas (parasite) MEN = -milder version of gonorrhea symptoms (burning urination, watery penile discharge) WOMEN = -usually asymptomatic -cervicitis symptoms (itchy, burning, discharge) Diagnosing: a) Urine NAAT test (best) b) culture TXT: -Azithromycin 1g x 1 -Doxycycline -Erythromycin

Cholelithiasis: 3 types of stones? MC?

Cholesterol stones (MC) Black stones = d/t hemolysis Brown stones = d/t infection

Constrictive Pericarditis: Underlying pathology? Symptoms? PE? Diagnosis? Test of choice? Treatment?

Chronic / "milder" form Chronic inflammation --> fibrosis & calcification of the pericardium --> DIASTOLIC dysfunction Symptoms: (+) HF symptoms (MC = progressive dyspnea) PE: (+) Kussmaul sign (JVD w/ inspiration) (+) Pericardial Knock (high-pitched 3rd heart sound) Test of choice = ECHO (+ pericardial thickening) CXR = (+) pericardial calcification Angio = (+) square-root sign TXT = pericardiectomy

HTN (pregnancy): Discuss the treatment of: a) Chronic "existing" HTN b) Gestational HTN

Chronic = TREAT W/ MEDS **TOC = methyldopa, labetelol Gestational HTN (thought to be 2/2 vasospasm) = W&W vs. medical therapy (depends on severity)

COPD: Discuss how CXR will differ...

Chronic Bronchitis ("dirty lungs"): increased interstitial markings Emphysema ("clear, enlarged lungs"): -hyper-inflated lungs -flattened diaphragms -decreased interstitial markings -parenchymal blebs or bullae (BUZZ)

COPD (chronic bronchitis): What is the diagnostic criteria?

Chronic cough > 3 months (year) For at least 2 consecutive years

Blepharitis: What is this? Types? Causes? Presentation? Concern? Treatment?

Chronic inflammation / infection of eyelid (+) "Eyelid Dandruff" (+) chronic "red-rimmed" eye (+) chronic itchy eyes Types: 1. Anterior: a) Causes = seborrhea condition (i.e. "eczema") or infectious (MC = staph) b) TXT = hygiene (baby shampoo), warm compresses 2. Posterior: a) Cause = meimbomian gland dysfunction b) TXT = hygiene, warm compress w/ routine expression of glands.

Chronic Pancreatitis: Causes? MCC? How does this present differently? Diagnostic test of choice? Treatment?

Chronic pancreatitis --> pancreatic calcification / fibrosis --> LOSS of exocrine / endocrine function (digestive enzymes, insulin/glucagon) Causes: -Chronic ETOH abuse (MCC adults) -CF (MCC kids) -Idiopathic Presents MUCH MILDER than acute pancreatitis !! (-) usually NOT painful (-) amylase/lipase NOT elevated TRAID: (+) new onset DM (+) steatorrhea / weight loss (+) pancreatic calcification (CT) Diagnostic test of choice = CT TXT: a) reduce risk factors (i.e. d/c ETOH) b) PO pancreatic enzymes c) pain control

Anti-arrhythmics: What are the 4 classes?

Class 1 = Na channel blockers Class 2 = beta-blockers Class 3 = K channel blockers Class 4 = CCB

Anti-arrhythmics (class I): Which group is considered FRONTLINE?

Class 1c (best tolerability)

Crohns Disease vs. Ulcerative colitis (IBD): Compare and contrast: -Location (including MC) -Symptoms -Labs -Diagnostic studies

Classic symptoms will be a combination of (intermittent): (+) abdominal pain (+) diarrhea (+/- bloody) Crohn's Disease: -"mouth-to-anus -MC location = terminal ileum -"skip lesions" (NOT continuous) -Full thickness inflammation -MAIN FEATURE = Abdominal pain (RLQ) + diarrhea (NON-bloody) -Labs = (+) ASCA marker -Barium = (+) string sign -Colonoscopy = (+) skip lesions (cobblestoning) Ulcerative Colitis: -large intestine (colon) ONLY -MC location = rectum -CONTINUOUS inflammation -Superficial (not full thickness) -MAIN FEATURE = Abdominal pain (LLQ) + bloody diarrhea -Lab = (+) P-ANCA -Barium = (+) "lead pipe (stovepipe) colon" -Colonoscopy = (+) UNIFORM inflammation

Mastitis: If patient has PCN allergy, what is another alternative ? Benefit of this?

Clindamycin (great because also has (+) MRSA coverage)

Breakdown the potential differentials for PROGRESSIVE loss of vision?

Closed-angle glaucoma Macular degeneration Retinopathy Cataracts

Premenstrual Syndrome (PMS): Clinical picture? Diagnostic criteria? TXT options?

Cluster of "physical, emotional & behavioral" symptoms that are associated with LUTEAL phase of menstruation. Physical = breast pain, bloating, cramps, HA.... Emotional = depression, irritability.. Behavioral = cravings, sleep disturbances.. To diagnosis this symptoms MUST only be present during Luteal phase (1-2 weeks prior menses) **MUST HAVE SYMPTOM FREE period of time each month (if symptoms are constant it is NOT PMS) TXT: -Lifestyle = diet, exercise, reduction caffeine / salt -SSRIs -NSAIDS -Birth control (suppress ovulation)

Discuss the difference between: a) Colles Fracture b) Smith Fracture Best test? TXT?

Colles Fracture (MC) = "CDDD" -DISTAL radial fracture + DORSAL angulation = "DINNER fork deformity" -"FOOSH" Smith Fracture ("reverse Collles") -Distal radial fracture + VOLAR angulation -"FOOSH" w/ wrist flexion **CAN'T tell them apart on PE" MUST get LATERAL XR (GOLD standard) to tell apart TXT = Sugar tong/volar splint (ORTHO consult if intra-articular)

Bartholin Cyst: MC reported symptoms? Treatment options?

Common Cause: a) NON-infectious (blocked duct) = NON-PAINFUL (just enlarged) b) Infectious (E.coli, Staph, STD) = (+) PAINFUL "Vaginal fullness /pressure" (+/-) pain Treatments: a) warm compress + I&D b) (+) ABX (if infectious) If recurrent or severe: a) I&D + placement of WORD catheter (to allow drainage) b) Marsupialization (I&D and then sew back folds to allow for permanent drainage)

Drug-induced SLE: Common drugs? What test do you order to r/o this?

Common drugs: a) Class 1a anti-arrhythmic (procainimide, quinidine) b) Isoniazid (INH) c) Hydralazine In drug-induced lupus, the following lab will be positive: (+) Anti-histone antibodies SLE symptoms will RESOLVE upon discontinuation of drug.

Mastoiditis: Cause? Symptoms? Gold standard? TXT?

Complication of untreated OM ! (+) Post-auricular pain Gold standard = CT scan TXT = ADMIT! (+) IV ABX (+) Drain (myringotomy) (+/-) ET tube placement (+/-) Mastoidectomy (if recurrent)

Primary HTN: Discuss the potential complications of HTN...

Complications: a) Optic nerve = retinopathy, retinal hemorrhages, blindness b) Brain = hemorrhages, aneurysms, TIA, CVA c) Heart = CAD, HF, MI, dissections, aneurysms, PVD d) Renal = stenosis, sclerosis, renal failure

CAD: Pathophysiology? Main feature? Describe the variations of this type of pain?

Components: -building plaque leads to decreased and/or obstruction to blood flow -coronary and/or cerebral tissues become ischemic -increased risk for infarct (MI) Symptom (MC) = ANGINA (+) sub-sternal chest PRESSURE (+/-) XRT neck, jaw, shoulder, arm, back (+) LEVINE sign!

Carpal Tunnel Syndrome: Pathophysiology? Risk factors? Symptoms? PE? Gold standard? TXT?

Compression of MEDIAN nerve by inflamed "transverse carpal ligament" Causes/RF: a) overuse injury "repetitive wrist flexion/extension" (computer work) b) DM, hypothyroidism c) pregnancy "Hand numbness/tingling" -worse @ night -SPARES 5th DIGIT -"Thenar atrophy" (late sign) PE: (+) Tinel sign (+) Phalen sign DX (MC) = clinical Gold standard = nerve condition studies TXT: -activity modification -volar splinting -NSAIDS -steroid injections -surgical decompression

Wolff-Parkinson-White (WPW): What is this? Symptoms? Diagnosis?

Condition with EXTRA aberrant conduction pathway ("Bundle of Kent") that leads to EARLY ventricular contraction. Symptoms: -asymptomatic (MC) -palpitations EKG (BUZZ): (+) DELTA-waves (+) Wide QRS

APGAR score: Components? Normal Score? Assessed at what times?

Conducted at 1 min & 5 min (repeat @ 10 min if abnormal) Score 10 = perfect Score 7+ = normal

Dysfunctional Uterine Bleeding (DUB): Explain WHY it is so important to have regular ovulation?

Continued unopposed estrogen & not regular shedding of lining --> endometrial hyperplasia --> risk factor for endometrial cancer !!

Crohn's Disease vs. Ulcerative colitis (IBD): Discuss the MC locations of pain? How does smoking affect these?

Crohn's (MC location = terminal ileum) = "RLQ pain" (+) NON-BLOODY diarrhea (+) worse with smoking UC (MC location = rectum) = "LLQ pain" (+) BLODDY diarrhea (+) BETTER with smoking

Avascular Necrosis (hip): Risk factors? Symptoms? PE? Best initial test? Gold standard? Treatment?

DECREASED blood flow to bone --> bone death & collapse HIGHEST RISK: -hip dislocations -hip fractures (femoral head & neck) -LT STEROID usage ("BL" AVN) "Hip pain + loss of I/E rotation" (may present with "limp") INITAL TEST = XR (r/o fracture) **But need the "AP + Frog Leg view" (+) CRESENT SIGN (late sign) (+) Ground-glass appearance GOLD STANDARD = MRI (better @ showing early stages) TXT: a) Initial = protective weight bearing + BISPHOPHONATES b) Definitive = hip replacement

Fibromyalgia: Discuss the diagnostic features of the pain associated with this condition?

DIFFUSE musculoskeletal pain (NOT joint pain) (+) At least 11/15 trigger points (+) present above & below waist (+) present BILATERALLY (+) present for at least 3 consecutive months

Patella Fracture: MC MOI? Gold standard test? TXT?

DIRECT BLOW (MC = knee is flexed "bent") Gold standard = "sunrise XR" TXT: a) NON-displaced = cast b) Displaced = ORIF

Acute Epiglottis: What is considered a risk factor in adults?

DM

Osteomyelitis: Who is "chronic" OM seen most commonly in? MC presentation?

DM **remember that CHRONIC OM = much MILDER presentation... MC = non-healing ulcer +/- sinus tract

ACS: In the ER, when giving IV Nitroglycerine, what must you remember?

DO NOT GIVE: a) hemodynamically unstable (HR<60 or SBP<90mmHg) b) PDE-inhibitor (viagra) within 24-48 hours c) RV infarct

ESOPHAGEAL VARICES: If a patient is placed on a BB, what MUST you educate them about?

DO NOT STOP ABRUPTLY!! (remember that abrupt discontinuation of BB --> can lead to "REBOUND HTN" = which can induce life-threatening re-bleed)

Dronedarone: How is this different from Amiodarone? Main usage? Unique ADRs? CI?

DOESN'T contain iodine (therefore no issues with thyroid problems or blue skin discoloration) MAIN usages: -PAROXYSMAL atrial flutter -PAROXYSMAL AFIB ADRs: a) Torsades DePoines b) QT prolongation c) Pulmonary fibrosis d) New or worsening HF (unique) CI: a) HF b) Permanent AFlutter/AFIB c) pregnancy d) QT prolongation

Metronidazole / Tinidazole: What must you remember to tell patients if prescribing these? Why? Recommendations?

DON'T COMBINE WITH ETOH!! Educate patients that they should separate medication & ETOH by: a) Metronidazole = 24-48 hrs b) Tinidazole = 72 hrs MAIN CONCERN = "disulfiram-like reaction": a) "Flushing" (MC symptom) b) Others: N/V, abdominal pain, SOB, tachycardia TXT = supportive

Syphillis: Alternative treatment options for PCN allergy?

DOXY (best) Macrolides Ceftriaxzone

Esophageal Dysmotility: PRIMARY SYMPTOM? Discuss the breakdown of common causes?

DYSPHAGIA ("difficulty swallowing") PRIMARY dysphagia (issue with esophagus): 1. Achalasia 2. Esophageal spasm 3. Esophageal stenosis 4. Zenker Diverticulum 5. Cancer SECONDARY dysphagia: 1. Neurogenic (CNS dysfunction)

Pulmonary HTN: MC symptom? Symptom suggestive of SEVERE disease? PE? EKG? Gold standard test?

DYSPNEA (MC) **exertional syncope is indicative of severe disease PE = (+) right-sided HF (JVD, hepatojugular reflex) EKG = (+) cor pulmonale (+) RVH (+) R-axis deviation Right-sided heart catherization (GOLD STANDARD) **allows you to actually measure pulmonary pressure

Dacryostenosis vs. Dacryocystitis: Discuss the difference.... Symptoms? Treatment?

Dacryostenosis = -very common in the first month life -lacrimal duct system hasn't full opened up -will self resolve -treat with warm compresses Dacryocystitis = -secondary infection that occurs d/t lacrimal blockage & fluid stagnation -MC = s. aureus -red, painful, swollen lacrimal gland -TXT = warm compresses + Abx

Dancer vs. Jones fracture: Detail the differences.... a) location b) severity c) treatment

Dancer fracture (MC; less severe): -AVULSION fracture @ base 5th metatarsal -TXT = walking boot x 2-3 weeks Jones Fracture (worse): -Transverse fracture of PROXIMAL 5th metatarsal. -TXT = NON-WEIGHT BEARING 6-8weeks In both cases you MUST obtain f/u XRAY (higher risk= malunion)

List common agents for: a) Decongestants b) Cough Suppressants

Decongestants: -Guanifacine (Mucinex) Cough Suppressants: -Dextromethorphan -Promethazine-codeine syrup

Paralytic Ileus: What is this? Causes? MC? 1st line imaging?

Decreased peristalsis (WITHOUT obstruction) Causes: a) post-op (MCC) b) narcotics c) DM d) Hypothyroidism e) Electrolyte (low K, high Ca) Abdominal XR (KUB) = 1st line imaging (+) uniform distention **abdominal CT usually isn't ordered UNLESS high suspicion (but KUB was either negative or inconclusive)

Hospital Acquired Pneumonia: What is this defined as? 4 MC risk factors?

Definition: NEWLY acquired pneumonia that occurs > 48 hrs after admission Risk factors: -Hospitalized > 5 days -ICU -Intubation -Immunocompromised

Cholecystitis: When are each of the following indicated: a) Delayed cholecystectomy b) EMERGENT cholecystectomy

Delayed (MC) = usually best to wait until gallbladder inflammation is reduced (easier to visual structures laparoscopically) **MC complication of removing gallbladder during acute infection = CUTTING CBD (emergency) EMERGENCY (indicated if): -gangrene gall bladder -sepsis

Pulmonary Embolism: Discuss the appropriate workup..... What are the classic results: a) EKG b) CXR c) ABG

Determine LIKELIHOOD of PE (1st step)... LOW probability of PE = obtain D-dimer (1st): a) D-dimer (-) = r/o PE b) D-dimer (+) --> obtain Helical CT HIGH probability of PE = obtain Helical CT (1st) Ordering a LE Doppler U/S and or Pulmonary Angiography are ONLY indicated in situations where: a) high suspicion for PE (but Helical CT was inconclusive) CLASSIC test results: a) EKG = S1Q3T3 b) CXR = "normal in setting of hypoxia" (rare = Hampton Hump/Westermark signs) c) ABG = initially Alkalosis (b.c. tachypnea = blowing off all CO2) --> however will progress to Acidosis

Leading cause of blindness in adults?

Diabetic Retinopathy

Gestational Diabetes: DX? Treatment of choice? Goals?

Diagnoses (@ 26-28W): a) 1hr GTT (if (+) obtain 3hr GTT) b) 3hr GTT INITIALLY: a) Diet/exercise b) Daily glucose monitoring If the patient is reporting fasting BG > 105 or post-prandial B > 120 --> start MEDICATIONS! TOC = INSULIN (most effective; doesn't cross placenta) Other alternative agents: a) Glyburide b) Metformin

Mitral Regurgitation: Diagnosis? Treatment?

Diagnosis: a) EKG b) ECHO ("hyperdynamic LV" + decreased EF) c) CXR (cardiomyopathy, pulmonary congestion) d) cardiac cath (definitive) TXT: a) Medical = decrease BOTH preload & after load b) Surgical = REPAIR is always preferred vs. replacement Indications for surgery: a) Symptomatic b) Decreased EF < 55%

Mitral Stenosis: Diagnostic studies? Treatment?

Diagnosis: a) EKG (may show left atrial hypertrophy) b) ECHO c) CXR d) Cardiac cath (definitive) Treatment = Surgical intervention a) Younger patients = balloon valvuloplasty b) Older/ severe patients = valve replacement (mechanical valves are best) **medications do not improve outcomes nor do they delay need for surgical intervention (why they aren't recommended)

Aortic Regurgitation: Diagnostic studies ? (most definitive)? Treatment options?

Diagnostic studies: a) EKG b) ECHO c) Catherization (definitive) TXT: a) Conservative = initiate meds that REDUCE after load (i.e. vasodilators) b) Valve replacement surgery (definitive TXT) Indications for surgery: (+) symptomatic (+) decompensated EF < 55%

Phenylketonuria (PKU): What foods should be avoided?

Diary (milk, cheese) Eggs Chicken, Fish, Meats Aspartame (DIET SODAS)

HF management: What lifestyle modifications should you suggest?

Diet/Exercise Salt reduction < 2g/day Fluid restriction < 2L/day Smoking cessation

Vulvar Cancer: What is DES?

Diethystillbestrol (DES) = drug that used to be given to pregnant women in 1970s for preterm labor & OB complications that now has been shown to increase risk of Adenocarcinoma (vulva)

HF Management (outpatient): Is Digoxin routinely used? Indications? Does it improve M&M? Biggest issue with digoxin?

Digoxin is NOT routinely used (no M&M benefit) Indications: a) refractory HF (symptoms despite euvolemic status) b) HF + AFIB Biggest issue = NARROW therapeutic range (risk of "Digoxin toxicity" Digoxin Toxicity (aka "Digitalis Toxicity): [SEVERE ACS like symptoms] (+) visual changes (+) hyperkalemia TXT = (+) aggressive IVF (+) digoxin-specific antibody (Fab)

AFIB & A.Flutter: What anticoagulant option should NOT be used in patient is on Amiodarone/Dronedarone?

Direct Thrombin Inhibitor (dabigatran "pradaxa")

If someone has a history of "HIT" what other medication should you use in place of Heparin/LMWH?

Direct Thrombin Inhibitors: a)Bivalirudin "Angiomax" (IV) b) Dabigratran "Praxada" (PO) Anti-factor Xa: a) Fondaparinux (IV) b) Rivaroxiban "Xarelto" (PO) c) Apixiban "Elliquis" (PO)

Patella Dislocation: What is this? MOI? MC type? Symptoms? PE? TXT?

Dislocation of patella out of PATELLOFEMORAL GROVE MC = lateral displacement MC = "twisting" injury (+) Knee edema + pain (+) diminished ability to bear weight (+) "apprehension test" DX = clinical (--> but get XRAY r/o FX) TXT = knee immobilizer, crutches, PT

Gonorrhea: Symptoms of dissemination? MC complications if left untreated?

Disseminated bacteremia: a) peripheral skin lesions b) gonorrhea arthritis (polyarthralgias) Untreated: a) PID b) Infertility

Antibiotic Review: On the boards, what is ALWAYS the answer if asked for 2nd line agent?

Doxycycline (BUT dont' give to kids < 8yo = brown teeth)

Familial Bilirubin disorders: Discuss the main points associated with: a) Dubin-Johnson syndrome b) Crigler-Najjar syndrome c) Gilbert Syndrome Which is the MC?

Dubin-Johnson Sydnrome: -under-excretion of DIRECT (conjugated) bilirubin, which is then deposited in the liver -think "Dubin" = "D" = "Direct" -elevated DIRECT (conjugated) -(+) BLACK liver (biopsy) -TXT = none Crigler-Najjar Syndrome (MOST SEVERE form): -knocked out UGT enzyme (which converts unconjugated bilirubin --> conjugated bilirubin) - "NEONATAL JAUNDICE" --> progresses rapidly to hepatic encephalopathy -NORMAL liver (bx) -TXT (initial) = phototherapy -TXT (definitive) = liver transplant Gilbert Syndrome (MOST COMMON): -underactivity of UGT enzyme (NOT fully knocked out) -Asymptomatic (MC) -TXT = none

Patent Ductus Arteriosus (PDA): Pathophysiology? Risk factors? Symptoms? PE? Diagnostic test of choice? TXT?

Ductus Arteriosus = NORMAL connection between the pulmonary artery & aortic arch that exists during fetal development to "bypass the lungs" and allow right --> left shutning of oxygenated blood (from placenta) to the fetal body. Usually closes within first 10-13 days of life. When FAILS to close = PDA Risk factors: a) Premature infants b) Rubella infection (within 1st trimester) Symptoms: a) Asymptomatic (MC) b) poor feeding / failure to thrive c) HF (adulthood) PE: (+) continuous MACHINE-like murmur (best @ LUSB) ECHO (gold standard) TXT: (+) given indomethacin (to close it)

COUGH: What is the general approach to distinguishing the MCCs of cough?

Duration < 3 weeks: -URI (2/2 post-nasal drip) -acute bronchitis -croup -bronchiolitis -pneumonia Durations > 3 week (chronic): -Asthma -COPD -Pertussis -TB -Allergies (2/2 post-nasal drip) -GERD -Malignancy

ACUTE Sinusitis: What aspect would make you think this was BACTERIAL? MC pathogens? TXT? Potential complications (if untreated)?

Duration > 7-10 days (more indicative of bacterial etiology) **VIRUSES usually get better or resolve within 1 week Pathogens (MC): -strep pneumonia -m. catarrhalis -h. influenzae TXT = Amoxicillin (or Augmentin) #1 complication if BACTERIAL sinusitis is untreated = (+) Pott's Puffy Tumor (+) Cavernous sinus infection & thrombosis

MURMURS: Discuss when to order ECHO vs. Cardiac cath?

ECHO (always initial diagnostic test of choice) **Cardiac caths are considered the DEFINITIVE test of choice (but are usually only order if ECHO in INCONCLUSIVE)

HF: When is ACID indicated?

EF < 30-35%

Atrial Flutter: Classic EKG description? Who is this commonly seen in?

EKG = "saw-tooth" pattern Common with patients who have underlying cardiac or pulmonary disease (CAD, HF, COPD)

Discuss how we interpret homocystine levels? What additional labs should you order?

ELEVATED homocystine levels = maker for increased heart disease risk..... Usually associated with: -Vitamin B6 or B12 deficiency -Folate deficiency

ACUTE CLOSED angle glaucoma: Symptoms? PE? Treatment?

EMERGENCY ! "SUDDEN PAINFUL EYE" + vision loss: (+) circumlimbal injection (+) "steamy cornea" (+) "fixed dilated pupil" TXT = ADMIT !!! (+) IV acetozolamide (+) IV mannitol (diuretic) (+) Beta-blocker optic drops (+) surgical correction (iretomy)

Orbital Cellulitis: MCC? Pathogens? Presentation (BUZZ)? Workup? Treatment?

EMERGENCY !! MC from SINUS INFECTION MC = ethmoid sinus MC = kids Pathogens: staph/strep (MC) "PAIN W/ EYE MOVEMENT" (pathoneumonic) Other symptoms: (+) periorbital edema (ptosis) (+) blurred vision WORK-up = high-resolution CT (always get this r/o abscess) TXT = ADMIT (+) IV antibiotics (VANCO, clinda) (+) blood cultures

Retinal detachment: MC risk factors? Symptoms? Fundoscopic? ER management ? Treatment?

EMERGENCY !!! "Flashing lights" --> "Floaters --> PAINLESS vision loss ("shade coming over eye") Risk factors: -Trama (MC) -Myopia (near-sighted) -Cataracts -Sickle-Cell anemia -Proliferative Diabetic Retinopathy Fundoscopic: (+) Ruggae (retinal detaching) ER management: -Pt should be in supine position w/ head turned TOWARD detached side -Immediate consult -TXT = surgery

Cholangitis: What is this? MC pathogens? Symptoms? Labs? Diagnostic test of choice? Treatment?

EMERGENCY !!! (infection of biliary tree) Pathophysiology: -gallstone lodged in CBD (chololedolithiasis) -leads to biliary stasis -allows an "ascending" INFECTION from intestines (MC = E.coli) to cause infection of the biliary tree Symptoms: a) "Charcot's Traid" = RUQ pain, fever, jaundice b) "Reynold's Pentad" = (above) + hypotension, AMS Labs: (+) elevated DIRECT bilirubin (+) elevated LFTs (+) ELEVATED ALK PHOS (**) Cholangiography (test of choice) TXT: a) NPO + IVF b) IV ABX c) ERCP (removal the stone) d) Cholecystectomy (delayed preferred)

Pericardial Tamponade: Causes? Symptoms? EKG? Diagnosis? TXT?

EMERGENCY!!! Causes: -untreated/severe pericardial effusion -severe trauma Symptoms = BECKS triad! (+) "distant/muffled" heart sounds (+) increased JVD (+) systemic HYPOTENSION Other PE findings: (+) pulses paradoxus (SBP drop > 10mmHg during inspiration) EKG = same as pericardial effusion DX = ECHO (+) diastolic collapse of cardiac chambers TXT = IMMEDIATE pericardiocentesis

Peripheral Vertigo: What is the MOST basic way to tell the below apart: a) BPV b) Labyrinthitis c) Vestibular neuritis d) Meniere's

EPISODIC vertigo (comes/goes): a) BPV = (-) hearing loss b) Meniere's = (+) hearing loss CONTINUOUS vertigo: a) Vestibular neuritis = (-) hearing loss b) Labyrinthitis = (+) hearing loss

Who is at highest risk for vitamin deficiencies?

ETOH abuse Eating disorders Elderly

AAA: Management? What factors indicate highest risk of rupture?

EVERYONE should be put on a Beta-Blocker! (reduces risk of rupture) Highest risk factors for rupture: a) AAA > 5.5cm b) AAA that has increased in size >0.5cm/year Surgical management: a) AAA 3-4cm = abdominal u/s every year b) AAA 4-4.5cm = abdominal u/s every 6 months c) AAA > 4.5cm = vascular surgery referral d) AAA > 5.5cm or expanding >0.5cm/year = IMMEDIATE surgery Surgical options: a) endovascular stent graft b) open repair

AGE /Diarrhea: Discuss management..... Contraindications?

EVERYONE: 1. Hydration (MAINSTAY): PO (preferred) vs. IV 2. Bowel rest / bland diet ("BRAT" diet = banana, rice, applesauce, toast) ____________________________________________ Medical therapy (adjunctive): 1. Antiemetics: a) Serotonin Inhibitor = Ondansetron (Zofran) **may cause QT prolongation b) Dopamine Blockers = Promethazine (Phenergran), Metoclopromide (Reglan) **Extrapyramidal symptoms ("Parkinsonism") = tremor, bradykinesia, rigidity ____________________________________________ 2. Anti-motility (anti-diarrhea): a) Bismuth Subsalicylate (Pepto-Bismol) **DO NOT use in children (remember salicylate use in kids = REYES syndrome) b) Opioid agonists = Diphenoxylate/Atropine (Lomotil), Loperamide (Immodium)

Vitamin D EXCESS: Discuss the BUZZ presentation....

EXCESS Vitamin D --> leads to HYPERCALCEMIA --> "bones, groans, stones, psychiatric overtones" Bones = bone pain Groans = abdominal pain Stones = kidney stones Overtones = confusion

CAD: What is the main indication for using Ranolozine (Ranexa)?

EXERTIONAL stable angina

Hyperemesis Gravidum: Defined as? Concern? Management?

EXTREME N/V (pregnancy) that results in : (+) decreased in body weight > 5% (+/-) ketoacidosis CONCERN = dehydration, electrolyte imbalances If severe: (+) admit (+) NPO x 48hrs + IVF (consider TPN if needed) (+) manage any electrolyte issues (+) Antihistamine/Antiemetic IV (promethazine, metoclopramide)

Eclampsia: Earliest sign? TXT?

Earliest sign = HYPER-reflexivia MgSO4 + DELIVERY ASAP!

HF: What is the single most important factor in determining M&M?

Ejection Fraction (EF) ! EF < 35% = heightened M&M

Primary HTN (JNC8): In what patient population should you be CAUTIOUS of starting a diuretic?

Elderly (CCB or ACEI/ARB are better)

What lab is indicative of a "FAMILIAL" bilirubin disorder?

Elevated Bilirubin with NORMAL LFTS

Mesenteric Ischemia (ACUTE): What are some risk factors?

Embolism risk factors: -AFIB (**) -Hypercoagualbility (pregnancy, cancer) Sudden decrease in blood flow risk factors: -shock Vasospasm risk factors: -cocaine use

Primary HTN: What does presence of (+) papilledema indicate?

End-stage Retinopathy (Stage 4) = MALIGNANT HTN

SHOCK (Addison's Crisis): Pathophysiology? Treatment?

Endocrine Shock: -DROP in cortisol -DROP in blood concentration & volume Low CO Low SVR Low PCWP Treatment: -Given corticosteroids / mineralocorticoids

Morton Neuroma: Pathophysiology? MC risk factor? MC location? Symptoms? PE? Gold standard? Treatment?

Entrapment / degeneration of PLANTAR DIGITAL nerve MC location = 3rd metatarsal head Usually related to supportive shoes (MC = high heels) "Foot pain and/or paresthesias" (worse w/ walking) PE = (+) TENDER palpable mass (pain worsened w/ "squeezing" foot) Gold standard = MRI (XRAYS = normal) **diagnosis is usually CLINICAL TXT: supportive shoes + steroid injection (usually curative) **consider surgery in refractory cases**

Entropion vs. Ectropion: Discuss differences: a) presentation b) complication c) treatment

Entropion = eyelid turning "inward" -idiopathic vs. trauma vs. spasm of orbicularis oculi muscle -can cause corneal trauma (abrasion) Ectropion = eyelid turning "outward" -MC associated with AGING (relaxation of orbiuclaris oculi muscle) -predisposes you to chronic dry eye & infection TXT (both): a) Symptomatic relief = eye drops b) Surgical correction can be considered if causing issues

Gastritis: 2 main classifications? What are the MCCs each? MCC overall?

Erosive "hemorrhagic": -chronic ETOH -chronic NSAIDS -stress Non-erosive "non-hemorrhagic": -H.pylori infection (MCC) -Autoimmune

Chlamydia: What is the TOC in pregnant women?

Erythromycin

Pyloric Stenosis: Which medication has been shown to possibility increase incidence of this?

Erythromycin

Recall the major affects of: a) Estrogen b) Progesterone c) Prostaglandins

Estrogen (prepares for pregnancy): -maintains bone health -increases clot risk -thickens uterine lining -makes cervical mucus "thin & alkaline" ("FERNNING pattern") -increases sensitivity to oxytocin (increases uterine contractions) -proliferation of mammary glands (BUT suppress milk production by inhibiting prolactin during pregnancy) Progesterone (maintains pregnancy): -stabilizes the uterus (reducing sensitivity to oxytocin & reducing contractions / spasms) -increases uterine blood flow -thickens cervical mucus -formation of "milk producing" lobules (breasts) Prostaglandins (important in LABOR): -cervical dilation -increase uterine contractions (realize that Cytotec, given to induce abortion or labor causes cervical dilation & uterine contractions)

Septic Arthritis: Etiologies? BUZZ associations? MC? MC routes of transmission? MC joint affected?

Etiologies = viral, bacterial, fungal MC = bacterial MC = Staph BUZZ etiologies: a) Sexually active = r/o Gonorrhea b) Neonate = r/o GBS MC = knee Routes of transmission: a) Hematogenous spread (sepsis, IVDU, osteomyelitis) b) Direct inoculation (trauma, surgery, steroid injection)

Aortic Stenosis: Etiologies? Outcome (if uncorrected)?

Etiologies: a) Ages < 70yo = CONGENTIAL (i.e. bicuspid aortic valve) b) Ages > 70yo = DEGENERATIVE (atherosclerosis) c) Rheumatic HDz Outcome = CHF AS --> increased "after-load" (obstruction to outflow from LV)--> puts extra strain on LV --> leads to LVH --> leads to decreased CO & CHF

Pulmonary Embolism: Etiologies? MCC? Risk factors?

Etiologies: a) Blood clot (MC): (90% = DVT) b) Air embolism (central line) c) Fat embolism (major fracture; surgery) MCC (95%) = lower extremity DVT (above the knee) RF = "VIRCHOW'S TRIAD" -hypercoagulability -venous stasis -venous injury

ARDS: Pathophysiology? Etiologies? MCC? Hallmarks? TXT? Prognosis?

Etiologies: a) Sepsis (MCC) b) Massive trauma (i.e. drowning) c) Aspiration of gastric contents Pathophysiology: Acute trauma to the lungs --> leads to sudden massive pro-inflammatory response --> leads to diffuse lung edema & alveolar damage HALLMARKS: 1. Severe hypoxia that is REFRACTORY to O2 (give supplemental O2 but pulse ox does NOT improve) 2. Diffuse (bilateral) infiltrates (CXR) = called "white out" pattern 3. PCWP < 18mmHg (normal) Prognosis = POOR TXT: a) treat underlying cause b) CPAP + PEEP (maintain O2 > 88%)

Peripheral Arterial Disease: Etiology? BIGGEST risk factor? Hallmark symptom? Discuss the variations depending on ischemia location.... Common PE findings?

Etiology = ATHEROSCLEROSIS (biggest risk factor = smoking) Hallmark Symptom = Claudication (discomfort/pain brought on by exercise) LOCATION of pain depends on site of ischemia: a) Aortic bifurcation/common iliac = buttock/thigh b) Femoral artery = thigh / proximal calf c) Popliteal artery = lower calf + foot d) Tibial/peroneal arteries = foot PE findings: -diminished distal pulses -cooler extremities -muscle wasting -thin/shiny skin -loss of hair -gangrene

Constipation: What are the main things you want to r/o in someone with CHRONIC constipation? Medical therapy options?

Evaluate for: -Low fiber diet -Narcotic usage -Endocrine (DM, hypothyroid) -Cancer Treatment: 1. Increase H20 + fiber (mainstay) 2. Stool softeners = Docusate (colace) 3. Bulking agents = methylcellulose (Citrucel), polycarbophil (Fibercon), Wheat Dextran (Benefiber) 4. Laxatives: a) Osmotic laxatives = polyethylene glycol (Gotytely, Miralax), Lactulose, Milk of Magnesia b) Stimulant laxatives = bisacodyl (Dulcolax), Senna

Hepatitis E: Transmission? Symptoms? Labs? TXT?

Everything is the same as Hepatitis A, except labs: (+) Anti-HEV (IgM)

Menopause & Osteoporosis: What is a major benefit of using SERMs (Reloxifene or Bazedoxifene)?

Evidence shows if you combine SERM + conjugated estrogen (CE), that you can both: -treat menopausal symptoms -reduce osteoporotic risk -COMBINATION of these two eliminates endometrial cancer risk of giving estrogen alone (thus eliminates need for progesterone & added breast cancer risk)

Cardiology basics: Give examples of Vagal maneuvers? Explain HOW these lower HR?

Examples: bearing down, carotid massage (infants = place ice pack to forehead stimulates vagal response) There are "baroreceptors" in the body which sense changes in vascular pressure (i.e. BP) and initiate the body's response (which is to increase HR to compensate) By massaging the carotid = you trick the baroreceptor into thinking there is a INCREASE in BP --> which causes it to LOWER the HR + decreases venous return (to compensate)

Cholesterol Absorption Inhibitors: MOA? Drugs? Benefit?

Ezetimibe (Zetia) MOA = inhibits absorption of cholesterol @ intestines Benefits: -BUT okay to use in pregnancy (category C) unlike statins Downside: -less effective in LDL lowering

Dystocia: What is this ? Common causes? TXT?

FAILURE of labor to progress naturally... Usually due to either: a) "POWER" = lack / reduced strength of uterine contractions b) "PASSAGER" = fetal presentation or size (i.e. SHOULDER DYSTOCIA) TXT : a) Initially can try INDUCTION agents (oxytocin, misoprostol) b) C-SECTION (MC treatment)

Menopause: What is the FIRST symptom of hypogonadism? Late symptoms of hypogonadism?

FIRST = Vasomotor ("hot flashes") (80% women) LATER = Vaginal atrophy +/- Osteoporosis

Radial Head Fracture: MOI? Classic presentation? Concern? TXT?

FOOSH "can't fully extend arm" CHECK for posterior fat pad TXT = LAPMS

Achilles Tendon Tear: Which medication is known to increase risk for this?

FQ (BBW = tendon rupture)

Primary HTN (JNC8): Outline the current treatment recommendations.... When should you add a 2nd-agent?

FRONTLINE (uncomplicated) = Thiazides IN GENERAL: -consider (+) 2nd agent if BP is still >20/10 mmHg above goal -it is better to add 2nd agent BEFORE maxing out dosage on original agent

Hyperlipidemia: What is the FRONTLINE treatment? Which medications are indicated for: a) LDL lowering b) TG lowering

FRONTLINE = "Lifestyle modification" -loose weight -exercise more -decrease ETOH -smoking cessation LDL lowering meds: a) HMG-CoA reductase inhibitors (i.e. statins) b) Cholesterol Absorption Inhibitors c) Bile Acid Sequestrants TG lowering meds: a) Fibrates b) Niacin c) Omega-3 fatty acids

ACS: Discuss the appropriate management of a STEMI?

FRONTLINE = PCI (most effective if within 90min onset of symptoms) If center is NOT PCI-capable (alternative) = anti-thrombolytic (fibrinolytic) therapy

What are the best meds to: a) lower LDL b) lower TG c) increase HDL

FRONTLINE meds: a) Lower LDL = Statin b) Lower TG = Fibrate c) Increase HDL = Niacin

Osteoporosis: Treatment? Frontline?

FRONTLINE: [weight bearing exercises] + [Bisphosphonates] + [Ca/VitD suppelmentation] Normal Ca/VitD = [1000-1200mg] / [400-800mg] daily Post-menopausal female (MAX): (+) Ca (1200mg QD) (+) Vitamin D (800mg QD) 2nd line = SERMS (Raloxifen) 3rd line = Calcitonin (spray)

ADHESIVE capsulitis: Also called? MC in which patients? Hallmark? Mainstay of therapy?

FROZEN SHOULDER MC = DM, hypothyroidism, PROLONGED immobilization "Loss of active & PASSIVE ROM" **DO NOT IMMOBILIZE THEM** (will only make it worse) Therapy: a) PT (mainstay) b) NSAIDS, steroid injections c) Surgical

Candidiasis: Pathogen? Risk factors?

FUNGAL infection Candida albicans Risk factors: a) Immunocompromised (DM, Pregnant, HIV) b) Recent usage of broad spectrum ABX c) LT corticosteroid usage

Pneumonia (Pneumoncystis jiroveci): BUZZ labs? CXR? DX?

FUNGUS ! Labs: -LDH are usually elevated (>220 U/L) (90%) -Low pO2 + increase A-a O2 gradient CXR (presents like fungus): (+) diffuse infiltrates (+) perihilar infiltrates DX: -bronchial lavage / biopsy -Cesyl violet, Giemsa, Diff-quit, Wright stain

Neural Tube Defects: Cause? Risk factors? Presentation? BUZZ findings? TXT?

Failed closure of the neural tube during embryonic development CAUSE = folate/folic acid deficiency Risk factors: -inadequate diet intake -MTHFR mutation -MEDS Presentation (varies): a) spina bifida (no herniation) b) spina bifida + myelomeningocele (herniation) c) anencephaly PE (BUZZ) = (+) gluteal cleft "tuff of hair" (+) gluteal cleft dimpling TX t= surgery

Carcinoid Tumors: Features? MC Sites? Symptoms? Classic lab test? DX? TXT?

Features: -RARE neuroendocrine tumors -Malignant (but good prognosis) -Slow growing -Low rate of metastasis -High association with paraneoplastic syndromes Sites: a) GI track (MC) b) Lungs (2nd MC) = "centrally located tumor" Symtoms: a) Asymptomatic (MC) b) Paraneoplastic Syndromes (SIADH, Cushing, etc.) c) "Carcinoid Syndrome" (10%) = high serotonin, bradykinin, histamine --> diarrhea, bronchospasm, flushing Lab (buzz) = (+) elevated 5-HIAA (Serotonin) levels (urine) DX = BIOPSY (+) PINK/PURPLE, "well vascularized" central tumor TXT = resection (usually resistant to chemo/XRT) **Octreotid (somatostatin analog) can be used to reduce diarrhea/flushing of Carcinoid syndrome

Peripheral Arterial Disease: MC location of ischemia?

Femoral/Popliteal area (80-90%)

Prenatal Care: When should "fetal heart tones" be able to be appreciated? Normal range?

Fetal heart tones can be heard: a) U/S: as early as 5-6 weeks b) Doppler: 9-12 weeks Normal Fetal HR = 120-160bpm

Spontaneous Abortion: Defined as? MCC? MC timeframe? MC symptom?

Fetal loss < 20W gestation MC = 1st trimester MCC = chromosomal abnormalities #1 MCC of vaginal bleeding (1st trimester)

Fetal Circulation: Outline how fetal circulation is different from adults?

Fetal lungs are NOT fully developed in-utero...therefore they have a "right --> left shunting" system to deter blood away from the lungs.... Oxygenated blood (mother/placenta) enters the fetal RIGHT ATRIUM and is shunted to left-side of the heart via 2 mechanisms: 1. Foramen Ovale (hole between right & left atrium) 2. Ductus Arteriosus (connection between pulmonary artery & aortic arch)

TB: What is the MOST CONSISTENT symptom associated with PRIMARY TB?

Fever

Compare & contrast: a) Fibrocystic breast disease b) Fibroadenoma c) Breast cancer

Fibrocystic breast disease: -CYCLIC (come & go) -Multiple TENDER masses -Masses are soft, mobile Fibroadenoma: -NON-CYCLIC -Single, NON-TENDER mass -Mass is firm, mobile Breast cancer (MC): -NON-CYCLIC -Single, NON-TENDER mass -Mass is hard, FIXED -May have axillary involvment

Compare the pelvic exam of: a) Uterine fibroids b) Adenomyosis

Fibroids: (+) ASYMMETRIC enlargement (-) non-tender uterus Adenomyosis: (+) SYMMETRICAL enlargement ("boggy uterus")

Restrictive Cardiomyopathy: Cause? Defining features? Symptoms? PE? Diagnostic studies? Treatment?

Fibrosis of heart muscle --> leads ventricular stiffness & noncompliance (DIASTOLIC dysfunction) Causes: -Amylodosis (MCC) -Sarcoidosis -Scleroderma -XRT/CHEMO Symptoms / PE = VERY MILD! (+) HF symptoms (RHF more common) (+) Kussmaul sign (JVD w/ inspiration) ECHO: (+) normal LV size & thickness (+) BL marked dilation of atria (+) diastolic dysfunction TXT = treat underlying cause + symptoms

Bone cysts: What are these? #1 way these present? TXT?

Fluid filled lesions MC = humerus / femur (+) Asymptomatic (incidental finding) (+) Pathologic fracture TXT = observation (if large or symptomatic = aspiration, steroid injection, surgery)

Macular Degeneration (wet): What is the GOLD STANDARD when diagnosis this form?

Fluorescein ANGIOGRAPHY

Antibiotic Review: Breakdown FQ & their usage? ADRs?

Fluroquinolones = generations 1-3 (mainly GM (-) coverage) MOST commonly used: a) 2nd generation = ciprofloxacin, ofloxacin (UTIs, GI infections) b) 3rd generation (respiratory FQ) = Levofloxacin, Moxifloxacin, Gemifloxacin (PNA, osteomyelitis) BBW = tendonitis & tendon rupture ADR: a) QT prolongation b) Cipro has VERY HIGH association w/ C. Difficile

Crohns Disease vs. Ulcerative colitis (IBD): What supplement should be added to treatment Sulfasalazine?

Folic Acid

Recall the normal parts of the menstrual cycle...

Follicular "proliferative" phase: (main driver = FSH) -pulsatile release of GnRH from hypothalamus stimulates release of FSH/LH from anterior pituitary -increasing FSH/LH cause follicle maturation @ ovary = which begins to secrete more estrogen -estrogen begins priming uterus for pregnancy (thickening lining, thinning mucus). OVULATION (Day 14): -normally estrogen negatively feedbacks & inhibits further release of FSH/LH -HOWEVER, around Day14, which mechanism switches to be a positive feedback. -This leads to the "LH SURGE" that allows for ovulation Luteal "secretory" phase: (MAIN DRIVER = LH) -after ovum is released, the "corpus luteum" begins secreting progesterone -progesterone continues to rise, stabilizing the uterus in preparation for pregnancy. -If ovum is not fertilized (sperm), the corpus luteum will degenerate on Day 25 to form the corpus albicans (no longer secrets progesterone) -This sudden loss of progesterone is what leads to menses. If your PREGNANT: -corpus luteum will be maintained for another 8 weeks, at which time the placenta will be matured enough to take over progesterone secretion -it is this continued secretion of progesterone that allows for "maintenance" of pregnancy

Tachycardia & Fever: What is the RULE OF THUMB when assessing someones heart rate while they are febrile? What are things that cause a paradoxical effect?

For every 0.1 degree (F) over 100F, the heart rate should raise by 10bpm over baseline.... Temp: 100F / HR: 90 Temp 100.1F / HR: 100 Temp 100.2F / HR: 110 ABNORMAL relationship: -salmonella -malignancy

Boxer Fracture: What is this? MC MOI? Treatment? What should you always evaluate for?

Fracture to 4/5th metacarpal head MOI = "closed fist" injury (punching something) Treatment (depends on angulation): < 40 degrees = ulnar gutter splint > 40 degrees = ORIF **always evaluate for "HUMAN BITE" --> high risk (+) Eiknella infection (TOC = Ampicillin/Sulbactam) ORTHO referral indications: -malrotation -severe angulation > 40 -open fracture -extends into articular space

Blow-out Fracture: What is this? MCC? Signs suggestive of this? Concern? Gold standard? TXT?

Fracture to ORBITAL FLOOR! MCC = trauma Concern = leads to EOM entrapment (+) orbital edema (can lead) --> exophthalmos (+) pain (+) diplopia MUST GET CT (study of choice) TXT = OPTHAL consult (surgery) (+) decongestants (reduce pressure & pain) (+) steroids (reduce inflammation) (+) ABX

Diabetic Retinopathy: Frontline treatment? Adjunctive therapy?

Frontline (both types) = STRICT GLYCEMIC control **limit progression Non-proliferative = may (+) pan-laseer therapy Proliferative = may (+) anti-VEGF (Bevacizumab) to reduce new neovascularization.

REYE Syndrome: What is this? MCC? Symptoms? Treatment?

Fulminant Hepatic Encephalopathy! MCC = ASA (salicylate) use in kids Symptoms: (+) Rash hands/feet (liver damage) (+) intractable HA/ vomiting (increased ICP) (+) AMS TXT: -supportive -lower ICP (IV mannitol)

HF Management: Discuss the main limiting factor when using Loop Diuretic?

Furosemide (Lasix) VERY POTENT diuretic a) potentially can cause severe low K+ (combine w/ K-sparing diuretic) b) potentially can cause severe hypovolemia -caution in Elderly -reserved for HF (NOT used to treat HTN)

Pharyngitis (GABHS): Also known as? Criteria to predict? Best initial test? Gold standard? Management?

GABHS = "strep pyogenes" (GM +) CENTOR criteria: 1. Fever (> 100.1 F) 2. Lack of cough 3. Pharyngeal exudates 4. Tender cervical LAD Scoring: 0-1 = unlikely (no ABX) 2 = obtain rapid strep test +/- throat culture to decide about ABX use 3-4 = very likely (+ give ABX) BEST initial test = rapid antigen (rapid strep test) GOLD standard = throat culture PEARL: **realize this test is very specific, BUT not very sensitive (if highly suspicious for GABHS but (-) rapid strep --> obtain throat culture)

Zollinger-Elison Syndrome: What is this? MC location? MC presentation? DX studies? Gold standard? Treatment?

GASTRINOMA "gastrin secreting tumor" 66% (malignant) MC location = duodenal wall "Refractory PUD" Diagnostic studies: a) Fasting gastrin > 150 (best screening test) b) Secretin Challenge Test c) Somatostatin Receptor Scinitgraphy (GOLD standard) TXT = resection

Phenylketonuria (PKU): Pathophysiology? Cause? CLASSIC patient? Symptoms? Diagnosis? TXT?

GENETIC (autosomal recessive) -Impaired amino acid metabolism -Unable to convert Phenylalanine --> Tyrosine (lack PAH enzyme) -Excessive Phenylalanine instead gets converted to KETONES (neurotoxicity) "Blond hair, Blue eyes, Fair skin" Symptoms: (+) vomiting (+) eczema (+) musty urine odor (+) growth retardation (+) intellectual delays (+) seizures DX = blood [phenylalanine] test (testing the urine for phenylacetic acid usually done initially) TXT: a) avoid foods containing phenylalanine b) (+) tyrosine supplementation

Peptic Ulcer Disease (PUD): MC complications?

GI perforation GI bleed Gastric cancer

Celiac Disease (Sprue): What is this? Cause? Epidemiology? Classic symptoms? Atypical presentation?

GLUTEN ALLERGY (not the same as "gluten intolerance") Pathophysiology: Ingestion of GLUTEN --> stimulates a AUTOIMMUNE reaction which destroys small bowel villi --> leading to malabsorption / vitamin deficiencies. **SHOWS UP IN CHILDHOOD** ("infant with signs of failure to thrive, diarrhea, weight loss") CLASSIC symptoms: (+) diarrhea / steatorrhea (malabsorption) (+) abdominal pain (+) weight loss (+) failure to thrive Atypical symptoms: (+) Dermatitis Herpetiformis (pruritic rash) (+) Fe-deficiency anemia (+) Neuropathy (d/t VB12 def) (+) profound fatigue

Clostridium Difficle (C.diff): Pathogen? MC associated with? MC symptom? DX? Treatment?

GM (+) spore forming ANAEROBIC bacillus RF = recent ABX use (MC = FQ, clindamycin) "Watery" diarrhea + colicky AP Diagnosis: a) Endoscopy = r/o pseudomembranous colitis (potential complication) b) Stool toxin (GOLD STANDARD) TXT: a) Metronidazole (PO/IV) (TOC) b) VANCO (PO only) (2nd line)

CAD: Discuss workup? Test of choice?

GOLD STANDARD = Angiography Initial workup: -EKG -Stress test (EKG vs. EHCO) -Cardiac enzymes

Cardiology basics: What tests are BEST for assessing cardiac ischemia? Explain the differences...

GOLD STANDARD = angiography (most accurate = localizes AREA of ischemia + DEGREE (%) of ischemia) ECG Stress Tests (usually the initial test done b.c. cheaper): 1. Exercise "Treadmill" stress tests (only tells you if you have ischemia, DOESN'T localize the area of the ischemia) 2. Pharmacologic stress tests (localizes the area of ischemia, but NO %) Myocardial Profusion Stress Imaging (localizes area of ischemia) ECHO Stress Tests (localizes area of the ischemia, but no %)

Deep Vein Thrombophlebitis (DVT): Discuss appropriate workup? Gold standard diagnostic test? Treatment? Discuss how to successfully interpret D-dimer results?

GOLD STANDARD = venography STEP 1 = use "WELL'S CRITERIA" to determine risk for DVT: a) Wells < 2 = lower risk --> obtain D-dimer level 1st, if (+) D-dimer then obtain doppler u/s b) Wells > 2 = higher risk --> go straight to ordering doppler u/s Remember that (+) elevated D-dimer ONLY indicates systemic inflammation (very sensitive for DVT, BUT not specific) (+) DVT = does NOT confirm diagnosis of DVT (but does support you getting a doppler ultrasound) (-) DVT = does RULE OUT diagnosis of DVT Treatment: a) Start immediate anticoagulation (UFH/LMWH) with bridging to Warfarin (upon discharge) b) Consider IVC filter if anticoagulation is contraindicated Appropriate anticoagulation timeframes: a) 1st DVT event (known cause) = AC x 3-6 months b) Recurrent DVT, UNK etiology and/or KNOWN underlying condition (i.e. Factor V Leiden) = LIFELONG anticoagulation

Chololedolithiasis: What is this? Main early symptom? Diagnostic test of choice? TXT? Why is this important?

Gallstone gets lodged in CBD causing INFLAMMATION of biliary tree (NOT infection) -now affects both liver & gallbladder (BUZZ = rising AST/ALT) -important b.c risk factor for developing Cholangitis (MEDICAL EMERGENCY) "PAINLESS JAUNDICE" (+/-) elevated direct bilirubin (+/-) elevated LFTs (AST/ALT) Diagnostic test of choice = ERCP (also therapeutic) TXT: a) ERCP (to remove stone) b) Cholecystectomy

Bacterial Vaginitis: Pathogen? Pathophysiology? Risk factors?

Gardenella Vaginalis (GM variable, anaerobic bacteria) Pathophysiology: Reduction in our normal flora (lactobacilli) allows for an overgrowth of Gardenella Risk factors: -Sex (MC) -Douching **REALIZE even though sex is a risk factor (b.c. it can throw off the NORMAL vaginal flora), this condition is NOT considered a sexually transmitted disease (STD).

Peptic Ulcer Disease (PUD): Which has a higher association with malignancy? a) Gastric ulcers b) Duodenal ulcers

Gastric ulcers (duodenal ulcers are almost ALWAYS benign)

GI Pathophysiology: Discuss the roles of the following in digestion @ stomach: a) Gastrin b) Histamine c) Hydrochloric acid d) Acetylcholine (AcH) e) Secretin

Gastrin --> stimulates release of Histamine --> stimulates the PARIETAL cells to secrete HYDROCHLORIC acid Acetylcholine (AcH) = "rest & digest" hormone --> ALSO stimulates hydrochloric acid secretion Secretin (produced by duodenum) --> INHIBITS gastrin (inhibits hydrochloric acid production) + stimulates HCO3 release from pancreas. Hydrochloric acid (important in digestion): -breaks down food -activates PEPSIN (important to digest proteins) -kills harmful bacteria

HYPOTHYROIDISM (pregnancy): Discuss managing a HYPOTHYROID patient in pregnancy?

General recommendation: -Achieve euthyroid state PRIOR pregnancy -Increase medication dose by 25-30% once pregnant -Repeat TSH q4-6weeks w/ dose titration to maintain TSH<2.5 -Then cut dose 1/2 postpartum

Endocarditis: Treatment? Alternative for PCN allergy? When is surgery indicated?

General treatment: Gentamycin + [PCN/naficillin/VANCO/Ceftriaixone/Clindamycin] x 4-6weeks (+) use Clindamycin (PCN allergy) (+) consider VANCO = MRSA (+) add Rifampin (if prosthetic valve) (+) consider AmpB (if fungal) When to start ABX: -Subacute cases = usually obtain blood cultures and THEN start Abx -Acute cases = start ABX immediately Surgery indications: -unresponsive to ABX -prosthetic valve -recurrent systemic emboli -fungal

BREAST CANCER: Treatment approach?

General treatment: [resection] + XRT Resection options: a) Lumpectomy (breast conserving option) b) Mastectomy (partial, total) c) Consider regional lymph node dissection (depending on metastatic risk & stage) Consider adding the following if Estrogen receptor (+): (+) HRT (i.e. SERMS) Consider adding the following if metastatic: (+) CHEMO (methotrexate)

Hemochromatosis: What is this? Presentation? Complication? DX? TXT? Health maintenance?

Genetic condition (rare) MC = Caucasians INCREASED [Fe] absorption @ intestine --> which ends up deposited in organs --> leading to organ dysfunction & failure Presentations: a) Liver cirrhosis b) Cardiomyopathy c) DM (2nd MC) d) Bronzing of skin (MC) DX = genetic test (HFE gene) TXT: a) Chelation therapy b) Phlebotomies Health maintenance: -avoid diet high in iron (red meat) -avoid ETOH -avoid VitC (increase iron absorption)

Brugada Syndrome: What is this? Epidemiology? Classic symptoms? EKG? TXT?

Genetic disorder that leads to interruption in normal cardiac conduction (predisposes them to fatal arrhythmias (VFIB)) MC = Asians Symptoms: -recurrent syncope -SUDDEN cardiac death (MC) "young healthy HS football player suddenly collapses and dies on field." EKG (V1-V3): -incomplete RBBB -ST elevations -T-wave inversions TXT = IMMEDIATE AICD placement to prevent VFIB.

Primary HTN: List some know risk factors?

Genetics (+FHX) Race (i.e. AA > risk) Age Gender (i.e. males > risk) Obesity Sedentary lifestyle Smokers ETOH abuse

HSV2: How does management change in pregnant woman?

Genital herpes in PREGNANCY poses higher risk of DISSEMINATION (highest during delivery) CONCERN = encephalitis Recommendation = c-section

Antibiotic Review: List Aminoglycosides.. Coverage? Uses? Cautions?

Gentamycin Neomycin Tobramycin GRAM (+) coverage: -skin infections -ENT Cautions = ototoxic

Amenorrhea: Discuss HOW the progesterone challenge test works?

Give 7-10 days of oral progesterone (Provera) = tricks your body into thinking that you ovulated When you suddenly STOP the exogenous progesterone: (+) bleeding = normal estrogen (-) bleeding = missing estrogen **If you are MISSING estrogen = check FSH levels **if your estrogen is OK, but your missing progesterone = check LH levels

Glaucoma: What is this? 2 types? MC?

Glaucoma = INCREASE in IOP Types: 1. Open angle glaucoma (MC) = age related, chronic 2. ACUTE, closed-angle glaucoma = MEDICAL EMERGENCY !

Crohn's Disease vs. Ulcerative colitis (IBD): Discuss the tests of choice in ACUTE FLAIR (i.e. presents to ER)? What is the gold standard?

Gold standard (both) = endoscopy / colonoscopy WITH BIOPSY **HOWEVER the following are CONTRAINDICATED in an acute flair: a) Colonoscopy (risk of perforation) b) Barium (risk of toxic megacolon) In an ACUTE FLAIR (preferred diagnostic tests are): a) Crohn's = upper GI series (XR) b) UC = sigmoidoscopy

COPD: Gold standard for diagnosis? Results? Which features is the MOST indicative of "disease severity?" What feature is BEST predictor of INCREASED M/M?

Gold standard = PFTs (FEV1/FVC ratio < 70%) PFT results show: a) DECREASED: vital capacity, FEV1, ratio FEV1/FVC b) INCREASED: total lung capacity, residual volume BEST indicator of disease severity = residual volume (RV) **remember that we worry about "air trapping" = CO2 retention BEST predictor of increased M/M = FEV1 < 1L

Temporal ("Giant Cell") Arteritis: Diagnosis? TXT? Major concern?

Gold standard = temporal artery biopsy !!! (+) lymphocyte infiltration (+) giant cells (granulomatous cells) (+) skip lesions TXT: (+) HIGH DOSE prednisone x 6 weeks Biggest concerns: a) if untreated --> leads to BLINDNESS b) HIGH association w/ Polymyalgia Rheumatica c) increased risk for aortic aneursyms

Gout vs. Pseudogout: List main differences?

Gout (purine metabolism) -MC = older men -Present similarly -MC joint = 1st metatarsal-phalangeal joint -XR = (+) punched out lesions -TXT = NSAIDS (frontline) Pseudogout (CPPD metabolism): -MC = older women -Present similarly (but (+) chondrocalcinosis) -MC joint = knee -XR = (+) multiple linear radiodensities -TXT = steroids injections (frontline)

Cataract: What is this? MCCs? MC symptom? PE finding? TXT?

Gradual progressive "opacification" of lens --> vision loss Causes: -Aging (MCC) -DM -Smoking -Congenital ("ToRCH" infections = toxoplasmosis, Rubella, CMV, HSV) PE = (+) absent red light reflex TXT = surgical

H. pylori: Type of organism? Diagnostic options? Gold standard (DX)? Treatment regimen?

Gram (-) bacillus (rod) GOLD standard = EGD + biopsy (+ rapid urease test = staining of biopsy specimen) However, if patient is unable / unwilling to undergo EGD (alternatives): a) Urea breath test b) Stool antigen test c) Serologic testing Treatment (PPI + 2ABX x 4 weeks): PPI + Amoxicillin + Clarithromycin **if (+) PCN allergy consider: a) PPI + Metro + Clarithromycin b) PPI + Bismuth + Metro + Tetracycline

Peptic Ulcer Disease (PUD): Why is it so important to diagnosis and manage this early if it is d/t H. pylori?

H.pylori --> leads to chronic gastric inflammation (if untreated) --> #1 cause of GASTRIC CANCER **very similar to the relationship (untreated GERD --> Barrett's esophagus--> esophageal CA)

Hypertrophic Cardiomyopathy: What valvular abnormalities does this murmur look identical to? Distinguishing feature?

HCM vs. AS: -murmur looks the same -HCM = (-) XRT carotids; QUIETER w/ squatting & LOUDER with standing/valsalva -AS = (+) XRT carotids; louder w/ squatting + quieter w/ standing/valsalva -BOTH diminish/resolve with Hand-grip HCM vs. MVP ("low volume lovers"): -BOTH will get worse with standing/valsalva -BOTH will get improve with squatting -HCM = RESOLVE with hand-grip -MVP = GET LOUDER with hand-grip

Menorrhagia: Discuss MC etiologies..... Appropriate workup? Frontline therapy?

HEAVY PERIODS MCC = Anovulation Etiologies: a) Organic causes: infections, bleeding disorders (MC = von Willebrand disease) b) Endocrine causes: Thyroid imbalance, PCOS, prolactinemia, anovulatory cycles, renal or liver dysfunction c) Anatomic causes: fibroids, polyps, endometrial hyperplasia FRONTLINE THERAPY = -NSAIDS -OCP or IUD **D/C or endometrial ablation = endometrial hyperplasia **removal of fibroids or polyps

What is "HELLP" syndrome? How does eclampsia differ from preeclampsia?

HELLP: "hemolysis, elevated LFT and low platelets" (severe form of preeclampsia) Eclampsia = [preeclampsia] + seizures

AFIB & A.Flutter: When is Digoxin preferred for "rate control"?

HF patients (BB / CCB are contraindicated)

Pelvic Fracture: MC MOI? BUZZ PE finding? What must you r/o? Complications? TXT?

HIGH IMPACT INJURY (i.e. MVA) BUZZ = (+) perineal ecchymosis RARELY an isolated fracture (always r/o 2nd fracture) HIGH risk = neurovascular injuries TXT = ORIF

HMG-CoA reductase inhibitors: What is the expected LDL reduction capability for: a) High intensity statin b) Moderate intensity statin c) Low intensity statin

HIGH intensity: reduce LDL > 50% Moderate intensity: reduce LDL 30-50% Low intensity: reduce LDL < 30%

Osteosarcoma: What association must you r/o?

HIGH rate of co-occurence between: -osteosarcoma -retinoblastoma

Colorectal Cancer: After treatment, what is the recommended health maintenance? When is recurrence the highest?

HIGHEST rate of recurrence = 3-5 years after completion of treatment RECOMMENDATIONS: a) colonoscopy 1 year after surgery & then q3-5yrs thereafter b) CEA q3 months x 3 years c) Abdominal + Chest CT every 6-12 months x 3 -5 years

Hepatitis C: What health maintenance is recommended?

HIGHEST risk cirrhosis HIGHEST risk hepatocellular CA Recommended routine screening for cancer with: a) AFP b) U/S

Syphilis: What should all patients be co-tested for?

HIV

Viral Hepatitis: What should you always test for in someone with Hepatitis B or C?

HIV (high incidence of co-infection)

Amenorrhea: Discuss the basic approach to treatment...

HPA issue = fix underlying cause Ovarian issue = (+) give OCP (replace estrogen & provoke periods and allow regular lining shedding) End-organ issue = fix underlying issue

Cervical Cancer (Squamous Cell): Discuss different HPV strains? Prognosis?

HPV (low-risk) = 6, 11 (usually manifests as genital warts) HPV (high-risk) = 16, 18, 31, 33, 45 Prognosis = without treatment 20% of these will progress to cancer over 10 year period (slow growing)

Sinus Bradycardia: Causes? MCC? Treatment?

HR < 60 bpm MCC = vagal stimulation (why we give Atropine as 1st line) Other potential etiologies: -normal (athletes) -hypothyroidism -"ABCD" (funnel) drugs = adenosine, BB, CCB, digoxin -Gram(-) sepsis TXT: -Rapid IV Atropine push -Fix underlying cause -Consider ICD placement (if recurrent)

Sinus Tachycardia: MCCs? TXT?

HR > 100bpm (but (+) NSR = regular R'R + 1p:1QRS) "PHAT HADES" (causes): -pain -hypovolemia -anxiety -temperature (fever) -hypoxia -anemia -drugs -ETOH withdrawal -systemic conditions (i.e. endocrine d/o = hyperthyroidism) TXT: -Rapide IV Adenosine push -Fix underlying cause **Do not cardiovert these

HSV: Difference between HSV1 & HSV2? Manifestations? Latency? BEST test? Other diagnostic tests? TXT?

HSV1 = oral (cold sores) HSV2 = genital Latency: a) HSV1 = trigeminal nerve b) HSV2 = sacral root ganglia INTERMITTENT episodes of: PRODROME (tingling, paraesthesias) --> outbreak of "PAINFUL grouped vesicles on erythematous base" HSV1 (can also cause): -keratitis -pharyngitis -esophagitis -encephalitis BEST test = PCR (most sensitive/specific) Other test = TZANCK smear ((+) giant multinucleated cells)) TXT: a) Valcyclovir (cream) b) Acyclovir (PO)

Breakdown the different "herpes" ?

HSV1/2 = herpes simplex HSV3 = herpes zoster (shingles) HSV4 = EBV HSV5 = CMV HSV6/7 = Roseola HSV8 = Kaposi Sarcoma ("Skin CA in HIV(+) patient)

What EKG findings are commonly seen in dialysis patients? Explain...

HYPERKALEMIA

MURMUR (basics): Discuss how "hand-grip" technique affects murmurs?

Hand-grip technique = affects LEFT-SIDED murmurs (aortic & mitral valve abnormalities) Aortic abnormalities = think of hand-grip technique like a GORILLA... a) AS = gorilla stands on the valve and PREVENTS any blood from flowing through the valve = DIMINISH AS murmur! b) AR = gorilla stands on the weak regurgitative valve and "falls right through" = ACCENTUATE AR murmur Tricuspid abnormalities = handgrip technique will ACCENTUATE both MS / MR !! "Low volume lovers" (MVP & Hypertrophic cardiomyopathy): a) Hand-grip will ACCENTRUATE MVP murmur b) Hand-grip will resolve hypertrophic cardiomyopathy murmur

OVERALL: When a patient complains of chest pain, what are the MC differentials you should be thinking of?

Heart: -angina -ACS -pericarditis -tamponade -ruptured AA/AAA Lungs: -PE -Pleuritis -Pneumothorax GI: -esophageal spasm -esophageal perforation (Borhaave's Syndrome) -GERD Musculoskeletal: -Costochondritis

Hemorrhoids: What are these? 2 types? MC symptom? Treatment options?

Hemorrhoid vein "VARICES" (rectum) Causes: -chronic constipation (MCC) -pregnancy -obesity -prolonged sitting -HTN 2 types: a) Internal b) External "PAINESS BRBPR" (MC) Treatment: -increase fiber /H20 -Sitz baths -initiate stool softeners -laxatives -surgical removal

Heparin vs. LMWH: a) Benefits of each b) Monitoring parameters c) Contraindications

Heparin (UFH): -MUST monitor aPTT -Higher incidence of HIT LMWH (Enoxaparin, Lovenox) -NO monitoring required -Lower incidence of HIT Contraindication (both): -prior incidence of HIT -pork allergy -active bleeding -aortic aneursym

Budd-Chiari Syndrome: What is this? MCC? MC risk factor? Presentation? Best INITIAL test? Gold standard? TXT?

Hepatic Vein obstruction MCC = thrombosis (clot) MC RF = hypercoagulable state TRIAD: (+) RUQ pain (+) Hepatomegaly (+) Ascites (MC) INITAL test = U/S Gold standard = venography TXT (treat like DVT): -anticoagulation -spironolactone (ascites) -revascularization

Viral Hepatitis: What are the different viruses? Break them down in terms: -acute vs. chronic -routes of transmission -vaccines available -curable or non-curable

Hepatitis A, B, C, D, E Acute (fecal-oral): A, E Chronic (bodily fluid): B, C, D Vaccines: A, B, D Self-limiting (no TXT): A, E Curable: C Non-curable: B, D **realize that Hepatitis D only occurs in conjunction with Hepatitis B

CHRONIC Hepatitis B: Discuss how to interpret: a) HBsAg b) HBeAg c) HBeAb b) HBsAb c) HBcAb

Hepatitis B "surface" antigen (virus itself) (+) HBsAg = 1st MAKER of acute infection Hepatitis B "e" = indicates viral replication (i.e. whether person is INFECTIOUS): (+) HBeAg = (+) now infectious (+) HBeAb = waning infection Hepatitis B "core" = indicates "acute" vs. "chronic" infection: (+) HBcAb (IgM) = acute infection (+) HBcAb (IgG) = chronic infection Hepatits B "surface" ANTIBODY: (+) HBsAb (alone) = immunity

Methotrexate: Biggest ADRs?

Hepatotoxicity Bone marrow suppression (Leukopenia)

Hernias (DIRECT): Outline what "Hesselbach" triangle is?

Hesselbach Triangle created by ("RIP")" -Rectus abdominus -Inferior epigastric vessels -Poupart's (inguinal) ligament

Hordeolum vs. Chalazion: Discuss differences: a) etiology b) presentation c) treatment

Hordeolum = "stye" a) MC = bacterial (staph) b) PAINFUL red, swollen lump c) TXT: warm compresses with (+/-) ABX and I&D (if no spontaneous drainage by 48hrs) Chalazion: a) MC = inflammatory (not infectious) b) PAINLESS edema (upper eyelid) c) TXT = warm compresses

Details (organism vs. TXT) for: a) Human bite b) Dog bite c) Cat bite d) Cat Scratch Fever

Human bite (Eikenella) Dog bite (Pasteurella) Cat bite (Pasteurella) Dog/Cat = "DOGmentin" = Augmentin (amox/calvulanic acid) Human = ampicillin/sulbactam (Unasyn) **REALIZE that "Cat-Scratch Fever": -from cat scratch/bite -BARTONELLA henselae (pathogen) -MC presenation = [non-tender papule @ site] + [regional LAD] -NO TXT (self-limiting)

Humerus Fractures: Discuss main points with: a) Humeral head fx b) Humeral shaft fx TXT?

Humeral head fracture = MUST r/o brachial plexus injury (axillary nerve) (+) "Deltoid sensation" Mid-Humeral Shaft fracture = MUST r/o radial nerve injury (wrist & thumb extension = "wrist drop")

What is the leading cause of death in neonates?

Hyaline Membrane Disease

Pyloric Stenosis: What is this? Epidemiology? Classic symptom? PE? Best (initial test)? Gold standard (test)? TXT?

Hypertrophy of pylorus --> leads to OUTFLOW obstruction of stomach INFANTS !!! (+) "projectile non-bilious" vomiting after eating (+) STILL HUNGRY (+) non-tender "olive" shaped mass (epigastrium) Best INITIAL test = abdominal u/s (b.c. doesn't expose infant to XRT) GOLD STANDARD = Upper GI contrast study (+) "string sign" TXT: a) initial = IVF (rehydrate them) b) definitive = pylorectomy

SHOCK: Review how the following changes in each type of shock: a) CO b) SVR c) PCWP

Hypovolemic: low CO, high SVR, low PCWP Cardiogenic: low CO, high SVR, high PCWP Obstructive: low CO, high SVR, high PCWP Distributive: a) Septic (BUZZ): HIGH CO, low SVR, low PCWP --> eventually will lead to normal LOW CO/SVR/PCWP (when organ failure occurs). b) Neurogenic: low CO, SVR and PCWP c) Anaphylatic = low CO, SVR, PCWP d) Hypoadrenal = low CO, SVR, PCWP

Primary Sclerosing Cholangitis: What co-existing condition is found in 90% cases? What does this condition put you at HIGHER risk for?

IBD (90% will also have ulcerative colitis) PSC = increases risk of cholangiocarcinoma

Polymyalgia Rheumatica: Pathophysiology? Epidemiology? Symptoms? Labs? DX? TXT?

IDIOPATHIC Inflammatory disorder --> bursitis, synovitis, tenosynovitits (PROXIMAL joints) MC = older females (>50yo) Muscle "STIFFNESS" (main feature): MC = neck, shoulder, pelvis BILATERAL Worse in am Worse with rest Classic: "Difficulty brushing hair" "Difficulty putting on coat" "Difficulty rising out of chair" Labs = (+) high ESR DIAGNOSIS of exclusion (must r/o Temporal Arteritis) TXT = low-dose CCS (+/- Methotrexate)

Irritable Bowel Syndrome (IBS): Cause? Epidemiology? Classic presentation? Diagnostic criteria? DX? TXT?

IDIOPATHIC Theorized pathophysiology: Something that causes the GI track to become HYPERSENSITIVE (stress, altered gut microbiota) --> leading to GI spasticity MC = young women -DIAGNOSIS OF EXCLUSION - (all diagnostic tests = normal) Rome Criteria: 1. Must report RECURRENT abdominal pain (minimum 1 day/week for at least 3 months) 2. (and) MUST also report at least 2 of the following: a) AP related to defecation (M C= "relieved by defecation") b) Altered bowel FREQUENCY c) Altered bowel CONSISTENCY CLASSIC patient: "young female presents with recurrent AP + alternating periods of constipation & diarrhea" (-she reports pain is RELIEVED by defecation) TXT (3 components): a) Pain (antispasmodics) = Dicyclomine (Bentyl), Amitriptyline (TCA) b) Diarrhea = Lopiramide (Immodium) c) Constipation = high fiber diet, bulking agents, laxatives (Tegaserod)

Intussusception: What is this? Epidemiology? Cause? Symptoms? PE? DX? TXT?

IDIOPATHIC (but commonly occurs after "viral illness") Intestinal segment INVAGINATION ("telescoping") into adjoining segment MC = CHILDREN TRIAD symptoms: (+) colicky AP (+) vomiting (d/t obstruction) (+) "currant jelly stools" (bloody/mucus) PE = (+) "sausage" shaped mass (MC = RLQ) DX/TXT = Barium Contrast Enema

Fibromyalgia: Pathophysiology? Epidemiology? Main components? DX? TXT?

IDIOPATHIC Central nervous sytem disorder MC = middle-age women Components: 1. DIFFUSE musculoskeletal pain (NOT joint pain) 2. Fatigue 3. Sleep/emotional disturbances Diagnosis of EXCLUSION ! TXT: a) exercise b) SSRI/TCA c) Pregabalin (Lyrica) = ONLY FDA-approved medication **NSAIDS are NOT effective***

Scoliosis: Defined as? Cause? Clues? PE? Gold standard test? Management?

IDIOPATHIC Spine curvature > 10 degrees. MC = to the right MC = young females "CLUES" = (+) uneven hip/shoulders (+) abnormal gait PE = (+) bend forward test Gold standard = XR + COBB angle Management: a) Angulation < 25 degrees = serial XRAYs q6months b) Angulation 25-40 degrees = bracing c) Angulation > 40 degrees = surgical consult.

Patellofemoral Syndrome: Also called? Pathophysiology? MC in who? Symptoms? PE? DX? TXT?

IDIOPATHIC ("Chondromalacia") = "RUNNER'S KNEE" Damage to patellar cartilage (repetitive trauma) --> leads to "mal-tracking" of the patella --> KNEE PAIN MC = runners "Anterior/retro-patellar pain" (+) worse w/ stairs (+) worse w/ prolonged knee hyperflexsion ("sitting") PE = (+) Apprehension test XR = SUNRISE view DX = clinical TXT = REST, NSAIDS, PT

Irritable Bowel Disease: What are the 2 types? MC age of onset? Cause?

IDIOPATHIC (likely autoimmune) 2 types: a) Crohn's Disease b) Ulcerative Colitis MC age of onset = 15-35 years

Juvenile Idiopathic Arthritis: What is this? Prognosis? Symptoms? DX? TXT? What must you regularly evaluate for?

IDIOPATHIC (maybe autoimmune) Presents in CHILDREN Resolves spontaneously < 16yo Presentation = arthritis (but whether monarticular, polyarticular or systemic varies) DX = clinical (+/-) ESR, CRP (+/-) RF (+/-) ANA TXT (same as) = RA **must preserve joint function Health Maintenance: Regular eye exams (evaluate & r/o anterior uveitis) **common complication

Meniere Syndrome: Also know as? Cause? How does it present? Treatment?

IDIOPATHIC Endolymphatic Hydrops (abnormal collection of inner ear fluid) EPISODIC VERIGO (+) hearing loss TXT (reducing fluid): a) Low salt, diuretics b) Medication options: (+) diuretics (loop) (+) carbonic anhydrase inhibitor (acetozolamide = has anticholinergic properties) (+) antihistamines (Meclizine) (+) BZD (last line)

Thoracic Outlet Syndrome: What is this? MC site of injury? Symptoms? PE? Gold standard? TXT?

IDIOPATHIC compression of neurovascular bundle as it exits the narrowed space between shoulder & 1st rib. MC injury = brachial plexus Symptoms: (+) UL arm pain/paresthesias (+) UL arm swelling (+) UL arm discoloration PE = (+) Adson Test (loss of radial pulse w/ head rotated to affected side + arm extended) Gold standard = MRI TXT = PT

Idiopathic Pulmonary Fibrosis: Pathophysiology? Etiology? Epidemiology? Prognosis?

IDIOPATHIC fibrosis (scarring) of the lungs MC = males MC = smokers Prognosis = POOR **most patients DIE within 10 years of diagnosis if they don't receive lung transplant.

Polymyositis / Dermatomyositis: What are these? Features? DX? TXT?

IDIOPATHIC inflammatory condition of STRIATED muscle PM: (+) BL proximal muscle WEAKNESS (+) Can have other system involvement (GI, lungs, heart) = "DYSPHAGIA" (common) DM (rarer) = adds (+) skin involvement (+) Heliotrope rash (purplish/bluish discoloration of upper eyelids) (+) Gottron's Papules (eczematous rashes on knuckles) (+) Photosensitive poikiloderma "shawl" rash (upper shoulders) DX = muscle biopsy (+ endomesial involvement) TXT = high-dose steroids

Sarcoidosis: What is this? Cause? Epidemiology? Symptoms? Labs? PFTs? CXR? Definitive DX?

IDIOPATHIC, multi-system GRANULOMATOUS disease Pathophysiology: exaggerated T-cell response which leads to formation of granulomas which impede organ function MC = YOUNG, black, females MC symptoms affected: a) LUNGS (90%) = restrictive lung disease (chronic NP cough, dyspnea) b) LAD (MC = hilar LAD "butterfly pattern") c) Skin = maculopapular rash, lupus pernio (PATHONEUMONIC), erythema nodosum e) Eyes = uveitis Labs (granulomas secrete ACE & Ca): (+) HIGH ACE (+) high calcium (+) high ESR PFTs = "restrictive pattern" (+) DECREASED TLC, VC, RV (-) NORMAL FEV1/FVC ratio CXR: (+) peri-hilar LAD (buzz) (+) ground glass appearance (pulmonary fibrosis) Tissue biopsy (GOLD STANDARD): (+) NON-caseating granulomas

Otitis Externa: When is systemic Abx indicated? Why? TXT?

IMMUNOCOMPROMISED (to prevent malignant OE) ABX with anti-pseudomonal coverage (best): -ceftipime -ciprofloxacin

HF: Defined as? Discuss the different pathophysiologies?

INABILITY of the heart to maintain sufficient perfusion for adequate organ function HF usually results from an initial: a) "Low output" (decreased CO) b) "High output" (increased CO) Low-output cases: Damage to heart --> leads to impaired cardiac function & DECREASED CO --> body sense this as "low BP" --> over-activation of "sympathetic" nervous system + RAAS system --> leads to fluid overload --> which only increases stress on the heart = leading to more & more damage (vicious cycle) High-output cases: Increased metabolic demands (i.e. O2) --> leading to increased heart activity + INCREASED CO ! (heart is forced to work "overtime" for prolonged times --> leading to hypertrophy & failure)

Meckel Diverticulum: What is the issue with leaving this intact?

INCREASED risk for: -intussception -volvulus

Peripheral Arterial Disease: Discuss the how the disease progresses if unmanaged? What symptom indicates ADVANCED disease

INDICATOR of severe disease = symptoms @ REST Progression of disease: -Claudication with EXERCISE -Progresses to claudication at REST Advanced disease increases risk for: -Acute Limb Ischemia ("Acute Arterial Embolism") -Gangrene (wet vs. dry)

Endometritis: What is this? MCCs? Presentation? Labs? DX? Prophylaxis? TXT?

INFECTION of endometrium (MCC postpartum) Causes: a) Non-obstetric b) Obstetric (PROM, retained conceptual products, c-section) Presentations: 2-3days after delivery (+) high fever & uterine/adnexal pain Labs: (+) HIGH WBC DX: -Empiric therapy is usually started without further imaging -If FAIL to respond to TXT, may want to obtain pelvic/abdominal US or abdominal CT **however U/S aren't very good to detecting this.

Endometriosis: Concern?

INFERTILY

Paget's Disease: Benign or malignant? Presentation? DX? Treatment?

INVASIVE "ductal carcinoma" of nipple Adenocarcinoma (breast) (progresses from ducts -->skin) (+) nipple ulceration (+) nipple eczematous rash DX = biopsy (+) Paget cells TXT = excision + XRT

Dysfunctional Uterine Bleeding (DUB): Pathophysiology? MC in who? Causes? MCC? Diagnosis? TXT (frontline vs. definitive)?

IRREGULAR vaginal bleeding in ABSENCE OF any anatomical abnormalities.... Diagnosis of EXCLUSION...you can only make this diagnosis if you have ruled out the following AND pelvic exam (normal): -r/o pregnancy (MUST test) -r/o fibroids -r/o polyps -r/o cancer Anovulation (MCC): Unopposed estrogen continues to build the endometrial lining --> Without progesterone, no menses occurs --> resulting in irregular shedding (bleeding) when the lining gets too thick. Common associations: a) Menarche/Peri-menopause (hormone levels are abnormal) b) PCOS c) Obesity d) Adrenal hyperplasia FRONTLINE = OCP (provoke ovulation) ALTERNATIVES: -ablation -hysterectomy (definitive)

COPD: Defining feature? Causes? MCC?

IRREVERSIBLE (progressive) OBSTRUCTIVE airway disease MCC (#1) = tobacco exposure (smoker vs. passive exposure) But in non-smokers (must consider): a) Anti-trypsin deficiency (genetic d/o that causes excess mucus production) b) Recurrent lung infections (damages alveoli)

Cirrhosis: What is this? MCCs? Symptoms? Labs? Gold standard? Treatment?

IRREVERSIBLE liver damage Causes: -ETOH (MCC USA) -Chronic viral hepatitis (MCC overall) -Nonalcoholic fatty liver disease (DM, hypercholesterolemia) -Hemochromatosis -Wilson's disease -Budd-Chiari Syndrome SXS = "liver failure symptoms" Labs: (+) high ALT >> AST (+) high unconjugated bilirubin (+) low albumin (best) (+) low PT/INR (+) high ammonia DX (gold standard) = biopsy TXT (definitive = liver transplant) Symptoms management: a) lower albumin = (+) lactulose b) ascites = fluid restriction, spironolactone c) portal HTN = BB, TIPS procedure d) pruritus = (+) bile acid sequestrates (cholestryamine)

Pneumoconioses: What is this? MC types? Symptoms? PFT? Treatment?

IRREVERSIBLE lung fibrosis secondary to repetitive inhalation of an ENVIRONMENTAL toxin.... Types: a) Asbestosis b) Silicosis c) Coal Worker's Lung d) Berylliosis e) Byssinosis Symptoms (vary): -asymptomatic -chronic NP cough -dyspnea on exertion PFT = RESTRICTIVE pattern (decreased TLC, normal FEV1/FVC) TXT: a) avoid toxin exposure b) supportive measures (O2, bronchodilators, steroids)

Dressler Syndrome: What is this? Clinical course? Why is this so important to recognize? TXT?

Idiopathic "post-MI" pericarditis: (1-2 weeks post-MI patient develops severe "pericarditis" symptoms) **looks just like another MI !!! Factors UNIQUE to pericarditis: (+) angina is relieved by leaning forward (+) ST elevation in ALL LEADS (MI usually only in 1-2 leads) (+/-) Fever (+/-) elevated WBC TXT: (+) morphine **this will spontaneously resolve, so TXT is focused on symptoms management (pain)

Fitz-Hugh-Curtis syndrome: What is this? MCC? Presentation? BUZZ findings?

Idiopathic complication of PID (liver involvement) --> hepatic fibrosis & scaring [PID symptoms] + RUQ pain (+) Violin-string adhesions **Diagnosis of exclusion

Cervical Cancer Screening: Discuss how the management of a abnormal PAP differs in a pregnant women..

If you have (+) LGIS (2 options): a) Defer treatment until postpartum b) Get colposcopy (safe in pregnancy) COLPOSCOPY: (+) CIN1 = repeat PAP smear @ postpartum (+) CIN2,3 = manage appropriately

Secondary Amenorrhea: Why is it so important to correct this?

If you have a case with amenorrhea in presence of NORMAL estrogen = this means that you are continuing to BUILD-UP the uterine lining without shedding **this hyperplasia increases chance of endometrial CA (MUST get them to start shedding that lining regularly)

SHOCK (Anaphylactic): Pathophysiology? Treatment? **WHAT must you remember about necessary monitoring for these patients?

IgE mediated MAJOR peripheral dilation ..... Low CO Low SVR Low PWCP Treatment: -IV epinephrine -MONITOR 4-6 hours **important to realize that research shows this clinical course follows a BIPHASIC model (they usually have a 2nd recurrence/decompensation within 4-6 hours = must observe)

DVT: Discuss the appropriate "bridging" of anticoagulation....

Immediately upon DVT confirmation = start UFH/LMWH + Warfarin (at the same time)...... **goal is to wean off UFH/LMWH upon discharge & to have Warfarin levels within therapeutic range at that time.

For any patients with underlying lung disease, what MUST you remember to keep updated?

Immunizations !!! Most important: -influenza -pneumococcal

Infective Esophagitis: MC seen in who? MC pathogens? Workup?

Immunocompromised patients a) Viral (CMV, HSV) b) Bacterial (MC = staph) c) Fungal (candida) Workup: a) EGD + cytology (definitive dx) b) figure out WHY they are immunocompromised

SHOCK (Distributive): Pathophysiology? Types?

Impaired OUTFLOW In general (only exception is Septic shock): -Decreased CO -Decreased SVR -Decreased PWCP Types: a) Septic shock b) Anaphylactic shock c) Neurogenic shock e) Endocrine shock

ACUTE HF exacerbation (inpatient): What is the "risk" associated with using positive inotropic agents?

Improves CO, HOWEVER, if the acute HF is due to underlying cardiac ischemic (CAD, MI), the positive inotropic agent will WORSEN ischemia ! **that is why we RESERVE their use in severe cases (shock)

Spirometry (PFTs): Explain how to interpret the "FEV1/FVC" ratio? What is normal?

In a perfect healthy patient the FEV1 should almost equal the FVC (normal FEV1/FVC ratio > 80%) We see DIMINISHED FEV1/FVC ratios (<80%) when there is an obstruction to air outflow (during expiration) MC = obstructive pulmonary diseases (asthma, COPD)

Crohns Disease vs. Ulcerative colitis (IBD): MC complications?

In general the below complications can occur with either form of IBD, however they are most commonly associated as following.... Crohn's: -abbesses -fistulas -malabsorption (i.e. Fe, VitB12) UC: -toxic megacolon -primary sclerosing cholangitis -COLON CANCER

CAP (Chlamydia pneumonia): Discuss the FRONTLINE medication?

In general, we treat chlamydia infections with EITHER: a) Azithromycin b) Doxycycline Sometimes BOTH will be answers on the boards (general rule): a) chlamydia (inside = PNA) = DOXY (best) b) chlamydia (outside = STI) = AZITHRO (best)

GERD: Workup? Goldstandard? TXT?

In most cases, empiric therapy is started WITHOUT any workup.. LIFESTYLE modification (frontline): -smaller meals -remain upright 30min post-meal -avoid triggers (chocolate, etc.) -loose weight -reduce ETOH -stop smoking Mild GERD: a) OTC therapy (antacids, H2B) = tums, ranitidine, famotidine, cimetidine Moderate/Severe GERD: a) (+) PPI = omeprazole, pantoprazole If patient FAILS empiric therapy, or symptoms worsen (additional workup may be done): a) EGD (1st) b) Esophageal manometry (2nd) c) 24hr pH monitoring (GOLD STANDARD) If d/t hiatal hernia: (+) Nissen Fundlopication

Rank NSAID options from "strongest" --> "least strong".....

In order of STRONGEST --> least strong: -Indomethacin (always answer on PANCE) -naproxen -ibuprofen (least strong)

PREMATURE LABOR: Discuss prophylaxis? Discuss management of active premature labor?

In patients with (+) history of premature labor (prophylaxis): (+) Progesterone (IM/vaginal) until 34 weeks ACUTE premature labor: (+) ADMIT (+) Rest + IVF (+) Tocolytics (suppress uterine contractions) (+/-) Steroids (if L/S < 2:1) Tocolytic options: -indomethacin (NSAID) -nifedipcine (CCB) -MgSO4

Hernias: Discuss overall treatment approach? What signs/symptoms suggest possible "incarceration" or "strangulation"?

Incarceration = hernia is NOT able to be manually reduced ("stuck") (+/-) redness/tenderness @ hernia site (+/-) bowel obstruction symptoms Strangulation (EMERGENCY) = where an incarcerated hernia has not resulted in ISCHEMIA --> leading to bowel necrosis (+) redness/PAIN @ hernia site (+) FEVER (+) bowel obstruction Incarcerated/Strangulated hernias = ALWAYS surgically correct ASAP (emergencies) Inguinal Hernias = usually surgically repaired **prophylactically to reduce risk of incarceration/strangulation Femoral Hernias = ALWAYS surgically repair **highest risk of incarceration/strangulation) Umbilical = "watch & wait" (congenital, usually resolve by age 2) Incisional = variable Spigelian (ventral) = variable

Vitamin K deficiency: BUZZ presentation?

Increased bleeding (petechiae, bruises)

Dermatomyositis: What other condition is this associated with?

Increased incidence of malignancy

Gestational DM: Why isn't glyburide the TOC?

Increased risk pre-eclampsia

ACS: What is defined as a "pathologic Q-wave"?

Indicates "necrosis" (old MI) Q-wave (defined as either): a) > 0.03 sec + 1mV deep b) > 25% QRS complex

"Narrow" QRS: What does this usually indicate? Is it always pathologic?

Indicates the rhythm is coming from the AV node ("junctional" rhythm) **NOT always pathologic: -can be normal (i.e. very highly trained athletes) -BUT may be secondary to something else (myocarditis, CAD, digoxin/BB/CCB toxicity)

Aortic Stenosis: Discuss the pros/cons of management options?

Indications for surgery: a) symptomatic b) EF < 50% AV replacement (ONLY definitive TX): a) Mechanical valve = more durable, BUT higher thrombotic risk (requires AC for life) b) Bioprosthetic valve (i.e. bovine, etc.) = less durable, LESS thrombotic risk) Temporary solutions: a) Percutaneous Aortic Valvuloplasty (PAV) = >50% restenosis rate b) Intra-aortic balloon pump

COPD: When is supplemental O2 indicated? Goals? What must you remember about this?

Indications: -O2 saturation < 88% -pO2 < 55mmHg -(+) pulmonary HTN/cor pulmonale GOAL = pulse ox > 90% (nasal cannula, BiPAP, or CPAP) **do NOT want them depended on high flow O2 (see below) REMEMBER that while O2 therapy can be used, NEVER prescribe "continuous high flow" O2 **this will cause a COPD patient to STOP breathing (their only drive to breath is the chronic hypoxic state they are used to = take that away & their respiratory drive will fail)

Hernias: Discuss the main points associated with each: a) Indirect Inguinal b) Direct Inguinal c) Femoral d) Umbilical e) Incisional f) Spiegelian

Indirect (MC type): a) Herniation through INTERNAL inguinal ring (due to patent process vaginalis) b) Origin = LATERAL to inferior epigastric artery (EXTENDS into the scrotum) c) MALES Direct Inguinal: a) Herniation through Hesselbach Triangle (d/t weakened floor of inguinal canal) b) Origin = MEDIAL to inferior epigastric vessels (DOES NOT extend into the scrotum) Femoral: a) Herniation through femoral ring (d/t weakness) b) MC = females c) HIGHEST risk of incarceration/strangulation Umbilical: a) Herniation through umbilical fibromuscular ring b) CONGENITAL Incisions: a) Herniation through prior surgical incision site. b) RF = obesity Spigelian "Ventral" hernias: a) Herniation through rectus abdominus muscles

Hernias: What is the MC TYPE?

Indirect Inguinal Hernia

Induction of Labor: When is this appropriate? Discuss the main steps... Contraindications?

Induction of labor is appropriate: -increased risk to mom or baby with prolonged pregnancy -failure to progress STEPs: 1. Give Cytotec (Misoprostol) vaginal suppository to cervix to "prime it" (soften, dilate) 2. Give Oxytocin (Pitocin) to increase uterine contractions 3. Amniotomy ("break the bag" "strip the membranes) CONTRAINDICATIONS: -prior uterine rupture -prolapsed cord -ACTIVE herpes infection -transverse fetal lie -placenta previa/abrupto

Parotitis: MCC? Classic symptom? PE? Treatment?

Infectious: Mumps (MCC), TB Sjogren's "PAIN WITH CHEWING" (+) parotid gland TTP TXT = supportive

ACS: Which MI location is the MOST COMMON? What atypical symptom can this present with?

Inferior / Posterior = RCA (+) epigastric pain !!! (RCA vessels/nerves sit on the diaphragm)

Mitral regurgitation: What TYPE of MI is usually associated with this?

Inferior MI

Uveitis (Iritis): MCC? MC treatment?

Inflammation / Infection (iris) Usually secondary to AUTOIMMUNE or systemic issue....(example = Sarcoidosis) Flurosciene stain = (+) cells & flares (WBC & proteins floating around in the acqeous humor) TXT (MC) = steroids

Optic Neuritis: What is this? #1 MCC? BUZZ presentation? PE? TXT?

Inflammation / infection (optic nerve) #1 MCC = multiple sclerosis (MS) **other causes are usually AUTOIMMUNE (i.e. SLE)** "VISION LOSS" (+) Marcus-Gunn Pupil TXT = Steroids (PO vs. IV) (good prognosis for return of vision) **"marcus-gunn pupil = "a Relative Afferent Pupil" "When you shine Ray of light into Unaffected eye, BOTH eyes dilate"

Bicep Tendonitis: PE finding? TXT?

Inflammation of LONG-head bicep (+) Yergason's Test TXT = NSAIDS +/- steroid injections

Myocarditis: Causes? MCC? Symptoms? Diagnostic tests? Gold standard? Treatment?

Inflammation of heart MUSCLE #1 cause = VIRAL -MCC = Coxsackie virus -others = Influenza, EBV, CMV Other causes: a) Autoimmune (SLE, RA, UC) b) Systemic (hypothyroidism, uremia) c) Medication induced (Abx, HCTZ, methyldopa, sulfonamide, lithium, cocaine, chemo drugs). d) Toxic (scorpion venom, diptheria toxins) Symptoms: [viral sxs] + 1-2 weeks later [Fever + MI/HF sxs] (MC sxs = fever, SOB, palpitations) Diagnostic tests: (+) elevated CKMB/Troponin (+) elevated ESR (+) cardiomyopathy (CXR/ECHO) (+) ventricular dysfunction (ECHO) Best INITIAL test = ECHO Gold standard = endomyocardial BX (+) lymphocyte infiltration (if viral) (+) myocardial tissue necrosis TXT: (+) supportive (HF symptoms) (+) treat underlying cause

Influenza: 2 types? Which is more severe? Manifestations? DX? Treatment?

Influenza A (most severe) Influenza B Infection can result in a wide array of MANIFESTATIONS: -URI -Pneumonia -"Flu" (severe N/V, myalgias) DX: a) rapid (nasal swab) b) viral culture (IFA/ELISA, DFA) TXT: a) supportive (analgesics) b) Neuraminidase Inhibitors (end '-vir" = Oseltamivir = "Tamiflu") may be used WITHIN 48hrs onset **realize that the below 2 antivirals are NO LONGER recommended d/t high resistance: -Amantadine -Rimantadine

Asthma: What is the treatment of choice for PREGNANT patients?

Inhaled mast-cell stabilizer (Cromolyn) **best safety profile

CAD: Which drug is best in preventing PROGRESSION to ACS? Which drug is best at reducing MORBIDITY/MORTALITY?

Inhibits progression = ASA Reduces M/M = BB

ACS: Discuss the appropriate: a) Initial treatment (in ER)? b) What should all patients be discharged on?

Initial TXT (in ED): a) obtain EKG (within first 10 min) b) "MONA-B" treatment = morphine + O2 + NTG + ASA + BB Discharged: a) Antiplatelet b) BB or CCB c) Statin d) ACEi/ARB

Peripheral Arterial Disease: Discuss the appropriate workup? Gold standard?

Initial workup: a) ABI (< 0.9 indicative of PAD) b) LE arterial duplex Gold standard = arteriography

Back Muscle Strain: MOI (MC)? Classic symptoms? Treatment?

Injury to PARASPINAL muscles (MC = heavy lifting or twisting) NONSPECIFIC pain +/- spasm Lasts < 4 weeks (-) XRT of pain NO neurologic symptoms NO bowel/bladder dysfunction PE = (+) paraspinal TTP (+/-) spasm DX = clinical TXT = rest, NSAIDS, muscle relaxants

Gamekeeper Thumb: What is this? MOI? Symptoms? PE? Concern? TXT?

Injury to ULNAR COLLATERAL ligament (UCL) MOI = FORCED ABduction thumb ("Skier Thumb") (+) Thumb pain (+) Weakened "pincher" strength Concern = (+/-) AVULSION FX (proximal phalynx) TOC = thumb spica + REFERRAL to hand surgeon

MURMUR (basics): Discuss how inspiration & expiration the accentuation of murmurs?

Inspiration = (+) accentuates RIGHT-SIDED murmurs Expiration = (+) accentuates LEFT-SIDED murmurs During inspiration, the blood flow to the RA/RV >>>> LA/LV **this should make sense b.c. as we inspire, the goal is to INCREASE O2, so the priority for the body is to bring as much "deoxygenated" blood to the RIGHT side of the heart so that it can make it to the lungs & pick up O2 During expiration, the blood flow to LA/LV >>>> RA/RV **the priority now is to get all the oxygenated blood from the lungs --> body (need the left-side to work harder)

Hyaline Membrane Disease: Pathophysiology? Risk factors?

Insufficient SURFACTANT production --> which leads to alveolar compromise & respiratory distress Risk factors: -Premature infants (MCC) -Gestational DM -Multiple births -C-section (stress response) **realize that HIGH insulin levels during gestation = impedes surfactant production.

Peptic Ulcer Disease (PUD): MC symptoms? Gold standard? TXT?

Intermittent "epigastric" discomfort a) stomach ulcer = WORSE with food b) duodenal ulcer = BETTER with food GOLD STANDARD = EGD + biopsy **MUST r/o cancer TXT: a) (+) H.pylori = PPI + 2ABX b) (-) H.pylori = -r/o Zollinger-Eillison Syndrome -r/o cancer -Supportive (H2B, PPI, carafate, sulcralfate) -Surgical options (vagotomy, Bilroth II)

Influenza (vaccine): 2 types? CI?

Intranasal (live "attenuated") IM vaccine (dead) General CI: -egg or gelatin allergy -currently ill Intranasal (live) vaccine is CI: -pregnant -immunocompromised (i.e. DM) -underlying lung/cardiac disease

COPD: What is the difference between: a) Ipratropium (Atrovent) b) Tiotropium (Spiriva)

Ipratropium (Atrovent) = SHORT-acting inhaled anticholinergic Tistropium (Spiriva) = LONG-acting inhaled anticholinergic

Primary HTN: Which of the following indicates a GREATER risk for CVD in a patient > 50yo: a) isolated SBP > 140 b) isolated DBP > 90

Isolated SYSTOLIC BP

What is the difference between: a) Jefferson fracture b) Hangman fracture

Jefferson ("was #1") = C1 "burst" fracture **d/t SEVERE "equal" downward force on head (i.e. falling on head) Hangman = BL fractures through the pedicles of C2. **d/t severe hyperextension.

Epistaxis: If you see RECURRENT nose bleeds in a adolescent male, what should you evaluate for?

Juvenile Nasopharyngeal Angiofibromas (JNA): -benign vascular tumor -AGGRESSIVELY growing -"recurrent UL epistaxis"

Anti-arrhythmics (class III): 2 MC drugs? What is unique about these?

K+ channel blockers: -Amiodarone -Dronedarone Considered FRONTLINE in many situations because has properties of ALL 4 classes of anti-arrhythmics Indications: -atrial arrhythmias -ventricular arrhythmias Downside: -LOTS ADRs -LOTS of DDI

Acute Pericarditis: What does the "Knuckle sign" indicate?

KNUCKLE sign = reciprocal PR elevation & ST depression (in AVR) **reflective of ATRIAL injury

What other LE injuries have a high incidence of NEURO-VASCULAR injury?

Knee dislocation Tibial Plateau fracture Proximal fibular fracture

Discuss the testing for: Recall how to test for the: a) Tibial nerve b) Superficial peroneal c) Deep peroneal What would the below injuries look like: a) L4 injury b) L5 injury c) S1 injury

L4 (injury = "foot drop" / loss knee jerk): a) Sensory = anterior thigh, medial foot b) Motor = foot dorsiflexion c) DTR = patella (knee jerk) L5 (injury = "heel walking") a) Sensory = lateral thigh, 1st dorsal web space b) Motor = big toe dorsiflexion/extension c) DTR = none S1 (injury = loss of ankle jerk): a) Sensory = posterior calf + lateral foot b) Motor = plantar flexion c) DTR = achilles reflex _________________________________________________ Superficial peroneal nerve (L4-S1): a) Sensory = anterior shin b) Motor = ankle eversion Deep peroneal nerve (L4-L5): a) Sensory = 1st dorsal webspace b) Motor = Foot dorsiflexion + toe extension ("foot drop") Tibial nerve (S1-S2): a) Sensory = bottom of heel b) Motor = ankle inversion

Atrophic Vaginitis: Pathophysiology? MC in who? Presenting symptoms? PE? DX?

LACK of estrogen = leads to vaginal tissue becoming: -thin -dry -friable MENOPAUSAL women (MC) Breastfeeding women Presenting symptoms: (+) vaginal irritation (+) dysuria (+) vaginal spotting (esp. after sex) (+) dyspareunia PE (vaginal skin will look): (+) dry & thin (+) shiny, smooth, friable (+/-) fissures DX = clinical

Epicondylitis: Compare & contrast: a) Lateral epicondylitis b) Medial epicondylitis

LATERAL ("tennis" elbow): -inflammation of extensor carpi radialis brevis muscle -MOI = repetitive wrist EXTENSION -(+) TTP over lateral epicondyle MEDICAL ("golfers" elbow): -inflammation of the pronator teres-flexor carpi radialis -MOI = repetitive wrist flexion (+) TTP over medial epicondyle TXT (both): a) Conservative = rest, counterforce bracing, Volar splint, ice, NSAIDS, steroid injections b) Surgery (refractory cases)

Low back pain: Should you always order XRAYs? What are some "red flags" that indicate need for immediate workup?

LBP (MCC) = muscle strain **usually resolves within 4 weeks Get XRAYS if (+) "Red Flags": 1. Known TRAUMA 2. Markedly limited ROM 3. Noticeable "deformity" (step-off) 4. Weight loss 5. History of cancer 6. Bowel or bladder dysfunction 7. Constitutional symptoms 8. Focal neurologic symptoms (LE weakness, etc.) 9. "Saddle Anesthesia" 10. Symptoms > 4 weeks

LDL: Discuss how LDL goals change in different patient populations?

LDL goal (optimal) < 100 mg/dL BUT more specific goals: a) General population or 1 RF = < 160 b) General population or 2 RF = < 130 c) High risk population (CAD, DM) = < 100 d) Metabolic syndrome = < 70 Risk factors: -smokers -HTN -FHX premature CAD -Age (>45 men, > 55 women)

Cervical Cancer Screening: If you get (+) CIN 2, 3 (HGILS) what is the appropriate management?

LEEP excision Cone knife biopsy Laser ablation

CAP: What is the MC pathogens in: a) Patients < 40 years old b) Patients > 40 years old

LESS 40 years (MCC) = Mycoplasma pneumoniae (atypical "walking pneumonia") OLDER 40 years (MCC) = Streptococcal Pneumoniae

HMG-CoA reductase inhibitors: What do you need to regularly monitor for someone who is on a statin?

LFTs CPKs

Menopause: Increases risk of what? MC symptoms? What know thing is proven to reduce symptoms?

LOSS of estrogen is associated with both an increased risk for OSTEOPOROSIS + women then lose their "CVD" protection (now their risk equals men's risk) Symptoms: (+) amenorrhea (+) insomnia (+) weight changes (+) vasomotor (hot flashes) (+) decreased libido (+) urogenital atrophy (+) mood disturbances **EXERCISE is known to ameliorate symptoms.

Discuss how each of the following presents: a) hypokalemia b) hyperkalemia c) hyporcalemia d) hypercalemia

LOW K+ = (+) wide QRS (+) flattened t-waves (+) U-wave HIGH K+ = a) Initially = (+) peaked t-waves, narrow QRS b) Eventually will progress to asystole (wide QRS --> asystole) LOW Ca+ = (+) prolonged QT interval HIGH Ca+ = (+) shortened QT interval

Endometrial & Ovarian Cancer: What is a KNOWN protective factor for both of these? Explain....

LT OCP usage: a) Endometrial cancer = keeps endometrium thin b) Ovarian cancer = suppresses ovulation

Mitral Stenosis: What is unique about this ECHO (compared to other valvular abnormalities)?

LV function = NORMAL

GOUT: Labs? XRAYs? Diagnostic test? TXT (acute flare vs. maintenance)? FRONTLINE?

Labs: (+) elevated [uric acid] (> 8.0) XRAY: (+) punched out lesions ("tophi") DX = JOINT aspiration (+) negatively birefringent needle-shaped rod ACUTE flare (TXT) = rest, hydration, NSAIDS (DO NOT start uric-acid lowering therapy during acute attack) **Reduce risk factors = avoid ASA, ETOH, red meat FRONTLINE = NSAIDS (Indomethacin >> Naprosyn >> Colchicine) ADJUNCTIVE THERAPY (uric acid lowering therapy): 1. Xanthine Oxidase Inhibitors (Allopurinol, Febuxostat "Uloric") 2. Uricosuric Drugs (Probenecid)

Lactose Intolerance: Cause? Epidemiology? Symptoms? Diagnostic test? TXT?

Lack enzyme needed to DIGEST lactose (mild-containing products) MC = AA, Asian, S. americans Symptoms: "colicky AP + flatulence + loose stool" (when ingesting lactose) DX = Hydrogen Breath Test (if you are truly lactose intolerant --> the undigested lactose will be fermented by GI bacteria and will give off EXCESS H+) TXT: lactose-free diet

Menopause: Defined as? Caused by? Mean age?

Lack of periods > 1 year FSH > 30 OVARYS stop ovulating = leads to drop in ESTROGEN (mean age = 50)

SHOCK: What lab should you always order? Intepretation?

Lactic Acid when body is lacking oxygen (decreased profusion) --> increased in anaerobic metabolism = INCREASE Lactic Acid --> metabolic acidosis Lactic Acid > 2.0 = hypo profusion

Vitamin D deficiency: Discuss the BUZZ presentation...

Leads to SOFTENING of bones... CHILDREN = "Rickets" (bowing legs) ADULTS = Osteomalacia (fractures)

Gestational DM: What marker can be ordered to assess for lung maturity? Normal value?

Lecithin-Sphingomyeline (L/S ratio) L/S ratio > 2 = NORMAL lung development

L-sided HF: Symptoms? PE?

Left HF (results in): a) Decreased CO b) Pulmonary congestion Symptoms: (+) dyspnea (MC) (+) orthopnea (+) chronic non-productive cough (+) pink/frothy sputum (surfactant) (+) fatigue PE: (+) pulmonary congestion (rales/rhonchi) (+) Cheyne-Stokes breathing (+) S3 or S4 (+) cool extremities (decreased CO)

ACS: What MI location is known as the "Widow maker" ? Why?

Left coronary artery (LM) (EKG changes will be similar to LAD MI) Called the "widow" maker because LM artery splits off into BOTH LAD & Left Circumflex = so occlusion of this site results in knock out of BOTH these vessels and usually results in death.

Discuss the major differences between: a) Legg-Calve-Perthes b) Slipped Capital Femoral Epiphysis Best INITAL test?

Legg-Calve-Perthes (aka "AVN (kids = MC young boys)") IDIOPATHIC (+) MC = unilateral (+) PAINLESS limp in children (+) Decreased ROM (hip lies INTERNALLY rotated) (+) Trendelenberg sign TXT (most will spontaneously resolve within 2 years) = close ORTHO F/u, protective weight bearing, bracing, Bisphosphonates Slipped Capital Femoral Epiphysis (adolescents = MC boys) -weakening of epiphysis (usually during GROWTH SPURT) leads to "slipping" or displacement of the femoral head off the femoral neck (+) MC = bilateral (+) PAINFUL limp (+) Decreased ROM (hip lies EXTERNALLY rotated) TXT = pinning-in-situ (SURGERY) BEST initial test: XR pelvis (AP + frog-leg lateral) views

Asthma: Why is Levalbuterol considered BETTER than Albuterol?

Levalbuterol = isomer of albuterol (preferred b.c. has less incidence of reflex tachycardia) **but usually not as well covered by insurance (why Albuterol is still frontline)

Streptococcal (pneumococcal) pneumonia: Which ABX has been shown to cause "drug-resistant" pneumococcal pneumonia in smokers when used as 1st LINE therapy?

Levofloxacin (Levaquin)

Colorectal Cancer: What is the MC site of metastasis?

Liver

QRS complex: Discuss how to evaluate these?

Look at leads = V1, V6 QRS (normal) = < 0.12 sec Assessing for: a) shape of QRS b) length (narrow, normal, wide) Wide QRS (>0.12sec) assess for: a) BBB b) ventricular hypertrophy c) K+ level d) WPW Lead V1 (right side heart): a) (+) R' = RBBB b) R-wave > S-wave = RVH Lead V6 (left-side heart): a) (+) R' = LBBB b) R + S > 30-35mm = LVH **women > 30mm **men > 35mm

SHOCK (hypovolemic): Discuss what lab value can be used to distinguish between fluid loss vs. blood loss?

Look at the "H/H" values.... (+) Fluid loss = normal to HIGH H/H (body tries to increase how concentrated the blood is (i.e. increase RBC production) in effort to retain more H20 & thus restore volume) (+) Blood loss = DECREASE H/H

ST-elevation: What is a "trick" used sometimes to differentiate worrisome ST-eelvation (ischemia/infarction), from other causes...

Look at the "shape of the ST-elevation: a) Convex down ("sad face") = ISCHEMIA b) Concave up ("happy face" ) = usually another cause (i.e. pericarditis, BBB, etc.)

P-wave / PR interview: Discuss how to evaluate these?

Look at these leads: LEADS 1, 2, AVR **realize that the p-wave comes from SA node & represents atrial function. NORMAL EKG: a) p-wave should be UPRIGHT (+) in all leads, except AVR b) p-wave should be single hump c) PR interval should be 0.12-0.20sec ABNORMAL findings: a) ATRIAL enlargement = "m-shaped," "biphasic" or tall p-wave b) AV-heart block = prolonged PR interval

Sarcoidosis: How will some people describe "Lupus Pernio"?

Looks like frost-bite

SHOCK (hypovolemic): -Pathophysiology? -Etiologies -Treatment?

Loss of blood volume --> leads to decrease in CO to try and re-establish profusion to organs.... -LOW CO -HIGH SVR (vasoconstriction) -LOW PCWP MC etiologies: a) severe dehydration (N/V, severe burns) b) major blood loss Treatment: -ABCDE -Fix underlying cause -IVF +/- blood transfusions

Lung Cancer: MC risk factor? Types? MC? Worst prognosis? MC locations of METs?

Lung CA = leading cause of cancer DEATH (USA) MC risk factor = SMOKING Types: a) Small cell lung cancer (highest rate of EARLY metastasis) b) Non-small cell lung cancer: -squamous cell carcinoma -adenocarcinoma (MC) -large cell carcinoma (very aggressive) MC areas of metastasis: -lymph nodes -brain -bone -liver -adrenals

Lung Cancer: Discuss the MAIN distinguishing features between: a) Lung Cancer b) Mesothelioma What diagnostic test can help distinguish these?

Lung Cancer (85% of all lung CA): (+) cancer of lung tissue (+) association w/ smoking (+) elevated CEA Mesotheioloma (15% of all lung CA): (+) cancer of lung PLEURA (or peritoneum) (-) NO association w/ smoking (+) associated w/ ASBESTOS (-) normal CEA **realize that Carcinoembryonic antigen (CEA) is elevated only with cancer of the LUNG TISSUE (will be normal in mesotheioloma)

If you see chlamydia symptoms + "buboes" what is this?

Lymphogranuloma venereum (LGV)

Crohns Disease vs. Ulcerative colitis (IBD): Treatment options?

MAINTENANCE THEARPY: 1. Start Aminosalicylate (maintenance therapy): -Mesalamine "Pentasa" (PO, suppository) -Sulfasalazine (more ADRs) 2. If patient shows no improvement / continues to have flairs SWITCH to immunmodulator ("step-up"): -Methotrexate -Anti-TNF drugs ("-mabs") = Adalimumab, Inflixima ____________________________________________ ACUTE FLAIRS: (+) Corticosteroids (+/-) ABX (metro) ___________________________________________ Surgical options ONLY available for Ulcerative Colitis (colectomy)

Klinefelter's Syndrome: What is this? HALLMARK? Symptoms? Increased risk for? TXT?

MALE born with "extra" X chromosome: a) normal = XY b) Klinefelters = XXY HALLMARK = Hypogonadism (low testosterone) + small testicles This condition can go undiagnosed until adulthood, because symptoms are very mild (scare pubic hair, small testicles, gynecomastia) MC symptom that results in diagnosis = INFERTILITY TXT = (+) TESTOSTERONE INCREASED risk for TESTICULAR cancer

Bone tumors: Malignant ones? Benign ones? What cancers MC metastasize to bone?

MALGINANT: -multiple myeloma -osteosarcoma (MC) -ewing sarcoma -chondrosarcoma BENIGN: -osteochondroma (may be precancerous) Metastatic cancers: -breast -lung -prostate -kidney

BREAST CANCER: What is the current recommendation for mammogram screening? Why are routine mammograms so important?

MAMMOGRAMS are very important when you realize that masses usually aren't palpable until they are > 1cm (therefore mammograms can catch early stage disease) Ages 40-44 = OPTIONS (women can choose to start having annual mammograms) Ages 45-54 = RECOMMEDNED **obtain annual mammograms Ages 55+ = can either space out q2years or continue with annual mammogram screening

Mean Arterial Pressure (MAP): a) Equation? b) What does this reflect? c) Normal range? d) Limitation?

MAP = (CO x SVR) MAP = (SBP) + 2(DBP) / 3 Reflects "blood PROFUSION" (organs) MAP > 60mmHg is needed for adequate profusion. LIMITATION: In cases where the SVR is very high (shock), the MAP can be falsely elevated.....

Herniated Disc: MC location? Symptoms? PE? Gold standard test? TXT? Concern?

MC = @L5-S1 RADIATING pain (along dermatome) that is WORSENED by "coughing, sneezing, Valsalva": (+) sensory deficits (+) motor deficits (+) diminished DTRs PE = (+) straight leg raise (reproduces pain) GOLD STANDARD = MRI (however, usually try conservative measures first unless "reg flag" present) TXT: -rest, heat/ice -NSAIDS +/- muscle relaxants -Steroid injections -PT -Surgical decompression Untreated / severe cases --> CAUDA EQUINA syndrome (emergency)

Endometrial Cancer: MC type? MCC? Epidemiology? Risk factors? MC presentation? DX? TXT?

MC = Adenocarcinomas MCC = unopposed ESTROGEN (caused chronic endometrial hyperplasia) MC = older, white POST-MENOPAUSAL women (78%) Risk factors: -obesity -no prior children -late menopause -unopposed estrogen therapy -PCOS MC presentation = "POSTMENOPAUSAL" bleeding DX = endometrial biopsy TXT = TOTAL hysterectomy + BL salpingo-oophrectomy

What is the MOST COMMON gynecologic cancer? Which gynecologist cancer has the highest mortality?

MC = Endometrial cancer Highest mortality = Ovarian cancer

POSTERIOR Epistaxis: MC area? RF? TXT?

MC = Palatine artery RF = HTN, atherosclerosis DIRECT PRESSURE (frontline) BUT higher risk of complication (vs. anterior) so most commonly: a) Admit b) Posterior packing + ABX c) Consider arterial vessel ligation (if recurrent or refractory) Packing > 24 hrs = RISK for toxic shock (packing should be removed within 24 hours + add ABX to reduce risk) ABX = cephalosporin / clindamycin

Ectopic pregnancy: MC location? MCC? Risk factors?

MC = TUBAL (i.e. fallopian tube) (95%) MCC = adhesions / scarring Risk factors: a) Prior ectopic pregnancy b) PID c) Prior intrauterine or intra-abdominal surgery d) IUD

AAA: Presentation? Workup? Diagnostic test of choice? What other condition can this look identical to?

MC = asymptomatic (+) tender, pulsatile abdominal mass Symptoms usually indicative of rupture: (+) SEVERE abdominal or back pain (+) hemodynamic instability (+) Flank ecchymosis Workup: a) Abdominal U/S (1st study) b) Angiography (gold standard) **REALIZE AAA (ruptured) can look very similar to severe case of kidney stones

Developmental Hip Dysplasia: MC risk factor? PE? TXT?

MC = breech delivery PE: (+) Ordalani/Barlow manuever (+) Galeazzi test TXT = Pavlik harness +/- surgery

Ovarian Cancer: MC type? Risk factors? Epidemiology? Symptoms? Dx? TXT?

MC = epithelial tumors Risk factors: 1. BRCA associated tumor --> h/o BRCA mutations (family) and/or LYNCH syndrome (colorectal cancer) increase risk of ovarian cancer 2. RISK increases with the MORE ovulatory cycles you have (MC = older white women) HIGH RATE OF METASTASIS (symptoms highly varied): (+) fixed abdominal mass (+) "Sister Mary Joseph" nodule (metastasis to umblicus) DX = biopsy TXT = resection

Rheumatic Fever: MC valve affected? What should you know if the aortic valve is involved?

MC = mitral valve **but know that the 2nd MC valve = Aortic valve (research has shown that if someone has aortic valve involvement they almost ALWAYS have tricuspid valve involvement too)

Olecranon Dislocation: MC type? Concern? TXT?

MC = posterior **ANY INJURY TO ELBOW** (worry about neurovascular injury) TXT = reduction ASAP!

Ankle Dislocation: MC type? What must you r/o? TXT?

MC = posterior RULE OUT PERONEAL NERVE INJURY TXT = closed reduction + splint

Bisphosphonates: MC ADR? Most serious ADRs?

MC ADR = esophagitis (important to educate patietns to take with FULL glass H20, 30 min before food & remain upright 30 min after taking) Most severe ADRs: 1. Jaw necrosis 2. Atypical fractures (MC = femur)

BREAST CANCER: MC presenting symptom? BUZZ symptoms? MC site of metastasis? Workup?

MC presenting symptom: (+) discrete, hard, fixed, non-tender breast mass (MC location = upper outer quadrant) Other unique BUZZ findings: (+) inverted nipple (+) pitting skin (dimpling) (+) nipple eczematous rash (+) bloody nipple discharge (+) skin discoloration (Peu d'orange d/t lymphatic obstruction) #1 site metastasis = REGIONAL lymph nodes (AXILARRY) (+) axillary LAD (bad sign) Best SCREENING test = mammography BEST initial diagnostic test = breast u/s DEFINITIVE diagnostic test = FNA + biopsy

Diverticulosis vs. Diverticulitis: MC risk factor? MC location? Differences? MC symptoms? Scan of choice? Gold standard? Treatment?

MC risk factor = chronic constipation MC location = sigmoid colon Scan of choice = CT scan Gold = colonoscopy Diverticulosis (VERY common): -small "out-pouching" of colon wall -Asymptomatic (MC) -Intermittent "PAINLESS HEMATOCHEZIA" (large volume) -TXT = increase H20, avoid constipating foods (nuts, popcorn), stool softeners Diverticulitis (acute flair): -Usually results from FB (MC = fecalith) getting trapped in a diverticula w/ secondary infection -"LLQ colicky pain" + fever" -May present w/ peritonitis (if results in perforation) -TXT = ADMIT (NPO + IV ABX ) -ABX = Metro + Cipro/Bactrim

VSD: MC type? Pathophysiology? Symptom? PE? Diagnostic test of choice? Treatment?

MC type = perimembranous (80%) -Hole exists between Right & Left Ventricles -Results in LEFT --> Right shunting = pushing of OXYGENATED blood into the right ventricle -Eventually may result in pulmonary HTN Symptoms: a) asymptomatic (MC) b) fatigue w/ feeding (d/t decreased CO) c) inadequate growth (d/t decreased CO) d) freqeunt respiratory infections PE: (+) harsh HOLOSYSTOLIC murmur (best @ LLSB) Diagnosis = ECHO (best) MOST close spontaneously (consider surgical closure for large defects +/- severe symptoms)

HF: Breakdown etiologies... MCC overall ?

MCC = CAD Low-output cases (cardiac etiology): -CAD (ischemia/infarction) -HTN -Valvular dysfunction -Cardiomyopathies High-output cases (non-cardiac): -Thyrotoxicosis -Severe anemia -Wet Beriberi (thiamine B1 deficiency) -Paget's Disease of bone

Corneal Abrasion: MCC? Symptoms? What should be checked 1st? Gold standard? Treatment?

MCC = FB or trauma ("contact lenses, etc.) Symptoms: (+) "FB sensation" (+) "localized corneal injection, pain, tearing" Management: -Check VISUAL acuity (1st) -Instill analgesic drops + Fluroescein stain (GOLD standard) -Remove FB (if applicable) -ABX drops (to prevent secondary infection ) -OPTHAL f/u within 24hrs ABX drops: (+) Erythromycin ointment (+) FQ (especially if contact lens) (+) AG

Acute Epiglottis: MCC? Epidemiology? Symptoms? CXR? Gold standard? TXT?

MCC = Haemophilus Influenzae B (Hib) **incidence reduced d/t presence of vaccine MC = kids Symptoms (3Ds): (+) Dysphagia (+) Drooling (+) Distress (tripoding, stridor) CXR (Lateral neck): (+) "thumb print sign" Gold standard = LARYNGOSCOPY (both diagnostic/therapeutic) TXT: a) MAINTAIN AIRWAY (most important) = keep child calm +/- intubation b) Dexamethasone c) ABX (Hib + Staph coverage) = cephalosporin + PCN/VANCO

Appendicitis: MCC? MC ages? Symptoms? PE? Diagnostic test of choice? Treatment?

MCC = fecalith (trapped) MC = ages 10-30 yrs (+) Peri-umbilical pain --> eventually localizes & intensifies in RLQ (+) SEVERE anorexia ("hamburger sign") (+/-) N/V (+/-) Fever PE: (+) McBurney' point tenderness (+) Rovsing sign (RLQ pain w/ LLQ palpation) (+) Psoas sign (RLQ pain w/ hip flexion/extension) (+) Obturator sign (RLQ pain w/ hip rotation) BEST initial test = U/S Diagnostic test of choice = CT + contrast Treatment: -ADMIT -IVF + NPO -Appendecomy

Secondary Amenorrhea: MCC? Discuss the appropriate workup & other potential etiologies...

MCC = pregnancy !! Workup: a) pregnancy test b) progesterone challenge c) TSH d) Prolactin level e) FSH, LH (-) Preg (+) Withdrawal bleed: (normal estrogen, normal FSH): -check LH levels -HIGH LH = PCOS -Low/normal LH = Ashermann Syndrome, hypothyroidism (-) Preg, (-) Withdrawal bleed: (NO estrogen): -check FSH levels -HIGH FSH = ovarian failure, menopause -Low/normal FSH = HPO axis dysfunction

Bacterial conjunctivitis: Possible pathogens? MC? TXT options? In a contact lens wearer, WHAT should you always cover for?

MCC = staph aureus MCC preschool = h. influenzae MOST worrisome: -chlamydia ("inclusion" conjunctivitis) -gonorrhea CONTACT lense wearers: -pseudomonas (+ FQ drops) TXT (rules): a) Non-CC/GC = drops = Macrolid, FQ, AG drops b) (+) CC/GC = PO (systemic) = Erythromycin c) (+) Contact lense wearer = FQ drops

Mastitis: MCC? MC in who? Presentation? DX? Treatment?

MCC = staph aureus MC = lactating mothers (+) UL breast erythema, edema, warmth, tenderness (+/-) fever or systemic symptoms DX = clinical (culture is NOT routinely done) TXT: (+) Tell mother to CONTINUE to breast feed (+) warm compress (+) empiric ABX (Naficillin, cephalosporin)

Iliotibial Band (ITB) Syndrome: MC in who? MC symptom? TXT?

MCC knee pain in RUNNERS "LATERAL knee pain" TXT = REST + NSAIDS + PT

Pericardial Effusion: MCCs? Symptoms? PE? EKG? Workup? Treatment?

MCCs: -severe/untreated pericarditis -malignancy -TB -XRT/chemo Symptoms/PE: [pericarditis symptoms] + ["muffled/distant heart sounds"] EKG: (+) sinus tachycardia (+) electrical alternans (BUZZ) = alternating QRS amplitudes (+) low-voltage QRS **must get ECHO or cardiac ultrasound to r/o tamponade! TXT: a) small effusion (no tamponade) = watch & wait + treat underlying cause b) large effusion (+/- tamponade) = pericardiocentesis

Anorectal Abscess & Fistula: MCCs? Risk factors? Symptoms? DX? TXT?

MCCs: a) STDs b) Staph aureus, E.coli Risk factors: -immunocompromised (**DM**) -high risk sexual behavior -IBD Abscess = rectal "fullness" / pain (worse w/ prolonged sitting, straining, coughing, etc.) Fistula (track that develops from abscess) = RECTAL DISCHARGE / pain DX = clinical (PE) TXT: = I&D + "WASH" + Abx -warm water -analgesics -sitz baths -high fiber diet

Malignant Otitis Externa: What is this? MCC? MC in who? Clue? Gold standard? Treatment?

MEDICAL EMERGENCY ! (Necrotizing OE ---> progresses to osteomyelitis (mastoid bone)) MCC = pseudomonas MC = immunocompromised MC = diabetics (+) Mastoid tenderness (they will look sick) Gold standard = CT scan TXT = ADMIT + IV antibiotics

Compartment Syndrome: What is this? MC etiologies? MC area affected? Symptoms? DX? TXT?

MEDICAL EMERGENCY! Buildup of pressure within the osseofacial muscle compartment... MC = anterior compartment (LE) Etiologies: -crush injury -fractures -burns Presentation = "6 Ps" -PAIN out of proportion (POOP) -PALLOR (decreased) -PRESSURE (>30mmHg) -PARESTHESIAS -PARALYSIS -PULSELESSNESS (late finding) DX = manometer (> 30mmHg = compartment syndrome) TXT = MEDICAL EMERGENCY (immediate surgical fasciotomy)

Toxic Megacolon: What is this? Risk factors? Classic presentation? Labs? DX? TXT?

MEDICAL EMERGENCY! EXTREME colonic distention (>6cm) with signs of systemic toxicity. Risk factors: -Hirschsprung Disease (kids) -Crohn's / UC -C.diff infection (pseudomembranous colitis) "LOOK REALLY SICK" (+) Fever (+) "ACUTE ABDOMEN" (+) hemodynamically unstable (+) AMS LABS = high WBC DX = KUB (+) dilated colon > 6cm (+) "thumb-printing" (loss of haustra) TXT = DECOMPRESSION! -bowel rest (NPO) -decompression (NG/surgical) -ABX (broad spectrum)

Cauda Equina Syndrome: What is this? Causes ? MC? Symptoms? PE? Gold standard test? Management?

MEDICAL EMERGENECY! Compression of the CAUDA EQUINA portion of the spinal cord ("horse-tail") @ L4/L5 or below Causes: -Central disc herniation (MC) -Trauma -Cancer (+) BL back pain (+) "Saddle anesthesia" (+) NEW onset bowel/bladder dysfunction (+) NEW onset sexual dysfunction PE = (+) loss of anal wink Gold standard = MRI TXT = surgical decompression (ASAP!) (+) Give IV steroids + UFH in ER = reduce pressure & prevent thromboemoblic events

Imaging: What medication should always be DISCONTINUED before you order any diagnostic study that requires IV contrast?

METFORMIN !! (remember metformin + IV contrast together increases risk of nephrotoxicity)

Paget's Disease: Treatment?

MOA (both) = inhibit osteoclastic activity 1. Bisphosphonates (PO)(frontline) = Alendronate 2. Calcitonin (SQ, nasal spray)

Ectopic Pregnancy: Discuss the use of Methotrexate: a) MOA b) Indications for use c) ADRs d) Follow-up protocol

MOA = -inhibits normal FOLATE synthesis which is vital to cell division & growth -it arrests embryos development and allows body to absorb fetus naturally Indications for use: a) b-HCG < 5000 b) Ectopic mass < 3.5cm c) ABSECE of fetal heart tones g) Hemodynamically stable f) Pt must agree to close f/u MOST WORRISOME ADR: Tubal rupture (why close f/u is so important) FOLLOWUP: (+) must obtain serial b-HCG levels

Bile Acid Sequestrants: MOA? Drugs? Benefit? Downside?

MOA = Inhibit the emulsification of TG Drugs: -Cholestyramine -Colestipol -Colesevelam Benefit: ONLY cholesterol med that is 100% safe in pregnancy (category B) Downside: Causes INCREASE TGs

Rotator Cuff Injuries: MOA? MC site injury? Types? Symptoms? PE? Gold standard test? TXT?

MOA = REPETITIVE "overhead" activities (painters, window washers) MC = Supraspinatus muscle Injury usually presents with: (+) anterolateral shoulder pain (+) PAIN w/ overhead activities ("brushing hair") (+) "night pain" (if sleeping on affected side) PE: (+) NORMAL passive ROM (+) decreased active ROM (+) Pain w/ ABduction (+) Pain w/ external rotation (+) Empty can test (+) Hawkin's Test (+) Neer's Test **Rotator cuff TEAR = (+) drop arm test DX: a) INITAL = XR (r/o fracture) b) GOLD = MRI TXT = rest, ice, NSAIDS, steroid injections, PT (consider surgery for large tears)

CCB: MOA? 2 types? Drugs? Indications for use?

MOA: -"smooth muscle relaxers" (peripheral acting) -slows SA/AV node conduction (central acting) Types: 1. Dihydrapyridine CCB (mainly peripheral): a) Drugs = ("-pines") = amilodipine, nifedipine, felodipine, nicardipine. b) MOA (mainly) = PERIPHERAL vasodilators c) Indications = HTN, Vasospasm (i.e. Prinzmetal angina, Raynauds syndrome) 2. Non-dihydrapyridines CCB (mainly central): a) Drugs = verapamil, ditalizem b) MOA (mainly) = slowing SA/AV node conduction c) Indications = anti-arrhythmics

Fibrates: MOA? Drugs? CI?

MOA: -limit TG synthesis @ liver -limit peripheral lipolysis Drugs: -Fenofibrate (Tricor) -Gemifibrozil CI: -concomitant use w/ statin -hepatobiliary disease (causes increase in bile acid)

Clavicular Fracture: MOA? MC site? TXT?

MOA: a) During birth b) Direct trauma MC = kids MC = "mid 1/3" TXT: a) Mid-distal 1/3 = sling b) Proximal 1/2 = ORTHO

Thiazide Diuretics: MOA? ADRs? CI? Precautions?

MOA: inhibit NaCL reabsorption at distal convoluted tubule (which inhibits H20 reabsorption & thus reduces blood pressure) Drugs: -Chlorothiazide -Hydrochlorothiazide (HCTZ) -Chlorthalidone ADRs: a) LOW: Na, K, Mg, Cl b) HIGH: Ca, uric acid, glucose c) hypovolemia Precautions: a) GOUT patients b) DM patients CI: a) CrCL < 30 b) sulfa allergy c) anuria

Supracondylar Fractures: MOI? Biggest concern? What MUST you assess for? TXT?

MOI = FOOSH w/ elbow extended Concerns: -brachial artery injury -MEDIAN nerve injury -Compartment syndrome (high risk) --> Volkmann Contracture Realize on XRAY: (+) anterior fat pad (may be normal) (+) POSTERIOR fat pad ("Sail sign" = NEVER NORMAL = compartment syndrome) TXT: a) non-displaced = LAPMS (initially) followed by LAC within 2 weeks b) (+) displaced = ORIF

Ankle Sprain/Strain: MOI? MC structures injured?

MOI = extreme inversion vs. eversion of ankle Injuries: a) INVERSION injury (MC) --> injure Anterior Talofibular Ligament b) EVERSION injury --> injure Deltoid ligament GRADES: a) Grade 1 = "stretching" ligaments b) Grade 2 = partial tear c) Grade 3 = COMPLETE tear

Maisonneuve fracture: MOI? Components of this? What must you remember?

MOI = twisting / direct trauma (SPIRAL FRACTURE) Components (3): (+) medial malleolus fx (+) proximal fibular fx (+) syndesmosis injury Patients typically come in with ANKLE pain --> then on Foot XR (+ medial malleous fx) **MUST know to get lower extremity XR to r/o proximal fibular fracture

Pharyngitis: If you prescribed Amoxicillin and the patient came back the next day with a diffuse rash, what would be the most likely etiology?

MONONUCLEOSIS (classic)

Crohns Disease vs. Ulcerative colitis (IBD): How does your colonoscopy screening recommendations change?

MORE FREQUENT SCREENING 8-10 years after diagnosis begin routine colonoscopy screening q1-2 years....

Adenocarcinoma: Where is this usually found? Odd associated symptoms? Treatment?

MOST COMMON type of lung cancer (35%) -Arises from MUCOSAL glands -MC = peripheries of lung -Gynecomastia (common) -TXT = resection

Low back pain: What are your differentials? MCCS?

MOST COMMON: -Muscle strain/sprain -Herniated Disk Other musculoskeletal eitologies: -Vertebral fracture -DDD -sciatica -sacroiliitis -spinal stenosis -ankylosing spondylitis -scoliosis/kyphosis NON-MSK etiologies: -cancer -AAA rupture -pyelonephritis ("flank pain") -nephrolithiasis ("flank pain")

Endocarditis: Breakdown different classifications & their MCCs? Which valve is MC affected?

MOST COMMON: -strep viridans -mitral valve 1. Subacute Bacterial Endocarditis (SBE) (MC type): -usually abnormal valves -usually more insidious presentation -MC = strep viridans 2. Acute Bacterial Endocarditis: -usually normal valves -usually more acute/severe presentation -MC = staph aureus, MRSA 3. Post-valve replacement: a) 0-2 months = staph or fungal b) 2+ months = staph 4. IVDU patients: -staph aureus/MRSA -tricuspid valve

Lupus (SLE): Discuss diagnostic labs? Most sensitive? Most specific? Best used as markers of disease progression?

MOST SENSITIVE (not specific) = (+) ANA MOST SPECIFIC (marker of disease progression): (+) ds-DNA (most specific) (+) Anti-Smith AB (specific)

Hypertrophic Cardiomyopathy: Cause? Defining features? Symptoms? PE? Diagnostic studies? Treatment?

MOST SEVERE form! (comes from ventricular wall thickening) 100% = genetic (MC = asians) Features: (+) Diastolic dysfunction (+) Sub-aortic outflow (hypertrophic ventricular walls & septum) (+) Systolic anterior motion of mitral valve Symptoms: a) Dyspnea (MC!) b) Chest pain c) Syncope d) Arrhythmia (i.e. AFIB) e) Asymptomatic --> SUDDEN CARDIAC DEATH Classic = adolescent dies suddenly on sports field PE: (+) harsh crescendo/decrescendo systolic murmur @ LLSB (looks like AS murmur; but remember HCM will have a paradoxical response to squatting & standing/valsalva) ECHO: (+) asymmetric ventricular hypertrophy (+) small LV size (+) diastolic dysfunction (+) systolic anterior motion of mitral valve TXT: a) frontline = BB + AICD b) surgical options = myomectomy or ETOH ablation

Pertussis: When are patients MOST contagious? When can you instruct children to return to school?

MOST contagious = Catarrhal Stage (first 1-2 weeks) **which is why this condition is so problematic, because when the patient is the least symptomatic (vague symptoms), they are the most contagious! Children may return to school: a) NO TXT = 3 weeks after onset b) (+) TXT = 5 days after txt completion

COPD: Treatment approach... What is the SINGLE most important part of management?

MOST important part = smoking cessation !!!! Medical Management: a) 1st line = SABA, short acting inhaled anticholinergics or combination. b) 2nd line = long-acting anticholinergics (tiotropium = "Spiriva") c) 3rd line = ICS (if FEV1/FVC 30-50%) Adjunctive therapy: a) Supplemental O2 b) Theophylline (refractory) ACUTE flair ups (consider adding): (+) PO steroids (+) Antibiotics

MR vs. TR: Murmur descriptions? Best way to tell them apart?

MR/TR (same murmur) = holosystolic "blowing" murmur SEE how the murmur changes with INSPIRATION ! Recall that with right-sided defects (tricuspid or pulmonic valves) = these will be accentuated with INSPIRATION (called (+) Carvallo's sign) MR = (-) Carvallo's sign TR = (+) Carvallo's sign

Vertigo: What should always be ordered in refractory vertigo? Why?

MRI (best) !!! R/O acoustic neuroma

Antibiotic Review: List the go to drugs for: a) MRSA coverage b) Anti-pseudomonas c) Osteomyelitis d) PCN allergy

MRSA: -Vancomycin (IV only) -Bactrim -Clindamycin -Doxycycline -Ceftaroline (5th generation) Antipseudomonal: -FQ (cipro is always best) -Cefepime (4th generation) Osteomyelitis = FQ (best bone penetration) PCN allergies (cephalosporins have 5-15% cross-reactivity): -Macrolides -VANCO -Clindamycin -Doxycycline

Parotitis: What should you always check in someone presenting with this (especially in kids)?

MUMPS (#1 cause of): -parotitis -orchitis -pancreatitis (kids)

AFIB & A.Flutter: Discuss approach with cardioversion? Definitive TXT?

MUST DETERMINE: a) Risk for CVA/MI (persistent > 48hrs are HIGHEST risk) b) Stable vs. Unstable (need for emergent electrical cardioversion or not) 1. AFIB < 48hrs (low risk), no emergent need: -"watch & wait" + place on anticoagulation based upon CHADS2 score recommendation 2. AFIB < 48hrs (low risk), EMERGENT NEED: -place them on LMWH/UFH and perform cardioversion -continue warfarin x 4 weeks post-procedure 2. AFIB > 48hrs (high risk), no emergent need: -place them on warfarin x 3 weeks -then perform cardioversion -continue on warfarin x 4 weeks post-procedure 4. AFIB > 48hrs (high risk), EMERGENT NEED: -place on LMWH/UFH -obtain TEE (before cardioversion) to assess for clots -if no clots, perform cardioversion -continue on warfarin x 4 weeks post-procedure. DEFINITIVE TXT = Ablation ("MAZE" procedure)

ACS: Does a "negative EKG" RULE OUT ACS? Discuss....

MUST KNOW that 50% of patients with ACS will have a "negative EKG" (therefore it does NOT r/o MI) **If a patient presents with MI-type symptoms, but negative EKG, MUST obtain serial EKGs....

What MUST you order before starting any immunmodulators (i.e. DMARS, TNF inhibitors)?

MUST R/O TB (PPD) **b.c. remember if they have latent TB & you place them on immunosuppressive therapy --> will most likely "spark" transition into Secondary Reactive TB.

GERD: What 2 things must you always r/o? What would be some alarm symptoms?

MUST R/O: -Barrett's Esophagus -Cardiac etiology (get EKG) -Cancer ALARM symptoms: (+) NEW onset > Age 45 (+) hoarseness (+) dysphagia (+) hemoptysis (+) EARLY SATIETY (+) weight loss

Myocardial Infarction: Discuss the appropriate management of NSTEMI?

MUST determine "TIMI risk score" TIMI Score < 3 (low risk): -Discharge on appropriate therapy -Complete outpatient workup (EKG, stress test, ECHO, etc.) TIMI Score 3+ (high risk): -Immediately initiate Glycoprotein IIb/IIIa + UFH/LMWH + ASA (in preparation for PCI) -PCI

Atrial Flutter & AFIB: Discuss how we approach treatment...

MUST determine if: a) Stable (medical management +/- optional cardioversion & ablation) b) Unstable (mandatory electrical cardioversion +/- abalation) Medical management (3 components): a) Vagal maneuver (1st) b) rate control c) rhythm control d) anticoagulation RATE control (ONLY if (+) RVR) a) 1st line = CCB (verapamil, diltazem) or BB b) 2nd line = digoxin Rhythm control: a) 1st line = Class 1c (flecainide, propafenone) b) 2nd line = Class III (amiodarone, dronedarone) c) 3rd line = Class 1a Anticoagulation = use "CHADS2" or "CHA2DS2 VASC" score

Spontaneous Abortions: Discuss management....

MUST ensure full passing of all conceptual products to prevent infection... **ALWAYS check "Rh status" in SAB --> administer Rhogam if Rh (-) mother. 1. Expectant management (allow them to pass naturally) 2. MEDICAL management (less <12 weeks): -Mifepristone -Misoprostal (Cytotect) -These medications cause cervical dilation & uterine contractions (basically "inducing labor") 3. Surgical management (up to 24 weeks): a) D&C (< 12 weeks) b) D&E (12-24weeks)

Candidiasis: If someone continues to get recurrent yeast infections, what should you do?

MUST evaluate & r/o reasons they might be immunocompromised: a) pregnancy test b) HIV test c) blood glucose +/- A1c

Rheumatic Fever: Describe the diagnostic criteria for "migratory polyarthritis"? What symptom confers the worse M/M?

MUST have MORE than simple arthritis (joint pain) Diagnostic: -2 or more "red, warm, swollen, painful" joints (CANNOT just be pain) -Migratory (lower --> upper joints) **CARDITIS confers the worst morbidity & mortality !

Primary HTN: What is the diagnostic criteria for HTN? According to the USPSTF, what is the current screening recommendations...

MUST have elevated BP (>140/90) on TWO separate occasions (6 weeks apart) Screening recommendations: a) For those BP (normal) < 120/80 = screen every 2 years b) For those BP = "pre-HTN" range (>120-139/80-89) = screen annually

If you have a case of REFRACTORY peptic ulcer disease (PUD), what should you always r/o? Workup? Treatment options?

MUST r/o: a) Zollinger-Ellison Syndrome b) Cancer Appropriate workup: Fasting [gastrin] + EGD/Biopsy #1 = treat underlying cause (i.e. resect tumor) #2 = if all underlying causes have been ruled out, consider: (+) Vagotomy (+) Billroth II procedure

Rheumatic Fever: What is the TOC if patient has a PCN allergy?

Macrolide (Erythromycin)

Hospital-Acquired Pneumonia: Treatment?

Main difference in treating HAP = MUST obtain sputum culture (to tailor antibiotic therapy) 1. Start empiric ABX 2. Obtain sputum & blood culture 3. Alter ABX if needed EMPIRIC THERAPY (3 ABX that provide coverage for Atypical + MRSA + Pseudomonas): FQ + VANCO + Cefpime

Asthma Exacerbation: Discuss management of ACUTE exacerbation? Goals?

Maintain pulse Ox > 90% In ER (most common): -nebulized SABA (albuterol) -nebulized anticholinergic (ipratropium) -O2 (if needed) Consider added these in SEVERE cases: -IV steroids -IV magnesium (bronchodilator) -IV epinephrine Discharge them on: -PO steroids x 3-5 days (reduces recurrence; MAX 60mg/day)

SHOCK (Septic): Discuss the natural progression of this.... What makes this UNQIUE compared to all the other types of shock? Treatment?

Major infection --> body attempts to clear the infection by INCREASING CO + DECREASING SVR (major peripheral vasodilation) --> which leads to shock --> eventually if uncorrected, will lead to ORGAN failure (decreased CO, SVR & PWCP) ONLY type of shock that we see (+) Increase CO (only "WARM shock" where the patient's have warm vs. cool extremities) Treatment: -ABCDEs -Pan culture -IVF + broad spectrum IV ABX -IV vasopressors

Thoracic Aortic Dissection: Management?

Management components: a) BP control (esmolol labetalol, nitroprusside) b) surgery Surgical options: a) Endovascular (TEVAR) b) Open repair IMMEDIATE surgery indications: a) Ascending +/- arch (all) b) Descending (w/ complications) Medical management: a) Descending (WITHOUT complications)

SVT: To whom should you be CAUTIOUS of giving Adenosine?

May cause bronchospasm (caution in patients with asthma or COPD)

Mononuceleosis: What is the limitation for using the Mono-spot test for diagnosis?

May take up to 4 weeks to become positive.

Cardiology basics: Discuss what these are used for / what they indicate: a) Mean arterial pressure (MAP) b) Pulse pressure c) Point of maximum impulse (PMI) d) (+) Thrill

Mean arterial pressure = CO x SVR = (SBP + 2DBP)/3 **used to indicate changes in CO or SVR **MAP > 60mmHg is needed for adequate tissue profusion. Pulse pressure = SBP - DBP **SBP - DBP > 40mmHg = WIDE pulse pressure **can be useful in detecting changes in cardiac "stroke volume" or "cardiac compliance" **stroke volume = amount of blood entering heart **compliance (elasticity) = CAD, coronary damage, fibrosis can all decrease the compliance PMI: **normal = "coin" sized, mid-clavicular @ 5th ICS **reflective of LV function **PMI usually enlarges, lateralizes with LVH or damage (+) Thrill: **represents "turbulent" blood flow (usually valvular abnormality)

Antibiotic Review: Which medications belong to "PCN family"? Coverage? Differences?

Med classes: 1. PCN = GM(+) coverage only 2. Aminopenicillins = GM(+) with some GM (-) coverage -ampicillin, amoxicllin 3. Cephalosporins = variable GM(+) & GM(-) coverage

Meniscal Tears? MC type? MOI? Symptoms? PE? Best test? TXT?

Medial meniscus tear (MC) Lateral meniscus tear MOI = repetitive trauma (degenerative process) (+) Knee locking (+) Knee buckling / giving out (+) Effusions after activities PE: (+) JOINT LINE TENDERNESS (+) McMurrary Test (+) Apley "grinding" test (+) Thessaly DX = clinical (MRI = best) TXT = conservative vs. surgical

Peripheral Arterial Disease: Treatment approach?

Medical management: (+) Cliostazol (mainstay) = PDE5 inhibitor (vasodilation) (+) Antiplatetlet therapy (ASA vs. Plavix) Surgical considerations: -Percutaneous transluminal angioplasty (PTA) -Arterial bypass -Endarterectomy Acute Arterial Embolism = (+) start HEPARIN immediately

Rh incompatibility: What mediation do we give? MOA? Administration schedule?

Medication: (+) Rh Immunoglobulin ("Rho-Gam") **MOA = blocks the synthesis of maternal antibodies against the babies blood type. Rh(-) mother: (+) Give Rho-Gam @ 28W (+) Give another dose within 72 hours of delivery (if baby was Rh(+)) **realize that the dose after delivery is to potentially protect FUTURE pregnancies Consider additional doses of Rho-Gam in ANY cases where feto-maternal hemorrhage could have occurred: -trauma -CVS or amniocentesis -ectopic pregnancy -SAB

Appendicitis: What condition is almost indistinguishable from this?

Mesenteric Adenitis (inflammation of mesentery lymph nodes)

Neural Tube Defects: What medications increase the risk of this?

Methotrexate Valporic acid Phenytoin Sulfasalazine ("IBD" txt)

SHOCK (Anaphylactic): Discuss the doses of Epinephrine?

Mild-Moderate: -Epi (0.3mg IM of 1:1000) q5-10 mins as needed Severe (+ cardiac collapse): -Epi 1mg IV (1:10,000)

What conditions most commonly misdiagnosed for a STEMI? Explain? What is a known way to try and distinguish these...

Misdiagnosed as STEMI: a) Prinzmetal Angina (MC) b) Cocaine vasospasm c) Pericarditis d) Takotsubo cardiomyopathy ST-elevation in 1-2 leads: a) STEMI (+ angio) b) Prinzmetal/Cocaine vasospasm (sxs resolved w/ CCB and (-) angio) c) Takotsubo cardiomyopathy (- angio) ST-elevation in ALL LEADS: a) Pericarditis

If a patient has BOTH (+) AFIB with WPW, what is this often misdiagnosed as? WHY must you recognize this? Treatment?

Misdiagnosed as VTACH or AFIB alone.... Way to tell the difference: a) VTACH = "QRS" complexes have same morphology b) AFIB + WPW = "QRS" complexes all have different morphologies. TXT: a) WPW treatment (Class 1c, Class III) b) Admit for ablation (dangerous rhythm) WHY is this important? DO NOT treat with AV nodal blockers (BB, CCB) --> this will accentuate the WPW accessory pathway and lead to VFIB (arrest)!

TURNER'S SYNDROME: Pathophysiology? Prenatal findings? MC earliest symptom? Symptoms? Associations? TXT? Presentation? BUZZ findings? Associated conditions? TXT?

Monosomy X (FEMALE born with ONLY 1 X chromosome = deletion of the other X chromosome) HALLMARK = hypogonadism + amenorrhea Prenatal U/S (high association w/ renal & cardiac abnormalities): (+) horseshoe kidney (+) CoA EARLIEST sign = lymphedema @ birth Symptoms: -AMENORRHEA (MC) -short stature (despite NORMAL growth hormone) -webbed neck -low set ears -widely spaced nipples -absence of sex characteristics TXT: (+) growth hormone (to increase height) (+) estrogen (+) progesterone

Pelvic Inflammatory Disease: Potential complications? MC?

Most common: -ectopic pregnancy -infertility Other potential complications: -Tubo-ovarian abscess -Fitz-Hugh Curtis Syndrome

Primary HTN: a) symptoms b) recommended initial workup

Most patients have NO SYMPTOMS: -MC reported symptom = "chronic dull HA" -However, anytime there is "end-organ damage" you may see symptoms Recommended initial workup (to assess for end-organ damage): a) Fundoscopic exam (r/o papilledema) a) CBC (H/H = RBC production = renal fxn) b) CMP (renal fxn) c) EKG (heart strain)

Multifocal Atrial Tachycardia: Defined by? MC seen in who? Treatment?

Multiple signals coming from different places.... Features: (+) Tachycardia (+) 3+ different p-wave morphologies MC = COPD patients TXT = a) treat underlying cause! a) BB or CCB **do not cardiovert**

Herniated Disk: Discuss how PT could help recurrent/refractory cases....

Muscle relaxation (which is possibly "pulling" on disk) MC = piriformis muscle

Hyperlipidemia: HOW do we determine whether we need to initiate a statin?

Must first determine whether: a) PRIMARY prevention (no prior h/o CVD) b) SECONDARY Prevention (+ h/o CVD = MI, TIA, CVA, etc.) PRIMARY prevention: a) LDL > 190 = high-intensity statin b) LDL 70-189 = calculate ASCVD risk score -Score > 7.5% = high-intensity statin -Score < 7.5% = no TXT vs. low-moderate intensity statin SECONDARY prevention group: a) Age < 75 = high-intensity statin b) Age > 75 = low-moderate intensity statin (whatever they can tolerate)

Primary HTN: What is defined as "Metabolic Syndrome"? Why is this important to identify?

Must have 3+: a) HTN b) Truncal obesity c) High TG d) Low HDL e) Hyperinsulinemia (with marked insulin resistance) (+) Metabolic Syndrome = higher DM & CV risk

TB: Pathogen? Stages (and their defining features)? When are you contagious?

Mycobacterium tuberculosis (acid-fast bacillus) STAGES: 1. Primary "Active" TB: -initial infection; CONTAGIOUS -insidious presentation (usually misdiagnosed as URI) -CXR = (+) middle/lower lobe consolidations 2. "Latent TB" (MC form): -NOT contagious -asymptomatic -(+) PPD test -NO evidence of active infection on CXR/CT 3. Secondary "Reactivated" TB: -CONTAGIOUS -occurs when a person who previously had "primary/active TB" infection becomes immunocompromised (HIV, steroids, cancer) -"CLASSIC symptoms (BUZZ) = chronic cough, blood streaked sputum +/- hemotypsis, night sweats, weight loss. -CXR = (+) Apex/upper lobe caviations ("Ghon/Ranke complex")

If you have a SUDDEN onset of new cardiomyopathy and/or heart failure, what should you rule out? What is the #1 cause of this?

Myocarditis Pericarditis #1 cause of BOTH: -idiopathic -VIRAL (MC = enterovirus; Coxsackie)

Acute Pericarditis: Discuss treatment options....

Myocarditis and/or Pericarditis: a) d/t non-cardiac cause (i.e. viral) = NSAIDS best (TOC = indomethacin) b) d/t CARDIAC cause (i.e. post-MI) = ASA best (+) ADD colchicine to reduce risk of recurrence

Myocarditis: Best way to distinguish this from Dilated Cardiomyopathy?

Myocarditis: (+) cardiac enzyme elevation Dilated Cardiomyopathy: (-) cardiac enzyme elevation

Scoliosis: What other condition can present w/ scoliosis? Explain....

NEUROFIBROMATOSIS (NF-1) Look for: -cafe-au-lait spots -skin tags -axillary freckles

Diarrhea: In who are anti-motility (anti-diarrheal agents) CONTRAINDICATED? Why?

NEVER use anti-motility agents in patients with INVASIVE (hemorrhagic) diarrhea = increased risk for toxicity DO NOT USE: a) bismuth-salicylate (pepto-bismol) b) Loperamide (Immodium) b) Diphenoxylate/Atropine (Lomotil)

Barium studies: When are these CONTRAINDICATED.... Explain....

NEVER use barium studies (swallow/enema) if there is a possibility of perforation! **if barium leaks into body it can cause a lot of irritation/inflammation! EXAMPLE: If you suspect Boerhaave syndrome, we use GASTOGRAFFIN studies instead!

Acoustic Neuroma: If this presents BILATERALLY, what must you r/u?

NF2

Vitamin B3 deficiency: Also called? BUZZ presentation?

NIACIN deficiency Pellagra = 4 Ds a) Dermatitis b) Diarrhea c) Dementia d) DEATH

Cystic Fibrosis: Treatment? MC infection?

NO CURE (average life expectancy = 30s) Management centered around symptom relief: -bronchodilators -mucolytics -decongestants -treatment of any lung infections (ABX) -pancreatic enzyme / vitamin supplementation **most patients will eventually need pancreatic / lung transplants MC infection = PSEUDOMONAS

Lupus (SLE): Management?

NO CURE! Initial management: (+) exercise (+) sun protection (+) NSAIDS/acetaminophen (joint pain) (+) Hydroxychloroquine (skin lesion) Acute flairs: (+) steroids Severe disease: (+) Methotrexate (frontline) (+) Balimumab

Osteoporosis: Is HRT currently recommended in post-menopausal women as a means to reduce risk for osteoporosis?

NO! USPTF currently recommends AGAINST ("D" recommendation)

Compare & contrast the following: a) Oral candidiasis b) Oral Leukoplakia c) Erythroplakia d) Oral Hairy Leukoplakia

NON-CANCEROUS: 1. Oral candidiasis: -Cause = candida albicans (fungal) -RF = immunocompromised vs. ICS use. -Painless/painful (either) -SCRAPABLE white plaques -DX = KOH PREP -TXT = nystatin rinse 2. Oral Hairy Leukoplakia: -Cause = EBV -PAINLESS -NOT-SCRAPABLE, thick "hairy looking" white plaques (MC = lateral border tongue) -DX = clinical -TXT = none ________________________________________________ PRECANCEROUS (--> Squamous cell carcinoma): 1. Oral Leukoplakia: -RF = tobacco -PAINLESS -NON-SCRAPABLE, white plaques -DX = biopsy r/o cancer -TXT = cryotherapy, laser ablation 2. Oral Erythroplakia: -RF = tobacco -PAINLESS -NON-SCRAPABLE, red plaques -DX = biopsy r/o cancer -TXT = cryotherapy, laser ablation

Sjogren Syndrome: What other conditions can be associated with this that you should rule out?

NON-HODGKIN lymphoma (**) Other autoimmune (SLE, RA, Scleroderma)

DCIS and LCIS: Discuss difference in management....

NON-INVASIVE carcinomas 1. Ductal carcinoma in-situ (DCIS): -DOES NOT penetrate basement membrane -lumpectomy + XRT 2. Lobular carcinoma in-situ (LCIS): -considered to be more "precancerous" compared to DCIS -close f/u with regular mammography -can (+) prophylactic SERMS (tamoxifen, raloxifen)

Breakdown the different classifications of CONGENITAL heart diseases....

NON-cyanotic congenital heart diseases: -VSD -ASD -Coarctation of Aorta -Patent Ductus Arteriosus CYANOTIC congenital heart diseases: -Tetralogy of Fallot -Truncus Arteriosus -Transposition of great arteries -Tricuspid Atresia Realize that: a) Non-cyanotic = result from left --> right shunting (oxygenated blood being pushed into right-side heart and into the lungs) b) Cyanotic = results from right--> left shunting (deoxygenated blood being pushed into left side of heart & then out into the body)

Neural Tube Defects? Recommended folic acid intake for pregnant woman? Recommended dosage for someone w/ history of NTD pregnancy?

NORMAL = 0.4mg/day High risk = 4mg/day

Discuss HOW the synovial fluid would DIFFER between each of the following: -Normal -Osteoarthritis -Rheumatoid Arthritis -Septic Arthritis -Reactive Arthritis

NORMAL = clear (+) string sign, WBC < 200, PMN < 25%, (-) culture OA = clear/cloudy fluid ("straw" colored), WBC 200-300, PMN 25%, (-) culture RA = yellow fluid, WBC 300-50,000, PMN 25-50%, (-) culture Septic Arthritis = yellow/green PURULENT fluid, WBC > 50,000, PMN > 50%, (+) culture Reactive Arthritis = normal fluid w/ (-) culture

HTN Emergency: What are the 2 exceptions to the recommended treatment?

NORMAL = lower MAP 25% (1st hour) + additional 5-15% over next 24hrs. EXCEPTIONS: 1. Aortic Dissection = normalize BP ASAP! 2. Ischemic CVA = don't lower BP (higher BP helps maintain some blood flow to the brain)

Beta-Blockers: Are these considered a frontline agent for HTN? When is it appropriate to use these? What patients should you NOT use these in

NOT 1st line agent (HTN) Mainstay of use = patients who have "HTN + h/o CVD (angina/prior MI/CHF)" Do NOT use these in: a) ANY respiratory disease (asthma, COPD, CF) b) DM1

Clostridium Difficle (C.diff): Does hand washing / hand sanitizer help this?

NOT killed by hand sanitizer

Rheumatoid Arthritis: Are XRAYs the best diagnostic tool? Why or why not?

NOT the best diagnostic tool (usually NORMAL for first 6 months)

Asystole: Treatment?

NOT the same as VFIB !!! (asystole is a "non-shockable rhythm") Treatment = CPR + epinephrine

Pill Esophagitis: MC seen with what? Educational points?

NSAIDS Bisphosphonates Educational points: -take pills w/ LOTS H20 -avoid lying down 30 min after ingestion

Pulseless Electrical Activity: What is this? What must you r/o?

NSR (on EKG) NO pulse Rule out the 5 H's and T's !! 5Hs: -hypoxia -hypovolemia -hyper/hypokalemia -H+ (acidosis) -hypothermia 5Ts: -toxins -tamponade -tension pneumothorax -thrombosis -trauma

3rd Degree AV Heart Block: What factor alters prognosis? Explain....

Narrow QRS (better prognosis) Wide QRS (worse prognosis) = higher association with anterior MI

Coarctation of Aorta: Pathophysiology? Classic presentation? PE? CXR findings? Diagnostic test of choice? Treatment?

Narrowing of aortic arch --> leads to dramatic reduction in CO MC location = distal to left-subclavian artery Classic presentation: a) infants = poor feeding/failure to thrive b) children / adults = SECONDARY HTN PE: (+) upper SBP >>>> lower SBP (+) weak femoral pulses (+) systolic murmur CXR (BUZZ): (+) "Rib notching" (+) "3-sign" ANGIOGRAPHY (gold standard) **unlike other defects where ECHO was TOC TXT: a) infant = (+) continue to give Prostaglandins to keep PDA open until surgical correction (i.e. balloon angioplasty) b) children = surgical correction

Rhinitis Medicamentosa: What is this? MCC? How to avoid?

Nasal decongestants = Oxymetazoline (AFRIN) **NOT intended to be use for prolonged periods... "REBOUND congestion" -associated with prolonged use of inhaled decongestants (AFRIN)) -most commonly seen with use > 5 days -WHY we don't typically give prescriptions for this

BREAST CANCER: Why is screening so difficult in pregnant women? If you find a lump in a pregnant woman, what is the most appropriate next step?

Natural changes in a pregnant or lactating females breast complicates mammography results and therefore is NOT used as the imaging modality of choice in the patients.... Recommendations: a) Obtain breast MRI +/- biopsy (if suspicious lesion) b) Defer mammography screening until after pregnancy or stop breast feeding.

Scaphoid Fracture: Also called? MOI? Symptoms? Gold standard? Concern? Treatment?

Navicular Fracture MOI = FOOSH **OFTEN misdiagnosed as "wrist sprain"** (+) wrist pain, swelling (+) snuff-box tenderness (BUZZ) Concern = high risk AVN (MRI = (+) "ground glass" appearance) Diagnosis: a) XRAY = may be normal b) MRI (gold standard) = best at r/o AVN TXT: a) non-displaced = Thumb-splica cast b) (+) displaced (>1mm) = ORIF

Cholesteatoma: What is this? BUZZ presentation? Gold standard? TXT?

Necrotic abnormal growth of SQUAMOUS cell epithelium **usually in reaction to chronic inflammation (i.e. recurrent OM) (+) "PAINLESS otorrhea" (+) TM perforation (common) (+) CONDUCTIVE hearing loss Gold standard = CT scan (r/o osteomyelitis) TXT = resection

Gonorrhea: Pathogen? Symptoms? Best test? TXT?

Neisseria Gonorrhea (GM (-) diplococci) MEN: a) initially = mild dysuria with white "milky" discharge b) progresses to = SEVERE dysuria & thick green/yellow penile discharge. WOMEN: a) asymptomatic (MC) b) cervicitis symptoms c) UTI type symptoms (dysuria) Diagnosing: a) Urine NAAT (best test) b) culture (ENDOCERVIX) TXT: (ALWAYS CO-TREAT for chlamydia) a) Gonorrhea = Ceftriazone IM x 1 or Cefixime PO b) Chlamydia (azithro, doxy or erythromycin)

Folic Acid Deficiency: BUZZ presentations

Neural Tube Defects Megaloblastic Anemia + NO NEURO symptoms

Nitrates: MOA? Types? When would you use these?

Nitrates = vasodilators -increase cardiac O2 supply -reduced cardiac workload -EFFECT = reduce BOTH preload & afterload Short acting nitrates (rescue therapy): a) NITROGLYCERINE (sublingual, patch, IV) Long-acting nitrates (maintenance therapy) a) Isosorbide mononitrate b) Isosorbide di-nitrate **mainly considered if angina is not well controlled on BB/CCB + NTG

Antibiotic Review: Recall the main uses of: a) Nitrofuratoin b) Fidaxomicin c) Metronidazole

Nitrofuratoin (Macrobid) -great GM(-) coverage -UTIs Fidaxomicin (Dificid) = C.diff Metronidazole (Flagyl): -great GM(-) coverage -GI/GU infections

What is Hydroxychloroquine?

Non-biologic DMARD & Antimalarial drug ! Used also alot for skin lesion (i.e. SLE)

BREAST CANCER: Types? MC?

Noninvasive vs. Invasive 1. Non-invasive: a) DCIS (ductal) b) LCIS (lobular) 2. Invasive: a) Ductal carcinoma (80%) b) Lobular carcinoma 3. Others: a) Paget's Disease b) Inflammatory Breast CA

AGE (secretory diarrhea): MCC (adults)? MCC (kids)? MCC ("travelers diarrhea")? List other main causes, and: a) tranmission b) BUZZ associations c) Concerns d) DX e) TXT

Noravirus (MCC adults) = "cruise ship diarrhea" Rotavirus (MCC kids) -->vaccine @ 2, 4, 6mo. E.coli (MCC "traveler diarrhea") -unsanitary H20 ("ice cubes") -TXT = none (but may give FQ shorten course) Other causes: 1. Vibrio cholera (GM (-) rod): -contaminated food/H20 -developing nations -"Rice water stools" -BIGGEST issue = severe dehydration -TXT = none 2. Giardia (protozoa): -lives in fresh water (streams) -"Backpackers Diarrhea" / "Beaver Fever" -recent camping / ingestion "stream H20" -"GREASY, FOUL SMELLING diarrhea" -DX = (+) stool cysts -TXT = metronidazole 3. Amebiasis (protozoa): -fecal-oral transmission -contaminated H20 -developing nation -HIGH risk = "Amebic Liver Abscess" -DX = (+) stool ova/parasites -TXT = metronidazole Food Poisoning: 1. Staph aureus (left out potato salad) 2. Bacillus cerius (undercooked rice / meat = "Chinese food") 3. Clostridium profinges (undercooked meat)

Primary HTN (JNC7/8): Breakdown what qualifies as: a) normal BP b) Pre-HTN c) HTN (stage 1) d) HTN (stage 2) e) Hypertensive urgency/emergency

Normal < 120/80 Pre-HTN = (120-139) / (80-89) HTN (stage 1) = (140-159) / (90-99) HTN (stage 2) > 160/100 HTN urgency/emergency = > 180/120 (+/- end organ damage)

Pulmonary HTN: What is the SINGLE most important therapy in someone with COPD & pulmonary HTN?

O2 !!!!!! (treats the underlying issue = chronic hypoxia)

COPD: What is the ONLY medical therapy proven to reduce mortality?

O2 supplementation (by treating chronic hypoxia, you reduce risk of progression to pulmonary HTN +/- cor pulmonale)

Croup: If you give the child either nebulized racemic epinephrine and/or dexamethasone, what MUST you do?

OBSERVE 3-4 hours afterwards (to watch for "rebound" symptoms)

List the MC complications associated with: a) OM b) OE

OM (untreated) --> Mastoiditis OE (untreated) --> Osteomyelitis (skull) "Malignant Otitis Externa"

Leiomyomata (uterine fibroids): What is the only cure? Other treatment options?

ONLY CURE: -menopause -hysterectomy

What is meant by "congestive HF"?

ONLY indicates that HF is accompanied by abnormal fluid accumulation **MC this is used to reference an ACUTE exacerbation of underlying HF

Hepatitis D: Discuss its occurrence? Associated with what?

ONLY occurs w/ Hep B (Hep D NEEDS HBsAg in order to work) HIGHEST association with LIVER FAILURE (liver overwhelmed with 2 separate infections)

SHOCK (cardiogenic): What MUST you remember is unique about treating this?

ONLY type of shock where IVF are CONTRAINDICATED (will only make it worse)

AFIB & A.flutter: Discuss how you determine whether or not to use BB vs. CCB for rate control?

ONLY used with AFIB + RVR (tachycardia) If cause of AFIB: a) cardiac in origin = CCB (1st line) b) non-cardiac origin (i.e. thyroid) = BB (1st line)

Hypertriglyceridemia: What is the recommended therapeutic approach?

OPTIMAL TG < 150 TG levels @ higher risk pancreatitis > 500 Approach to management: a) TG < 500 = lifestyle modification (OM3, increase exercise) b) TG > 500 = initiate Fibrate or niacin therapy

Knee Dislocation: MC MOA injury? Symptoms? Concern? Workup? Gold standard test? Treatment?

ORTHO EMERGENCY MC = direct blow (high velocity) (+) knee pain, swelling (+) inability to bear weight (+) GROSS deformity (PE) HIGH RISK of neurovascular injury!! MC = popliteal artery 2nd MC = peroneal nerve injury Appropriate workup: a) PE = pulses + peroneal nerve fxn b) ABI c) Angiography (gold standard) d) Neurovascular CONSULT (asap) TXT (ADMIT) = prompt reduction via longitudinal traduction

Hip Dislocation: MC type? MCC? Classic presentation? TXT? Biggest concern?

ORTHO EMERGENCY !!! MC = posterior MCC = MVA ("slamming on brakes with knee hyperextended") Leg is "shortened" & held in FIXED "internally rotated / flexed" position (classic) (+) Hip pain (+) inability to bear weight Complications: a) AVN (!!) --> obtain MRI b) Sciatic nerve injury TXT = ORIF (immediately)

Pulmonary Embolism: What surgeries have the highest risk?

ORTHOPEDIC (hip & knee surgeries)

Hip Fracture: MC RF? Types? Presentation? Concern? TXT?

OSTEOPOROSIS (MC RF) Types: a) Femoral head/neck Fx (worse) b) Intertrochanteric Fx c) Subtrochanteric Fx Leg is shortened & held in fixed "EXTERNALLY rotated + ABducted" position (classic) (+) hip pain (+) inability to bear weight Concern: a) AVN (highest risk w/ femoral head & neck fractures) b) DVT/PE TXT = ORIF (asap)

Plantar Fasciitis: Pathophysiology? Risk factors? Symptoms? Workup? Treatment?

OVERUSE injury --> leads to inflammation / "micro-tears" of plantar fascia (aponeurosis) Risk Factors: (+) flat feet (+) bone spur ("Haglund's Deformity") "Sharp heel pain" (+) WORST in morning (or w/ rest) (+) improves throughout the day PE: (+) point tenderness over calcaneus (where tendon inserts) Workup = XR (r/o flat feet and/or bone spur) TXT: RICE + NSAIDS + stretching (PT) + shoe inserts **steroids & surgery ONLY considered in severe cases.

SHOCK (obstructive): Pathophysiology? Etiologies? Treatment?

Obstruction to OUTFLOW of blood.... Decreased CO Increase SVR Increase PCWP Etiologies: -tamponade -severe PE -pneumothorax Treatment: -ABCDEs -Fix underlying cause !! -IVF -Inotropic agents (dopamine, dobutamine, epinephrine)

Obstructive vs. Restrictive Lung Disease: Pathophysiology? Conditions?

Obstructive Lung Disease (increased lung volume, main issue is with impaired airflow and/or impaired gas exchange @ alveoli): -asthma -COPD -smoking -alpha 1-antitrypsin deficiency -cystic fibrosis -bronchiectasis Restrictive Lung Disease (decreased VOLUME; realize that anything that causes lung FIBROSIS will result in this): -sarcoidosis -idiopathic pulmonary fibrosis -pneumoconiosus -scleroderma -SLE -drug induced (amiodarone) -obesity -spine deformities (kyphosis, scoliosis)

Peripheral Arterial Disease: What is Leriche Syndrome?

Occlusion in the aortic bifurcation/common iliac artery that results in the following TRIADE: (+) buttock/thigh claudication (+) impotence (+) decreased femoral pulses

Irritable Bowel Syndrome (IBS): What are some "red flags" that would indicate further workup?

Older @ diagnosis Weight loss GI bleeding FHX cancer

Orbital Cellulits: Main DDX? DISTINGUISHING factor?

Orbital cellulitis (behind septum): (+) periorbital edema/redness (+) PAIN w/ EOM Preseptal cellulitis (front of septum) (+) periorbital edema/redness (-) Pain w/ EOM

Ovarian Cysts: If you are seeing these in POST-MENOPAUSAL woman, what should you obtain? Explain why...

Order CA-125 level (assess for ovarian CA) **this is HIGHLY abnormal in postmenopausal woman because they are NO LONGER OVULATING! Ovarian

Mitral Stenosis: Discuss what "Orthner's syndrome" is & how it relates to mitral stenosis...

Orthner's Syndrome = (+) CHRONIC HOARSENESS **comes from enlarged left atrium "pushing" on the laryngeal nerve causing laryngeal nerve palsy.

SVT: Define the following: a) Orthodromic SVT b) Antidromic SVT Which is more common?

Orthodromic SVT ("narrow complex SVT")(95%) = impulse goes down the NORMAL SA--> AV node pathway 1st and then returns via accessory pathway. Antidromic SVT ("wide complex SVT") (5%) = impulse goes down the accessory pathway 1st and returns via normal pathway

What is the MOST COMMON form of arthritis?

Osteoarthritis

PAD vs. PVD: Discuss the MAIN distinguishing factors....

PAD: -LE pain with EXERCISE (hallmark), better w/ rest -LE temperature / pulses DIMINISHED -non-healing ulcers occur (MC = lateral malleolus) PVD: -LE pain "heaviness" with REST, better w/ activity -LE temperature / pusles NORMAL -non-healing ulcers (MC = medial malleolus)

Dysmenorrhea: What is this? 2 types? Main differences? TXT?

PAINFUL PERIODS Types: a) Primary = d/t high prostaglandin & leukotriene levels; commonly presents in teens; NOT pathologic b) Secondary = d/t secondary cause; usually presents later on; TREAT underlying issue TXT: (+) NSAIDS (FRONTLINE) = naproxen best (also decreases uterine blood flow & reduces heaviness of menses) (+/-) Suppress ovulation (symptom relief) = OCP, Nuvaring, vaginal ring (+/-) Treat underlying pathology (if necessary)

Chancroid: What is this? Cause? Diagnosis? Treatment?

PAINFUL necrotizing ulcer (+/-) inguinal LAD Pathogen = Haemophilus ducreyi (GM (-) coccibacillius) DX = culture (Chocolate Agar) Treatment: a) Azithromycin x 1 (BEST) b) Erythromycin x 7d c) Ceftriaxone x 1

Cervical Cancer Screening: Discuss current recommendations regarding PAP smear (cytology) screening..

PAP SMEAR screening: -start @Age 21 -stop @Age65 (or at time of hysterectomy) Frequency of Screening: a) Ages 21-29 = PAP smear (cytology) q3years b) Ages 30-65 = PAP smear (cytology) q3years OR cytology/HPV co-testing q5 years **REALIZE that after Age 65, while PAP smears may not be required, annual PELVIC exams are still recommended

PCI vs. CABG: Discuss when each of these are indicated?

PCI: -Less < 3 diseased vessels -Does NOT involve left main (LM) -LV function normal (EF > 40%) -Stenosis < 70% CABG: -3+ diseased vessels -Involves LM -Decreased EF < 40% -Severe stenosis > 70%

Pulmonary Embolism: When is prophylaxis indicated? What are some prophylaxis measures?

PE prophylaxis indicated (preoperatively): -high risk procedure (ortho/neuro) -prolonged immobilization -pregnant female -history of DVT/PE -hypercoagulable condition (i.e. FactorVLeiden) Prophylaxis measures: a) LOW risk = early ambulation b) Moderate risk = compression stockings/device c) High risk = LMWH (SQ) x 1

Toxic Megacolon: #1 complication?

PERFORATION --> peritonitis --> septic shock

Premenstrual Dysphoric Disorder (PMDD): How does this DIFFER from PMS? Frontline treatment?

PMDD = PMS with SEVERE functional impairment -can't go to school/work -negatively impacting relationships FRONTLINE = combo-OCP (FDA approved = deospirenone + ethinyl estradiol)

Tarsal Tunnel Syndrome: Pathophysiology? Symptoms? PE? What does this loo like? Differences? TXT?

POSTERIOR tibial nerve compression (basically "carpal tunnel" syndrome of foot) MCC = overuse injuries (+) Medial Malleolus pain (+) Heel / sole pain or paresthesias PE = (+) Tinel sign CAN MIMIC "plantar fasciitis," BUT: a) PF = "pain worse in am, better w/ use" b) TTS = "pain is WORSE w/ use" TXT = same as carpal tunnel (RICE, NSAIDS, steroid injections, surgery)

TB: Discuss how to INTERPRET PPD test results?

POSTIVIE test if: a) > 15mm (normal population) b) > 10mm (immigrant, healthcare worker) c) >5mm (immunocompromised, close contact w/ people who have active TB)

Antibiotic Review: Recall which is preferred between: -Amoxicillin -Ampicillin

PREFERRED = Amoxcillin (better PO absorption = needs less frequent dosing)

Describe what the difference is between: -preload -afterload Name the medications that work on these......

PRELOAD = pressure the blood has to overcome to ENTER the heart (diastolic pressure) AFTERLOAD = pressure the blood has to overcome to EXIT the heart (systolic pressure) Meds that REDUCE preload: -diuretics -morphine Meds that REDUCE afterload: -hydralazine -CCB Meds that REDUCE BOTH: -nitrates -ACE-inhibitor

Pulmonary HTN: Treatment?

PRIMARY (idiopathic) = CCB (frontline) **reduce afterload **consider lung transplant SECONDARY = fix underlying cause !!!

Osteoporosis: 2 types? DEXA score breakdown? Recommended screening?

PRIMARY Osteoporosis: a) Type 1 (post-menopausal) b) Type 2 (senile; M=W) SECONDARY Osteoporosis (d/t underlying condition): -HIGH cortisol (steroids, Cushings) -DM DEXA (T-score): a) Osteopenia = -1 to -2.5 b) Osteoporosis = < -2.5 Screening (women only): a) DEXA scan @ Age 65 b) Repeat q2-3years Start obtaining DEXA scans earlier / more often if : a) atypical fractures b) LT HRT c) chronic steroid usage d) rheumatoid arthritis

Spinal Stenosis: Symptoms? Gold standard test? Treatment?

PROGRESSIVE narrowing of either the spinal canal or neural foramen: a) Central = spinal canal b) Lateral = neural foramen Cause = UNK MC = males (> 60years) Symptoms: (+) progressive back pain (+/-) claudication & radiculopathy (+) WORSENED by exercise (how to differentiate from Ankylosing Spondylitis) (+) IMPROVED by leaning forward (+ shopping cart sign) GOLD standard = MRI Treatment: a) Conservative (best) = weight loss, PT, NSAIDS b) Corticosteroid injections c) Spinal fusion / decompression (last)

Why do we care about QT interval? Is a prolonged or shortened QT more dangerous? What factors are known to disrupt the QT interval?

PROLONGED QT interval = increases risk of cardiac arrhythmias !!! Factors known to PROLONG QT: -Amiodarone/Dronedarone -Anorexia/Bulemia -LOW Ca

SBO/LBO: Discuss how the signs/symptoms change based upon: a) proximal vs. distal obstruction b) partial vs. complete obstruction

PROXIMAL = more pronounced vomiting DISTAL = more pronounced "abdominal distention" PARTIAL (still have bowel sounds) = (+) high-pitched musical COMPLETE = ABSENT bowel sounds

PROM / PPROM: Discuss management of each condition...

PRROM (prior 37W): -TRY TO DELAY DELIVERY -Admit, rest, IVF, continued fetal monitoring -If less < 34W = give steroids (increase fetal lung maturity) -Administer ABX (reduce risk of infection) -ANY signs of maternal or fetal distress = (+) delivery PROM (after 37W): -ADMIT with "expectant management" for first 24 hours (see if delivery occurs naturally) -If NO spontaneous delivery within 24 hrs we (+) INDUCE labor to reduce risk of complications & infections IN EITHER CASE if you have (+) cord prolapse = OB EMERGENCY (surgery asap)

Peptic Ulcer Disease (PUD): What does this condition refer to? Causes? MCC?

PUD refers to ULCERATIONS of either: a) stomach b) duodenum Causes: -H.pylori (MCC) -chronic NSAIDs (2nd MCC) -chronic ETOH -chronic stress -Zollinger Ellison syndrome ("refractory PUD")

Peripheral Venous Disease: Patients who suffer from either varicose veins and/or chronic venous insufficiency, what are they at HIGHER risk for?

PVD (increased risk for): -SVT/DVT and/or PE -non-healing ulcerations **all of this has to do with the fact they have chronic venous STASIS (predisposes you to thromboembolic events +/- non-healing processes)

Peripheral Venous Disease: Discuss the different conditions that fall under this umbrella...

PVD: a) ACUTE manifestation = Superficial & Deep Vein Thrombosis (SVT/DVT) b) CHRONIC manifestations = varicose veins, chronic venous insufficiency

Asthma Exacerbation: Discuss how you expect their PaCO2 to look? What is considered a "warning sign" of impeding respiratory failure? Management?

PaCO2 levels normally are LOW (b.c. they are hyperventilating & blowing off excessive CO2) "WARNING sign" of impeding respiratory failure = if you see PaCO2 levels "normalizing" or are now high..... (+) intubate ASAP (+) increase Albuterol + O2 **if their O2 saturations don't improve, consider: (+) IV epinephrine

Chronic Pancreatitis: What does this put you at higher risk for?

Pancreatic cancer

Lung Cancer: List common "Paraneoplastic syndromes"? Which type of lung cancer are these most commonly seen with?

Paraneoplastic syndromes classically associated with: a) Small Cell Lung CA (MC) b) Squamous Cell Lung CA c) Carcinoid tumors Variations: 1. Hypercalcemia (MC type of paraneoplastic syndrome) - most commonly seen w/ Squamous Cell 2. Cushing Syndrome (ectopic ACTH production) 3. SIADH/Hyponatremia 4. Lambert-Eaton Syndrome (antibodies against Ca-channels) = leads to muscle weakness (BETTER w/ movement) **similar to Myasthenia Gravis (which is WORST w/ movement)

Paronychia vs. Felon: Differences? MC pathogen? R/O __________? TXT?

Paronychia = soft tissue infection around nail bed MC = staph TXT = I&D + ABX Felon = soft tissue infection (abscess) on VOLAR surface of finger MC = staph TXT = I&D + ABX **imaging is ONLY necessary if concerned for osteomyelitis (--> MRI best)

AFIB & A.Flutter: What is defined as: a) Paroxysmal b) Persistent c) Permanent

Paroxysmal = < 7 days (or recurrent) Persistent = constant for > 7 days Permanent = constant > 1 year

Pneumonia (HIV patients): Pathogens? MCC? Presentation? DX? TXT?

Pathogens: a) Streptococcus "Pneumococcal" (MCC) b) Pneumocystis jiroveci (FUNGUS) Presentation = "atypical" (common to be AFEBRILE) DX = CXR + sputum cultures TOC = BACTRIM

Tetralogy of Fallot (TOF): Pathophysiology? 4 components? Classic presentation? PE? CXR? Diagnostic test of choice? TXT?

Pathophysiology = CYANOTIC heart defect (Right --> left shunting) **shunting of deoxygenated blood into the left-side of the heart and then OUT TO THE BODY! 4 components: (+) over-riding aorta (+) VSD (+) RV hypertrophy (+) pulmonic valve stenosis Classic presentation: a) infants = "blue baby syndrome" = baby becomes blue with crying or bottle/breast feeding b) older children = (+) TET spells (sudden onset of hypoxia & cyanosis; resolved by squatting down) PE: (+) Harsh holosystolic murmur (best @ LUSB) CXR = (+) boot-shaped heart ECHO (best) TXT: a) Give prostaglandins until surgical correction (to keep ductus arteriosus open) b) surgical repair

Deep Vein Thrombophlebitis (DVT): Pathophysiology? Presentation? PE? Biggest concern?

Pathophysiology: (+) [Virchow's Triad] --> formation of clot in the deep venous system 50% DVTs --> progress to PULMONARY EMBOLISMS !! Symptoms/PE: (+) Sudden onset of UNILATERAL red, swollen painful leg (+) Homan's sign (calf pain w/ dorsiflexion foot) (+) LE "cording"

Alpha-1-Blockers: What kind of patient are these beneficial for?

Patients with concomitant HTN + BPH.

Anti-arrhythmics (class I): Class 1c drugs are contraindicated in who?

Patients with structural heart disease: -LVH, reduced EF (<40%) -valvular disorders -congenital heart defects

Acute Pericarditis: 2 MC complications? What MUST you always order to evaluate for these?

Pericardial effusion --> Pericardial Tamponade **must get ECHO and/or cardiac ultrasound to r/o!

Heart Sounds: Discuss what each of the following tells you: a) Physiologic split of S2 b) Paradoxical split of S2 c) FIXED split of S2

Physiologic split of S2 (NORMAL): -occurs with INSPIRATION (only) Paradoxical split of S2: -occurs with expiration (only) -usually indicative of SEVERE aortic stenosis FIXED split of S2: -indicates L-->R shunting of blood or delays PV closure -usually represents either congenital defect (ASD, VSD), pulmonary HTN or mitral regurgitation

Volvulus: What is this? Cause? MC location? Symptoms? DX? TXT?

Piece of bowel "flips" on itself --> bowel obstruction (idiopathic) MC location = sigmoid colon Symptoms (bowel obstruction): -abdominal pain / distention -N/V KUB = (+) "bird beak" / (+) colon distention DX/TXT = endoscopic decompression (flex sigmoidoscopy)

3rd TRIMESTER Bleeding: MCCs? Distinctions?

Placenta previa = PAINLESS Placenta abruption = PAINFUL

Gestational Diabetes: Pathophysiology? Risk factors? Complications?

Placenta releases hormones that INHIBIT insulin --> leading to hyperglycemia & insulin resistance (pregnancy) Risk factors: -OBESITY -Prior h/o gestational DM -Multiple gestations Risk to MOM: -premature labor -placental issues (PROM, abruption) -preeclampsia / ecclampsia -developing DM later on (50%) Risk to baby: -macrosomia -shoulder dystocia --> Erb's palsy -HYALINE membrane disease -development of DM later on

Discuss how to interpret the following PTLE lab values: a) PT b) PTT c) INR d) Bleeding time

Platelet components: a) "hooks" = Thromboxane A2 + ADP b) "glue" = PT vs. PTT 1. PT = (think "PO) = Coumadin/Warfarin (PO drug) 2. INR = ratio PT/PTT (used to measure efficacy of Coumadin) 3. PTT = (think "IV") = UFH/LMWH (IV drugs) **IV puts the drug directly into the BLOOD (so helps you remember that any BLEEDING disorders also affect PTT (vWF, hemophilia, etc.) 4. Bleeding time = represents PLATELET function (ASA, clopidogrel, prasugrel, Antifactor Xa, Direct Thrombin inhibitors)

PNEUMONIA: Recall the classic CXR findings for: a) Pneumococcal b) Mycoplasma pneumoniae c) Pneumocystis jiroveci (i.e. HIV)

Pneumococcal = "lobar" infiltrates Mycoplasma = diffuse "patchy" (interstitial) infiltrates (classic = CXR is much worse than PE findings) Pneumocystis jiroveci (looks like fungus): (+) diffuse bilateral (interstitial) infiltrates (+) perihilar infiltrates OTHER Fungal: (+) cavitation lesions surrounded by consolitation

PNEUMOCOCCAL VACCINE: Discuss the recommended use?

Pneumococcal vaccine = provides immunity for STREPTOCOCCAL pneumoniae (MCC of CAP) HEALTHY / low risk: -Kids = all receive PCV13 vaccine (4-dose series) -Age 65+ = receive PCV23 vaccine HIGH RISK: -MAY receive PCV23 q5 years throughout your life -Age 65+ = receive PCV13, followed by PCV23 one year later **PCV13 and PCV23 MUST be separated by 1 year **PCV23 and PCV23 doses MUST be separated by 5 yrs

Compare & Contrast: a) Polymyalgia Rheumatica b) Polymyositis/Dermatomyositis

Polymyalgia Rheumatic: -Idiopathic -BL proximal muscle STIFFNESS -MC = neck, shoulder, pelvis -HIGH ESR -DX = exclusion (must r/o Temporal Arteritis) -TXT = low-dose steroids Polymyositis/Dermatomyositis: -Idiopathic -BL proximal muscle WEAKNESS -MC = neck, shoulder, pelvis, PHARYNX (dysphagia) -HIGH creatinine kinase (CK) & Aldolase (+) Anti-JO Ab (+/-) Anti-SRP Ab (PM) (+/-) Anti-Mi-2 Ab (DM) -DX = muscle biopsy -DM associated with increased risk malignancy -TXT = high-dose steroids

Congenital Heart Disease: What are some clues that should make you think of these?

Poor feeding Failure to Thrive (inadequate growth, etc.) Cyanosis (newborn/infant)

Knee Dislocation: DISCUSS common findings if you had injury to: a) Popliteal artery b) Peroneal nerve c) Tibial nerve

Popliteal artery injury: (+) DIMINISHED distal pulses (+) Cold distal extremity (+) Ecchymosis Superficial Peroneal nerve: (+) decreased sensation along anterior shin (+) inability to INVERT ankle Deep Peroneal nerve: (+) decreased sensation in 1st dorsal web space (+) inability to dorsiflex foot / extend toe ("foot drop") Tibial nerve injury: (+) diminished sensation on heel (+) inability to EVERT the ankle

Takotsubo Cardiomyopathy: What patient population is this classically seen in?

Post-menopausal women

Discuss the MAIN distinguishing factors between: a) Postpartum "blues" b) Postpartum depression

Postpartum BLUES: a) resolves by D10 b) NO thoughts of harming themselves or baby c) Edinburgh Score < 10 d) TX T= none Postpartum DEPRESSION: a) does NOT resolve by D10 b) MAY have thoughts of harming themselves or baby c) Edinburgh Score > 10 d) TXT = antidepressants

Preeclampsia: Defined as? Cause? Risk factors? Symptoms? Workup? TXT?

Preeclampsia (by definition) occurs = AFTER 20 weeks gestation & up until 6wks postpartum Cause = UNK Risk factors: nullparious (1st baby), extremes of age (<20, >35), gestational DM, multiple gestation, chronic HTN SYMPTOMS: 1. Elevated BP 2. Widespread edema: a) Brain = SEVERE HA b) Optic nerve = visual disturbances ("black spots") c) Kidneys = proteinuria d) Liver = SEVERE epigastric pain +/- XRT back Workup: -Urine collection (24hr) -CBC (RBC, PLTE) -BMP (creatinine) -Uric acid level -LFTs TXT (ONLY CURE is delivery): (+) ADMIT (+) IVF + REST (+) Labetalol (BP) (+) MgS04 (seizure prophylaxis) (+/-) Steroids (if < 34W to aid in fetal lung development) **want to try and keep them pregnant for as long as possible (INDUCE @ 37W)

Cystic Fibrosis: Preliminary test? Definitive test?

Preliminary TEST = "Sweat chloride test" (+) given Pilocarpine (to simulate sweating) (+) measure [Cl] = >60mmol/L is indicative of CF DEFINITIVE test = genetic test

PVCs: MCCs? Feature? Treatment?

Premature Ventricular Contraction (PVC) **heartbeat initialized by the VENTRICLES (QRS that comes "earlier" than expected) MCCS: -Caffeine (#1) -Electrolyte abnormalities Usually feels like a "skipped beat" (+) t-wave will be in the OPPOSITE direction of QRS TXT: a) asymptomatic = none b) (+) symptoms = BB, CCB-

Premature Labor: Indications? Workup?

Premature labor (indications): -cervical shortening -cervical dilating -regular uterine contractions Workup: -serial u/s -NITRAZINE pH test (+ test = BLUE = indicates pooling amniotic fluid in vaginal canal) -Fetal Fibronectin -L/S ratio (< 2:1 = lung IMMATURITY)

EARLY Menopause: Also called? Defined as? Known risk factor?

Premature spontaneous ovarian failure (menopause < age 40) RF = (+) smoking

Bowel Obstruction: SBO vs. LBO: -symptoms -diagnostic studies -treatment

Presentation is SIMILAR: (+) SEVERE abdominal pain (+) abdominal distension (+) obstipation (**diarrhea = early finding) (+) inability to pass flatulence (+) N/V SBO: a) "bilious" vomiting b) DX (KUB) = "multiple air-fluid levels" c) TXT = NPO + IVF + NG decompression LBO: b) "feculent" vomiting b) DX (DUB) = colonic dilation c) TXT = surgical decompression (laparotomy) ABDOMINAL KUB (first line imaging)

Compartment Syndrome: What is the #1 complication that can occur if not treated early?

Pressure --> lead to decreased / absent blood flow to affected area --> tissue ischemia & necrosis BUZZ = VOLKMANN ischemic contracture

Amenorrhea: What are the 2 types? Definitions of each?

Primary Amenorrhea: -absence of menarche by Age 16 Secondary Amenorrhea (either): -prior menarche with absence of menses > 3 months (if regular before) -prior menarche with absence of menses > 6 months (if irregular before)

What are the 2 types of HTN? Main differences?

Primary HTN (95%): -Also referred to as "Essential" or "Idiopathic" HTN -Usually (+) FHX Secondary HTN (5%): -Due to a underlying secondary cause -Should suspect this in patients who are: very young, refractory HTN, or those who present with VERY HIGH BP.

Atrial Myxoma: What is this? Cause? MC location? Symptoms? Diagnostic test of choice? Treatment? Prognosis?

Primary cardiac tumor (rare) MC = atrial MC = benign (75%) Causes: -idiopathic (MC) -familiar (genetic) Symptoms are VAGUE and usually make early diagnosis challenging: -asymptomatic -constitutional symptoms -HF symptoms -SUDDEN CARDIAC DEATH Test of choice = ECHO TXT = surgical removal

Lactation: Discuss hormones that are responsible.

Prolactin = produces milk Oxytocin = required for RELEASE milk **realize that prolactin INHIBITS estrogen release, which is why during breastfeeding: (-) no menses (+) peri-menopausal state (vaginal dryness, etc.)

Gastritis: Explain HOW NSAIDS contribute to increased GI irritation or bleeding?

Prostaglandins = PROMOTE mucus secretion (stomach) which acts as "protective layer" NSAIDS = INHIBIT prostaglandins

Ductus Arteriosus: What keeps this open during development? What closes this within first 10-14 days of life?

Prostaglandins = keep it OPEN Prostaglandin inhibitors (i.e. NSAIDS = Indomethacin) = CLOSES IT

Primary Amenorrhea: Discuss treatment of: a) Turner Syndrome b) HPA dysfunction c) Androgen insensitivity d) Imperforate hymen

Provoke periods with OCP: -Turner Syndrome -HPO axis dysfunction -Androgen insensitivity SURGICAL correction: -Imperforate hymen

Pseudogout: Pathophysiology? Epidemiology? Presentation? XR? DX? TXT?

Pseudogout = improper calcium pyrophosphate dehydrate (CPPD) metabolism. MC = older women (v.s GOUT = older men) Presentation: 1. UL red/painful/swollen joint (MC = KNEE) **similar to gout (but gout (MC) = podagra) 2. (or) also commonly presents with chondrocalcinosis (calcium deposits into cartilage) XR = (+) "linear radiodensities" (chondrocalcinosis) Aspiration (BUZZ) = (+) POSITIVELY birefringent rhomboids TXT: a) Steroid injections (frontline) b) NSAIDS ***Allopurinol, Probenecid, Febuxostat (Uloric) have no place in therapy

Pulmonary HTN: Defined as? End result? Classifications? Features of each?

Pulmonary HTN (defined): mean pulmonary arterial pressure > 25mmHg Unmanaged pulmonary HTN --> lead to right heart failure (cor pulmonale) CLASSIFICATIONS: 1. PRIMARY pulmonary HTN ("idiopathic) (MC) **MC = younger women 2. SECONDARY pulmonary HTN: a) Due to chronic hypoxia (MCC = COPD) b) Due to Left-sided heart failure c) Due to chronic thromboembolic events (i.e. recurrent PE)

AFIB: What is the most FREQUENT source of the abnormal automatic foci that result in AFIB?

Pulmonic veins / LEFT atria ("man cave of AFIB")

Acute Bronchiolitis: What is the BEST predictor of disease severity in CHILDREN? When is admission indicated?

Pulse OX Admission indicated if O2 < 96% (children)

Cardiology basics: Discuss what would cause a "widened" & "narrowed" pulse pressure?

Pulse pressure = SBP - DBP WIDE pulse pressure (ex: aortic regurgitation): (+) rise in SBP (during ventricular contraction) (+) drop in DBP (during ventricular relaxation) NARROWED pulse pressure (ex: aortic stenosis): (+) drop in SBP (+) rise in DBP

Vitamin B6 deficiency: Also called? MCC? BUZZ presentation?

Pyridoxine deficiency MCC (TB drug) = Isoniazid (INH) "Sideroblastic anemia" Peripheral neuropathy

Torsades: What is usually the 1st INITAL sign?

QT prolongation

QT prolongation: Common causes? Why is this worrisome?

QT prolongation is associated with increased risk VFIB & sudden cardiac death.... MCC: -Amiodarone/Dronedarone -TCAs -Macrolides (i.e. Z-pack) -Electrolyte abnormalities (low Ca, Mg, K) = realize the low Ca is why eating disorder patient are at increased risk.

Tricuspid Stenosis: Causes? Common? Symptoms? PE? Treatment?

RARE Causes: -congenital (MC) -IVDU --> staphylococcal endocarditis Symptoms (--> RHF) PE: (+) mid-diastolic murmur @ LLSB (xiphoid border) TXT: a) medical = reduce preload b) surgical Surgical indications: -symptomatic -reduced EF < 55% / CHF

Pulmonic Regurgitation: Cause? Common? Symptoms? PE? Treatment?

RARE (either) = Congenital vs. Rheumatic HDz Symptoms: -asymptomatic -RHF symptoms PE: (+) decrescendo early diastolic murmur @ LUSB (called "Graham Steell Murmur) TXT = NONE (usually well-tolerated)

Tricuspid Regurgitation: Causes? Common? Outcome? PE? TXT?

RARE!!! Causes: a) congenital (MC) = "Ebstein anomaly" b) Rheumatic Heart Disease c) medication induced = Phenermine/Fenfluramine (Phen-fen) UNTREATED --> leads to RHF PE: (+) holosystolic (pan-systolic) BLOWING murmur @ Left-mid sternal border TXT: a) meds = reduce preload b) surgical = repair (preferred) vs. replacement

Vulvar cancer: Common? Risk factors? Types? MC? Symptoms? TXT?

RAREST type of GYN cancer Types: -Squamous (MC) -Adenocarcinoma -Melanoma (skin) Risk factors: 1. Lichen sclerosis 2. DES exposure in utero MC presenting symptoms: -asymptomatic -chronic vulvar itching (MC) -abnormal post-menopausal bleeding TXT: Resection +/- CHEMO

Bilirubin: Recall the pathway & difference between "indirect" and "direct" bilirubin? What are signs of: a) elevated INDIRECT bilirubin b) elevated DIRECT bilirubin

RBC breakdown --> HEME --> coverted to Indirect (unconjugated) bilirubin (NOT H20 soluble) --> which is then transported to liver for "conjugation" --> Liver conjugates indirect bilirubin in to DIRECT (conjugated) bilirubin (which is now H20 soluble) Direct bilirubin (conjugated) ---> broken down into urobilinogen (gives pee "yellow" color) & stercobilin (give feces "brown" color) High INDIRECT bilirubin = (+) jaundice High DIRECT bilirubin = (+) dark urine and (+) light colored stools ("clay colored")

Bronchiectasis: Pathophysiology? Causes? MCC?

RECURRENT inflammation/infection of airways --> leading to IRREVERSIBLE bronchial dilation #1 cause = CF Other potential causes: a) recurrent lung infections b) alpha1-antrypsin deficiency

Heart Sounds: For valvular "regurgitation" & "stenosis" discuss: a) heard best if valves are open or closed? b) classic "description" of the murmur c) overall result of the defect

REGURGITATION: -best heard when valve is CLOSED -"blowing" sounds -leads to VOLUME overload STENOSIS: -best heard when valve is OPEN -"harsh"/"rumble" sounds -leads to PRESSURE overload

Campylobacter jejuni: What condition is this associated with?

REMEMBER (classic): [campylobacteri infection] --> leads to post-infecitous GUILLIAN-BARRE SYNDROME!

Mitral Valve Prolapse: What is unique about the murmur associated with this?

REMEMBER that for all murmurs: a) Maneuvers that INCREASE venous return = ACCENTUATE murmurs(i.e. squatting, lying down, hand-grip technique) b) Maneuvers that DECREASE venous return = DULL murmurs (i.e. Valsalva maneuvers, standing) **MVP murmurs are the OPPOSITE!

Coarctation of Aorta: What lab value is usually ELEVATED?

RENIN!! -body senses low BP (d/t decreased CO) -continues to activate RAAS system -eventually leads to SECONDARY HTN + elevated renin

Atrophic Vaginitis: Discuss treatment options? Important considerations.... What is the BEST treatment option?

REPLACE ESTROGEN However important considerations: -PO estrogen (alone) after menopause can increase risk of endometrial hyperplasia & endometrial cancer (should combine with progesterone to protect the uterus) -PO estrogen + progesterone = reduces the risk of the endometrial cancer (from estrogen alone), HOWEVER the systemic combination has shown to increase risk of BREAST cancer if used > 5 years in postmenopausal period BIG PICTURE = local / topical treatments are always BETTER ! (+) Vaginal estrogen (Vagifem or vaginal ring) +/- progesterone IUD

Asthma: Is Theophylline used regularly? Why or why not?

RESERVED for SEVERE asthma -narrow therapeutic index -cardiac side effects -increased doses needed in smokers

Asthma: Pathophysiology? MC symptoms? PE? Diagnosis? Gold standard?

REVERSIBLE obstructive airway disease.... Airway HYPERSENSITIVITY (IgE mediated) ---> leads to BRONCOCONSTRICTION (smooth muscle contraction + airway edema) --> which results in an OBSTRUCTION to airflow MC symptoms: (+) dyspnea (+) wheezing (+) chronic cough (worse @ night) PE: (+) prolonged expiratory phase (+) decreased breath sounds (+) hyper-reasonate to percussion GOLD STANDARD = Pulmonary Function Tests (PFT) Other diagnostic tools: 1. Bronchodilator Challenge = if FEV1 improves by at least 10% after given a bronchodilator 2. Methylcholine Challenge (less common) = if FEV1 decreases by at least 20% after given methylcholine (bronchoconstrictor)

HMG-CoA reductase inhibitors: If your patient experiences rhabdomyalitis, what should you do? Pathophysiology? Hallmark symptom?

RHABDOMYOLITIS: -excessive muscle breakdown = leads to increased myoglobin -myoglobin is NEPHROTOXIC and causes AKI (kidney damage) -BUZZ = (+) "Dark / Coca-cola" urine (from myoglobin) Management: -IMMEDIATELY discontinue statin -obtain CPK levels (assess extent of muscle damage) -admit for aggressive IV therapy

Cor Pulmonale: What is this?

RIGHT SIDED heart failure that occurs 2/2 PULMONARY etiology Most common cause = pulmonary HTN (i.e. seen a lot w/ chronic bronchitis patients secondary to their chronic hypoxic state)

Breakdown different BP disorders in pregnancy... Main ways to distinguish these?

RULE OF THUMB: a) high BP < 20W = probably preexisting b) NEW ONSET high BP > 20 W = probably related to pregnancy 1. HIGH BP, NO (-) proteinuria: a) Chronic "pre-exisiting" HTN (present before < 20 W and continues after > 6 weeks postpartum) b) Gestational HTN (NOT present before 20W, resolves by 6 weeks postpartum) 2. HIGH BP, (+) PROTEINURIA = BOTH are NOT present before < 20W and resolve upon delivery): a) Preeclampsia b) Eclampsia

Appendicitis: #1 complication? Signs/symptoms?

RUPTURE (+) rebound tenderness (+) abdominal rigidity

Boerhaave Syndrome: What is this? MCC? Symptoms? PE? CXR? Diagnostic study of choice? TXT?

RUPTURED esophagus ! Causes: a) Forceful vomiting (MCC) = ETOH, bulimics b) Iatrogenic = EGD complication "SUDDEN severe retrosternal CP" (+/-) hematemesis PE: (+) Hamman's Sign (crepitus on chest auscultation) CXR (initial study) = (+) pneumomediastiunum (air in mediastinum) Gold standard = Gastrograffin contrast esophagram (+ leakage) TXT: a) small/stable = IVF, NPO, ABX b) large/unstable = surgical epair

Cholecystitis: Discuss the appropriate use of: a) RUQ u/s b) HIDA scan What is the BEST answer on PANCE (usually)?

RUQ u/s = TEST OF CHOICE (both cholelithiasis & cholecystitis) **HIDA scans are reserved for questionable diagnoses (i.e. RUQ u/s is "inconclusive")

Recall the innervation of the: a) radial nerve b) median nerve c) ulnar nerve d) axillary nerve Describe the motor & sensory of each.....

Radial nerve: a) Sensory = 1st dorsal webspace b) Motor = wrist & thumb extension (injury --> WRIST DROP) Median nerve: a) Sensory = volar pad index finger b) Motor = thumb opposition Ulnar nerve: a) Sensory = volar pad of pinky b) Motor = criss-cross fingers Axillary nerve = deltoid sensation GILBOY: A) shoulder = axillary b) Humerus = radial c) Elbow = ulnar d) Elbow "SOUTH" = median

Salmonella/Shigella: What other condition are these oftentimes associated with?

Reactive (Reiter's) Arthritis "can't see, can't pee, can't climb a tree"

RSV Infection: Research has shown that children who have had RSV are at higher risk of developing __________ later on in life.

Reactive airway disease (i.e asthma)

Ankle Fracture: Discuss WEBER classification system... MC type? TXT?

Realize that "ANKLE FRACTURE" (means) = distal fibula or tibial fracture WEBER A = fracture DISTAL (below) syndesmosis (stable) WEBER B (MC type) = fracture @ level of syndesmosis (stable vs. unstable) WEBER C = fracture PROXIMAL (above) syndesmosis (WORSE kind) TXT: a) Weber A, B = closed reduction + cast b) Weber C (unstable) = ORIF

COPD: 2 extremes? Pathophysiology? Defining features of each?

Realize that the below 2 types usually co-exist, which one being more dominant!! 1. Chronic Bronchitis ("blue bloaters") -excessive mucus production leads to airway obstruction & impaired gas exchange -younger, obese -CHRONIC PRODUCTIVE COUGH + EDEMA -PE = (+) rhonchi -CXR = (+) "dirty lungs" (increased lung markings) -Spirometry = LOW pO2 + HIGH pCO2 (respiratory acidosis) 2. Emphysema ("pink puffer"): -alveoli damage causes them to be non-compliant (floppy), causing them to "collapse" easily ("air trapping" = limits gas exchange) -older, thin, smoker -PROGRESSIVE SOB -PE = normal (clean lungs) or decreased breath sounds -CXR = (+) hyper-infalted, flattened diaphragms, decreased lung markings -Spirometry = NORMAL pO2 + pCO2

Rheumatic Fever: Cause? Epidemiology? Why is it so important to treat this?

Recall the progression.... Initial GBS infection (i.e. pharyngitis) that goes untreated --> leads to Scarlett Fever --> Rheumatic Fever --> leads to Rheumatic heart disease

MURMUR (basics): Recall the "MR TAPS" system...

Recall: a) S1 = "lub" (M/T valves closing) b) S2 = "dub" (A/P valves closing) SYSTOLIC MURMURS: "MR. TAPS" -Mitral regurgitation -Tricuspid regurgitation -Aortic stenosis -Pulmonic stenosis These murmurs radiate "up": a) MR/TR (holosystolic) = S1, apex, bell b) AS/PS (crescendo/decrescendo systolic) = S2, base, diaphragm *EVERYTHING ELSE IS DIASTOLIC MURMUR**

Hepatitis B (vaccine): Whom is this recommended? Contraindications?

Recommended: a) Neonate whose mother (+) HepB b) DM (ages 19-59) c) Men who have sex with men d) IVDU e) Healthcare workers f) Travelers to endemic areas g) Chronic liver disease CI = allergy to baker yeast

"Trousseau's Sign" of malignancy: What cancers are MC? Pathophysiology?

Recurrent migratory thrombophlebitis is really indicating recurrent blood clotting (hyper-coagulability) Most indicative of ADENOCARCINOMA (considered an "early sign") MC cancers: -gastric cancer -pancreatic cancer -lung cancer

When is tonsillectomy considered?

Recurrent tonsillitis Peri-tonsillar abscess Enlarged tonsils causing OSA

HF Mangement (outpatient): a) Discuss various components... b) Which agents improve M&M? c) What is the usually approach to starting treatment?

Reduce PRE-LOAD (improves symptoms): (+) Loop diuretics (frontline) (+/-) K+ sparing diuretics Reduce AFTER-LOAD (improve M&M): (+) ACE-inhibitor or ARB (+) BB (+/-) Nitrates + Hydralazine GENERALLY for new-HF patient: a) Start ACEi + diuretic (initially) b) ADD BB (once stabilized)

Asthma Exacerbation: In what patients should you ALWASY be cautious of giving PO steroids? What the the DAILY DOSE limit when treating acute asthma exacerbation? (always on the boards)

Remember that PO steroids = INCREASE glucose levels (caution in DM; consider adjusting medications) PO steroids = DO NOT EXCEED 6Omg/day (avoid Cushings)

Plantar Fasciitis: Discuss the risk vs. benefit of using steroid injections....

Reserved ONLY for severe or refractory cases (injecting steroids into fascia INCREASES risk facia rupture)

Strabismus: What can this be a early sign of? What should you always order?

Retinoblastoma (get MRI)

In a child with a ABSENT red light reflex, what are your top differentials?

Retinoblastoma Congenital cataract (r/o ToRCH infections)

Retinopathy: Breakdown the different types?

Retinopathy = damage to RETINA 1. DIABETIC retinopathy: a) Non-proliferative (MC)(microaneurysms) = not associated with vision loss ("hard exudates" "cotton wool spots") b) Proliferative (neovascularization) 2. Hypertensive retinopathy = d/t uncontrolled HTN

Conjunctivitis: Discuss the MCC of Neonatal conjunctivitis? How do we try to prevent this? TXT?

Right after birth, we give baby: (+) erythromycin ointment (+) silver nitrate solution (+) tetracycline ointment Neonatal conjunctivitis: a) DAY 1 = silver nitrate (irritation) b) Day 2-5 = gonorrhea c) Day 5-7 = chlamydia d) Day 7+ = HSV

Thoracic Aortic Dissection: Risk factors? Symptoms? Diagnostic tests? Gold standard?

Risk factors: -HTN (MOST important) -age (MC = 50-60yo) -males -underlying connective tissue disorders (i.e. Marfans, etc.) "RIPPING/TEARING" severe chest pain (+) XRT to neck, jaw, upper back (+) decreased peripheral pulses (carotid, radial, femoral) (+) HTN Initial tests: a) CXR = (+) WIDENED mediastinum (BUZZ) b) Chest CT + contrast Gold standard = angiography

Umbilical cord prolapse: 2 MC risk factors.... Management?

Risk factors: 1. PPROM, PROM 2. BREECH presentation (i.e. fetal malpresentation) Management = EMERGENCY (straight to OR)

CAP: Recall some of the odd pneumonias: a) Rodent exposure b) Infected animals c) Birds d) Missisippi River Valley e) San Joaquin Valley (CA) f) Southeast US

Rodents: a) Yersinia pestis (plaguw) = "fleas on rodents" b) Hantavirus = rodent urine/feces Infected animals (rabbits, cattle): a) Francisella Tularensis (Tularemia) b) Coxiella Burnetti (bacteria = "Q-fever") Birds = chlamydia pneumonia Mississippi River = Histoplasmosis (fungal) San Joaquin Valley "Fever" = Coccidiomycosis (fungal) Southeast US = Blastomycosis (fungal)

Alpha-2 Blocker: Moxonidine is also known as? What is this also used to treat?

Rogaine (treats hair loss)

Rotator Cuff Injuries: 2 variations?

Rotator cuff inflammation (tendonitis/bursitis) Rotator cuff TEAR

TB: Who should be routinely screened for TB?

Routine screening recommended in patients who are either: a) High risk of contracting TB b) High risk of reactivation TB (i.e. immunocompromised) Examples: -patients who travel to endemic areas -healthcare workers -homeless -IVDU -immunocompromised (HIV)

Heart Sounds: Breakdown difference between S1 & S2.... -systole vs. diastole -which valves are open/closed

S1 = "lub" = M/T valves close (systole)= ventricles contract S2 = "dub" = A/P valves close (diastole) = atria contract

Heart Sounds: What does the following indicate? a) S3 ("gallop") b) S4 ("rub")

S3 ("gallop"): a) Patients < 30yo = "physiologic gallop" (not pathologic) = usually disappears when they sit/stand b) Patients > 30yo = PATHOLOGIC = indicates "volume overload" = LV failure or CHF S4 ("pressure overload") = HTN, LVH

Discuss the relative rates of conduction between: a) SA node b) AV node ("Junctional") c) Ventricles

SA node (main conductor) = >60bpm AV node = 40-60bpm Ventricles = < 40bpm

Asthma: What is the MAIN counseling points to educate your patients about use of Maintenance medications?

SABA are NOT intended to be used daily = doing so REDUCES the number & sensitivity of B2 receptors (lungs) & makes the medications less effective ICS = ALWAYS wash your mouth out after use (increase risk of Thrush)

Peripheral Venous Disease (chronic venous insufficiency): Pathophysiology? Symptoms? PE? Treatment?

SAME CONCEPT as varicose veins, BUT now involves BOTH superficial + deep veins !!! Pathophysiology: -the movement of blood through the LE venous system occurs AGAINST gravity (flows up) -this process requires LE muscle to contract to propel the blood UPWARDS & the valves to open/close appropriately to prevent blood BACK-FLOW -PVD occurs when the valves don't function correctly & blood is allowed to moved backwards & pool in LE Risk factors: -obesity -pregnancy -prolonged sitting/standing Symptoms / PE: (+) Chronic LE EDEMA (halmark) (+) LE "heaviness" or "ache" (worse @ rest; better w/ activity) (+) Stasis dermatitis (eczematous rash, itching) (+) LE skin discoloration (brown = hemosiderin deposits) (+) non-healing ulcers (MC = medial malleous) **REALIZE LE pulses / temperature = NORMAL!! TXT: a) Mainstay = exercise, compression, leg elevation b) Surgical options = venous valve transplant

Bowel Obstruction: What are the MC causes of: a) Small bowel obstruction b) Large bowel obstruction Other potential causes?

SBO (MCC) = "adhesions" (from prior intra-abdominal surgeries) LBO (MCC) = colon cancer Other potential causes: -hernias (incarcerated, strangulated) -volvulus -intussception -fecal impaction

SCFE: If you are seeing this in a YOUNG child, what is the most appropriate next step?

SCFE is most commonly due to a SUDDEN GROWTH spurt, therefore if you are seeing this in a young child (pre-adolescent) it is considered ABNORMAL... Rule out endocrine issues like: -hypothyroidism -hypopituitarism

Acoustic Neuroma: Type of tumor? Causes? Presentation? Gold standard? TXT?

SCHWANNOMA of acoustic nerve (CN 8) "UL sensiorneural hearing loss" = ACOUSTIC NEUROMA (until proven otherwise) Presentation: (+) SENSIORNEURAL hearing loss (+) Tinnitus (+) Balance issues / vertigo Gold standard = MRI TXT = resection

Syphilis: Diagnosis? BEST test? TXT?

SCREENING TESTS (not specific): (+) RPR (+) VDRL BEST test (needed to confirm diagnosis): (+) fluorescent treponemal Abx absorption (FTA-ABS) PRIMARY & SECONDARY: -Benzathine PCN "G" -Single IM x 1 (2.4 million U) TERITARY: -Benzathine PCN "G" -IM (2.4 million U) -Injections weekly x 3wks Neurosyphilis: -PCN IV q4hrs for 10-14d

Colorectal Cancer: Screening options? Recommended timelines?

SCREENING colonoscopy: a) NO FHX: start @ age 50 b) (+) FHX: start @ age 40 OR 10 years prior to age your 1st degree relative was diagnosis Colonoscopy results: a) Normal = repeat q10yrs b) Abnormal = repeat q3-5yrs IF your patient does NOT want to undergo colonoscopy (alternative screenings); a) Fecal occult blood annually b) Sigmoidoscopy q5 years c) Barium enema q5 years d) CEA q5 years

Fractures: Discuss the treatment options for "greenstick" fracture?

SEEN IN KIDS!!! MUST look at "degrees" of angulation..... Angulation < 15 degrees = closed reduction (cast 4-6 weeks) Angulation > 15 degrees = ORIF (referral to orthopedic surgeon)

BREAST CANCER: Discuss the use of SERMS ? Drugs? Concerns?

SERMS (tamoxifen, raloxifen) These are primarily used as prophylaxis in: a) postmenopausal women b) (+) estrogen receptor positive disease c) women with strong predisposition to breast cancer (i.e. 1st degree family relative)

Jarisch-Herxheimer reaction: What is this? Pathophysiology behind it? Prevention? Main concern?

SEVERE reaction following initiation of syphilis treatment -FEVER + TOXIC SHOCK -thought to occur d/t sudden mass destruction of the Treponema palladium spirochetes, which then release pro-inflammatory molecules Prevention: (+) antipyretics during first 24 hours treatment MAIN CONCERN: If occurs in pregnant women, can cause premature labor and/or major obstetric complications (fetal distress or demise) **BUT this risk does not outweigh benefit of treating all pregnant women

What is the MAIN symptom that distinguishes Ethlos-Danlos vs. Marfans?

SKELETAL involvement (+) TALL /THIN --> Marfans (-) normal stature --> ED

ACS: SOC ordering for cardiac bio-markers? Initial elevation? Peak elevations? Return to baselines? Which biomarker is best?

SOC = serial cardiac biomarkers (3 sets; 8 hours apart) Troponin (I/T): -BEST (most specific) -begin rising 2-4 hours after start of event -peak elevation = 12-24hrs -return to baseline = 7-10 days CKMB: -peak elevation = 12-24 hrs -return to baseline = 3-4 days

Anal Carcinoma: MC type? MCC? MC risk factor? Symptoms? TXT?

SQUAMOUS cell carcinoma MCC = HPV **usually associated with HIV patients" (makes them immunocompromised enough that HPV causes cancer) "Anal fullness/pain/bleeding" TXT = [resection] + XRT/CHEMO

Rules of "6": List the 6 MCCs of: a) ST depression b) ST elevation c) Wide QRS

ST-depression: 1. ischemia (MC) 2. sub-endocardial ischemia/infarct 3. posterior MI 4. LVH 5. reciprocal changes 6. digoxin effect ST-elevation: 1. STEMI (MC) 2. Vasospasm (Prinzmetal, Cocaine) 3. Pericarditis 4. Takasubo Cardiomyopathy 5. RBBB/LBBB 6. Brugada syndrome Wide QRS: 1. RBBB/LBBB 2. Ventricular rhythm or hypertrophy (MC = VTACH) 3. WBW 4. Hypokalemia 5. Meds 6. Paced heart

ACS: If you see ST-elevation, list top etiologies & how to differentiate them...

ST-elevation (few leads): -STEMI (not transient) -Prinzmetal (transient) -Cocaine-induced (transient) -Brugada Syndrome **realize that with Prinzmetal & Cocaine-MI, if you give a (+) CCB/Nitrate, it usually resolves the ST-elevation (trick)... ST-elevation (ALL leads): -Pericarditis

WPW: TXT? DOC?

STABLE treatment: a) Vagal manuvers b) Class Ic (DOC) c) Class Ia d) Class III (Amiodarone) UNSTABLE: Synchronized cardioversion DEFINITIVE TXT: Abalation

DeQuervain Tenosynovitis: Pathophysiology? Causes? Symptoms? PE? DX? TXT?

STENOSING tenosynovitis of the ligaments: -ABductor pollicus longus (APL) -Extensor pollicus brevus (EPB) Causes = overuse (MC), pregnancy ("new mom" = repetitive holding newborn irritates theses ligaments) "Wrist" pain (worse w/ gripping anything" (+) FINKELSTEIN TEST DX = Clinical TXT = thumb-spica splint x 3W (+/- NSAIDS, steroids, PT)

Central Retinal Vein Occlusion: MCC? Symptom? Fundoscopic Exam? Prognosis? Treatment?

SUDDEN "painless" loss vision (unilateral) MCC = ischemia Fundoscopic: (+) Hemorrhages (+) "Blood & Thunder" (+) Cotton wool spots Prognosis = NOT emergency TXT = surgery

Central Retinal Artery Occlusion: Causes? Symptom? Fundoycopic? Treatment? Prognosis?

SUDDEN "painless" vision loss (unilateral) Thromboembolic event "clot" (MCC) Fundoscopic exam: (+) decreased pallor (+) fovea atrophy (+) "cherry red spot" **MUST be corrected within 90 minutes or will lead to PERMANENT BLINDNESS (emergency) TREATMENT: -Ocular massage -O2 -Carbonic anhydrase inhibitor (Acetozolamide IV) -IMMEDATE ophthalmology consult

Breakdown the potential differentials for SUDDEN LOSS OF VISION?

SUDDEN VISION LOSS 1. PAINLESS: -amaurosis fugax -central retinal artery occlusion -central retinal vein occlusion -retinal detachment 2. PAINFUL: -acute angle closure glaucoma -optic neuritis

Aspiration of FB: Symptoms suggestive of this? MC location of FB? Gold standard test ?

SUDDEN onset of: -coughing -chocking -SOB MC location = right middle lobe CXR = (+/-) regional hyperinflation (affected side) **but realize these are not the best test b.c. not all FB are radio-lucent. Bronchoscopy (gold standard) = BOTH diagnostic & therapeutic

Anal Fissure: What is this? MCC? MC location? Symptoms? Treatment?

SUPERFICIAL anal mucosal tear MCC = constipation (straining) MC= posterior midline "PAINFUL" hematochezia (BRBPR) 80% (resolve spontaneously) TXT (supportive) -increase hydration -increase fiber -Sitz baths -stool softeners -bulking agents -laxatives -NG topical ointment (pain)

Mallory-Weiss Tear: What is this? MCC? MC seen in who? Symptoms? Gold standard (DX)? TXT?

SUPERFICIAL longitudinal tear in esophageal mucosa MCC = forceful vomiting MC = alcoholics / bulimics "Hematemesis" (small volume) (+/- melena) Diagnosis is usually CLINICAL! Gold standard = EGD TXT: -Most spontaneously resolve (without TXT) -May add (+) acid-suppressing med (which promotes healing) **If continues to bleed = treat like esophageal varices.

Idiopathic Pulmonary Fibrosis: Symptoms? PE? PFT ? CXR? Definitive diagnosis? Treatment?

SXS = "Chronic NP cough + progressive SOB" PE = (+) inspiratory crackles, cyanosis, nail clubbing PFT = "restrictive pattern" (+) decreased TLC, RV (-) NORMAL FEV1 & FEV1/FVC ratio CXR: (+) ground glass opacities (+) diffuse reticular opacities ("honeycombing") Definitive diagnosis = BIOPSY! (+) HONEYCOMBING TXT: -SUPPORTIVE (mainstay) -Lung transplant (definitive)

Ectopic pregnancy: Symptoms? PE? Labs? DX? TXT?

SYMPTOMS suggestive ectopic: (+) vaginal bleeding (+) UL pelvic/shoulder pain (SEVERE) (+) syncope (+) hemodynamic instability PE = (+/-) adnexal mass Labs: (+) LOW b-HCG REMEMBER: When b-HCG levels > 1500, a gestational sac should be visible within uterus DX = transvaginal U/S (b-HCG > 1500 combined with ABSENCE of a UTERINE gestational sac confirms diagnosis) Management: a) Methotrexate (if indications met) b) Give RHOGAM (if RH(-)) c) Laparoscopic salphingostomy (1st choice if ruptured or unstable)

PCI: What MUST you prescribe post-PCI?

Same post-MI regimen: a) anti platelet (ASA + Plavix) b) BB (or CCB) c) ACEi (or ARB) d) Statin ONLY difference is if you placed a BMS/DES, you MUST additionally prescribe DUAL-antiplatelet therapy (ASA + Plavix)

Sarcoidosis: How does the biopsy results differ from TB?

Sarcoidosis = NON-caseating granulomas TB = CASEATING granulomas

Gestational Diabetes: What health maintenance is recommended?

Screen for DM @ 6 weeks postpartum & annually thereafter.

According to the USPTF, what is current lung cancer recommended screening?

Screening should begin @ Age 55 for patients who: a) Current smokers 30+ pack year history b) Smokers 30+ pack year history (who quit within last 15 years) Recommendation = CT annually

Vitamin C deficiency: Discuss the BUZZ presentation...

Scurvy = 4 Hs a) Hematologic (anemia, HEMORRHAGE "GUMS" ) b) Hair/tooth loss c) Hyperkeratosis (skin) d) Healing (impaired wound healing)

"PULSELESS" VTACH: What is this? Mangement?

See (+) electrical activity on the monitor, BUT (-) pulse.... Management: -1st line = DEFIBRILLATION + CPR (30:2) -2nd line = epinephrine

Shoulder Dislocation: What "BUZZ" words would make you think of posterior shoulder dislocation?

Seizures Electric-convulsive therapy (ECT) Lightening strike Electrocution

Abruption placentae: What is this? Risk factors? MCC? Symptoms? DX? TXT?

Separation of the placenta from the uterine wall. Risk factors (most common): -Maternal HTN (MCC) -Trauma -Smoking -Excessive ETOH Symptoms: (+) PAINFUL vaginal bleeding (+) hemodynamically UNSTABLE DX = pelvic u/s (DO NOT perform pelvic exam) TXT = C-section ASAP

CAP (Legionnaire's Disease): What Serogroup accounts for 80% cases? What MUST you know about transmission?

Serogroup 1 NOT transmitted from person-to-person (transmitted via contaminated H20 droplets)

Prinzmetal Angina: Pathophysiology? Classic patient? Classic features? TXt?

Severe coronary vasospasm (presents like MI) "older, female, smoker" (+) Angina = worse in AM (may "wake them up at night") & usually occurs concomitantly with other vasospasm disorders (migraines, Raynaud's) (+) Transient ST-elvation (resolves with CCB/Nitrate) (+) Transient increase in cardiac biomarkers TXT: a) CCB (frontline) b) Nitrates

Aldosterone Antagonists: Explain WHY these medications help treat sex hormone imbalances (i.e. acne, hirsutism)?

Sex hormones are produced by testicles/ovaries BUT these hormones must be ACTIVATES (@ kidneys) Aldosterone Antagonists work @ the kidneys & additionally REDUCE the activation of these sex hormones.... Acne/Hirsutism --> result from HIGH testosterone (i.e. PCOS patient) **by inhibiting the activation of testosterone to its active form, you IMPROVE these symptoms....

Shoulder Dislocations: What 2 complications must you evaluate for?

Shoulder dislocation can ADDITIONALLY cause (either): 1. Hill-Sach's Lesion =compression fracture to humeral head 2. Bankart Lesion = glenoid labrum tear (MRI)

Sialolithiasis/Sialadenitis: Difference? MC location? Presentation? TXT? What should be avoided in these patients?

Sialothithiasis = "stones" Sialadenitis = when that stone gets lodged in the duct causing localized inflammation/infection. MC = Calcium stones MC = Wharton's Duct (submandibular gland) "POST-PRANDIAL" salivary pain & swelling. TXT: a) Sialogogues (increase salivary flow) b) Lithotripsy **AVOID anticholinergic drugs**

Colorectal Cancer: What are the most common signs/symptoms? Initial test? Gold standard? Treatment?

Signs/symptoms: (+) CHANGE in bowel habits (+) PAINLESS bleeding (stool) (+) weight loss (+) NEW ONSET "Fe deficiency anemia" (+) elevated CEA levels (+) "apple core" lesions (Barium enema) Colonoscopy + BX (gold standard) TXT = colectomy + CHEMO

What are the 2 rhythms that you do not SHOCK (even if unstable)?

Sinus Tachycardia MAT

Sinus Tachycardia vs. SVT: Discuss the main DISTINGUISHING features of these?

Sinus tachycardia (normal SA-->AV conduction): (+) NORMAL rhythm (normal p-waves/QRS) (+) FAST rate (usually < 130) SVT ("atrial tachycardia"): (+) ABNORMAL rhythm (so fast that p-wave & t-wave are merged = indistinguishable p-waves) (+) FAST rate (usually > 130) **realize that SVT the signal is NOT coming from SA node (coming from atria), this in conjunction with the REALLY FAST rate means that the p-waves are usually indistinguishable (merged w/ t-waves)

CHRONIC sinusitis: Defined as? MC pathogen? BUZZ PE finding? Workup? (what must you r/o)?

Sinusitis > 8-12 weeks Causes: a) Bacterial (MC = staph) b) Fungal MUST r/o FB or malignancy ! (tumor could be causing obstruction --> fluid stagnation & secondary infection) PE = (+) nasal polyps Workup: a) XR (Water's view) b) CT scan

Pneumothorax: Treatment?

Small pneumothoracies (< 20%) = "watch and wait" a) supportive (O2) b) follow-up CXR Large pneumothoracies (> 20%) OR tension pneumothoracies: a) IMMEDIATE needle decompression (1st) @ 2nd ICS b) Followed by chest-tube placement (2nd) @ mid-clavicular line

In general, what does a (+) ANCA indicate? Conditions which we see this?

Small vessel vasculitis (general): -Primary Sclerosing Cholangitis -Wegners (granulomatous polyangitis) -Ulcerative Colitis

Vasculitis: Which disorders are categorized as: a) Small vessel vasculitis b) Medium vessel vasculitis c) Large vessel vasculitis

Small vessel: 1. Granulomatous Polyangitis (Wegners) 2. Henoch-Schonlein Purpura Medium Vessel: 1. Polyarteritis Nodosa (PAN) 2. Kawasaki Disease Large Vessel: 1. Temporal Arteritis ("Giant Cell") 2. Takayasu Arteritis

Leiomyomata (uterine fibroids): What are these? Cause? Epidemiology? Symptoms? PE? DX? TXT?

Smooth muscle tumor (benign) Cause = ESTROGEN MC = 30s-40s (resolves after menopause) Symptoms: a) Asymptomatic (MC) b) Irregular menstrual bleeding c) Dysmenorrhea d) Pelvic fullness PE = (+/-) pelvic mass (on bimanual exam) DX = pelvic u/s TXT options: 1. Observation (if asymptomatic) 2. Medical therapy (inhibit estrogen production & limit growth): a) GnRH antagonists = Leuprolide (Lupron) b) Androgen antagonists = Danazol 3. Surgical options: a) Myomectomy (preserve fertility) b) Hysterectomy (definitive)

Cervical Cancer: Types? General risk factors? Symptoms?

Squamous Cell (MC) MCC = HPV infection Adenocarcinoma (NOT associated with HPV) MCC = prior DES exposure Symptoms: a) Asymptomatic (MC) b) irregular vaginal bleeding or pain

MURMUR (basics): Discuss WHY the following maneuvers affect murmurs? a) squatting b) leg raise c) lying down d) valsalva e) standing Exceptions?

Squatting, leg raise, lying down = INCREASE VENOUS RETURN (which accentuates all murmurs) Valsalva maneuvers, standing= DECREASE venous return (which decreases the intensity of all murmurs) EXCEPTION (which is the opposite = "low volume lovers"): -MVP -Hypertrophic cardiomyopathy murmurs

V. Flutter: Treatment?

Stable (same as VTACH): a) Mediation (Class III, 1b, 1c) b) ICD placement Unstable: Synchronize cardioversion + ICD placement

Arrhythmias: What is the RULE OF THUMB when treating these?

Stable = medical management (medication) Unstable = electrical management (cardioversion, ablation, etc.) Definitive TXT (all) = ablation

Pulmonary Embolism: Treatment approach?

Stable PE: 1. Anticoagulation OK = start UFH/LMWH asap + start warfarin @ the same time (bridging therapy) & continue PO anticoagulation for minimum 3 months 2. Anticoagulation contraindicated = IVC filter UNSTABLE PE: 1. Anticoagulation OK = thrombolytic therapy (streptokinase, urokinase, alteplase) 2. Anticoagulation contraindicated = Thrombectomy/embolectomy

CAD: Describe HOW to breakdown the "type of angina" ?

Stable vs. Unstable angina: a) Stable = occurs with activity (NOT rest), lasts < 3 min, relieved by rest or NTG b) Unstable = occurs either @ rest or has increased in severity or frequency, lasts > 3min, NOT relieved by rest or NTG CLASSES (angina): a) Class 1 = no limitation with normal activities b) Class 2 = mild-moderate limitation with normal activities c) Class 3 = severe limitation with normal activities d) Class 4 = limitation @ rest

Hypertensive Retinopathy: Stages? TXT?

Stage 1 = arterial narrowing Stage 2 = AV nicking Stage 3 = Hemorrhages, cotton-wool spots Stage 4 = PAPILLEDEMA ("malignant HTN") TXT = strick BP control

Internal Hemorrhoids: Classifications? Treatment?

Stages: a) STAGE 1 = confined to anal canal b) STAGE 2 = protrudes, but spontaneously reduces c) STAGE 3 = protrudes, requires MANUAL reduction d) STAGE 4 = protrudes, unable to be reduced Stages 1-2 (treat conservatively) = hydration, fiber, stool softeners, laxatives Sages 3 & 4 (high risk) for strangulation (emergency) = SURGICAL REMOVAL

Thoracic Aortic Dissection: Outline the different classification systems.... MC location? Location with WORST prognosis?

Stanford classification DeBakey classification MC = ascending Worse prognosis = ascending Stanford: a) Type A = ascending +/- arch b) Type B = descending DeBakey: a) Type 1 = ascending + arch b) Type 2 = ascending only c) Type 3 = descending only

Hospital Acquired Pneumonia: MC pathogen? Which pathogen must you always cover for?

Staph aureus / MRSA (MC) Pseudomonas (MUST cover for) **HIGH association with ICU/ventilator use **pseudomonas has the WORST prognosis!

Toxic Shock Syndrome: What is this? MCC? Presentation? DX? TXT?

Staph aureus infection (MCC = prolonged tampon or diaphragm usage) PRESENT: (+) high fever (+) diffuse rash ("sunburn") (+) hypotension DX = clinical TXT = admit + IV ABX

COPD: Discuss when the following are appropriate: a) steroids b) antibiotics Which ABX are frontline?

Steroids: a) ICS = consider if FEV1/FVC 30-50% b) PO steroids = exacerbations only (limit use; overuse associated with developing DM) Antibiotics = reserved in treatment of acute bacterial exacerbations of CHRONIC bronchitis (FQ = frontline)

Hypothalamus-Pituitary-Ovarian (HPO) dysfunction: What are some known risk factors that can cause this?

Stress Anorexia Extreme exercise Severe illness Prolactinoma Pituitary adenoma **remember if you had a tumor secreting prolactin (this inhibits estrogen)

Short-Acting Nitrates: Which form is the MOST effective? Dosing?

Sublingual (most effective) May take up to 3 doses (q5 min) = if no relief, SUSPECT ACS!

Supraventricular Arrhythmias: Breakdown the different types? MC? MC symptoms?

Supraventricular Arrhythmias: a) SVT b) Multifocal Atrial Tachycardia (MAT) c) Atrial Flutter d) AFIB (MC) Symptoms (range): -asymptomatic -palpitations "racing heart rate" -chest pain -SOB -fatigue -syncope

Hemorrhoids: When is surgery indicated? Why?

Surgery indicated: -all stage 4 internal hemorrhoids -failed conservative treatment -strangulated Options: -rubber band ligation (preferred) -sclerotherapy -hemorrhoidectomy

Breast Abscess: Signs/symptoms? Diagnosis? Treatment?

Suspect ABSCESS if you have: (+) refractory mastitis (+) induration / flucuance (PE) Workup / TXT: -BREAST U/S (best test) -I&D + send for culture -Start empiric ABX ABX options: -Naficillin (TOC) -VANCO or Clindamycin (if (+) PCN allergy) **TELL MOTHER TO STOP BREASTFEEDING (from affected breast**

Hyaline Membrane Disease: Symptoms? CXR ? TXT? Prevention?

Suspect this in any neonates who present with respiratory distress... CXR: (+) ground glass appearance (+) AIR BRONCHOGRAMS TXT: (+) CPAP (+) given exogenous surfactant PREVENTION (premature): Babies who are born < 36W are given corticosteroids to stimulate excess surfactant production.

Papilledema: What is this? What does it indicate? MCCs? Symptoms? Workup? Treatment?

Swelling of optic disk (enlarged, hazy margins) INDICATES increased ICP. Causes: a) Malignant HTN b) Pseudotumor cerebri (HTN) c) "Space occupying lesion" (brain tumor) d) brain hemorrhage e) brain herniation (edema) Symptoms (range): -asymptomatic -intermittent visual changes -intermittent headaches -N/V -AMS Workup: a) Head CT or MRI = r/o tumor b) LP = r/o brain infection TXT: a) Initially (bring pressure down) = IV acetazolamide, diuretics, BB b) Definitive = fix underlying cause

Osteomyelitis: Symptoms? Labs? Best initial test? Gold standard? Treatment?

Symptoms ("refusal to bear weight"): (+) bone pain (+) decreased ROM (+) soft issue redness, edema & pain Labs (may be normal) (+) WBC (+) ESR (if ESR normal, OM unlikely) Best initial test = MRI Gold standard = bone aspiration ACUTE OM = Immobilization + IV ABX (2weeks) + PO ABX (4 weeks) -Staph = Naficillin (+/- MRSA) -Salmonella = FQ, ceftriaxone -Pseudomonas = FQ, cefipime CHRONIC OM = surgical debridement

Mitral Regurgitation: Symptoms? PE?

Symptoms (depend on the stage): a) CHF type symptoms b) Pulmonary congestion/HTN symptoms c) Predisposition to AFIB (d/t atrial hypertrophy) PE: (+) Holosystolic (pansystolic) "BLOWING" murmur + XRT (axilla) (+) Fixed split S2 (+/-) decreased S1 (if severe) (+/-) PMI displacement (+/-) S3 gallop "FIXED" split S2" (explanation): -S2 = closing of AV & PV -As disease progresses, you get EARLY closure of the aortic valve (LVH = decreased EF = early closure) + DELAYED closure of pulmonic valve (pulmonary HTN = increased pressure hindering the closure of the PV)

Lung Cancer: Classic symptoms? BUZZ PE findings? Discuss workup...

Symptoms (range): -Asymptomatic -New or changing cough -Hemoptysis -Hoarseness (chronic) -Weight loss -Paraneoplastic syndromes PE = (+) supraclavicular LAD Workup DEPENDS on location... a) CXR (usually initial test) b) CT scan (used for staging) c) Sputum cultures / Bronchoscopies (ONLY for central lesions) d) Transthoracic needle biopsy (for peripheral lesions)

Rheumatoid Arthritis: Classic symptoms? MC joints? PE? Labs? XRAY results? Frontline treatment?

Symptoms (symmetric) a) Joint redness, swelling pain b) Symptoms last > 1 hour c) WORSE w/ rest d) Symptoms wax/wane ("flairs") e) Systemic manifestations (eyes, heart, lungs) MC joints = small joints (hands) PE (spares DIPJ): (+) BILATERAL joint redness, edema (+) ulnar deviation fingers (+) swan-neck deformity (+) boutonnière deformity Labs: (+/-) elevated CRP, ESR (+/-) elevated RF (+/-) Anti-CCP (most specific) XRAYs = (+) bone erosions FRONTLINE = NSAID + DMARD (goal is to preserve joint function) DMARD (options) = methotrexate (MC) sulfasalazine, enteracept, rituximab

Pneumothorax: Symptoms? PE? CXR?

Symptoms (vary in severity): (+) severe UL chest pain (+) severe SOB (+) hemodynamic instability PE (unilateral): (+) decreased / absent BS (+) decreased fremitus (+) HYPERREASONACE to percussion CXR (varies): (+) decreased peripheral lung markings (affected side) (+) ABSENT lung markings (affected side) (+) tracheal DEVIATION (away from affected side)

Pulmonic Stenosis: Symptoms? PE? Treatment?

Symptoms = "right sided HF" symptoms (+) JVD (+) peripheral edema (+) ascites PE: (+) HARSH mid-systolic ejection crescendo-decrescendo murmur (@ LUSB) + XRT neck (+) Systolic ejection click (d/t forceful opening of pulmonic valve = usually accentuated by expiration) **murmur looks almost identical to AS but it accentuated at LUSB (vs. RUSB in aortic stenosis) Treatment = balloon valvuloplasty

Congenital Syphilis: Discuss MC symptoms? Usually appear by what age? Treatment recommendation for pregnant women?

Symptoms MC < age 2 -chronic nasal discharge (snuffles) -Hutchinson teeth -saddle nose -seniorneural hearing loss -CNS abnormalities **Pregnant women are treated just like everyone else!

Constrictive Pericarditis: What does this look identical too?

Symptoms are almost identical to "restrictive cardiomyopathy" [diastolic dysfunction] + [HF symptoms]

Bronchiectasis: Symptoms? PFTs? CXR? Gold standard of DX?

Symptoms: (+) CHRONIC productive (foul-smelling) cough (+) Massive hemoptysis PFT = (+) obstructive pattern -decreased FEV1 -decreased FEV1/FVC ratio CXR = (+) bronchial dilation "tram track" appearance" High-resolution CT (GOLD standard): (+) bronchial dilation ("tram track") (+) signet ring sign (pulmonary artery coupled w/ dilated bronchus)

Gastritis: MC symptoms? Workup? Gold standard (DX)? Discuss management? Treatment?

Symptoms: (+) Intermittent EPIGASTRIC discomfort (+) Dispepsia Workup: a) H. pylori testing b) EGD (gold standard) Treatment: a) (+) H. pylori = PPI + 2ABX b) (-) H. pylori = acid reduction therapy (H2B, PPI, carafate, sucralfate)

Pulmonary Embolism? Symptoms? PE? What is considered the: a) BEST 1st initial test b) Gold standard

Symptoms: -May be asymptomatic -Sudden dyspnea -Sudden chest pain **MOST specific sign/symptom: -dyspnea (80%) -tachypnea/tachycardia (70%) PE = usually NORMAL ! BEST initial test = helical (spiral) CT Gold standard = Pulmonary Angiography (CTA) **really only ordered if above test is inconclusive

Mitral Stenosis: Symptoms? PE?

Symptoms: -dyspnea (MC), hemoptysis, cough -"Mitral facies" (reddish cheek discoloration 2/2 chronic hypoxia) -predisposes you to AFIB -Ortner's Syndrome **symptoms primarily come from the resulting left-atrial hypertrophy + pulmonary congestion. PE: (+) OPENING snap (d/t forceful opening of stenotic valve) (+) LOUD S1 (d/t forceful closure of stenotic valve) (+) "Mid-diastolic" rumble murmur @ apex ( best heard in left-lateral decubitus position, no radiation) **RECALL = the "rumble" quality comes from turbulent blood flow through the stenotic valve

Arrhythmias: What is the difference between "synchronized" vs. "unsynchronized" cardioversion?

Synchronized = true cardioversion (where you attempt to shock @ specific part of the rhythm) Unsynchronized = "defibrillation" (where you shock at NONSPECIFIC part of the rhythm = pulseless)

Baker Cyst: What is this? MCCs? Symptoms? DX? TXT?

Synovial fluid collection (posterior knee) Causes: a) OA (MCC) b) meniscus tears c) RA d) trauma "FULLNESS" behind knee (usually not painful) (+/- limited ROM) DX (r/o DVT if painful) = U/S TXT: -fix underlying cause -NSAIDS -Steroid injections

Secondary HTN: Recall the effects nicotine has on the body? How can this lead to HTN?

Systemic VASOCONTRICTORS !! Which is why they can lead to: -HTN -CAD -PVD/PAD

TB: What are some "extra-pulmonary" symptoms that can be seen with SECONDARY "Reactivation" TB?

TB spine = "Pott's Disease" (+) back pain TB lymph nodes = LAD TB --> pericarditis

Polymyalgia Rheumatica: What MUST you r/o? Best test to do this?

TEMPORAL ARTERITIS (both will have high ESR) TEST = temporal artery bx

Vitamin B1 deficiency: Also called? BUZZ presentations?

THIAMINE deficiency --> Beriberi 1. WET Beriberi (CV): a) Increased CO --> HF 2. DRY beriberi (CNS): a) Neurologic issues = peripheral neuropathy, ENCEPHALOPATHY, psychosis

Peptic Ulcer Disease (PUD): Which drug is considered TOC? Discuss common ADRS/DDI: a) Omeprazole b) Cimetidine

TOC = PPI (most effective) Omeprazole (PPI): -VB12 deficiency (--> neuropathy) -Low Mg -Low Ca -Causes INCREASE warfarin Cimetidine (H2B): -anti-androgenic effects (gynecomastia, acne, impotence) -causes INCREASE warfarin

Premature Labor: What does MgSO4 toxicity look like? If a patient experiences this, what should you administer?

TOXICITY = respiratory distress, cardiac collapse, weakness (+) give Calcium Gluconate

Amaurosis Fugax: What is this? MCC? Symptoms? Treatment?

TRANSIENT "blurred" vision TRANSIENT "loss" of vision MCC = embolic event ("TIA" of retina = causes transient interruption to blood flow) TXT = fix underlying cause

Thromboangitis Obliterans: Presentation? PE? Diagnosis? Treatment?

TRIAD (3): (+) migratory "superficial" thrombophlebitis (+) claudication (i.e. PAD) (+) Raynaud's Phenomenon PE: (+) abnormal Allen's test Gold standard = Aortography (+) occlusive lesions of small/medium vessels TXT (no cure): -STOP USING TOBACCO (definitive management) -May add (+) CCB for symptom management (i.e. Amilodipine)

COPD (true or false): combination therapy with an anticholinergic + SABA shows greater response than when either is used alone...

TRUE

Hepatitis A (true or false): After a person recovers from acute Hep A infection, their "Anti-HAV IgG" will remain elevated throughout the res of their life?

TRUE

PCOS (true or false): There seems to be genetic component

TRUE

Primary HTN (true or false): HTN is more common & tends to be more severe in AA patients....

TRUE

Celiac Disease (Sprue): TRUE or FALSE: True celiac disease shows up in childhood.

TRUE (people who claim to have been diagnosed with Celiac in adulthood MORE LIKELY have a gluten intolerance, not a true allergy)

What is the BEST way to determine if a patients so-called "hip pain" is truly a hip issue vs. back issue?

TRUE "hip pain" does NOT extend past the knee (nerves from the hip do not innervate past knee) **therefore if the patient reports the pain RADIATES down entire leg = MUST think of back etiology

Rheumatic Fever: Treatment? What is done to try and prevent LT effects and possible Rheumatic Heart Disease?

TXT: -rest -anti-inflammatories (ASA, steroids, etc.) -Benzathine PCN IM q4weeks (for either 5 years or until age 21, whichever comes first) **PCN treatment goal is to prevent Rheumatic heart disease

Pertussis: TXT? What complication do we worry about in young children?

TXT: a) Supportive b) Macrolid (TOC = erythromycin) Biggest complication (young children) = apnea +/- cerebral hypoxia during coughing fits (can lead to death)

CAP: Describe the difference between typical vs. atypical pneumonia presentations? Classic PE findings?

TYPICAL: 1-10 day of worsening cough (productive), fever, SOB, pleuritic chest pain ATYPICAL (presents "mild PNA"): -afebrile or only low-grade fever -mild pulmonary symptoms (non-productive cough) -may have other systemic symptoms (diarrhea, myalgia, etc.) PE findings: (+) decreased BS (+) dullness to percussion (+) increased tactile fremitus (+) crackles ("rales")

SHOCK: What PE finding is the EARLIEST sign of shock?

Tachycardia

Pilonidal cysts/abscess/fistula: What is this? TXT?

Tender abscess NEAR gluteal cleft (with small midline pits) TXT: a) I&D (initial) b) If recurrent, evaluate & r/o fistula

Erythema Nodosum: What is this? MCCs?

Tender nodules that develop along ANTERIOR shins... MCC: -Sarcoidosis -Streptococcal infection -TB -Fungal infection ("cocciodiomyocosis") -OCP use -Leukemia

Antibiotic Review: List Tetracyclines... Coverage? Usage? Cautions?

Tetracycline Doxycycline Minocycline GREAT GM (+) coverage: -Acne -Skin infections -STIs **DO NOT USE in kids < 8 years old = causes "brown discoloration" teeth

Normal Vaginal Physiology: a) Normal discharge b) Normal pH c) Normal microscopic

The following are NOT pathologic (normal): a) discharge = clear/white, odorless b) pH = 4.0-4.5 c) (+) squamous cell epithelium

Deep Vein Thrombophlebitis (DVT): If a patient has recurrent DVTs, what conditions should you rule out?

The following conditions predispose you to HYPERCOAGULABILITY: -Factor V Leiden -Prothrombin gene mutations -Protein C or S deficiency -Antiphospholipid syndrome -Lupus -Malignancy -Pregnancy

Dihydrapyridine CCB: Discuss known DDI?

The following will increase [CCB]: -grapefruit -antifungals -macrolides CCB will INCREASE [ ] of: -statins -carbamazepine -digoxin **WHY you always see warning for increased RHABO when combining statin + CCB (just need to make sure to reduce statin dose to reduce risk)

Carpal Tunnel Syndrome: What is a PE finding of "LATE STAGE" disease?

Thenar Atrophy

Rh incompatibility: Discuss WHY we give Rho-Gam @ 28weeks?

Theoretically lasts 12 weeks..

MURMURS (basics): What is the "rule" of thumb" with diastolic murmurs?

There are NO benign diastolic murmurs...... Diastolic murmurs: -mitral stenosis -tricuspid stenosis -aortic regurgitation -pulmonic regurgitation

AV Heart Blocks: Detail the 3 types and their classic EKG findings? Treatment?

These all represent a interruption in the conduction of the signal from SA node --> AV node 1st degree: -PR prolonged (> 0.20sec) BUT consistent -P:QRS ratio remains intact (no dropped QRS) -TXT = none ________________________ 2nd degree: 1. Mobitz I (Wenckebach): -PR interval is prolonged & keeps getting longer & longer, UNTIL QRS is dropped -TXT (asymptomatic) = none -TXT (symptomatic) = atropine or pacemaker 2. Mobitz II: -Some but not all signals are passed to the AV node -PR intervals are prolonged (constant), but for some reason random QRS are dropped leading to irregular p:QRS association of either 2:1 or 3:1 -TXT (high rate of progressing to Type 3) = pacemaker __________________________ 3rd degree: -None of the signals are being passed to AV-node -NO association between P:QRS -TXT = permanent pacemaker

HF Mangement (outpatient): Discuss when its appropriate to use "Nitrates + Hydralazine"?

These are reserved for patients who are contraindicated / cannot tolerate ACEi/ARB or BB. Examples: -AA -uncontrolled Asthma -Pregnant -ACEi intolerant (cough, etc.)

TB: What is a Ghon & Ranke complex? MC locatin?

These represent OLD healed primary TB infections (essentially the body "walling" off the TB) GOHN complex = initial infectious granuloma that forms after a person undergoes PRIMARY TB infection --> this complex can then become calcified to form the Ranke complex MC location = middle/lower lobes

COPD (emphysema): Explain WHY these patients have "NORMAL" pO2 & pCO2?

They develop a habit of breathing through "pursed lips" = which creates a NEGATIVE pressure & helps force the alveoli to remain open (allowing for relatively normal gas exchange)

What are some signs/symptoms indicative of LIVER DISEASE? (hepatitis, cirrhosis)

Think of the Liver's functions & results if those were absent.. 1. Detoxification (impaired): (+) pruritus (toxin buildup) (+) asterixis (ammonia buildup) (+) hepatic encephalopathy 2. Production of Albumin (important for fluid balance / BP ): (+) "third spacing" (ascites, edema) (+) high BP (portal HTN--> esophageal varicies) 3. Conjugation of Bilirubin: (+) jaundice 4. Production of clotting/hormonal factors: (+) easy bruisability (+) petechiae (+) palmer erythema (+) telangiectasia (high oestradiol) (+) gynecomastia (high estrogen) 5. Blood glucose production: (+) hypoglycemia (fatigue) (+) weight loss

Venous HUM murmur: Pathophysiology of this? Maneuvers that will diminish this murmur?

Thought to be d/t turbulent blood flowing from head/neck (via jugular veins) returning to heart.... CLASSIC: murmur diminishes when turning head to contralateral shoulder

Superficial Thrombophlebitis: Pathophysiology? Symptom? PE? Diagnosis? TXT?

Throw a small clot in the SUPERFICIAL venous system --> leading to acute/local vein inflammation Symptoms/PE: (+) redness, edema and pain along superficial vein DX = clinical (may order a venous duplex u/s if needed to r/o DVT) TXT (usually self-limiting): -Rest -Leg elevation / compression -Warm compress -NSAIDS

PCOS: What OTHER conditions can mimic this and needs to be r/o?

Thyroid (hypo) Cushings

Fibromyalgia: What are the MOST important possible underlying conditions you must r/o?

Thyroid (low) Vitamin D deficiency

ACS: Diagnostic criteria for STEMI?

To diagnose a STEMI, you MUST have either: 1. ST elevation (1mm) in 2+ consecutive leads 2. (OR) new LBBB **new occurrence LBBB is considered a "STEMI equivalent"

Spirometry (PFTs): Outline the basic concepts regarding: a) Total Lung Capacity (TLC) b) Tidal Volume (TV) c) Force Vital Capacity (FVC) d) Residual Volume (RV) e) Forced Expiratory Volume (FEV1)

Total Lung Capacity (TLC) = total volume in lungs when they are MAXIMALLY inflated. Tidal Volume (TV) = volume of air that moves in/out of the lungs when we breath QUIETLY Forced Vital Capacity (FVC) = total volume of air forcefully exhaled after maximal inspiration..... (the residual volume (RV) is whatever air is left in the lungs) Forced Expiratory Volume-1 = similar to the FVC above, however specifically refers to the total volume of air forcefully exhaled after 1 SECOND after maximal inspiration

CHRONIC Hepatitis B: Routes of transmission? MC? Treatment? What does a chronic infection put you at higher risk for?

Transmission (bodily fluids): -Congenital "mom to baby" (MC) -Sexual intercourse -IVDU -Blood products (transfusions) **ALL pregnant women are tested for Hepatitis B, if (+) HBsAg (active infection) --> the baby will receive vaccine @ birth TXT = NO CURE (suppress "viral load") -peginterferone -tenofavir -entecavir **CHRONIC infection = increased risk for hepatocellular carcinoma

Cardiology basics: Discuss the 2 different types of ECHOCARDIOGRAMS.... Benefits / Cons of each....

Transthoracic ECHO (TTE): -most commonly used (HF or valvular abnormalities) -gives great information about heart function, CO, wall motion abnormalities Transesophageal ECHO (TEE): -MORE invasive -BUT provides you better visualization of the structures (esp. posterior cardiac wall)

CAP (atypical): Discuss the management approach and options?

Treated similar to Typical CAP.... Bacterial (ABX options): a) Doxycycline b) Macrolide Viral = supportive measures Fungal = "-azoles" vs. AmpB

Menopause: Treatment options? Discuss use of HRT....

Treatment involves: a) Exercise b) Promoting bone health (Ca/VitD supplementation, Bisphosphonates, Calcitonin, SERMs) c) Non-HRT (i.e. Paroxetine (SSRI) = rebranded & FDA approved for menopause = "Brisdell") d) HRT (last resort) HRT = improves symptoms (+) ESTROGEN alone after menopause: -increased risk clotting -increased risk of endometrial cancer (+) ESTROGEN + Progesterone > 5 yrs after menopause: -reduces risk of endometrial cancer -BUT increased risk of breast cancer **therefore a SAFER option for relief of symptoms is: -LOCAL (not systemic) hormones -EX: Vaginal estrogen + Progesterone IUD HRT contraindications: -undiagnosed vaginal bleeding -liver dysfunction -prior endometrial or breastCA -smokers > 35 yo -prior thromboembolic event or migraines (w/ auras)

Syphilis: Pathogen? Transmission? Stages & symptoms?

Treponema Pallidum (spirochete) Transmission: a) SEXUAL (direct contact) b) Congenital (in utero via placenta) PRIMARY syphilis: a) chancre (painless) b) regional PAINLESS lymphadenopathy SECONDARY syphilis: (highly variable presentation) a) Mucocutaneous involvement (MC) = rash (+involves palms/soles) LATENT syphilis = asymptomatic period w/ (+) serology TERTIARY syphilis: a) (+) GUMMAS (granulomas skin) b) Usually involves bone, CV and/or CNS ("neurosyphillus")

Prenatal Screening: What genetic conditions are we screening for?

Turner's syndrome Klinefelter syndrome Trisomy 13 Trisomy 18 (Edwards syndrome) Trisomy 21 (Down syndrome)

Shoulder Dislocation: MC type? MOI? Symptoms? Gold standard test? TXT? What neurosensory function should always be checked?

Types: a) Anterior (MC) = "fall with arm ABducted, externally rotated + extended" (SNOWBOARDER) b) Posterior (rare) = SEIZURES "shoulder pain" + loss active ROM (+) loss deltoid contour **MUST CHECK AXILLARY NERVE before & after reduction** (deltoid sensation) GOLD = XRAY ("Y" view) TXT = manual reduction + immbolization (sling) (+/- NSAIDS, PT)

Mesothelioma: Types? MC sites? Biggest risk factor? Symptoms? DX? TXT?

Types: a) Benign b) Malignant (80%) Sites: a) Lung pleura (MC) b) Peritoneum BIGGEST risk factor = chronic ASBESTOS exposure Symptoms: -asymptomatic -chronic NP cough / dyspnea -pleuritic chest pain -constitutional symptoms -weight loss DX = pleural biopsy (via video-assisted thorascopy "VATS") TXT: a) localized = resection b) diffuse = resection + XRT/chemo

Atherosclerosis: 2 types?

Types: a) Coronary Artery Disease (CAD) b) Peripheral Vascular/Arterial Disease (PVD/PAD)

Thrombophlebitis: Risk factors?

Types: a) Superficial Thrombophlebitis b) Deep Venous Thrombosis (DVT) "Virchow's Triad" (risk factors for thromboembolic events): 1. Hyper-coagulability (obesity, OCP, pregnancy, malignancy, Factor V Leiden) 2. Venous stasis (prolonged sitting/lying down = long flight, road trip, bed-ridden, PVD) 3. Venous injury (IV/central line, surgery, trauma, infection)

DIARRHEA: Breakdown the MCCs and how to distinguish them.

Typically diarrhea is due to either: -infectious etiology -osmotic changes (malabsorption issues) -hormonal issues 1. Infectious diarrhea = usually has other associated symptoms (F/C/N/V) -Non-inflammatory / Noninvasive "Secretory" (watery) -Inflammatory / Invasive "Bloody" 2. Osmotic diarrhea = (-) DECREASE diarrhea with fasting -Celiac disease -Lactose Intolerance 3. Hormonal diarrhea = diarrhea is UNCHANGED with fasting -Serotonin ("Carcinoid syndrome") -Gastrin (Zollinger-Eillison) -Calcitonin (Thyroid medullary CA)

U-wave: What does this represent? Explain its significance?

U-wave = repolarization of the perkinje fibers REalize that the U-wave is ALWAYS there, however in a normal EKG the repolarization of the ventricles (t-wave) is so much stronger that it eclipses the U-wave.... ONLY when the repolarization of the Perkinje Fibers are DELAYED does it become evident on EKG (= low K)

ACS: Discuss how to tell the difference between: a) UA b) NSTEMI c) STEMI

UA: (+/-) ST depression (-) ST elevation (-) cardiac marker elevation NSTEMI: (+) ST depression (-) ST elevation (+) cardiac marker elevation STEMI: (+) ST elevation (+) cardiac marker elevation

Anticoagulation: Discuss the monitoring requirements & reversal agents for: a) UFH or LMWH b) Warfarin (coumadin) c) Factor Xa inhibitors

UFH/LMWH primarily used in inpatient setting): a) UFH = monitor aPTT b) LMWH = no monitoring required (may use Factor Xa if desired) c) REVERSAL (both) = protamine sulfate Warfarin / Coumadin (outpatient) : a) Must monitor PT / INR b) REVERSAL = Vitamin K Xarelto (outpatient): a) NO monitoring b) NO reversal agents **these are gaining popularity amongst patients because they do NOT require frequent INR monitoring, however no reversal agents exist.

Nasal polyps: MCC UL polyps? MCC BL polyps? Treatment?

UL polyps (usually d/t chronic inflammation): -allergic rhinitis (MCC) -chronic sinusitis BL polyps (MC = kids): -cystic fibrosis (must r/o!) Treatment: a) Rule out/treat any underlying pathology b) TOC = nasal steroids (fluticasone)

H.pylori: How does PPI therapy affect diagnostic tests for this?

UREA breath test: H.pylori converts [urea] --> [CO2] which can be measured If the patient is on current PPI therapy, can lead to FALSE (-) urea breath test!! **recommendation = stop PPI treatment for 5 days & then obtain urea breath test

Sarcoidosis: What is the MC reason someone dies from Sarcoidosis: a) In USA b) In Japan

USA = lung complications Japan = heart complications

Hepatocellular carcinoma: MC type? Risk factors? Presentation? Diagnosis? TXT?

USUALLY METASTATIC (lung, breast) **primary hepatoceullar carcinoma is rare RF for PRIMARY heptocellular cancer: -chronic viral hepatitis -cirrhosis SXS = [liver failure] DX = U/S + APF (best) **biopsies avoid d/t high risk of seeding** TXT = resection

GERD: What is the main concern when someone has a longstanding history of unmanaged GERD?

Uncontrolled GERD (years) --> leads to chronic inflammation of the esophagus --> predisposes it to cellular dysplasia ("BARRETT'S esophagus") --> which is a precursor to Esophageal cancer Barrett's Esophagus = transition from squamous cells (normal) to columnar epithelium

COPD: If not managed appropriately, what is the MC outcome?

Unmanaged COPD --> chronic hypoxia (which leads to): -pulmonary HTN -heart failure (cor pulmonale) MC w/ chronic bronchitis (remember that empyema O2/CO2 are relatively normal)

Peri-tonsillar Abscess: MC caused by? MC pathogen? Distinguishing features? 1st line test? Treatment?

Untreated tonsillitis / pharyngitis (MCC) MC = GABHS (strep pyogenes) Distinguishing features: (+) Hot potato "muffled" voice (+) TRISMUS (BUZZ) (+) Uvula deviation (BUZZ) GOLD standard = CT + contrast TXT = I&D + ABX ("step it up") -Amox/clavaunic acid (Augmentin) -Amp/sulbactam (Unasyn)

GI Bleeding: Breakdown various causes? Common symptoms? a) Upper GI bleed (MCCs) b) Lower GI bleed (MCCs) c) Lower GI bleed (MCC kids)

Upper GI bleed ("hematemesis, melena"): -Esophageal varices (MCC) -Mallory Weiss tear -PUD -Cancer Lower GI bleed ("BRBPR"): -Hemorrhoids (MC) = painless -Diverticulosis = painless -Colonic Ateriovenous Malformatin (AVM) = painless -Colon cancer = painless -Anal fissure = PAINFUL (+) BLOODY diarrhea: -Inflammatory AGE -Ulcerative colitis GI bleed (kids) = Meckle Diverticulum (congential)

Pelvic Inflammatory Disease: Appropriate workup?

Urine NAAT (GC/CC testing) B-HCG (r/o ectopic) Pelvic U/S (r/o abscess)

HYPERTHYROIDISM: Discuss the current recommendation in treating this?

Use of both hyperthyroid medications has issues: a) PTU = rare OB complications b) MMX = possible teratogenicity Recommendation: PTU (1st trimester) & convert to MMX thereafter **ANY RADIOACTIVE IODINE is contraindicated in pregnancy!

Antibiotic Review: Why are 3rd generation FQ nicknamed "respiratory FQ"?

Used a lot in treatment of PNA (because they have "atypical" coverage)

Bile Acid Sequestrants: What are these also used for?

Used in pregnancy in cases of "cholestasis of pregnancy"

Acute Pancreatitis: What is the Ranson criteria?

Used to determine: a) likelihood of pancreatitis b) prognosis Score 3+ = pancreatitis likely Score < 3 = pancreatitis UNLIKELY Score 7+ = 100% mortality

Asthma: What would be an indication that someones asthma is not controlled on a SABA PRN alone?

Using: a) SABA > 2x/week b) Using > 1 SABA inhaler/month c) Greater > 2 exacerbations/year

ET dysfunction? MCCs? Symptoms? Frontline?

Usually occurs d/t "swelling" which is secondary to inflammation or infection.... MCCS: -s/p viral infection (URI) -allergic rhinitis -craniofacial abnormalities (Down Syndrome) FRONTLINE = decongestants -oxymetazoline (AFIN) -pseudoephedrine (Sudafed) -phenylephrine

Ashermann Syndrome: What is this?

Uterine "adhesions" or scarring that can occur following D&C... Falls into the category of "end-organ dysfunction": -normal HPA -normal estrogen

Dysmenorrhea: What are some of the MCCs of secondary dysmenorrhea?

Uterine fibroids (MC) Endometriosis Adenomyosis Pelvic Inflammatory Disease (PID) IUD implant

Lung Function: Discuss the V/Q ratio.... What is meant by V/Q mismatch? What disorders are associated with V/Q mismatch?

V = ventilation Q = profusion (@ alveoli) V = Q (normal) V/Q ratio = 1 (normal) V/Q mismatch is when V/Q does NOT = 1 Low V/Q (ventilation is impaired): a) Physiologic (base of lung) = natural phenomenon b.c. "air rises" and there is less ventilation @ bases of lungs b) Pathologic (airway obstruction) = asthma, chronic bronchitis High V/Q (profusion is impaired): a) Physiologic (apex of lung) = natural phenomenon b.c. there are less alveoli @ apices so less profusion occurs there. b) Pathologic (profusion obstruction @ alveoli) = emphysema, PE, FB

Pulmonary Embolism: What alternative diagnostic study can be done if Helical (spiral) CT is contraindicated? (i.e. can't receive IV contrast)

V/Q scan **result of "V/Q mismatch" is suggestive of PE

Antibiotic Review: Discuss the main uses of: a) VANCO (PO) b) VANCO (IV)

VANCO (PO) = GI issues **stays in GI track (not well absorbed) VANCO (IV) = MRSA

Lupus (SLE): What lab is usually "falsely positive"?

VDRL /RPR (+ falsely) = SYPHILUS (d/t (+) Anticardiolipin Ab) Classic = SLE patient who tests FALSLY (+) for syphilus

Nausea in pregnancy: Discuss recommended management?

VERY COMMON Conservative management (FRONTLINE): -diet modification (avoid triggers) -ginger -Vitamin B6 (pyridoxine) -Vitamin B6/doxylamine succinate (antihistamine) = "Diclegis" Adjunctive/Refractory cases (+antihistamines): -Benadryl -Promethazine -Metoclopramide (Reglan)

Vaginal Cancer: MC type? MC risk factor? TXT?

VERY RARE!! Usually metastatic spread of another cancer.... MC = squamous If (+) DES exposure in utero --> CLEAR CELL carcinoma TXT (can't resect vagina) = XRT

Ankle Fracture: What MUST you r/o in a WEBER C ankle fracture?

VERY UNSTABLE Commonly associated with: -Deltoid ligament injury -Medial Malleolus fracture

HSV1/2: What must you educate patients about possible transmission?

VIRAL SHEDDING can occur anytime (even if they aren't having any symptoms or current outbreak) = CAN BE CONTAGIOUS at any time

Congenital Heart Disease: What is the MOST common congenital heart abnormality?

VSD

Wide QRS: What MUST you always r/o?

VTACH

VTACH: Features? Treatment?

VTACH (3+ consecutive PVCs) (+) pulse: -May use Class Ib, Ic, III, ICD placement -1st line = amiodarone

Pertussis: Vaccine? What trend have we been seeing as a result of parents NOT vaccinating their children?

Vaccine = DTAP, tdaP Illness is the MOST severe = children Adults: -Disease is much more mild (usually presents with mild "URI" symptoms) -Issue is that adults are UNAWARE they have pertussis, so if they come into contact with a child that has NOT been vaccinated, the child may become severely ill.

MCC vaginitis? MCC cervicitis?

Vaginitis = BV Cervicitis = chlamydia

AV Heart Blocks: What PE maneuver can assist in diagnosing these? Explain...

Valsalva Manuever (increases parasympathetic signaling to SA & AV nodes) **IF the Valsalva Manuver RESOLVES the EKG changes = confirms diagnosis

Peripheral Venous Disease (varicose veins): Pathophysiology? MC location? Risk factors? Symptoms? PE? Treatment?

Venous valve non-compliance (superficial veins) --> leads to fluid backup --> leads to ENLARGED (dilated), tortuous veins (aka "varicose veins') MC = superficial saphenous vein Risk factors: -obesity -pregnancy -prolonged sitting/standing Symptoms / PE: (+) LE dilated / tortuous veins (ache) (pulses/temperature = NORMAL) TXT: a) MAINSTAY = increased exercise, compression stockings, leg elevation b) Surgical options = sclerotherapy, radiotherapy, laser ablation

Vitamin A: Discuss the BUZZ presentations with: a) Vitamin A deficiency b) Vitamin A EXCESS

Vitamin A DEFICIENCY = blindness (initially = "night blindness") Vitamin A EXCESS: a) Teratotoxicity b) Pseduotumor cerebri

Apthous ulcers: What deficiencies could contribute to these?

Vitamin B12 Folic acid

Niacin: MC ADR? Precautions? Counseling point?

Vitamin B3 ADR: -Flushing (MC) -HA -Pruritus -Hyperglycemia -Hyperuricemia Caution: -DM -Gout **taking a ASA325mg or ibuprofen 30 min before decreases ADRs.

TB: What adjuntive therapy can be added to reduce "neuropathy" side effects associated with Isoniazid?

Vitamin B6 (pyridoxine)

Leiomyomata (uterine fibroids): What has been shown to POSSIBLY prevent fibroids in premenopausal women?

Vitamin D

What is the difference between: a) Vulvodynia b) Vaginismus Symptoms of each? Possible therapies?

Vulvodynia: -idiopathic chronic vulvar pain -generalized vs. localized -"burning / STABBING" pain -painful intercourse (+) Q-tip test TXT = focused on "calming" the nerves: (+) topical anesthetics (lidocaine +/-gabapentin) (+) oral Gabapentin (+) oral Nortripyline (TCA) Vaginismus: -chronic pelvic muscle spasm (levator ani, etc.) -painful intercourse TXT = focuses on relaxing muscles (+) vaginal PT (+) oral muscle relaxants (+) trigger point injections **CONFUSION is that people who have vulvodynia ALSO typically have vaginismus (chronic nerve inflammation --> leads to chronic muscle spasms).

Recall the difference between: a) Weber test b) Rinne test

Weber test: a) Lateralize TOWARDS conductive hearing loss. b) Lateralize AWAY from sensiorneural hearing loss. Rinne test: a) AC > BC (NORMAL) b) BC > AC (conductive hearing loss)

Hyaline Membrane Disease: By what week of gestation is sufficient surfactant made?

Week 35

Trichomonas: Discuss which is best: a) Wet mount b) Culture

Wet Mount = (+) motile flagellated protozoa Culture = (+) PMNs Wet mount is EASIER but VERY difficult to isolate protozoa before the solution kills them (best to use NS & look QUICKLY) **Culture is considered BEST (however not routinely done b.c. requires very expensive media = diamond media)

CAP (typical): Discuss the management approach and options?

When approaching treatment (must consider): a) CURB-65 (determine if outpatient vs. inpatient treatment) b) Any prior ABX use within last 3mo. c) Any underlying lung disease OUTPATIENT (no prior ABX/lung dz): -Macrolide (azithro = has addition anti-inflammatory properties in lungs) -Doxycycline OUTPATIENT (+prior ABx or lung Dz): -FQ (alone) -Macrolide + B-lactam INPATIENT: -FQ (alone) -Macrolide + B-lactam SIDE NOTES: a) FQ used are "respiratory FQs" (levofloxacin, moxifloxacin, gemfloxiacin) **ciprofloxacin is ONLY appropriate if you need to cover pseudomonas b) B-lactams: cephalosporins (ceftriaxone IM) or Ampicillin/Amoxicillin (or Augmentin) **KNOW PCN G is sometimes used to treat streptococcal pneumonia

Asthma: When is it appropriate to "step-down" in treatment?

When asthma symptoms are WELL-CONTROLLED > 3 months (okay to attempt to "step down")

Endometriosis: What is this? MC sites? Symptoms? PE? Pelvic u/s? Gold standard test? TXT?

When endometrial tissue is found OUTSIDE uterus (fed by estrogen) MC = ovaries (60%) (but can be found anywhere) Symptoms: -asymptomatic -PAINFUL periods -PAINFUL intercourse -PAINFUL defecation -Infertility PE: (+) tender uterine nodularity (+) "fixed uterus" (+/-) retroverted uterus (common) Pelvic u/s: (+/-) endometrioma ("chocolate cyst") **present if involving ovaries GOLD STANDARD = laparoscopy + BIPOSY FRONTLINT (TXT) = OCP (suppress ovulation) + NSAIDS (pain) Alternative treatment options: -GnRH inhibitors (Leuprolide "Lupron") -Androgen antagonists (Danazol) -Ablation (temporary fix; usually needs to be repeated) -HYSTERECTOMY

Primary HTN (JNC8): When is treatment recommended? BP goals?

When should you initiate treatment? a) YOUNGER < 60 yo = BP > 140/90 b) OLDER > 60yo = BP > 150/90 c) (+) DM/CKD = BP > 130/80 Treatment goals are the same as above....

Rh incompatibility: What is this? What is the concern? What labs do we routinely obtain to screen for this?

When the baby's blood type ISN'T the same as the mother's blood type. CONCERN= mom will make antibodies against the fetal blood MC type = RH incompatibility -90% population (RH+) -If the MOM is Rh(-) and the father is Rh(+), then the baby could be Rh(+) and we run the risk of mom making Abx against the babies blood. @ 1st prenatal visit: a) moms blood type b) Rh status c) Coomb's test (looking for ABX)

Adenomyosis: What is this? MC in who? Symptoms? PE? DX? TXT?

When the endometrial tissue begins growing INTO the uterine muscular (ESTROGEN fed) MC = 40s Symptoms: -asymptomatic -PAINFUL PERIODS PE = (+) TENDER, symmetrically enlarged uterus ("Boggy Uterus") -Diagnosis of Exclusion- (diagnosis usually suspected, but CONFIRMED when post-hysterectomy uterus is examined) TXT = hysterectomy (will diminish/resolve with menopause)

Placenta previa: What is this? 3 types? Risk factors? Symptoms? DX? TXT? Delivery options?

When the placenta either partially or completely covers the cervical os.... 3 types: a) complete b) marginal c) low-lying Risk factors (same as abruption) PAINLESS bleeding (MC) **usually prior to 20 weeks DX = trans-abdominal U/S Prognosis: 50% of cases will self-resolve as the uterus continues to grow the placenta will naturally MOVE UPWARDS... TXT: a) pelvic rest b) give RHOGRAM if RH(-) mother in any cases of bleeding. DELIVERY: a) Placenta > 2.4 cm from cervix = may attempt NSVD b) Placenta < 2.4cm from cervix = MUST HAVE C-SECTION

Lung Cancer: What is Pancoast Syndrome? MC associated with which type of lung cancer?

When the tumor is located in the apical or "superior sulcus" of the lung.... Features: 1. Shoulder pain 2. UL arm/hand muscle atrophy 3. Horner's syndrome (tumor compresses cervical cranial nerve) = UL miosis (constricted pupil), ptosis, anhydrosis MC: -small cell -squamous cell

Lung Cancer: What is SVC syndrome? Features? MC seen with?

When tumor is compressing the SVC (MC = small cell) Features: -dilated neck veins -facial plethora -facial edema -UL UE edema

UTIs (pregnancy): What is the main concern regarding these? Recommended treatment? Which medications are CONTRAINDICATED?

Women who are pregnant are naturally IMMUNOCOMPROMISED, which makes them more susceptible to UTIs, and also means they tend to be ASYMPTOMATIC... If screening UA shows possible UTI we treat empirically.... Normal FRONTLINE UTI TXT: nitrofurantoin, ciprofloxacin PREGNANCY: -Frontline: Nitrofurantoin, ampicillin, cephalexin -CONTRAINDICATED: FQ (risk to baby bone development) -Sulfonamides (Bactrim) are recommended against in 3RD trimester

Primary Amenorrhea: Discuss the MCCs? Distinctions of each?

Workup: -pregnancy test -progesterone challenge (+) withdrawal bleeding: -normal estrogen -normal uterus -MCC = Anovulation NO withdrawal bleeding: (indicates abnormal estrogen) a) no breast development: -TURNER syndrome (high FSH) -HPO axis dysfunction (low FSH, low LH) b) NORMAL breast development: -Androgen insensitivity (high testosterone) -Imperforate hymen (normal hormone levels)

Hyperlipidemia: What PE finding indicates a FAMILIAR cholesterolemia (genetic predisposition)?

Xanthomas = deposits of lipid material in connective tissue

Is Metronidzole safe in pregnancy?

YES

BREAST CANCER: Does having (+) breast cancer in one breast INCREASE your risk of developing future breast cancer in your remaining breast?

YES!!! (1-2% increased risk in contralateral breast)

Secondary HTN: If you suspect this in someone who has concurrent impaired renal function, what is the MCC underlying pathology: a) Younger patient b) Older patient

YOUNG (MCC) = fibromuscular dysplasia OLDER (MCC) = atherosclerosis

Ankle Sprain/Strain: Discuss appropriate management?

You need to use OTTAWA Rules to determine whether you need to obtain a Ankle XRAY.... OTTAWA RULES (obtain ANKLE XRAY if): (+) lateral mallelous TTP (+) medial mallelous TTP (+) navicular TTP (mid-foot) (+) 5th metatarsal TTP ("dancer fx"?) (+) INABILITY to bear weight TXT: a) GRADE 1-2: RICE b) GRADE 3 = ortho/PT referral

CAP: What patient population do you usually consider for ATYPICAL pneumonia?

Young, otherwise healthy, adults

Acute Pericarditis: Causes? Symptoms? PE? EKG? Diagnostic Studies? Test of choice?

[ACS symptoms] +/- FEVER (+) sharp pleuritic chest pain (BUZZ = better w/ sitting & leaning forward) PE: (+/-) pericardia friction rub (best heard sitting/leaning forward) EKG: (+) Diffuse ST elevation + PR depression (in all precordial leads = V1-V6) (+) Knuckle sign (PR elevation + ST depression in lead AVR) Other tests: (+/-) elevated WBC (+/-) elevated cardiac biomarkers (IF also has myocarditis) Test of choice = ECHO or cardiac ultrasound **must r/o pericardia effusions & tamponade Treatment: [ASA or NSAID x 1-2 weeks] **(+) adding Colchicine may reduce duration of symptoms

Endocarditis: Symptoms? Workup? Diagnostic criteria? Which diagnostic test is best?

[FEVER] + vague symptoms **best to look for diagnostic criteria Workup: -CBC -Rh factor -TTE/TEE -3 blood cultures (1 hr apart) DUKE CRITERIA (to diagnosis must have): [2 major] [1 major + 3 minor] [5 minor] MAJOR criteria: 1. At least 2+ positive blood cultures (reflective of known organisms) 2. (+) ECHO involvement (valvular vegetations, valvular abscess, NEW valvular regurgitation) MINOR criteria: 1. Fever 2. Known risk factor 3. Vascular involvement (petechiae, splinter hemorrhages, Roth spots) 4. Immunologic involvement (Janeway lesions (painless), Osler nodes (painful), acute GN, (+) Rh factor) 5. At least 1+ blood culture DX = TEE best !

Viral Hepatitis: Classic symptoms?

[Prodromal phase] --> Icteric phase **ACUTE viral hepatitis = usually only experiences PRODROMAL phase **CHRONIC viral hepatitis = usually progresses to icteric phase Prodrome = "flu-like" (+) fever (+) malaise (+) anorexia, N/V (+) abdominal pain Icteric phase = (+) JAUNDICE

ACS: Discuss the progression of "EKG changes" seen with a STEMI?

[peaked t-waves] --> [ST elevation] --> [Q-wave] if necrosis occurs

Vaginitis: Etiologies?

a) Infectious (BV, Candida, Trich) b) Non-infectous (atrophic)

ACUTE Sinusitis: Causes? MC? MC location? Symptoms? Best XRAY view? Gold standard test? TXT?

a)Viral (MCC) --> usually following URI b) Bacterial MC location = MAXILLARY (+) Nasal congestion (+) Rhinorrhea (+) Sinus pressure (+) Headache (+) F/C XRAYs = "Water's view" (through mouth) Gold standard = CT scan TXT = supportive -nasal decongestants (AFIN) -nasal corticosteroids (fluticasone) -nasal saline rinses -oral antihistamines (benadryl) -oral decongestants (guanifacine)

Antiviral medications: Discuss the use of: -acyclovir -ganciclovir -foscarnet

acyclovir = MC used ganciclovir = reserved for more serious viral infections (CMV, EBV) **think "gangs" are hardcore foscarnet = LAST RESORT (big gun) **lots of serious ADRs (renal toxicity, seizures)

Valvular Disease: MC type?

aortic stenosis

Cocaine-induced MI: Pathophysiology? EKG? TXT?

cocaine --> overstimulates "alpha" receptors --> uncontrolled coronary vasospasm --> acute coronary ischemia (+) transient ST elevation TXT : a) CCB b) Nitrates **NEVER given BB in setting of recent cocaine use (unopposed alpha = leads to severe vasospasm)

What is Fetal Fibronectin (fFN)? Limitations to its use?

fFN = glycoprotein that promotes adhesion of the placenta / uterine wall Accurate reflection of preterm labor UP UNTIL 34W Preterm labor = these adhesions are broken and you can see if fFN is present in vaginal vault -Between W22-34 it is ABNORMAL to have any fFN -After W34, the body will naturally start preparing for labor & breaking down these adhesions so this test becomes a less reliable marker for preterm delivery after that point. (+) cervical shortening in COMBO with (+) fFN = good predictors of preterm labor

LABS: In general what do the following indicate: a) high ESR b) high CRP c) high ANA

high ESR/CRP = non-specific makers of INFLAMMATION ANA = indicates autoimmune process (non-specific)

Osteochondroma: Research shows this has the HIGHEST risk of malignant transformation if present where? TXT?

pelvis (always resect)