USMLE STEP 2 CK-2

Peripheral Vasodilation Septic/Distributive Shock. High CO, Low PCWP & PVR.

# 82yo 8hr hx of increased confusion. dementia, HTN and renal insufficiency, Fever pulse 108 irregularly irregular. BP 82/60. Warm extremities. Urinalysis >100 WBC. Cause of hypotension?

Clindamycin

# 87yoF, 2 day hx of difficulty breathing, aphasia since cerebral infarct 6 months ago. fever. 102 pulse, RR 34. Rhonchi over right lower lung field with dullness to percussion. Right sided facial weakness, aphasia and loss of gag reflex. Consolidation in right lower lung field on CXR. Most appropriate pharmacology?

Rh incompatibility

# 8hr old newborn, jaundice, and respiratory distress. Hepatosplenomegaly, scattered petechiae, HgB 4, total serum bili 15, direct 0.3, Cause?

Ureteral Ligation

# 8hrs after total abdominal hysterectomy for treatment of severe endometriosis, no urine output despite fluid bolus and furosemide. hemorrhage of 1500ml treated with 3 units of packed RBC. Fever. Serum creatinine went from 0.7 to 1.5. US shows mild bilateral hydronephrosis and no urine in the bladder. Cause of the anuria?

High-dose ASA (for antiin ammatory, antipyretic, and antithrombotic effects) and IVIG (to prevent coronary artery aneurysms).

# Treatment for Kawasaki Disease?

Enterotoxic E. coli (ETEC)

# afebrile 32yoF, cramping abdominal , watery stools, no blood, no neutrophils in stool. leukocyte count 8500. Causal organism?

Family hx of early onset

# strongest predisposing factor for developing dementia, Alzheimer type. As far as smoking, low education, head injury, gender, and family hx of early onset.

Family Hx

# strongest predisposing risk factor for Asthma. Between FH, Urban living, exposure to animal dander, exposure to cigarette smoke.

1 yo & 4 yo fever and maculopapular rash a week after receiving MMR vaccine due to infection with vaccine-strain measles virus used in vaccine. no treatment necessary it is mild and self limiting. transmissible so avoid contact with immunocompromised individuals until rash resolved.

MMR vaccine

Central retinal vein occlusion.

Painless vision loss, dilated retinal veins and widespread retinal hemorrhages intermixed with patches of white exudates. Dx?

Howell-Jolly bodies nuclear remnants of RBC usually removed by functional spleen, but SCD have functional asplenia.

Patient with sickle cell, what will you see on peripheral smear?

decreased total serum calcium. seen in nephrotic range proteinuria

Patients with Hypoalbuminemia can have

psychogenic from organic causes of male erectile dysfunction. Normal nocturnal erections indicates intact vascular and nerve function in the penis.

Persistence of nocturnal and early morning penile erections helps differentiate

>20 indicates Primary HyperAldosteronism <20 indicates Secondary Hyperaldosteronism (Fibromuscular Dysplasiai)

Plasma Aldosterone concentration/Plasma Renin Activity

men sex with men travelers to countries where hep A is prevalent chronic liver dz IVDU

vaccination for Hep A

Meningcoccal Vaccine (MCV4)

vaccination for asian countries, sub Saharan Africa and Hajj to Mecca, Saudi Arabia

Hep A Hep B Typhoid Polio Booster

vaccination for travel to North Africa

slow conduction in AV node and decrease pulse rate in supra ventricular tachycardia. useful in determining site of conduction in 2:1 AV block

vagal maneuvers

systemic error (bias)

validity and accuracy are measures

Factor V Leiden AD

venous thromboembolism, MI, stroke in a patient with family hx of venous thromboembolism or <50yo developing venous thromboembolism

herepes gingivostomatitis

vesicular eruption on anterior oral mucosa (buccal, hard palate, gingiva, tongue) and perioral.

herpetic whitlow, HSV grouped vesicles on an erythematous base tingling, burning, pain are common ,most resolve in 2-3 weeks if immunocompromised requires antiviral (Acyclovir)

young, multiple sexual partners, mild systemic symptoms. Painful, vesicular hand rash.

spondylolisthesis Spinal Stenosis Narrowed Spinal canal. Flexion of the spine causes widening of the spinal canal, while extension causes narrowing of the canal. Threfore sympotms are exacerbated by extension of the spine (standing and downhill walking). Improves with flexion of spine whith sitting and uphill walking. Mild to moderate: NSAIDs and abdominal muscle strengthening. Advanced: Epidural corticosteroid injections can provide relief. Refractory: Surgical laminectomy may achieve signi cant short-term suc- cess, but many patients will have a recurrence of symptoms.

#37yoM, 3months of low back pain, Moderate relief from NSAID, forward flexion produces no pain, hyperextension increases the pain. sensation and reflexes are normal. Diagnosis?

Family Therapy

*

Septic Shock BOUNDING PERIPHERAL PULSES early then leads to cool and clammy extremities if left untreated.

Cardiac Index & SV INC Pulse Pressure INC Hypotension Peripheral Vasodilation DEC SVR Low/Nor, PCWP

Preload HIGH CO LOW Afterload HIGH Elevated LDH reflective of poor organ and tissue perfusion

Cariogenic Shock Preload CO Afterload

reopening of fascial incision presents with popping sensation followed by copious serosanguineous drainage and incisional bulge resistance encountered during probing of incision rules it out.

Fascial Dehiscence

internal device placed after rupture of membranes when external monitoring cant reliably measure fetal heart rate (maternal obesity)

Fetal Scalp Electrode

Sickle cell disease on Hydroxyurea

0% HgA 80% HgS 17% HgF 0% HgC

Sickle Cell Disease not on Hydroxyurea

0% HgA 90% HgS 7% HgF 0% HgbC

Carcinoid syndrome Urinary 5-hydroxyindoleacetic acid (5-HIAA) excretion

intermittent flushing, bronchospasm, abdominal cramping, secretory diarrhea and right side valvular heart dz

Does not change incidence of horizontal transmission (person to person on unwashed hands), or late onset GBS sepsis.

intrapartum antibiotic prophylaxis to GBS

Streptococcus pneumoniae

most common cause of bloodstream infection in patients with sickle cell

Choroidal inflammation characteristic of posterior Uveitis IBD, Ankylosing spondylitis or CMV

painless vision loss and floaters

cerebrovascular disease resulting in vascular dementia Stepwise decline, early executive dysfunction, cerebral infarct on imaging. in a patient with atherosclerotic risk factors

1 yr ago difficult balancing checkbook, 5months ago unsteady on feet, past month isolated and depressed, increased urinary frequency and urgency. DM2, HTN, High Cholesterol

Amaurosis Fugax Retinal embolism embolic plaques and retinal whitening due to ischemia.

painless, rapid, transient <10 min monocular vision loss in a patient with a carotid bruit

Oral amoxicillin therapy

A 27-year-old woman, gravida 2, para 1, at 12 weeks' gestation comes to the physician for a prenatal visit. She feels well. Pregnancy and delivery of her first child were uncomplicated. Medications include folic acid and a multivitamin. Her temperature is 37.2°C (99°F), and blood pressure is 108/60 mm Hg. Pelvic examination shows a uterus consistent in size with a 12-week gestation. Urine dipstick shows leukocyte esterase; urinalysis shows WBCs and rare gram-negative rods. Which of the following is the most appropriate next step in management?

Aspirin

16yo, comatosed post suicide attempt, pulse 100, RR28, BP100/66, Pupils reactive to light, DOLLS EYE REFLEX present. Metabolic Acidosis. Most likely substance?

Pilosebaceous Follicle

17yoF with rash on face and upper back. What structure primarily involved?

BNP & S3

2 major signs of CHF

Miliary tuberculosis

2 months of fatigue, fever, weight loss, non productive cough, IV drug user and recent incarceration. CXR: Diffuse reticulonodular pattern

Osteoporosis

24yo F with Anorexia nervosa compared to other women in age group and increased risk of?

Roseola Infantum (HHV-6)

3 day hx of fever (>104 3-5 days then resolves before rash) followed by blanching erythematous macular rash

Pneumocystis jiroveci pneumonia Indolent (HIV) or acute respiratory failure (immunocompromised) fever, dry cough, low oxygen levels HIGH LDH diffuse reticolar infiltrates on Imaging Induced sputum or BAL stain tx: TMP-SMX + prednisone if decreased oxygen levels Prevention: TMP-SMX (CD4<200), Antiretrovirals in HIV

3 weeks progressive dyspnea on exertion, dry cough, fatigue, intermittent fever, chills. in a patient with thrush, and male sex with male.

VSD from rupture of the inter ventricular septum Blood in RA 65% Oxygen, RV 79% Increased right sided heart pressures from left to right shunt Low CO Elevated PCWP

3-5 days post MI, hypotension, tachycardia, holosystolic murmur at left sternal border.

Peripartum cardiomyopathy Transthoracic Echocardiogram showing dilated LV cavity with global systolic dysfunction and EF <45% confirm the diagnosis. Urgent or immediate delivery only for advanced heart failure or hemodynamic instability.

38 week gestation progressive dyspnea on exertion, lower ext edema, third heart sound associated with mitral regurgitation (holosystolic murmur at apex)

Elevated plasma levels of citrate (substance added to stored blood) which chelates calcium and magnesium. Lead to paresthesias.

Hypocalcemia post transfusion

LOW Preload LOW CO High Afterload

Hypovolemic Shock Preload CO Afterload

Mean +/- 1.96 X SE of the mean Large wider CI indicated there is a wider range of possible effects Small narrower CI indicated there is a narrower range of possible effects.

95% CI of the mean is calculated by

xanthine oxidase inhibitor used as irate lowering therapy to prevent recurrent gout.

Allopurinol

Goodpasture's

Anti-GBM antibodies

Influenza

If pt has an egg allergy, avoid what vaccination?

Felty's syndrome HLA-DR4 tx underlying RA

Rheumatoid arthritis, splenomegaly, necrotizing skin lesions, neutropenia

red to orange body fluids + urine, saliva, sweat, tears. discoloration of soft contact lenses

Rifampin Side effects

Pulmonary arterial pressure. PAP > 30 = Pulmonary HTN

Right heart catheterization most accurate method of measuring

Atrial septal defect

S2 is widely split and does not vary with respiration.

increase insulin sensitivity of peripheral tissue

Thiazolidonediones (PIOGLITAZONE)

1st trimester bleeding, closed Os, normal heart sound. uncomplicated pregnancy with normal outcome, therefore management is expectant with outpatient observation. Serial ultrasounds

Threatened Abortion

reduce postpartum hemorrhage (uterine atony) by stabilizing fibrin, inhibit fibrinolysis and plasmin activity.

Tranexamic Acid

most common cause of proteinuria in children and cast be caused by fever, exercise, seizures, stress or volume depletion. More common in boys is orthostatic, increased protein when partientr stands up. If no hematuria on urinalysis then urine dipstick should be REPEATED on 2 subsequent occasions.

Transient/orthostatic Proteinuria

shifting of fluid from intracellular to extracellular space due to an excess osmotically active substance in the blood stream such as glucose (Hyperglycemia) as in DKA or Hyperosmotic Hyperglycemic state serum osmolality will be elevated (hypertonic Hyponatremia) administration of insulin shuttles glucose intracellularly and water follows restoring extracellular fluid sodium concentration to normal.

Translocation Hyponatremia

multiple myeloma

high Ca, Phos, alk phos, urine hydroxyproline

Clomiphene

Woman with PCOS, trying to concieve most appropriate pharmacotherapy?

Subarachnoid hemorrhage

Xanthochromia seen in CSF

Paget's disease

bone pain, bone resorption and sclerosis on skull X-ray, leg xray shows cortical thickening with mild bowing normal Ca, Phos, HIGH alk phos & Urine hydroxyproline

Paget's disease of bone focal increase in bone turnover in which osteoclast dysfunction leads to bone breakdown and compensatory increase in bone formation. pelvis, skull, spine, long bones mosaic pattern of lamellar bone enlarging cranial bones lead to increase hat size, headaches, hearing loud due to entrapment of CN VIII benign giant cell tumors and osteosarcoma

bone pain, headache, unilateral hearing loss, femoral bowing

otosclerosis

bony overgrowth of the stapes footplate that results in conductive hearing loss

PDA

continuous machinery murmur best heard in left infraclavicular area

Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia) AD

diffuse telangiectasia (ruby colored paspules that blanch with pressure) recurrent epistaxis widespread Arteriovenous malformations (arteriovenous shunting) chronic hypoxemia, digital clubbing, reactive polycythemia (Increased hct) recurrent nose bleeds

Hypertrophic pulmonary osteoarthropathy associated with underlying lung disease like lung cancer, TB, Bronchiectasis, Emphysema. Dx: CXR

digital clubbing, sudden onset arthropathy, commonly affecting wrist and hand joints.

Urinary outflow obstruction due to renal calculi. post obstructive diuresis when intermittent episodes of high volume urination can overcome the obstruction. Excess diuresis lead to potassium wasting and dehydration causing weakness.

flank pain, poor urine output, intermittent episodes of high volume urination.

Behcet syndrome

genital aphthous ulcers that are recurrent and painful. Scrotum and heal spontaneously within 1-3 weeks.

-decreased insulin -decreased pH -decreased mineralocorticoid activity

hyperkalemia results from

Extracellular shift of Potassium & loss of insulin dependent potassium uptake across cell membranes administration of insulin drives K into cells

in DKA measured serum potassium levels are initially high due to:

vitamin B12 deficiency

increased methylmalonic acid

CMV & TOXO

neonatal INTRACRANIAL CALCIFICATIONS

symptomatic aortic stenosis Aortic Valve Area <1cm NEED AORTIC VALVE REPLACEMENT if asymptomatic then monitored closely with follow up echo every 6-12 months.

progressive fatigue, exertional dyspnea, mid systolic murmur in RU sternal border with radiation to carotids

Riedel Thyroiditis (Riedel Struma)

progressive fibrosis of the thyroid gland and surrounding tissues

Erythema Multiforme erythematous papule that evolve into target lesions with dusky central area. Red inflammatory zone surrounded by a pale ring, and an erythematous halo at periphery. Cell mediated immune response associated with HSV, Mycoplasma, or Sulfonamides, malignancy, collagen vascular diseases. self limited and symptoms alleviated with antihistamines and topical glucocorticoids.

started as small red papules that enlarged but not painful or pruritic.

Beta blocker (propranolol)

treatment for essential tremor?

The results are not adjusted for comorbidities

#

Release of preformed thyroid hormone subacute granulomatous Thyroiditis The subacute form presents with a tender thyroid, malaise, and URI sym ptom s. ↓ uptake on RAI and scan during the hyperthyroid phase. Tr e a Tm e n T β-blockers for hyperthyroidism; levothyroxine for hypothyroidism. Subacute thyroiditis is usually self-limited; for severe cases, treat with NSAIDs or with oral corticosteroids. Subacute thyroiditis is not a "cute" thyroiditis—it is painful!

# 1 week hx of palpitations and heat intolerance. pulse 100 irregular. enlarged tender thyroid gland. Low TSH, High T4 & T3. 1% iodine uptake. Mechanism of illness?

abruptio placentae ComPliCaTions Preeclampsia: Prematurity, fetal distress, stillbirth, placental abruption, sei- zure, DIC, cerebral hemorrhage, serous retinal detachment, fetal/maternal death. Eclampsia: Cerebral hemorrhage, aspiration pneumonia, hypoxic enceph- alopathy, thromboembolic events, fetal/maternal death.

# 10 week gestation. BP 140/94, 342g of protein on 24 hour urine collection, and 115 Cr. Patient is at increased risk of what complication?

CT scan of Abdomen Duodenal Hematomas occur following blunt abdominal trauma. Commonly seen in children. Occurs when blunt force rapidly compresses the duodenum against vertebral column. Blood collects between submucosal and muscularis layers of the duodenum causing partial or complete obstruction. 24-36 hours after with epigastric pain and vomiting due to failure to pass gastric contents beyond obstructing hematoma. Diagnosis confirmed with CT imaging of the abdomen. Most resolve in 1-2 weeks. Managment involves decompression by nasogastric tube and parenteral nutrition. Surgery or percutaneous drainage may be considered to evacuate hematoma if nonoperative management fails. Plain Abdominal radiograph shows Dilated stomach with scanty distal gas.

# 12yo B sudden onset vomit and moderate to severe abdominal pain, pain exacerbated by eating. Admitted to hospital 18hrs ago after hit by car. No findings on abdominal Ultrasound. Severe epigastric tenderness. bowel sounds decreased. in moderate distress with pulse 122, respiratory 25, BP 94/58. most appropriate next step in diagnosis?

Breathing into a paper bag.

# 15yo B chest and left arm pain while sitting in class. SOB, tingling sensation around mouth, light headed. pulse 110, RR 44, 100% oxygen sat. Lungs clear to auscultation. Regular rhythm no murmurs or clicks. Management?

Trichophyton rubrum

# 15yo B with lesion on right buttock increasing in size. on the wrestling team. 1x1 cm erythematous scaly pruritic plate. today 4x4 annular lesion with erythematous margins and well defined raised edges. likely organism?

increased serum LDH

# 18yoF, lump in her neck first noticed 1month ago, asymptomatic, 3cm left supraclavicualr lymph node, firm and rubbery, spleen palpated 3cm below left costal margin. Lab?

Rocky Mountain Spotted Fever Rocky Mountain spotted ever starts on the wrists and ankles and then spreads centrally. Give doxycycline for suspected Rocky Mountain spotted fever or ehrlichi- osis. Classic triad- headache, fever, rash (vasculitis). Palms and soles rash is seen in Coxsackievirus A infection (hand, foot, and mouth disease), R o c k y M o u n t a i n s p o t t e d f e v e r , a n d 2 ° S y p h i l i s (you drive CARS using your palms and soles).

# 18yoM, rash and stuporous for 24hrs. fever, chills, severe headache for 4days. camping for 3 weeks and drinking from stream water without boiling. Diffuse erythematous maculopapular rash on trunk extremities, palms, soles. Multiple abrasions, petechiae, purpura over the lower exts. basilar inspiratory crackles and S3 gallop. Hematocrit 32%, leukocyte count 5500, platelet count is 20,000. Dx?

Echo

# 1day hx of non radiating substernal chest pain in a 37yo M. Had an URI 1 week ago. Fever, 106 pulse, 14 RR, 122/88 BP, 2/6 systolic crescendo-decrescendo murmur along left sternal border. Normal troponin I. Most likely to confirm the diagnosis?

Measure Serum Amylase Midepigastric pain, nausea, vomiting, Elevated Amylase and Lipase are consistent with ACUTE Pancreatitis. With several gallstones on ultrasound and not an alcohol drinker most likely due to Gallstones (second most common cause) ALT>150 95% psoitive predictive value for diagnosing gallstone pancreatitis. After pancreatitis resolved partient is at increased risk of recurrence due to gallstones. EARLY CHOLECYSTECTOMY is recommended for medically stable patients who recover from acute pancreatitis and are surgical candidates.

# 20 wk gestation severe epigastric pain radiates to back. Vomited once. Fever. Next step in management?

Zinc due to increased fetal excretion Delayed wound healing, suppressed immunity, male hypogonadism, Dec adult hair (axillary, facial, pubic), dysgeusia, anosmia. Associated with acrodermatitis enteropathica (defect in intestinal zinc absorption). May predispose to alcoholic cirrhosis.

# 20yo with Wilson Dz. Hair loss, decreased taste sensation, cut on arm not healing. patchy alopecia and tsticular atrophy. Cant distinguish taste of salt, lemon or sugar. Deficiency of?

EBV

# 21yo F, 3day of fever, sore throat, fatigue. Sexually active with multiple partners. tender enlarged lymph nodes in anterior cervical chain b/l. high lymphocytes. High AST & ALT. Rapid Strep test is negative. Causal organism?

viral pleurisy

# 21yoF, sudden onset severe right sided chest pain increased with deep inspiration, SOB and difficult taking deep breaths. 3 week vacation at andes mountains. fever. faint, erythematous macular nonpruritic rash over cheeks and trunk. dullness to percussion at right lung base and inspiratory rub with no crackles or wheezes. dx?

Deficiency of Serum Glucoronosyltransferase due to Gilbert Syndrome

# 22yo 2 day of nausea and diarrhea, Increased total Bili and Indirect Bili. Two weeks later her symptoms resolved and exam showed no abnormalities. Total Bili has decreased as well as indirect bili. Mechanism of this patients hyperbilirubinemia?

Atropine Cholinesterase inhibitor poisoning Often due to organophosphates, such as parathion, that irreversibly inhibit AChE. Causes Diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Excitation of skeletal muscle and CNS, Lacrimation, Sweating, and Salivation. May lead to respiratory failure if untreated. Organophosphates are often components of insecticides; poisoning usually seen in farmers. Atropine alone does not help Antidote—atropine (competitive inhibitor) + against muscle paralysis pralidoxime (regenerates AChE if given early).

# 22yo exposure to unknown gas, vomit, diarrhea, mitosis, copies oral secretions, rhinorrhea, muscular fasciculations. Diffuse wheezing heard bilaterally. generalized tonic clonic seizure. Pharmacotherapy?

antiplatelet IgG antibodies IDIOPATHIC THROMBOCYTOPENIC PURPURA IgG antibodies are formed against the patient's platelets. The platelet-antibody complex is destroyed by the spleen. Bone marrow production of platelets is ↑, with ↑ megakaryocytes in the marrow. The most common immunologic disor- der in women of childbearing age. ITP is associated with a range of conditions, including lymphoma, leuke- mia, SLE, HIV infection, and HCV infection. Platelet count > 30,000 and no bleeding: No treatment required. Plateletcount<30,000 or clinically signicant bleeding symptoms: Corticosteroids or IVIG. If platelet count fails to improve or bleeding recurs, consider splenectomy ± rituximab ± thrombopoietin (TPO) receptor agonist to increase platelet production (romiplostim or eltrombopag). n pregnant patients, severe thrombocytopenia may occur in the fetus.

# 22yoF, heavy menstraul bleeding and easy bruisability for 2 months. ecchymoses along upper and lower ext. Low platelet count. increase of megakaryocytes on bone marrow. after 1 week of prednisone therapy platelet count increases. most likely explanation?

Postviral Myocarditis Recent upper respiratory tract infection followed by sudden cardiac failure suggests dilated cardiomyopathy secondafry to acute viral myocarditis. From Coxsackie B virus. On echo see dilated ventricles with diffuse hypokinesia resulting in low ejection fraction. (dilated ventricles with diffuse hypokinesia) HisTo r y/Pe Often presents with gradual development of CHF symptoms. Examination often reveals displacement of the left ventricular impulse, JVD, an S3/S4 gallop, or mitral/tricuspid regurgitation. Diagnosis Echocardiography is diagnostic. CXR shows an enlarged, balloonlike heart and pulmonary congestion.

# 23yo, 10day hx of SOB, severe fatigue, lightheadedness, fever muscle pain and cough resolved after 6 days. pulse 85, RR 22, BP 100/60, lungs clear to auscultation. pedal edema b/l. Central hilarity opacification bilaterally. Frequent premature ventricular contraction on ECG. Generalized hyperkinesis. Decreased CO. Cause?

Fat embolism syndrome

# 24yo SOB post ORIF of a mineshaft femoral fracture. petechial hemorrhages of the conjunctivae and petechiae over the chest. Respiratory Alkalosis. CXR: Fluffy infiltrates in both lungs. Dx?

Isoniazid therapy only

# 25yo nurse with PPD of 12mm. Negative PPD 2 years ago. No abnormalities on CXR. Next step in management?

surreptitious administration of Thyroxine

# 25yoF, tremulousness and fatigue for 1m, pulse 120, nervous, no optho abnormalities, thyroid gland barely detectable by palpation and nontender. Iodine uptake decreased.

toxic megacolon in association with UC

# 27yo bloody stools for 4days. 8-10 loose stools daily past month. 2 wks of generalized weakness, fatigue, decreased appetite 5Ib weight loss. sensation of abdominal fullness for 2 days. no pain. Fever, pulse 100, RR 22, BP 90/60. contender and distended upper quadrants. Bowel sounds are decreased. Gross blood in rectal vault. HgB 10. Hematocrit 30%. Abdominal xray shows dilation of transverse colon. Dx?

AIDS

# 27yo, 2months of cough and SOB, weight loss past 6months, Her B diagnosis 3yrs ago, fever, tachycardia, low BP, 90% PaO2, anterior and post cervical LAD, white plaques over buccal mucosa. Leukocyte 2800 with segmented neutrophils 79%, lymphocytes 14%, Monocytes 7%. CXR shows diffuse bilateral infiltrates. Dx?

colposcopy

# 27yo, High grade squamous intraepithelial lesion on pap. No gross abnormalities on exam. next step?

Hypokalemia If a patient is on digitalis, potassium levels must be carefully monitored. Hypokalemia sensitizes the heart to digitalis toxicity, because K+ and digitalis compete for the same sites on the Na+/ K+ pump. Renal losses: Diuretics (eg, loop or thiazide)

# 2hours after perforated gastric ulcer, a 75yoF has multifocal premature ventricular contractions. Hx of CHF treated with digoxin and diuretic therapy. Most likely abnormal serum concentration?

inflammation within the first dorsal extensor tendon compartment De Quervain's Tenosynovitis New mothers who hold their baby with thumb outstretched. Inflammation of the abductor polices longs and extensor policies braves tendons.

# 2month hx of pain of right wrist exacerbated by lifting her child. Ulnar deviation odf the wrist with thumb in palm produces pain tende ness over radial styloid. Underlying cause?

Abnormal chloride channel airway epithelium due to CF Affected individuals exhibit recurrent pulmonary infections (especially with Pseudomonas and Staphylococcus aureus) with subsequent cyanosis, digital clubbing, chronic cough (the most common pulmonary symp- tom), dyspnea, bronchiectasis, hemoptysis, chronic sinusitis, rhonchi, rales, hyperresonance to percussion, and nasal polyposis. Patients with pancreatic insuf ciency usually have greasy stools and at- ulence; other prominent GI symptoms include pancreatitis, rectal pro- lapse, hypoproteinemia, biliary cirrhosis, jaundice, and esophageal vari- ces. type 2 DM, "salty-tasting" skin, male infer- tility (agenesis of the vas deferens), and unexplained hyponatremia. Patients are at risk for fat-soluble vitamin de ciency (vitamins A, D, E, and K) 2° to malabsorption and may present with manifestations of these de ciencies (ie, night blindness, rickets, neuropathy, coagulopathy). ulmonary manifestations are managed with chest physical therapy, bron- chodilators, corticosteroids, antibiotics (should cover Pseudomonas), and DNase. Administer pancreatic enzymes and fat-soluble vitamins A, D, E, and K for malabsorption. Nutritional counseling and support with a high-calorie and high-protein diet are essential for health maintenance. Patients who have severe disease but can tolerate surgery may be can- didates for lung or pancreas transplants.

# 32 yo, progressive cough productive of copious 1cup daily sputum and hemoptysis. 12 year hx of productive cough, one episode of hemoptysis yearly. nasal polyps since childhood. expiratory wheezes and honchi, in right upper lobe of lung. clubbing but no cyanosis. FEV1 of 43% FEV1:FVC 59% Sputum culture grows pseudomonas. Explanation?

Thrombotic Thrombocytopenic Purpura (TTP)

# 32yoF, 16 week gestation, 6hr of fever and waxing and waning consciousness. Fever. Fluctuating level of consciousness, hematocrit 11%, platelet 52,000, Creatinine 3.5, Schistocytes on blood smear. Dx?

Penicillin G Benzathine for Syphilis

# 32yoF, fatigue, fever, red bumps entire body for 2 days. addicted to heroin, prostitutue. Fever, scattered erythematous maculopapular rash over trunk and extremities indulging palms and soles. generalized LAD. Next step, is administration of?

Primary Sclerosing Cholangitis (PSC)

# 32yoM, fatigue, dark urine, hx of Ulcerative Colitis, presents with jaundice and scleral icterus. High total Bili, High Alk Phos. Dx?

Measure Platelet Count

# 37 weeks gestation, mild epigastric pain, headache, BP150/98. Urine protein 3+. Next step in management?

Cardiac Tamponade Excess uid in the pericardial sac, leading to compromised ventricular ll- ing and ↓ cardiac output. The rate of uid formation is more important than the size of the effusion. Risk factors include pericarditis, malignancy, SLE, TB, and trauma (commonly stab wounds medial to the left nipple). Presents with fatigue, dyspnea, anxiety, tachycardia, and tachypnea that can rapidly progress to shock and death. Examination of a patient with acute tamponade may reveal Beck triad (hypotension, distant heart sounds, and JVD), a narrow pulse pressure, pulsus paradoxus, and Kussmaul sign (increased JVD on inspiration). Echocardiogram shows right atrial and right ventricular diastolic collapse. CXR may show an enlarged, globular, water-bottle-shaped heart with a large effusion. If present on ECG, electrical alternans is diagnostic of a large pericardial effusion. Tx: Aggressive volume expansion with IV uids. Urgent pericardiocentesis (aspirate will be nonclotting blood). Decompensation may warrant pericardial window.

# 37yo 2 days of progressive SOB, Stage 3 breast cancer treated with radiation and chemotherapy one year ago. anxious. pulse 140, RR 32, BP 75/48. Systolic BP decreases 15 with deep inspiration. Oxygen sat of 90% on RA. JVD. Trace pretibila edema. Cardiomegaly and perihilar infiltrates on CXR. ECG shows sinus tachycardia and decreased voltage. Cause of these findings?

Renovascular HTN

# 37yo 3m hx of headaches, BP 190/105. Renal arteriography shows 80% obstructive lesion on left. Left renal vein renin assay shows ratio of 1.5:1. Dx?

Increased catecholamine production PHEOCHROMOCYTOMA A tumor of chromafin tissue that secretes catecholamines and is found either in the adrenal medulla or in extra-adrenal sites. Most commonly associated with MEN 2A and 2B. Presents with paroxysmal tachycardia, palpitations, chest pain, diaphore- sis, hypertension, headache, tremor, and anxiety. CT and MRI are both sensitive for pheochromocytomas (see Figure 2.3- 21). A nuclear MIBG scan can localize extra-adrenal lesions and meta- static disease. Look for elevated plasma-free metanephrines (metanephrine and normeta- nephrine) or 24-hour urine metanephrines and catecholamines. Tr e a Tm e n T Surgical resection. Preoperatively, use α -adrenergic blockade rst (phenoxybenzamine) to control hypertension, followed by β-blockade to control tachycardia. Never give β-blockade rst, as unopposed α-adrenergic stimulation can lead to severe hypertension.

# 37yo F, 6months of intermittent headaches, heart palpitations and sweating. BP 180/104. Most likely explanation of increased BP?

Small Bowel Stricture

# 37yo, 24hr after onset of severe abdominal cramps. 2 episodes of vomiting, severe constipation for 2 days. 5yr hx of Crohns. Distention, diffuse tenderness, visible peristalsis, high pitched bowel sounds. increased bowel gas, upright X-ray of abdomen shows multiple air fluid levels with no free air. explanation?

Adenomyosis

# 37yoF, 1yr hx of increasing pain during menstrual periods. she had an uncomplicated tubal ligation 2yrs ago. soft, tender uterus constant in size with 8 week gestation and no adnexal masses. Dx?

Switch to a different method of contraception

# 3day hx of urinary frequency and pain with urination. 2 UTI in past mont both resolved with tx. Sexually active with one partner and uses diaphragm for contraception. postcoital voiding and increased fluid intake have not prevented the recurrence. How can she reduce risk of future espisodes?

Organophosphates

# 3yoF, unconscious, pupils 1mm, unresponsive to light, rhinorrhea and drooling, poor air entry to lungs and diffuse wheezing, no movement of extremities. DTRs absent. Exposure too?

Serum Antinuclear Antibody Assay

# 42 yo F, 1yr of increases drinking and difficulty swallowing due to dry mouth. swelling of her cheeks. dental cavities. enlarged parotid glands. red eye. dry cracked lips. next step in management?

nonalcoholic steatohepatitis (NASH) NON-ALCOHOLICFATTYLIVER DISEASE Steatosis of hepatocytes leads to liver injury. Some patients progress to non- alcohol steatohepatitis (NASH) and are at risk of liver fibrosis and cirrhosis. Associated with insulin resistance and the metabolic syndrome. Dx: Largely a diagnosis of exclusion. Liver biopsy may show steatosis or steatohepatitis. Tx: Weight loss, diet, and exercise. If non-alcoholic steatohepatitis is present, consider vitamin E and pioglitazone.

# 42yo F, Acetaminophen 3-4x weekly for headaches. Does not smoke or drink. No illicit drug use. BMI 39. Trace pitting edema of LE. Alkaline Phos 110, AST 84, ALT 69, LDH 150. Total Cholesterol 259. Explanation for increased AST & ALT?

Biopsy and culture of the sinus mucosa for fungus

# 42yo, Low grade fever, headache, facial swelling for 3 days. hx of DM. Tenderness over right maxillary sinus. Opacity of the sinus on CT. Mild ketoacidosis. Next step in diagnosis?

Resistance of kidneys to ADH (Vasopressin) Nephrogenic DI (ADH resistance): The kidneys fail to respond to circu- lating ADH. Causes include renal disease and drugs (eg, lithium, demeclocycline). Presents with polydipsia, polyuria, and persistent thirst with dilute urine. Most cases are normonatremic. Water deprivation test: In psychogenic polydipsia and normal renal physi- ology, water restriction will lead to more concentrated urine. In central and nephrogenic DI, patients excrete a high volume of inappropriately dilute urine. Desmopressin acetate (DDAVP, a synthetic analogue of ADH) replace- ment test: Central DI: ↓ urine output and ↑ urine osmolarity (by 50-100%). Nephrogenic DI: No effect is seen on urine output or urine osmolar- ity. Nephrogenic DI: First-line treatment consists of salt restriction and water intake. Thiazide diuretics can be used to promote mild volume depletion and to stimulate ↑ water reabsorption. Decrease action of ADH leads to decreased renal water reabsorption and therefore water loss with polyuria. This results in dilute urine and hypernatremia.

# 42yoF, increased thirst past 6months. awakens several times each night to use bathroom and get drink of water. bipolar disorder treated with lithium. Hypernatremia High serum Osmolality of 280 and High Urine Osmolality of 200 two hours after fasting from fluids serum osmolality is 295, and urine osmolality is 250. Mechanism of increased thirst?

Caudate Nucleus due to Huntington Disease Atrophy of Caudate Nucleus seen as enlargement of lateral ventricles A rare, hyperkinetic, autosomal dominant disease involving multiple abnor- mal CAG triplet repeats within the HD gene on chromosome 4. The num- ber of repeats typically expands in subsequent generations, leading to earlier expression and more severe disease (anticipation). Presents at 30-50 years of age with gradual onset of chorea (purpose- less, involuntary dancelike movements), altered behavior, and dementia (begins as irritability, clumsiness, dgetiness, moodiness, and antisocial behavior). Weight loss and depression may also be seen. There is no cure, and disease progression cannot be halted. Treat symp- tomatically. Reserpine or tetrabenazine can be given to minimize unwanted move- ments. Psychosis should preferably be treated with atypical antipsychotics to ↓ the risk of extrapyramidal side effects or tardive dyskinesia. SSRIs are rst-line therapy for depression. Genetic counseling should be offered to offspring.

# 42yoM with facial grimacing, poor articulation of speech for 3 months. 1 year hx of irrational behavior and chronic fidgeting. father had a facial tic and committed suicide at 50yo. Disjoined and poorly coordinated gait. 19/30 on mini mental exam. Atrophy of?

Graves Disease The autoimmune form of hyperthyroidism. Thyroid- stimulating antibodies ↑ synthesis of T3/T4. Exophthalmos (direct stimulation of orbital fibroblasts by antibodies), pretibial myxedema, and thyroid bruits are seen only in Graves disease

# 47yoF, increasing eye pain and bulging of eyes. Exopthalmos, injected sclera. Ocular motility is restricted. MRI of eyes shows enlargement of several extraocular muscles of the orbits but not the tendinous insertions. Diagnosis?

COPD

# 47yoF, progressive SOB and cough for past week. productive of 1tbsp of sputum daily. yellow in color. six similar episodes over past year. Smoker. pulse 120, RR 24, BP 130/90. Breathing with pursed lips and using accessory muscles of respiration. Diffuse wheezes are heard in all lung fields. Trace pretrial edema. Most likely cause of these findings?

Air embolism

# 47yoM, 2 hours after pins and needles sensation and weakness in right leg and 1 hour hx of confusion.. Scuba diving for 6 hours in deep water diving. Tachycardia. RR 20, BP 160/90. Diffuse crackles on auscultation. S4 gallop. Systolic ejection murmur over left sternal border. Dx?

T-Cell Dysfunction IL-12 receptor deficiency Dec Th1 response. Autosomal recessive. Disseminated mycobacterial and fungal infections; may present after administration of BCG vaccine. Low IFN-γ.

# 4yo with Intradermal skin testing with PPD, tetanus toxoid and antigens for candida and trichophyton is nonreactive. Infection with Mycobacterium TB. Most likely explanation?

Medulloblastoma

# 4yo, progressive unsteadiness, can't run without falling, difficult standing without support, tips over when sitting unsupported, clumsy when reaching for toys, 95th percentile for head circumference, nystagmus on lateral gaze. mild dysarthria. broad based gait and ataxic. dysmetria and terminal tremor on finger to nose. dx?

Atrophic Gastritis The Schilling test measures the absorption of cobalamin via ingestion of radiolabeled cobalamin with and without intrinsic factor. The patient is given an unlabeled B12 IM shot to saturate B12 receptors in the liver and an oral challenge of radiolabeled B12. The radiolabeled B12 will pass into the urine if properly absorbed, as the liver's B12 receptors will be saturated from the IM dose. Radiolabeled B12 in urine: Dietary B12 de ciency. No radiolabeled B12 in urine: Consider pernicious anemia, bacterial overgrowth, or pancreatic enzyme de ciency; test the hypothesis with the addition of intrinsic factor, antibiotics, or pancreatic enzymes to radiolabeled B12. Chronic fundal (type A) Gastritis/Atrophic Gastritis associated with pernicious anemia , autoimmune destruction of parietal cells which produces intrinsic factor limits B12 absorption. Loss of parietal cells decrease acid secretion (Achlorhydia) compensatory increase in gastrin release

# 50yF, Hx of Hypothyroid, tingling in her hands and feet difficult maintain balance over past 2months, pale, easy fatigue, SOB, megaloblastic anemia. Abnormal Schilling test is corrected by oral administration of Intrinsic Factor. Cause of her anemia?

MR angiography of the renal arteries Renal artery stenosis Especially common in patients < 25 and > 50 years of age with recent-onset HTN. fibromuscular dysplasia (younger patients) and atherosclerosis (older patients). Continuous bruit in the right periumbilical area Elevation in serum Creatinine >30% Recurrent flash pulmonary edema Diagnose with MRAor renal artery Doppler ultrasound. May be treated with angioplasty or stenting. Consider ACEIs in unilateral disease. (In bilateral disease, ACEIs can accelerate kidney failure by preferential vasodilation o theeferentarteriole.)Opensurgeryisasecond option if angioplasty is not ef ective or feasible.

# 52yo frequent headaches past year. BP 170/104. Funduscopic exam shows arteriolar narrowing bilaterally. A left abdominal bruit is heard. Cr 1.6. Most appropriate next step in diagnosis.

Increased iron stores in hepatocytes HEMOCHROMATOSIS state of iron overload in which hemosiderin accumulates in the liver, pan- creas (islet cells), heart, adrenals, testes, and pituitary. 1° hemochromatosis: An autosomal recessive disease characterized by muta- tions in the HFE gene that result in excessive absorption of dietary iron. 2° hemochromatosis: Occurs in patients receiving chronic transfusion therapy (eg, sickle cell disease or α-thalassemia). abdominal pain, DM, hypogonadism, arthropathy of the MCP joints, heart failure, impotence, or cirrhosis. Examination: Bronze skin pigmentation, cardiac dysfunction (CHF), hepatomegaly, and testicular atrophy. Labs may reveal evidence of DM. Hemochromatosis does not affect the lung, kidney, or eye. ↑ serum iron, percent saturation of iron, and ferritin with ↓ serum trans- ferrin. A transferrin saturation (serum iron divided by TIBC) > 45% is highly sug- gestive of iron overload. Perform a liver biopsy (to determine hepatic iron index), MRI, or HFE gene mutation screen. Perform a liver biopsy (to determine hepatic iron index), MRI, or HFE gene mutation screen. Weekly phlebotomy to normalize serum iron levels, and then maintenance phlebotomy every 2-4 months. Iron chelating agents such as deferoxamine, deferiprone, or deferasirox can be used for maintenance therapy. ComPliCaTions Cirrhosis, hepatocellular carcinoma, restrictive cardiomyopathy, arrhyth- mias, DM, impotence, arthropathy, hypopituitarism.

# 54yoM, impotence, decreased libido, dull abdominal pain for 3 months. Increased thirst and nocturne 3-4x nightly. 11Ib weight loss. Tan that he developed 3 months ago has not faded. Spider angiomata on cheeks and upper chest and deeply pigmented skin. Tenderness in RUQ of abdomen. Liver span is 14cm. testicular atrophy. Liver biopsy will show?

Viral infection

# 55yoF, fever, neck pain, fatigue for 2 weeks. Weight loss. 4days after URI. Pulse 110. Thyroid gland diffusely enlarged and tender to palpation. ESR 110.

Hypercalcemia Serum calcium > 10.2 mg/dL (corrected for serum albumin). The most com- mon causes are hyperparathyroidism and malignancy (eg, breast cancer, squamous cell carcinoma, multiple myeloma). psychiatric overtones (weakness, fatigue, altered mental status).

# 55yoF, known metastatic breast cancer admitted to the hospital because of confusion progressing to obtundation over the past 24hours. barely arousble. Abnormal serum concentration?

Zinc

# 56yF, Short Bowel Syndrome, diffuse maculopapular rash and hair loss since 2 week hospital stay for TPN. Deficiency of which trace element?

rectus Sheath Hematoma

# 57yoF, 8 hrs after increasingly severe right sided abdominal pain. Diagnosed with DVT 1 week ago and started on Warfarin. Tender, firm, 6cm mass just lateral to umbilicus. Dx?

Fluid restriction A common cause of euvolemic hyponatremia that results from persistent ADH release independent of serum osmolality CNS disease (eg, head injury, tumor), pulmonary disease (eg, sarcoid, COPD, pneumonia), ectopic tumor production/paraneoplastic syndrome (eg, small cell lung carcinoma), and drugs (eg, antipsychotics, anti- depressants, NSAIDs). URINE OSMOLALITY > SERUM OSMOLALITY. Excess water reabsorption in kidneys results in HYPONATREMIA. Urinary sodium level is often ≥ 40 mEq/L. Fluid restriction is the cornerstone o SIADH treatment. If hyponatremia is severe (< 110 mEq/L) or if the patient is significantly symptomatic (eg, comatose, seizing), cautiously give hypertonic saline. Patients must be monitored in the ICU to prevent central pontine myelinolysis. Demeclocycline, an ADH receptor antagonist, or vasopressin receptor antagonists (conivaptan) can help normalize serum sodium.

# 57yoM Small cell carcinoma of there lungs. Serum Na:128 Serum Osm: 270 Urine Na: 40 Urine Osm: 400 Next step?

Stasis dermatitis with Ulcer

# 5cm ulcer with 3mm red border on anterior surface of leg above ankle. moderate edema from toes to mid calf bilaterally. feet are warm and pulses are weakly palpable. diagnosis?

Factor VIII deficiency X-linked clotting factor de ciencies of factors VIII (hemophilia A, 80%of cases), IX (hemophilia B), and XI (hemophilia C) Presents as a young boy with spontaneous hemorrhage into the tissues and joints that, if untreated, can lead to arthropathy and joint destruc- tion. Spontaneous intracerebral, renal, retroperitoneal, and GI hemor- rhages are also seen. Mild cases may have major hemorrhage after surgery, trauma, or dental procedures but are otherwise asymptomatic. ↑ PTT is prolonged on basic bleeding workup. PT and bleeding time are n orm al. Best initial test: Mixing study. Mix the patient's plasma with normal plasma, which will correct the PTT in hemophilia patients as it contains all clotting factors. tx: desmopressin (DDAVP), which releases factor VIII from endothelial cells.

# 5yo B with FH of hemophilia, Hemarthrosis on exam. Prolonged PTT and corrects to normal following testing of 1:1 mixture of the patients plasma and normal plasma. Cause?

internal carotid artery

# 65yoM 30 min after could not speak and had transient blindness of left eye. Hx of DM & Hypercholesterolemia. Funduscopic exam shows Highly refractive, bright yellow plaque. Most likely site of artery stenosis?

bronchogenic carcinoma (lung cancer)

# 67yoM, aching burning sensation in distal lower extremities for 3 weeks, exacerbated by walking and relieved by elevation of the feet. Metatarsophalangeal joints and ankles are warm, swollen, tender and erythematous. clubbing of fingers and toes. Dx?

Chronic Inflammation Anemias of chronic disease is a common finding in RA. Anemia of Chronic Inflammation/Diseas To limit bacterial proliferation, the body "hides" its iron in situations of chronic inflammation such as infection, malignancy, RA, or SLE. This results in a micro- or normocytic anemia with high levels of iron storage in the form of ferritin, but low serum iron. HIGH Ferritin

# 6m of excessive fatigue. Rheumatoid Arthritis treated with methotrexate and NSAID. Mild pallor on exam. MCV 72 LOW Iron, TIBC, Transferrin most likely cause of anemia?

Fibrosis of the SCM Muscle.

# 6wk old infant, prolonged labor and forced delivery. LGA. Head is rotated to the left with chin deviated to the right. head can be moved to midline only with difficulty. 2cm hard contender oval mass palpated at right side of neck. Cause of the findings?

Constriction of vessels in the lungs. Cor pulmonale is right-sided heart failure due to pulmonary hypertension. A mean pulmonary arterial pressure of > 25 mm Hg (normal = 15 mm Hg). Pulmonary arterial hypertension. ↑ pulmonary venous pressure from left-sided heart disease. Hypoxic vasoconstriction 2° to chronic lung disease. Chronic thromboembolic disease. Pulmonary hypertension with an unclear, multifactorial etiology. Presents with dyspnea on exertion, fatigue, lethargy, syncope with exer- tion, chest pain, and symptoms of right-sided CHF (edema, abdominal distention, JVD). History: COPD, interstitial lung disease, heart disease, sickle cell anemia, emphysema, and pulmonary emboli. Examination: Loud, palpable S2 (often split), a ow murmur, an S4, or a parasternal heave. Patient may also be hypoxemic, especially on exertion. CXR shows enlargement of central pulmonary arteries. ECG demonstrates RVH. Echocardiogram (initial test) and right heart catheterization (definitive test) may show signs of right ventricular overload and may aid in the diag- nosis of the underlying cause. Tr e a Tm e n T Supplemental O2, anticoagulation, vasodilators, and diuretics if symptoms of right-sided CHF are present. Treat underlying causes of 2° pulmonary hypertension. Some treatments for pulmonary arterial hypertension include prostanoids, endothelin receptor antagonists, and phosphodiesterase inhibi- tors. Some patients have vasoreactivity and respond well to high-dose calcium channel blockers.

# 72yo F with COPD, 3 months of SOB, nonproductive cough, light headed, fatigue, early satiety with 5Ib weight loss. Tachycardia, RR 20, BP 130/90. JVD with prominent a wave, breath sounds are distant. RV heave and loud S2. Liver is tender, smooth and pulsatile. Trace edema of LE. Cause of the findings?

Pneumoconiosis Affects upper lobes. Small, rounded nodular opacities seen on imagi ng. Interstitial lung disease characterized by inflammation and/or fibrosis of the interstitium. Presents with shallow, rapid breathing; dyspnea with exertion; and a chronic nonproductive cough. Patients may have cyanosis, inspiratory squeaks, ne or "Velcro-like" crackles, clubbing, or right heart failure. CXR/CT (initial test): Reticular, nodular, or ground-glass pattern; "honey- comb" pattern (severe disease). PFTs: ↓ TLC, ↓ FVC, ↓ DLCO (initial test): May be normal if the cause is extrapulmonary, normal FEV1/FVC. Serum markers of connective tis- sue diseases should be obtained if clinically indicated. Surgical biopsy (de nitive test): Often to con rm a diagnosis of IPF

# 72yo M, 6months of SOB, smoker. Coal miner. Decreased breath sounds at apices. Clubbing of fingers. Oxygen sat of 88%. Bilateral upper lobe masses and areas of consolidation. Cause of SOB?

Increased Parathyroid Hormone related peptide concentration Ectopic PTHrp will result in Low PTH, High Ca, Low/Nrml Phosphate

# 72yo M, constipation for 6 weeks. SCC of the lungs. Calcium concentration high at 12.8. Most likely explanation for the serum calcium concentration?

flaccid neurogenic bladder

# 72yoF, cerebral infarct, residual right hemiparesis. and has frequent urinary dribbling. palpable smooth mass in suprapubic area. explanation of incontinence?

SIADH A common cause of euvolemic hyponatremia that results from persistent ADH release independent of serum osmolality Associated with CNS disease (eg, head injury, tumor), pulmonary disease (eg, sarcoid, COPD, pneumonia), ectopic tumor production/paraneoplastic syndrome (eg, small cell lung carcinoma), and drugs (eg, antipsychotics, anti- depressants, NSAIDs). URINE OSMOLALITY > SERUM OSMOLALITY. Excess water reabsorption in kidneys results in HYPONATREMIA. urinary sodium level is often ≥ 40 mEq/L. Restrict Fluid and address the underlying cause. CORNER STONE OF TX to restrict fluid. If hyponatremia is severe (< 110 mEq/L) or if the patient is signi cantly symptomatic (eg, comatose, seizing), cautiously give hypertonic saline. Patients must be monitored in the ICU to prevent central pontine myelinolysis. Demeclocycline, an ADH receptor antagonist, or vasopressin receptor antagonists (conivaptan) can help normalize serum sodium.

# 72yoF, hyponatremia 3 days after admission to hospital following a cerebral infarct. receiving 5% dextrose in 0.45% saline since admission. Normal Vitals. Serum NA: 120 Serum Osmolality: 255 Urine Na: 50 Urine Osmolality: 358 cause of hyponatremia?

Repetitive Nerve Stimulation A paraneoplastic autoimmune disorder caused by antibodies directed toward presynaptic calcium channels in the neuromuscular junction. Small cell lung carcinoma is a significant risk factor. Presents with weakness of proximal muscles along with depressed or absent deep tendon re exes. Extraocular, respiratory, and bulbar muscles are typi- cally spared. Weakness will improve with ↑ activity. Repetitive nerve stimulation reveals a characteristic incremental response. Also diagnosed by autoantibodies to presynaptic calcium channels and a chest CT indicative of a lung neoplasm. Tr e a Tm e n T Treat small cell lung carcinoma; tumor resection may reverse symptoms. 3,4-diaminopyridine or guanidine can be given; acetylcholinesterase inhibitors (eg, pyridostigmine) can be added to either regimen.

# 72yoM with lung cancer, 2m of weakness in his legs. dry mouth, constipation, tingling of hands and feet, mild bilateral ptosis does not worsen after upward gaze for 1 minute. mild weakness of hip flexion bilaterally. After several attempts he can rise from a chair with his arms folded across his chest. DTRs are absent. Confirm the diagnosis?

Blood 1+ Protein 1+ RBC 0-5 WBC 0-5 Pigmented granular casts Renal tubular epithelial cells. ACUTE Tubular Necrosis Muddy Brown Casts

# 72yoM, decreased urine output 2 days after admission to the hospital. fever, tachycardia, Tachypnea, Bp 90/64, creatinine has increased to 3. Urinalysis?

cor pulmonale Cor pulmonale is right-sided heart failure due to pulmonary hypertension. A mean pulmonary arterial pressure of > 25 mm Hg (normal = 15 mm Hg). Chronic thromboembolic disease. Pulmonary hypertension with an unclear, multifactorial etiology. Presents with dyspnea on exertion, fatigue, lethargy, syncope with exer- tion, chest pain, and symptoms of right-sided CHF (edema, abdominal distention, JVD). History: COPD, interstitial lung disease, heart disease, sickle cell anemia, emphysema, and pulmonary emboli. CXR shows enlargement of central pulmonary arteries. ECG demonstrates RVH. Echocardiogram (initial test) and right heart catheterization (de nitive test) may show signs of right ventricular overload and may aid in the diag- nosis of the underlying cause. Supplemental O2, anticoagulation, vasodilators, and diuretics if symptoms of right-sided CHF are present. Treat underlying causes of 2° pulmonary hypertension. Some treatments for pulmonary arterial hypertension include prostanoids, endothelin receptor antagonists, and phosphodiesterase inhibi- tors. Some patients have vasoreactivity and respond well to high-dose calcium channel blockers.

# 72yoM, dyspnea for 6 weeks, JVD, ascites, pitting pretrial edema of both lower extremities. Mild cardiomegaly on CXR. hospitalized a few times for DVT & PE. No evidence of pulmonary edema. Cause?

Begin Isoniazid and Vit B6

# 77yoM PPD skin test showed 15mm induration. Resides in skilled nursing facility. No fever, sweat or cough. normal CXR. most appropriate next step?

Destruction anf dilation of distal airways.

# 77yoM, 15 minutes after cough productive of large amounts of blood tinged sputum, lifelong hx of chronic productive cough, recurrent episodes of pneumonia. 15 minutes after arriving bleeding stops spontaneously. tachycardia. Tachypnea, bronchophony in right lateral lung. CXR shows thin walled cystic spaces in Right lower lobe with some air fluid levels. Explanation?

Wiskott-Aldrich syndrome n X-linked recessive disorder seen only in male patients. Symptomsusuallypresent at birth. Patients have ↑ IgE/IgA, ↓ IgM, and thrombocytopenia. The classic presentation involves bleeding, eczema, and recurrent otitis media. Remember the mnemonic WIPE: Wiskott-Aldrich Infections Purpura (thrombocytopenic) Ec z e m a . ↑↑ risk of atopic disorders, lymphoma/leukemia, and infection from Spneumoniae,Saureus,and Hinfluenzae type b (encapsulated organisms;think back to how IgM functions). Treatment is supportive (IVIGand antibiotics). Patients rarely survive to adulthood. Patients with severe infections may be treated with bone marrow transplantation.

# 7month old, persistent fever, prolonged bleeding following circumcision, at 3months developed eczema. frequent episodes of thrush and otitis media, pneumococcal bacteremia, fever, white plaques over oral cavity, Normal IgA and IgE, LOW IgG and IgM. Low platelet count. Diagnosis?

C1 esterase inhibitor deficiency hereditary angioedema AD recurrent episodes of angioedema lasting 2-72 hours and provoked by stress or trauma. Can lead to life-threatening airway edema. Total hemolytic complement (CH50) to assess the quantity and function of complement. Purified C1 esterase and FFP can be used prior to surgery.

# 8yoB, 1hr after sudden onset facial swelling, Several episodes in past one requiring endotracheal intubation. Once after cut lip. Voice is horse. edema of lips and tongue on exam. Mild inspiratory stridor. serum study likely to be abnormal?

FEV1: Dec FVC: Normal TLC: Inc ASTHMA

# 9yo with intermittent non productive cough. Cough exacerbated with exercise and worse at night. PFTs? FEV1 FVC TLC

Lidocaine therapy

# Before D&C supplemental oxygen and midazolam are administered. A paracervical block with lidocaine is performed in preparation for uterine evacuation. five minutes later patient reports numbness of her lips and twitching of her hands. Cause of symptoms?

PCP

# Bilateral NYSTAGMUS, Constricted pupils, Hypertonia, Decreased sensation to pinprick. Substance taken?

acute respiratory distress syndrome (ARDS)

# CXR bilateral diffuse hazy densities with cephalization of the pulmonary vasculature and perihilar fullness. Most likely diagnosis?

Hyperosmolality

# Cause of confusion in a patient undergoing nonketotic hyperosmolar hyperglycemia Glucose >600

Mupirocin Ointment

# Child with diaper rash, 2cm crusted papular honey colored lesion with clear discharge in groin area. Topical administration of?

psychogenic polydipsia Primary Polydipsia: due to increased water intake that leads to dilute urine (urine osmolality <1/2 of plasma osmolality) and Hyponatremia (sodium <137). After water deprevation urine osmolality >600. Due to intact ADH and ability to concentrate urine in absence of water intake.

# Drinking 12-15 glasses of water a day. Serum Sodium 122 (LOW) Urine sodium 20 Urine Osmolality 200 Cause of Hyponatremia?

Second degree AV block

# Dx?

calculation of ankle brachial index

# Elder man 2 months of cramping pain in calf after walking, pain relieved by rest. post tibial and dorsals pedis pulses are palpable but decreased. Next step in diagnosis?

spinal stenosis

# Elder man with gradually increasing pain in both hips and thighs. pain exacerbated by walking and improves with leaning forward at the waist. Dx?

Hypertension INTRACEREBRAL HEMORRHAGE Bleeding within brain parenchyma. Commonly affects deep brain regions such as basal ganglia, thalamus, pons, and cerebellum. Some risk factors include hypertension, tumor, and illicit drug use. Hypertension is the most common cause of intracerebral hemorrhage. Earlysymptoms/signs:Focalmotororsensoryde citsthatoftenworsen as the hematoma expands. Late symptoms/signs: Features of increased intracranial pressure (eg, vomiting and headache, bradycardia, reduced alertness) immediate non con head CT Look for hyperdense areas, mass effect, or edema that may predict herniation. Suspect herniation if patient develops Cushing triad (hypertension, bradycardia, irregular respirations), fixed pupils, or loss of conscious- ness. Herniation is a medical emergency. Treat with surgical evacuation of blood, removal of CSF, corticosteroids, or mannitol.

# Elder man, 1hour after unconscious. bradycardia, BP 180/90. 4mm pupils non reactive to light. oculocephalic reflex absent. most likely underlying cause of finding?

Postrenal Obstructive Uropathy due to BPH

# Elderly male with 3wk hx of malaise, nausea, bloating, generalized itching. hx of type 2 DM, BPH. Smoker. Suprapubic distention and tenderness. BUN and Cr have risen to BUN 93, Cr 6.7. Cause?

Normal Thymus

# Interpretation of the density in the right lung field?

Decreased Lactase activity in the brush border

# Lactose hydrogen breath test is positive. What small bowel abnormalities?

Xray of Sacroiliac Joints. HLA-B27 is found in 85-95% of cases. Radiographs may show fused sacroiliac joints, squaring of the lumbar ver- tebrae, development of vertical syndesmophytes, and bamboo spine NSAIDs (eg, indomethacin) for pain exercise to improve posture and breathing. TNF inhibitors or sulfasalazine can be used in refractory cases.

# Most approiptate intimal step when suspect Ankylosing Spondylitis due to low back pain in young male difficulty bending and improvement as day progresses. range of motion of the back is limited to 30 degrees of flexion.

transesophageal echocardiography Patient has COARCTATION OF THE AORTA

# Most appropriate next step in evaluation of HTN, in a patient with 180/90BP in RUE, and 176/88 in LU, Femoral and pedal pulses are decreased.

OCP

# Most appropriate recommendation for a 22yo woman who has a FH of ovarian cancer?

Acute exacerbations: High-dose, IV corticosteroids. Plasma exchange in patients who do not respond to corticosteroids. Disease modifying medications: Immunomodulators for relapsing-remitting MS can decrease number of relapses. Treat with "ABCs": Interferon-β1a (Avonex/Rebif), interferon-β1b (Betaseron), and copolymer-1 (Copaxone). Symptomatic therapy is crucial and includes baclofen for spasticity, cho- linergics for urinary retention, anticholinergics for urinary incontinence, carbamazepine or amitriptyline for painful paresthesias, and antidepres- sants for clinical depression. MRI (diagnostic test of choice for MS) shows multiple, asymmetric, often periventricular white matter lesions (Dawson ngers), especially in the corpus callosum. Active lesions enhance with gadolinium. CSF reveals ↑ IgG index, or at least two oligoclonal bands not found in the serum (nonspecific).

# Most appropriate tx for MS?

DM

# Most likely complication of a 23yo who has signs and symptoms of PCOS?

Hep B Immune globulin and Hepatitis Vaccine

# Needle stick from a Hep B positive patient. HbsAg + HbCoreAb - HbSurfaceAb - Pharmacotherapy to prevent infection?

Relative Risk Reduction

# New report states that 50% reduction in new vertebral fractures among patients with osteoporosis who were treated with drug X. Patients were assigned to undergo treatment with drug X or a placebo. The incidence of new fractures was 10% in the drug X group and 20% in placebo group. Which of the following was most likely presented as the 50% reduction in fractures?

B lymphocytes Bruton agammaglobulinemiaAn X-linked recessive B-cell deficien y found only in boys. Symptoms begin after6 months of age, when maternal IgG (transferred transplacentally) is no longer active. Life-threatening; characterized by encapsulated Pseudomonas, Spneumoniae,and Haemophilus infections after 6 months of age. Quantitative Ig levels. If low, confi m with B- and T-cell subsets (Bcells are absent;Tcells are often high). Absent tonsils and other lymphoid tissue may provide a clue. Treat with prophylactic antibiotics and IVIG.

# child with fever, irritability, previous infections with pneumococcal bacteremia, perioribital cellulitis caused by Haemophilus Influenza type B, CSF with leukocyte at 500 and 95% segmented neutrophils. Gram stain gram + diplococci. Cell type involved in underlying condition?

MVP

# congenital heart defect in Marfan? 3/6 late systolic murmur following a click heard at apex. Fainter and shorter where squats.

excisional biopsy with narrow margins. BASAL CELL CARCINOMA

# elderly male with lesion on chest. Landscaper for 35 years 8mm lesion with an ulcerated base and shiny slight;ty raised borders on upper chest. most appropriate next step in diagnosis?

Cataracts

# elderly women with difficulty in vision when driving at night, yellowing of the lenses. due to?

Histoplasma capsulatum

# fever and cough with yellow sputum. exploring caves and live in Ohio. scattered honcho b/l, CXR bilateral hilar lymphadenopathy and infiltrate in right upper lobe. 1.5cm cavitary lesion in right upper lobe, enlarged lymph nodes in mediastinum b/l and several small scattered indeterminate nodules bilaterally. dx?

Lymphangitis

# fever, area of swelling and redness on forearm, red streaks extending from forearm to elbow. Epitrochlear lymph nodes enlarged.

ectopic pregnancy

# greatest risk for which condition related to bilateral tubal ligation?

Low Calcium Alcoholics are the most common patient population with hypomagnesemia.

# homeless 66yoM admitted for jaundice, eats irregularly, 20Ib weight loss, 20yr hx of alcoholism, wasted, icteric sclera, palmar erythema, spider angiomata, LOW magnesium. Serum studies?

Neutrophil

# infant with persistent abscess. multiple infections since birth. cultures of abscess grow staph aureus, also infection with pneumonia and empyema. cell type involved in the underlying condition?

Spinal dysraphism (spina bifida)

# male newborn with bilateral clubfoot deformity, did not move lower extremities at birth, did not cry when received a shot in heel, moves upper extremities but not lower extremities. Bladder palpable and full. Dx?

IV Prostaglandin Start IV PGE1 to maintain or open the PDA. transposition of great vessels The most common cyanotic congenital heart lesion in the newborn Without a septal defect (ASD or VSD) and a PDA, it is incompatible with life. A PDA alone is usually not suf cient to allow adequate mixing of blood. Risk factors include diabetic mothers and, rarely, DiGeorge syndrome. Critical illness and cyanosis typically present within rst few hours after birth Examination reveals tachypnea, progressive hypoxemia, and extreme cyanosis If a VSD is pres- ent, a systolic murmur may be heard at the left sternal border. Diagnosis Echocardiography. CXR may show a narrow heart base, absence of the main pulmonary artery segment, an "egg-shaped silhouette," and ↑ pulmonary vascular markings. Start IV PGE1 to maintain or open the PDA. If surgery is not feasible within the rst few days of life or if the PDA can- not be maintained with prostaglandin, perform balloon atrial septostomy to create or enlarge an ASD. Surgicalcorrection(arterialoratrialswitch)isde nitive.

# newborn is cyanotic 1 hr after birth. tachycardia and tachypnea, pulse ox of 60% despite oxygen. Cyanosis. systolic ejection murmur at apex. most appropriate next step in management?

21-hydroxylase deficiency An elevated serum 17-hydroxyprogesterone level is diagn ostic of 21-hydroxylase de ciency. Fludrocortisone is appropriate for severe 21-hydroxylase de ciency. Possible surgical correction of ambiguous genitalia.

# newborn with ambiguous genitalia. no palpable gonads in inguinal canal or perineum. 46XX. 17hydroxy is increased. virilization is secondary to which enzyme deficiency?

Sensitivity Increased Specificity Decreased

# number of yes responses needed for a screening test to be considered positive is decreased to one from 2 (considered positive) effect on sensitivity and specificity?

Serum Niacin Concentration Deficiency

# numerous watery stools, skin thickened and rough, ulceration of tongue and oral mucosa, affect is blunted. what vitamin deficiency?

Pin Fixation SLIPPED CAPITAL FEMORAL EPIPHYSIS Displacement of the femoral epiphysis from the femoral neck, through the growth plate. Pre- sents in obese children ages 10-16. Associated with hypothyroidism and other endocrinopathies. Immediate surgical screw xation to reduce risk of AVN. No weight bearing should be allowed until the defect is surgically stabi- lized.

# obese 14yo boy constant dull left sided groin pain with associated limp for a week. tenderness and decreased range of motion at the left hip. increased radionuclide scan uptake in epiphyseal region. Next step in management?

Pin Fixation SLIPPED CAPITAL FEMORAL EPIPHYSIS Displacement of the femoral epiphysis from the femoral neck, through the growth plate. Pre- sents in obese children ages 10-16. Associated with hypothyroidism and other endocrinopathies. Immediate surgical screw xation to reduce risk of AVN. No weight bearing should be allowed until the defect is surgically stabilized.

# obese 14yo boy constant dull left sided groin pain with associated limp for a week. tenderness and decreased range of motion at the left hip. increased radionuclide scan uptake in epiphyseal region. Next step in management?

superficial thrombophlebitis

# older female 2 day of localized tenderness and swelling of calf, pain at rest that increases with weight bearing. smoker. superficial varicosities bilaterally. tenderness induration and erythema and thickening in a linear distribution approx 1cm wide along the medial aspect from just below the left knee to ankle. Dx?

plantar fasciitis

# pain in heel worse with exertion. Pain worst in morning when she firsts starts to walk?

Switch to insulin

# pregnant woman with uncontrolled diabetes on metformin. Most appropriate adjustment to current regimen to control her blood glucose during pregnancy?

oral acyclovir

# treatment to prevent chronic pain in a patient with shingles.

Decreased circulating Angiotensin 2 Concentration.

# mechanism of improved BP in a patient started on Lisinopril?

Specificity (true- negative rate) 100-5 = 95%

* 100 asymptomatic patients with normal exam. 81 of the patients with diagnosed pneumococcal pneumonia and 5 asymptomatic patients had positive urine ELISA test. Specificity of the new urine ELISA test for diagnosing pneumococcal pneumonia?

Allograft rejection

* 12 days post liver transplant, fever, HIGH Alk phos & AST, biopsy of liver shows mononuclear infiltrate with a significant number of eosinophils in hepatic triads.

Methotrexate Approach a woman of reproductive age presenting with abdominal pain as a ruptured ectopic pregnancy until proven otherwise. The classic triad of ectopic pregnancy PAVEs the way for diagnosis— Pain (abdominal) Amenorrhea Vaginalbleeding Ectopic pregnancy Medical treatment (methotrexate) is suf cient for small, unruptured tubal pregnancies. Surgical options include salpingectomy or salpingostomy with evacuation (laparoscopy vs laparotomy). (In Hydatidiform Mole Labs show markedly ↑ serum β-hCG (usually > 100,000 mIU/mL). Pelvic ultrasonography reveals a "snowstorm" appearance with no gesta- tional sac or fetus present)

* 12hr hx of mild right lower abdominal pain. LMP 8 weeks ago. RLQ tenderness. Slightly soft normal sized uterus and right adnexal tenderness. serum b-hCG is 2430. US shows 3cm complex right adnexal mass. No gestational sac in uterus or fluid in cut-de-sac. Most apporpitate intimal step in management?

ceftriaxone (parenteral) due to predisposition to pneumococcal sepsis

* 17month old infant with sickle cell disease. fever. rhinorrhea, cough for 3 days. daily penicillin prophylaxis and all appropriate immunizations. clear rhinorrhea. spleen palpable 2cm before costal margin. Leukocyte 18,700 segmented neutrophils 65% Lymphocytes 30% Bands 3% Monocytes 2% Pharmacology for this patient?

Amniotomy and vaginal delivery

* 18F, 37week getstation, regular uterine contraction every 3min, herpes 6 weeks ago, no lesions since then, no lesions on exam, membranes intact, fetal movement appropriate, cervix 100% effaced, 5cm dilated, vertex at -1 station. next step in management?

Blood Trace Protein 1+ RBC 0-5 WBC >50 Casts None WBC Clumps Pyelonephritis WBC casts (pyelonephritis) Pyelonephritis: Admit to hospital, IV fluids, IV third-generation cephalosporins; Suppressive antibiotics with agent culture susceptible for remainder of pregnancy and follow-up culture.

* 19yo 2 days of high grade fever, left sided back pain, pain with urination. 2-3 urinary tract infections annuan=lly during past 3 years. fever. severe left costovertebral angle tenderness. Blood? Protein? RBC? WBC? Casts? Microscopic findings?

Psychogenic Polydipsia. Primary Polydipsia: due to increased water intake that leads to dilute urine (urine osmolality <1/2 of plasma osmolality) and Hyponatremia (sodium <137). After water deprevation urine osmolality >600. Due to intact ADH and ability to concentrate urine in absence of water intake.

* 19yo generalized tonic-clonic seizure. son had excessive thirst and urination for the past 6 month. Serum sodium concentration 121, serum osmolality 250, urine osmolality 50. Dx?

Schizophrenia

* 20yoM auditory hallucinations, bizzarre behavior over past year, he feels like he is in a dream, he talk to his grandpa who dies, treated with thyroxine for hypothyroid, hyperreflexia of lower ext, mild resting tremor of upper ext, voice is monotonous, face immobile, seems anxious, stares at physical and barely answer questions. urine toe negative. All labs are normal. Diagnosis?

brief psychotic disorder Diagnosis requires at least 2 of the following, and at least 1 of these should include 1-3 (first 4 are "positive symptoms"): 1. Delusions 2. Hallucinations—often auditory 3. Disorganized speech 4. Disorganized or catatonic behavior 5. Negative symptoms (affective flattening, avolition, anhedonia, asociality, alogia) Brief psychotic disorder—lasting < 1 month, usually stress related.

* 23yoM, auditory hallucination and confusion since wife was killed 1 week ago, confused and disorganized, sad affect, preoccupied and difficulty concentrating. hears brothers voice telling him everything will be okay. Diagnosis?

IV Ampicillin and Gentamicin Listeria Meningitis

* 2hour old newborn onset of fever, mother was treated with ampicillin at time of delivery because of uterine tenderness and fever. and has a hx of genital herpes. no active lesions at time of delivery. newborn is grunting. pulse 188, RR 80, Most appropriate next step in management? Leukocyte 1400 Segmented neutrophils 50% Bands 15% Eosinophils 5% Monocytes 8%

appendicitis RLQ rebound pain Look for fever, mild leukocytosis (11,000-15,000 cells/ L) with left shift, and UA with a few RBCs and/or WBCs.

* 32yoF, 2days of V/D/Right sided pelvic pain. Fever. RR20, Pulse100, RLQ tenderness with rebound, bowel sounds decreased. right adnexal tenderness. negative pregnancy test. HIGH Leukocyte HIGH neutrophils HIGH bands LOW Lymphocytes No adnexal mass on US. Diagnosis?

Allergic bronchopulmonary aspergillosis Allergic bronchopulmonary aspergillosis (ABPA): hypersensitivity response associated with asthma and cystic fibrosis; may cause bronchiectasis and eosinophilia. Bronchiectasis: A disease caused by recurrent infection and in ammation in the bronchi/ bronchioles that lead to brosis, remodeling, and permanent dilation of bronchi Presents with chronic productive cough accompanied by frequent bouts of yellow or green sputum production, dyspnea, and possible hemoptysis and h alitosis. Associated with a history of cystic brosis (CF), pulmonary infections, hypersensitivity, immunode ciency, localized airway obstruction, aspira- tion, autoimmune disease, or IBD, but seen more closely in allergic bron- chopulmonary aspergillosis, tuberculosis, and non-tuberculous mycobac- terium such as Mycobacterium avium complex (MAC). Examination reveals rales, wheezes, rhonchi, purulent mucus, and occa- sional hemoptysis. CXR: Shows ↑ bronchovascular markings and tram lines (parallel lines out- lining dilated bronchi as a result of peribronchial in ammation and brosis). High-resolution CT (de nitive test): Dilated airways (ie, larger than pul- monary arteries) and ballooned cysts are seen at the end of the bronchus (mostly lower lobes). Medications: Antibiotics (oral and inhaled, for bacterial infections), con- sider inhaled corticosteroids. Lifestyle: Bronchopulmonary hygiene (cough control, postural drainage, chest physiotherapy). Surgery: Consider lobectomy for localized disease or lung transplantation for severe disease. EOSINOPHILIC PULMONARYSYNDROMES eosinophilic pulmonary in l- trates and abnormal peripheral blood eosinophilia. Includes allergic bronchopulmonary aspergillosis, Löf er syndrome, acute eosinophilic pneumonia, and drug-induced (eg, NSAIDs, nitrofurantoin, sulfonamides). Presents with dyspnea, cough, potentially blood-tinged sputum, and/or fever. CBC: May reveal peripheral eosinophilia. CXR:Showspulmonaryin ltrates.

* 32yoF, asthma, 3month progressive cough. cough become productive of thick yellow sputum occasionally tinged with blood. 1 month hx of SOB after walking 2 blocks. scattered end expiratory wheezes heard bilaterally with coarse bronchi at lung bases. High Serum IgE. CXR shows linear atelectasis at lung bases and thickened airways and irregular cystic opacities in central distribution. Diagnosis?

Endometrial Biopsy Endometrial biopsy should be performed: If the endometrium is ≥ 4 mm in a postmenopausal woman, or If the patient is > 35 years of age with risk factors for endometrial hyperplasia (eg, obesity, diabetes).

* 37yoF, 6month hx of irregular heavy vaginal bleeding. Physical exam and labs are normal. Obese. most appropriate next step in management?

Bromocriptine First line: Dopamine agonists (eg, cabergoline, bromocriptine). Surgery: Indicated in adenomas refractory to medical management or with compressive effects (eg, visual loss).

* 37yoF, Irregular menses, visual field shows field deficits bilaterally, milky white discharge from both breasts. serum prolactin high. MRI shows pituitary micro adenoma. next step?

IV Penicillin G

* 38week gestation admitted for spontaneous rupture of membranes 2hrs ago. moderate contractions every 5-6min, 20 weeks gestation treated with ampicillin for group B strep UTI. cervix is 2cm dilated, 80% effaced, vertex -1 station, administration of which to prevent group B strep infection in the newborn?

Closure of Ductus Arteriosus In infancy, critical coarctation of the aorta requires a patent PDA for survival. Such infants may present in the first few weeks of life with poor feeding, lethargy, tachypnea, and eventual shock like state when the PDA closes. Differential cyanosis may be seen with lower O2 saturation in the left arm and lower extremities (postductal areas) as compared to the right arm (preductal area). Echocardiography with color ow Doppler is the diagnostic test of choice. CXR in young children may demonstrate cardiomegaly and pulmonary congestion. If severe coarctation presents in infancy, the ductus arteriosus should be kept open with prostaglandin E1 (PGE1).

* 3day old 1 hr after sudden onset difficulty breathing. tachycardia, RR 84, BP 64/40 in UE and 36/20 in LE. Examination shows pale, cold extremities with mottling. Gallop heard over precordium. Cardiomegaly with pulmonary edema on CXR. Underlying mechanism for the condition?

Duplex scan

* 3days post ORIF of mineshaft femoral fracture, 63yoF has tenderness and tightness to palpation of left calf. study to confirm the diagnosis?

Placenta accreta ↑ risk of placenta accreta. Vasa previa (fetal vessels crossing the internal os). Preterm delivery, PROM, IUGR, congenital anomalies. Recurrence risk is 4-8%.

* 3owk gestation bright red vaginal spotting for 6hrs. central placentae prevue on US. in addition to counted vaginal bleeding this patient is at increased risk for which of the complications of pregnancy?

Uveitis inflammation of uvea; specific name based on location within affected eye. Anterior uveitis: iritis; posterior uveitis: choroiclitis ancl/or retinitis. May have hypopyon (accumulation ofpus in anterior chamberrJ)orconjunctivaIredness.Associated withsystemic inAammatory disorders (eg, sarcoidosis, rheumatoid arthritis, juvenile idiopathic arthritis, HLA-B27- associatecl conditions).

* 3yo G 6 week hx of intermittent progressive knee pain. pain in both knees. mild tenderness dn swelling of the knees. ESR is 55. Positive for Antinuclear Antibodies. Greatest risk for what condition during the next 2 years.

Intramuscular Epinephrine CROUP (LARYNGOTRACHEOBROCHITIS) parainfluenzavirustypes1(mostcommon), inspiratory stridor that worsens with agitation, a hoarse voice, and a characteristic barking cough (which worsens at night). AP neck lm may show the classic "steeple sign" from subglottic nar- rowing Mild cases: Outpatient management with cool mist therapy and fluids. Moderate cases: May require supplemental O2, oral or IM corticosteroids, and nebulized racemic epinephrine. Severe cases (eg, respiratory distress at rest, inspiratory stridor): Hospitalize and give nebulized racemic epinephrine; consider intubation if there is danger of airway compromise.

* 3yo, coughing & SOB, mild rhinorrhea for 2 days. drooling, difficult speaking. Edema of face and hands, supraclavicular and intercostal retractions. Inspiratory stridor and expiratory wheezes heard bilaterally. SUBGLOTTIC NARROWING. Most appropriate initial pharmacology?

blighted ovum A blighted ovum is a pregnancy where a sac and placenta grow, but a baby does not. It is also called an 'anembryonic pregnancy' as there is no embryo (developing baby). Because a blighted ovum still makes hormones, it can show up as a positive pregnancy test. A blighted ovum (also known as "anembryonic pregnancy") happens when a fertilized egg attaches itself to the uterine wall, but the embryo does not develop. Cells develop to form the pregnancy sac, but not the embryo itself.

* 42 yo F 14 weeks gestation. Closed cervix and a uterus consistent in size with 6 week gestation. Normal uterus with a gestational sac and no cardiac activity on US. Dx?

FNA biopsy

* 42yoF contender lump on right side of neck that discovered 1 month ago. 2cm mass in right pretracheal area, the mass moves when patient swallows. no LAD. studies is most likely to establish a diagnosis?

urethral diverticulum

* 42yoF, intermittent loss of small amounts of urine over past 3 weeks. only after voiding. 3cm midline cystic tender mass in mid third of the vagina. postvoid residual is 50. most likely diagnosis?

Haemophilus influenzae Small gram ⊝ (coccobacillary) rod. HaEMOPhilus causes Epiglottitis (endoscopic appearance "cherry red" in children; "thumb sign" on x-ray), Meningitis, Otitis media, and Pneumonia. Treatment: amoxicillin +/− clavulanate for mucosal infections; ceftriaxone for meningitis; rifampin prophylaxis for close contacts. Pneumonia in adults 40-65 Spneumoniae Haemophilus influenza Mycoplasma Viruses Anaerobes

* 43 yoM, 3 days of fever, chest pain, malaise, loss of appetite, cough productive of yellow phlegm and a 36hr increased SOB, smoker, pulse 112, respiratory 22, crackles and wheezes heard at left base, breath sounds decreased. increased left tactile remits and dullness to percussion at left base. Small gram negative bacilli and leukocytes on sputum. pneumonia caused be?

Fibrillation potentials in multiple muscles of multiple extremities. AMYOTROP HI C LATERAL SCLEROSIS loss of upper and lower motor neurons. Presents with asymmetric, slowly progressive weakness (over months to years) affecting the arms, legs, diaphragm, and lower cranial nerves. Some patients initially present with fasciculations (muscle twitching). Weight loss is common. Associated with UMN and/or LMN signs (see Table 2.10-9). Sensation, eye movements, and sphincter tone are generally spared. Emotional lability is a common feature. EMG/nerve conduction studies reveal widespread denervation and spontaneous action potentials (fibrillation potentials). Riluzole may delay disease pro- gression by ↓ glutamate.

* 47yo M 6month hx of progressive weakness began in his right leg, spread to other extremities, mild difficult swallowing solids and liquids, atrophy of the right quadriceps and both deltoid muscles and fasciculations in both quad muscles. Babinski present bilaterally. Electromyography and nerve conduction studies are most likely to show?

CT scan meningeal stretch signs (Kernig and Brudzinski signs), can be seen in SAH or Meningitis ALWAYS get a CT before LP to rule out increase ICP

* 47yoF, fever, nausea, vomiting, severe headache for 24hr, Fever, weakness of right upper extremity and nystagmus, kerning sign, most appropriate next steP?

no intervention is necessary

* 4yoB develops chickenpox 8 hours after visiting newborn sister in nursery. mother has a history of chickenpox prior to pregnancy. most appropriate recommendation to prevent chickenpox in the newborns?

Proliferation of hematopoietic progenitor cells Acute myelogenous and lymphocytic leukemias are clonal disorders of early hematopoietic stem cells (blasts) resulting in unregulated growth and differentiation of WBCs in bone marrow. As the bone marrow becomes overwhelmed, anemia (↓ RBCs), infection (↓ mature WBCs), and hemorrhage (↓ platelets) result. Best initial test: CBC with smear showing blast cells. Most accurate test is a bone marrow biopsy with flow cytometry to classify leukemia type. In AML, the leukemic cells are myeloblasts In general, ALL and AML are treated with chemotherapy. Patients with a leukemia subtype of unfavorable genetics may be candidates for bone marrow transplantation.

* 52yo, fever, fatigue, weakness for past 2 months. diffuse cervical LAD, liver edge is palpated 2cm below right costal margin, spleen 2cm below. Low Hematocrit Hugh Leukocyte High Myeloblast, Metamyelocyte, Myelocyte Low platelet count. Underlying mechanism?

Pleural metastases pleural effusion: Presents with dyspnea, pleuritic chest pain, and/or cough. Examination reveals dullness to percussion and ↓ breath sounds over the effusion. A pleu- ral friction rub may be present.

* 52yoF, 2 weeks of SOB with exertion, SOB when walking across room, Breast cancer 8yrs ago and had mastectomy followed by chemo. RR24. No JVD. Dullness to percussion over the lower half of the right lung, left lung clear. heart sounds normal and no peripheral edema. cause of the patients dyspnea?

Osteoarthritis Acommon,chronic,nonin ammatoryarthritisofthesynovialjoints.Charac- terized by deterioration of the articular cartilage and osteophyte bone forma- tion at the joint surfaces. Presents with crepitus, ↓ ROM, and initially pain that worsens with activity and weight bearing but improves with rest. Morning stiffness generally lasts for < 30 minutes. Stiffness is also experienced after periods of rest ("gelling"). Radiographs show joint space narrowing, osteophytes, subchondral scle- rosis, and subchondral bone cysts Physical therapy, weight reduction, and NSAIDs. Intra-articular cortico- steroid injections may provide temporary relief.

* 57yoF, increasing pain in left groin and anterior thigh over past year. Active range of motion of hip joint reproduces pain. 20 degree hip flexion contracture. Normal ESR. Most likely diagnosis?

Acute Respiratory Failure only

* 57yoM, 3hr of progressive lethargy. 5yr hx of myasthenia graves, thymectomy did not improve symptoms. smoker. Takes prednisone and azathioprine. Lethargic and difficult to arouse. Marked bilateral ptosis. Breath sounds decreased. pH 7.19 (LOW) PcO2 70 High Hco3- 25 normal

IV labetalol AORTIC DISSECTION Most commonly 2° to HTN. The most common sites of origin are above the aortic valve and distal to the left subclavian artery. Most often occurs at 40-60 years of age, with a greater frequency in males than in females. Sudden tearing/ripping pain in the anterior chest (ascend- ing) or back (descending). Examination: Patients are typically hypertensive. If hypotensive, consider pericardial tamponade, hypovolemia from blood loss, or other cardiopulmonary etiologies. Asymmetric pulses and BP measurements. A murmur of aortic regurgitation may be heard if the aortic valve is involved with a proximal dissection. Neurologic de cits may be seen if the aortic arch or spinal arteries are involved. CT angiography is the gold standard of imaging. Monitor and medically manage BP and heart rate as necessary. Avoid thrombolytics. Begin β-blockade before starting vasodilators to prevent reflex tachycardia. If the dissection involves the ascending aorta, it is a surgical emergency; descending dissections can often be managed with BP and heart rate con- trol.

* 62yoM, sudden onset severe chest pain, tearing sensation in midchest that radiates to the back. pulse 104, RR 24, BP 200/120 in RUE, 180/100 in LUE, Decreased Left brachial pulse, 2/6 diastolic decrescendo murmur at right sternal border. Widened mediastinum. Most appropriate initial step in pharmacotherapy?

exercise stress test ANGINA PECTORIS Substernal chest pain 2° to myocardial ischemia (O2 supply-and-demand mismatch). The classic triad consists of substernal chest pain that is usually precipi- tated by stress or exertion and is relieved by rest or nitrates. ECG is the best initial test for any type of chest pain. Stress testing: ST-segment or wall-motion changes with exercise or phar- macologic stress are diagnostic of CAD.

* 72 yo F has had indigestion while walking uphill or briskly, relieved after a few minutes of rest, not related to eating or relieved by antacids. Most appropriate next step in diagnosis?

Diuretic Therapy to treat CHF

* 72M, SOB for 3days, HTN & CAD, 2L of O2 via nasal canula, pulse110, resp 20, BP150/80, bilateral crackles and wheezes in all lung fields, hematocrit low, Cardiac index low, pulmonary artery occlusion pressure 28. on ABG Respiratory Alkalosis . Most appropriate step in management?

Aortic Stenosis Most often seen in the elderly. PE:Pulsus parvus et tardus(weak,delayed carotid upstroke) and a single or paradoxically split S2 sound; systolic murmur radiating to the carotids.

* 72yo M, Progressive SOB over past 4 days. JVD, Bilateral basilar crackles, Carotid upstrokes diminished, 4/6 systolic murmur is heard throughout the precordium with radiation to carotids.

Hypothyroidism

* 77yoM, progressive forgetfulness over 2 years. rarely leaves the house and no longer cares for himself. 2+ non pitting edema lower extremities. Deep tendon reflexes 1+, gait is slow. uninterested and responds to questions slowly. Mini mental exam 20/30. Low NA Alk phos HIGH AST High cause of the symptoms?

Topical Antibiotic Therapy OTITIS EXTERNA A clinical diagnosis. Obtain a culture for severe or refractory cases. Order a CT scan if the patient appears toxic. Tx: Clean the ear and give antibiotic (ofloxacin or cipro oxacin) (TOPICAL FLUOROQUINOLONES) and steroid eardrops. Add systemic antibiotics in patients with severe disease, immunode ciency, or diabetes.

* 7yo pain and itching of the right ear for 2 days. forward flexion of pinna and trigs elicits severe pain. ear canal is erythematous, tympanic membrane can't be visualized due to purulent drainage in the canal. next step in management?

acute myocardial infarction

* 82 yo F, 6 hours after onset of SOB, difficult speaking in complete sentences, DM, HTN, Smokes. Tachycardia, 85/50, JVP 4cm above sternal angle and decreases by 2cm with inspiration. crackles heard over lower third of both lungs. S3. systolic murmur at left sternal border without radiation. Pulmonary vascular congestion bilaterally on CXR. Dx?

Increase the frequency of dose to every 3hours.

* 82yoF, metastatic Breast Cancer. Severe low back pain and left thigh pain. 5mg of morphine syrup every 4hrs. it is moderately effective but loses effectiveness 2-3 hours after each dose. Otherwise tolerating the morphine without side effects. Most appropriate next step in pain management?

decreased renal blood flow resulting in AKI from CHF

* 82yoM, CHF, furosemide & lisinopril, coronary angiography and stent placement 5yrsago, 10year hx of CKD, trace edema in ankles. 1month ago vs today NA increased K increased CL increased HCO3 increased BUN increased to 24 Creatinine increased to 2.3 No abnormalities on urinalysis. most likely explanation for changes in lab values?

Finasteride Medical therapy includes α-blockers (eg, tamsulosin, terazosin), which relax smooth muscle in the prostate and bladder neck-HOWEVER due to patients Orthostatic Hypotension, can make it worse. Next. best option is 5α-reductase inhibitors (eg, finasteride), which inhibit the production of dihydrotestosterone. Transurethral resection of the prostate (TURP) or open prostatectomy is appropriate for patients with moderate to severe symptoms/complications (including renal insuf ciency, recurrent UTIs, bladder stones).

* 87yoM, 1yr hx of difficulty starting his urinary stream and occasional postvoid dribbling. Arises to void 2x nightly. BP 140/80 while supine, 100/60 while standing. Enlarged prostate. Most appropriate pharmacotherapy for this patients urinary symptoms?

Insertion of a radiopaque nasogastric tube

* 8hour old newborn regurgitates his first feed. Drools constantly. Not urinated or had a bowel movement. Most appropriate initial diagnostic procedure?

Indomethacin Acute attacks: High-dose NSAIDs (eg, indomethacin) are first line. Colchicine may also be used but is inferior to NSAIDs. Steroids are used when NSAIDs are ineffective or contraindicated, as in renal disease. Maintenance therapy: Allopurinol for overproducers, those with contraindications to proben- ecid treatment (tophi, renal stones, chronic kidney disease), and refrac- tory cases; probenecid for under-secreters. Allopurinol can ↓ the incidence of acute urate nephropathy. Weight loss and avoidance of triggers of hyperuricemia will prevent recur- rent attacks in many patients. Avoid alcohol consumption.

* Acute gout exacerbation. Celecoxib has provided no relief. most appropriate next step in pharmacotherapy?

No cleaving of C-terminal peptidse on Angiotensin 1

* After treatment with ACE inhibitor, BP decreases. Explanation?

Observation Herniation of stomach upward into the chest through the diaphragm. Three common types: Sliding hiatal hernia (95%): Gastroesophageal junction and a portion of the stomach are displaced above the diaphragm, usually asymptomatic Hx/PE: May be asymptomatic. Patients with sliding hernias may present with GERD. Dx: Incidental nding on CXR; also frequently diagnosed by barium swal- low or EGD. Slidinghernias:Medicaltherapyandlifestylemodi cationsto↓GERD symptoms.

* Asymptomatic type 1 sliding hiatal hernia. Most appropriate next step in management of the hernia?

lumbar radiculopathy (sciatica)

* Awakening with severe back pain that radiates down outer aspect of leg to the foot, increases with bending and defecation. Began after lifting her child from car seat. straight leg raise to 75degrees produces pain. Explanation for these findings?

Drain cleaner

* Child on kitchen floor surrounded by liquid that had spilled out of several bottles from under the sink. Ulceration on the lips, buccal mucosa, and pharynx. Patient most likely ingested?

Thoracoabdominal Aortic Dissection Sudden tearing/ripping pain in the anterior chest (ascend- ing) or back (descending). Most commonly 2° to HTN. 40-60 years of age, with a greater frequency in males. CT angiography is the gold standard of imaging. Begin β-blockade before starting vasodilators to prevent re extachycardia.

* Elderly Man EM after constant severe back pain. most severe at tip of left scapula and extends to the left costovertebral angle. Had consumed several bottles of beer earlier. Tachycardia, tachypnea, HTN, femoral pulses decreased. High leukocyte count, 8-10RBC on urinalysis, Sinus tachycardia and 1mm ST elevation, and left axis deviation on ECG. Nitroglycerine doesn't resolve the pain. IV morphine and labetalol are administered. 15min later pulse and BP improve. Pain is also decreased. Diagnosis?

Heparin therapy DVT unilateral lower extremity pain and swelling. Homans sign is calf tenderness with passive foot dorsi exion (poor sensi- tivityandspeci cityforDVT). Diagnosis Doppler ultrasound; a spiral CT or V/Q scan may be used to evaluate for PE Tr e a Tm e n T Anticoagulate with IV unfractionated heparin or subcutaneous low- molecular-weight heparin (LMWH) followed by PO warfarin for a total of 3-6 months.

* Elderly female EM 2 hours after sudden onset of constant pain in left foot. Irregularly irregular HR. left foot is cold. dorsals pedis and posterior tibial pulses are absent on the left. femoral pulses are present bilaterally. Next step in management?

Cephalosporin (Parenteral; Cefazolin) Use of prophylactic antibiotics has been shown to reduce the risk of infection. For most patients, current guidelines recommend cefazolin or cefuroxime administered IV within 60 minutes of skin incision as prophylaxis during hip or knee arthroplasty. Prophylaxis should be discontinued within 24 hours of the procedure.

* Elderly going to have total knee replacement. He has RA treated with prednisone. Most appropriate management regarding prophylactic antibiotic therapy?

Interferon alpha IFN-α: chronic hepatitis B and C, Kaposi sarcoma, hairy cell leukemia, condyloma acuminatum, renal cell carcinoma, malignant melanoma. Mixed cryoglobulinemia presents with palpable purpura, arthralgias, nephritic/ nephrotic syndrome, low C3, and positive HCV. Chronic HCV infection: Medications and treatment duration vary based on genotype, cirrhosis status, and history of prior treatment. Typically either two direct-acting antivirals (DAAs) or one DAA plus ribavirin. Interferon is still used occasionally today.

* Hep C Virus RNA + Antibody to Hep C + Cryoglobulins + A biopsy specimen of skin lesion shows cryoglobulins and is consistent with essential mixed cryoglobulinemia..Most appropriate pharmacotherapy?

US to confirm Gestational age Elevated MSAFP (> 2.5 MoMs) is associated with: Open-neural tube defects (anencephaly, spina bi da). Abdominal wall defects (gastroschisis, omphalocele). Multiple gestation. Incorrect gestational dating. Fetal death. Placental abnormalities (eg, placental abruption). Reduced MSAFP (< 0.5 MoM) is associated with: Trisomy 21 and 18. Fetal demise. Incorrect gestational dating.

* MSAFP concentration is 2.8 multiples of the median based on her LMP 18 weeks prior. Most appropriate next step in management?

bilateral varicoceles

* Man unable to conceive, ILL DEFINED SOFT MASSES palpated bilaterally, high in the scrotum, most likely cause of the masses?

Radiation Therapy

* Mastectomy for treatment of breast cancer which was lymph node positive 6months ago. Now has severe upper back pain, weakness of both legs, tingling in legs and feet, with urinary incontinence. Next step in management?

Toxin induced inflammation of the colonic mucosa

* Mechanism of diarrhea in a patient with C. Diff?

Streptococcus Pneumoniae

* Patient with Multiple Myeloma is most susceptible to infection with?

Topical Mupirocin IMPETIGO Local infection of the epidermis that primarily occurs in children and is caused by both group A streptococcal and staphylococcal organisms. It is transmitted by direct contact. Streptococcal impetigo can be complicated by acute streptococcal glomerulonephritis. Pustules and honey-colored crusts on an erythematous base, often on the face around the mouth, nose, or ears Mild localized disease: Topical antibiotics (mupirocin) are suf cient. Severe disease (non-MRSA): Oral cephalexin, dicloxacillin, or erythro- mycin. Severe disease (MRSA likely): Oral trimethoprim-sulfamethoxazole, clindamycin, or doxycycline.

* Rash on the face of a 7yo G. Appropriate initial therapy?

Colonoscopy to the cecum Colorectal Cancer Rectal lesions: Usually present with bright-red blood per rectum, often with tenesmus and/or rectal pain. Rectal cancer must be ruled out in all patients with rectal bleeding. De nitivediagnosis:Colonoscopywithbiopsy. Evaluate for metastases: CXR, LFTs, and an abdominal/pelvic CT. Staging is based on the depth of tumor penetration into the bowel wall and the presence of lymph node involvement and distant metastases. Surgical resection of the tumor is rst-line treatment. Adjuvant chemotherapy is appropriate in cases with Follow with serial CEA levels to detect recurrence, colonoscopy, LFTs, CXR, and abdominal CT to screen for metastases.

* Rectal Adenocarcinoma. Most appropriate next step in management?

Randomized, controlled clinical trial RANDOMIZED CONTROLLED TRIALS An experimental, prospective study in which subjects are randomly assigned to a treatment or control group. Random assignment helps remove confounding and ensure that the two groups are truly comparable. The con- trol group may be treated with a placebo or with the accepted standard of care. The study can be masked in one of two ways: single blinded, in which patients do not know which treatment group they are in, or double blinded, in which neither the patients nor their physicians know who is in which group. Double-blinded studies are the gold standard for studying treatment effects Advantages of RC T s are as follows (see also T able 2.4-1): Minimize bias. Have the potential to demonstrate causal relationships, because expo- sure is assigned randomly, which minimizes confounding. Disadvantages include the following: Costly and time intensive. Some interventions (eg, surgery) are not amenable to masking.

* Review of which type of clinical study is likely to be most useful in developing treatment strategy for this patient who on colonoscopy has a large ulcerating rectal mass consistent with rectal cancer.

95% probability that the difference between the two cure rates is between 8% and 26%

* Study determined that 95% CI for the difference is between 8 and 26. with a statistical significance of p=0.0002 accurate interpretation of these results?

Pneumococcal vaccine

* asymp 27yo HIV+, all childhood immunizations are up to date. MMR 4 years ago. last tetanus 6yrs ago. HepB Ab +, CD4 450. Immunization most appropriate to administer?

exposure to high decibel sound (meningitis can cause sensorineural hearing loss)

* child with decreased hearing at high frequencies bilaterally. viral meningitis at age 2. Multiple ear infections from 1-3yo. last physical exam 3 years ago was normal. occasional ear pain after snorkeling. He constantly wear headphones and cannot hear her when she speaks to him. most likely cause?

Restrict intake of phosphorus

* chronic renal failure secondary to glomerulonephritis. HTN controlled with ACEi. mild edemas of lower extremities. most appropriate recommendation to minimize complication of renal failure?

Diverticulitis LLQ pain, Fever, Nausea/Vomit, Leukocytosis, urinary urgency and frequency, dysuria due to bladder irritation from inflamed sigmoid colon. On CT: Increased inflammation in pericolic fat, Diverticula, Bowel wall thickening, Soft tissue masses (phlegmons), Pericolic fluid collection suggesting abscess. In diverticulitis, CT scan (used to diagnose) may reveal in ammation or abscess Complications: abscess, fistula (colovesical fistula - pneumaturia), obstruction (inAammatory stenosis), perforation (white arrows in [!t) (- peritonitis). Treat with bowel rest (NPO), NG tube placement (if severe), and broad-spectrum antibiotics (metronidazole and a uoroqui- nolone or a second- or third-generation cephalosporin), colonoscopy after initial stage.

* elderly woman, lower abdominal pain and fullness for 1 week and burning on urination and pneumaturia for 1 day. hysterectomy 10 years ago. tender mass in LLQ of abdomen. Cause of symptoms?

Physiologic Discharge.

* healthy 40F, few drops of yellow discharge from left nipple while performing a self breast exam. Fluid can be expressed when squeezes her nipples but no spontaneous discharge. No masses, mammography no masses or calcifications.

reasurance Menopause: Hormone replacement therapy (HRT; combination estrogen and pro- gestin): If moderate to severe vasomotor symptoms SHORT-term therapy. May ↑ the incidence of breast cancer. May ↑ cardiovascular morbidity and mortality. Contraindications: Vaginal bleeding, breast cancer (known or sus- pected), untreated endometrial cancer, a history of thromboembolism, chronic liver disease, and hypertriglyceridemia. Non-HRT: SSRI/SNRIs, clonidine, and/or gabapentin to ↓ the frequency of hot ashes. Topical estrogen preparation: For vaginal atrophy. Does NOT have the same contraindications as systemic HRT. Supplements ± bisphosphonates: For osteoporosis. DEXA scan is used to measure bone mineral density (BMD). Supplemental treatment includes daily calcium/vitamin D and weight-bearing exercise.

* healthy 52yoF, irregular menses during past year. no breakthrough bleeding. lubricant for vaginal dryness. most appropriate next step?

Abnormal pressure distribution caused by sensory neuropathy.

* hx of DM, painless lesion on foot. peripheral pulses are decreased bilaterally. no ankle reflexes. sensation to pain and touch is absent in lower extremities, up to the knee. Cause of the lesion?

Peripheral muscarinic receptors. Often due to organophosphates (eg, parathion) that irreversibly inhibit AChE. Organophosphates commonly used as insecticides; poisoning usually seen in farmers. Muscarinic effects: D iarrhea, Urination, M iosis, Bronchospasm, Bradycardia, E mesis, Lacrimation, Sweating, Sa livation. Reversed by atropine, a competitive inhibitor. Atrop ine can cross BBB to relieve CNS symptoms. Nicotinic Effects: Neuromuscular blockade (mechanism similar to succinylcho line). Reversed by pralidoxime, regenerates AChE if given early. Pra lidoxime (quaternary amine) does not read ily cross BBB. CNS effects: Respiratorydepression, lethargy,seizures, coma.

* ingestion of organophosphate insecticide. vomit, diarrhea, copious oral secretions. Receptor site responsible for clinical manifestations?

Chemotherapy

* mass involving left upper and lower lobe of lung, biopsy shows uniform small round cells with darkly staining nuclei. Most appropriate initial treatment?

NO treatment necessary

* needle stick with HepB+ patient. Physican who was stuck is vaccinated against HepB. Lab show adequate concentration of antiHepB antibodies. Most appropriate management to prevent HepB infection in the physician?

Gonadal Dysgenesis 45XO (Turner syndrome) lymphedema of the hands and feet in the neonatal period lymphatic defects (result in webbed neck or cystic hygroma; lymphedema in feet, hands),

* newborn female 2/6 systolic murmur best heard over the mid back. redundant skin at nape of the neck, edema of the dorsal of the hands and feet. Dx?

diabetes insipidus (DI) DI is a result of ADH dysfunction, whereas SIADH is Euvolemic Hyponatremia Central DI (ADH de ciency): The posterior pituitary fails to secrete ADH. Causes include tumor, ischemia (Sheehan syndrome), pituitary hemorrhage, traumatic brain injury, infection, metastatic disease, and autoimmune disorders

* one day after remove of meningioma, 42 yo F comatose, remains intubated. receives 2L of 0.9% saline and urine output of 6L. Explanation for Hypernatremia? Serum Na: 155 Urine Specific Gravity: 1.004

mitral valve prolapse predispose to infective endocarditis

* precordial heave. gallop and grade3/6 holosystolic murmur in 4th intercostal space at midclavicular line. Strep progenies Group A infection. Antistreptolysin O titer increased. most likely explanation of cardiac finding?

complete AV block

* pregnant mom has SLE. fetus is at greatest risk of?

Cutaneous larva migrans Cutaneous larva migrans—pruritic, serpiginous rash from walking barefoot on contaminated beach

* pruritic rash on back for 4 days. employed as a plumber has to move around on his back under houses. multiple erythematous serpiginous tracks on back that are 2-10cm in length. Leukocyte count 10,000 (15% eosinophils). Stool for ova and parasite is negative. Most likely diagnosis?

Adverse effect of Haloperidol oculogyric crisis prolonged involuntary upward deviation of the eyes due to ACUTE DYSTONIA (Neuroleptic Malignant Syndrome would have Fever with the muscle rigidity, with abnormal vital signs and sweating)

* schizophrenia brought to EM unable to see anything for past 3hours. on a car trip for past 6days, last night heard voices so stopped at an EM where he got haloperidol and was released 1 hour later. regularly scheduled medication is IM Fluphenazine every 3weeks. 98.8, pulse 88, BP 142/78. Lying on stretcher, moaning with upper extremities held rigidity to his side. eyes roasted superiorly, neck is rigid. Most likely cause of visual problems?

Migraine Prophylaxis: -Gabapentin, Topiramate -TCA (Amitriptyline or venlafaxine) -Beta Blocker (propranolol) -CCB Abortive: Triptans after OTC NSAID failed

* severe throbbing headaches associated with nausea, vomiting, photophobia. Most appropriate prophylaxis?

Subclavian artery

* single entrance stab wound at base of left side of the neck. tachycardia, dec respiration, Hypotensive, breath sounds decreased on left. Obvious tense pulsatile hematoma. Location of cardiovascular injury?

Atrial Fibrillation Tx: Rate Control, Rhythm Control, Anticoagulation (reduce risk of stroke) Rate Control: Beta Blockers (Metropolol, Esmolol), NonDihydropyridine CCB (Diltiazem, Verapamil)

-Absent P waves -Irregularly irregular QRS

1. Down Syndrome (Trisomy 21) 2. Trisomy 18

1. LOW MSAFP, LOW Estriol, HIGH b-HCG, HIGH Inhibin A 2. LOW MSAFP, LOW Estriol, LOW b-HCG, Normal Inhibin A

Hodgkin's lymphoma Reed-Sternberg cells (large multinucleate lymphocytes) characteristic. 15-19yo prolonged fever, night sweats, weight loss, painless firm LAD. Large supraclavicualr node highly suspicious of malignancy. mediastinal mass on CXR, lead to compressive symptoms (dysphagia, dyspnea) Lymph node biopsy is diagnostic. excellent prognosis with combination chemo

16yoB, intermittent fevers, daily spikes to 100.6, swelling above his right collarbone enlarged to size of a quarter. multiple small right anterior cervical lymph nodes. right supraclavicular fossa has a solitary from 2.5cm palpable lymph node. Biopsy as shown. Dx?

carotid duplex ultrasound AMAUROSIS FUGAX: Painless, rapid, transient (<10 min) monocular vision loss. Curtain descending over the visual field is high;y suggestive of diagnosis. Most common etiology is retinal ischemia due to atherosclerotic emboli originating from the ipsilateral carotid artery. Therefore patients with vascualr risk factors (Hypertension, Hyperlipidemia, smoking) should be evaluated with a duplex Ultrasound of the neck. See embolic plaques and retinal whitening (due to ischemia) on fundoscopic exam. These patientsd have an increased risk of stroke.

2 days after an episode of blindness in one eye that lasted 15min, vision loss began at top and gradually involved entire visual field. Most appropriate next step in diagnosis?

increased Calcium Sarcoidosis Hx: Can present with fever, cough, malaise, weight loss, dyspnea, and arthritis. Examination: Lungs, liver, eyes, skin (erythema nodosum, violaceous skin plaques), nervous system, heart, and kidney may be affected. CXR/CT (initial test): Radiographic ndings of lymphadenopathy and nodules are used to stage the disease. Biopsy (de nitive test): Lymph node biopsy or transbronchial/video- assisted thoracoscopic lung biopsy reveals noncaseating granulomas. PFTs: Restrictive or obstructive pattern and ↓ diffusion capacity. Other ndings: ↑ serum ACE levels (neither sensitive nor speci c), hypercalcemia, hypercalciuria, ↑ alkaline phosphatase (with liver involve- ment), lymphopenia, cranial nerve defects, arrhythmias. Systemic corticosteroids are indicated for deteriorating respiratory function, constitutional symptoms, hypercalcemia, or extrathoracic organ involvement.

26yoM, SOB, painful bumps on legs, fever, 2-3cm tender red nodules on anterior shins, CXR bilateral hilarity fullness. Serum abnormality?

Small Bowel Obstruction strictures due to crohns

27yoF, 5 days of headache, severe, diffuse abdominal pain, and nausea and vomiting, exacerbated by eating relieved by vomiting. vomit is large amounts of semisolid material mixed with clear green liquid not clear yellow. Crohns dz. fever, tachycardia, hypotensive. dry oral mucosa and pale conjunctivae, abdomen distended, diffusely tender, tympanic. bowel sounds are decreased. Diagnosis?

Legionella pneumonia tx with Levofloxacin (fluoroquinolone) or azithromycin (Macrolide) Aerobic Gram - Bacillus fever with BRADYCARDIA

45 yo M fever, mildly productive cough, headache, lethargy, abdominal cramps, watery diarrhea. reduced breath sounds and crackles in the right base of chest. Elevation of segmented neutrophils with band forms.

Unicameral bone cyst

<20, X-ray shows full thickness lytic bone lesion with well defined borders and surrounding reactive sclerosis

Lennox-Gastaut syndrome

<7yo, wide array of seizure types + mental retardation

Neissera meningitidis Ceftriaxone + Vancomycin

>1month old with meningitis and petechial rash on extremities

could be endocervical or endometrium. Therefore require colposcopy, endocervical curettage and endometrial biopsy. Atypical endometrial hyperplasia on biopsy is a precursor to endometrial cancer. Due to prolonged unopposed estrogen exposure from obesity and chronic anovulation (PCOS). As anovulatory patients don't have progesterone therefore unable to decrease endometrial proliferation and estrogen goes unopposed. In obese patients high estrogen levels from peripheral conversion of androgens to estrogens. Other risk factors = Nulliparity, Early Menarche, Late Menopause, Tamoxifen therapy. All of which increase uterine estrogen exposure.

>35yo with atypical glandular cells on pap

COPD diagnosed with Spirometry FEV1/FVC <0.7 severe COPD may lead to pulmonary HTN resulting in RV hypertrophy and S4

>40, hx of smoking, chronic cough (sputum production), progressive dyspnea on exertion. Diagnosed based on?

polymyalgia rheumatica associated with Giant cell temporal arteritis inflammatory markers are elevated

>50, acute or subacute pain, stiffness of the shoulders and pelvic girdle. focal tenderness.

Clinical features of Alzheimer Disease

>65yo death within 10 yrs of diagnosis

Decreased gluconeogenesis Von Gierke disease (type I) Severe fasting hypoglycemia, high Glycogen in liver, high blood lactate, high triglycerides, high uric acid (Gout), and hepatomegaly.

A 2-month-old boy is brought to the physician because of a 6-week history of persistent diarrhea and vomiting, most pronounced after formula feedings. He has had a 113-g (4-oz) weight loss since birth. He currently weighs 3100 g (6 lb 13 oz) and is 51 cm (20 in) in length. He appears irritable. Examination shows jaundice. The lungs are clear to auscultation. No murmurs are heard. The liver is palpated 2 to 3 cm below the right costal margin, and the spleen is palpated 1 to 2 cm below the left costal margin. Laboratory studies show: Glucose 35 Total Bili 2.3 Urine Glucose NEGATIVE Reducing substances in urine 3+

Tetralogy of Fallot

A 2-week-old newborn is brought to the physician because his lips have turned blue on three occasions during feeding; he also sweats during feeding. He was born at 38 weeks' gestation and weighed 2466 g (5 lb 7 oz); he currently weighs 2778 g (6 lb 2 oz). His temperature is 37.8°C (100°F), pulse is 170/min, respirations are 44/min, and blood pressure is 75/45 mm Hg. A grade 3/6 harsh systolic ejection murmur is heard at the left upper sternal border. An x-ray of the chest shows a small boot-shaped heart and decreased pulmonary vascular markings. Which of the following is the most likely diagnosis?

Heroin

A 25-year-old man is brought to the emergency department after being discovered semiconscious and incoherent at home. On arrival, he is stuporous. His blood pressure is 105/70 mm Hg, pulse is 80/min, and respirations are 12/min. Examination shows cool, damp skin. The pupils are pinpoint and react sluggishly to light. Which of the following is the most likely substance taken?

Measurement of serum insulin and C-peptide concentrations INSULINOMA umor of pancreatic β cellsoverproduction of insulinhypoglycemia. May see Whipple triad: low blood glucose, symptoms of hypoglycemia (eg, lethargy, syncope, diplopia), and resolution of symptoms after normalization of glucose levels. Symptomatic patients haveblood glucose and C-peptide levels (vs exogenous insulin use). ∼ 10% of cases associated with MEN 1 syndrome. Treatment: surgical resection.

A 27-year-old nurse comes to the emergency department because of nervousness, dizziness, palpitations, and excess perspiration for the past 3 hours. She has had similar episodes over the past 6 months. The symptoms improve following ingestion of orange juice or soft drinks. She says that she has had a great deal of stress. She has been drinking two alcoholic beverages daily for the past month; before this time, she seldom drank alcohol. Examination shows no abnormalities. Her serum glucose concentration is 30 mg/dL. Intravenous glucose is administered, and the patient's symptoms improve. Which of the following is the most appropriate next step in diagnosis?

Nortriptyline

A 27-year-old woman comes to the physician because of a 3-year history of chronic diarrhea and intermittent, crampy, lower abdominal pain. The pain is usually relieved with defecation and does not occur at night or interfere with sleep. She says she is frustrated by her symptoms and has stopped traveling because of her frequent, urgent need to use the bathroom. She has no history of serious illness and takes no medications. Her temperature is 37°C (98.6°F), pulse is 70/min, respirations are 14/min, and blood pressure is 120/80 mm Hg. The lower abdomen is mildly tender to palpation; there is no rebound tenderness or guarding. The remainder of the examination shows no abnormalities. Results of laboratory studies are within the reference ranges. Test of the stool for occult blood is negative. Antigliadin antibodies are not present. Which of the following is the most appropriate pharmacotherapy?

Axillary-subclavian venous thrombosis

A 32-year-old man who is a jackhammer operator comes to the physician because of pain and swelling of his right arm for 3 days. The symptoms are moderately exacerbated by exertion. Examination of the right upper extremity shows erythema and moderate edema. Capillary refill time is less than 3 seconds. Which of the following is the most likely diagnosis?

Meniere's disease

A 35-year-old woman comes to the physician because of two 12-hour episodes of dizziness over the past 3 months. During episodes, she experiences the acute onset of rotatory vertigo and imbalance, decreased hearing, tinnitus, a sense of fullness of the right ear, and vomiting. Examination shows a mild hearing loss of the right ear. Which of the following is the most likely diagnosis?

Streptococcus pneumoniae Acute sinusitis (symptoms lasting < 1 month): Most commonly associated with viruses, S pneumoniae, H influenzae, and M catarrhalis. Bacterial causes are rare and characterized by purulent nasal discharge, facial or tooth tenderness, hyposmia/anosmia, and symptoms lasting > 10 days. Chronic sinusitis (symptoms persisting > 3 months): A chronic inflammatory process often due to obstruction of sinus drainage and ongoing low-grade anaerobic infections. Most cases of acute sinusitis are viral and/or self-limited and are treated with symptomatic therapy (decongestants, antihistamines, nasal saline lavage, pain relief). Acute bacterial sinusitis: Consider amoxicillin/clavulanate for 10 days or clarithromycin, azithromycin, trimethoprim-sulfamethoxazole (TMP- SMX), a fluoroquinolone, or a second-generation cephalosporin for 10 days. Chronic sinusitis: Antibiotics are similar to those used for acute disease, although a longer course (3-6 weeks) may be necessary. Adjuvant therapy with intranasal corticosteroids, decongestants, and antihistamines may be useful in combating the allergic/in ammatory component of the disease. Surgical intervention may be required.

A 37-year-old woman comes to the physician because of a 1-day history of throbbing facial pain. She describes the pain as 7 out of 10 in intensity. Over the past 9 days, she has had nasal congestion, purulent nasal discharge, sore throat, and a nonproductive cough. She does not smoke. Her husband and children have had no recent illness. Her temperature is 38.5°C (101.3°F). Examination shows congested nasal mucosa and purulent discharge on the left. There is tenderness to palpation over the left cheek and no transillumination over the left maxillary sinus. The tympanic membranes are normal, and there is no erythema of the throat. Examination shows no cervical adenopathy. The lungs are clear to auscultation. Which of the following is the most likely causal organism?

placenta previa

A 37-year-old woman, gravida 5, para 4, at 34 weeks' gestation comes to the emergency department because of vaginal bleeding for 2 hours. She has had no prenatal care. Her second child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate; her other three children were delivered vaginally. Her pulse is 92/min, respirations are 18/min, and blood pressure is 134/76 mm Hg. The abdomen is nontender, and no contractions are felt. There is blood on the vulva, the introitus, and on the medial aspect of each thigh. The fetus is in a transverse lie presentation. The fetal heart rate is 144/min. Which of the following is the most likely diagnosis?

Intravenous immune globulin Kawasaki Disease High-dose ASA (for antiin ammatory, antipyretic, and antithrombotic effects) and IVIG (to prevent coronary artery aneurysms).

A 4-year-old boy is brought to the physician because of temperatures to 39.4°C (102.9°F) for 8 days. Examination shows anterior cervical lymphadenopathy, nonexudative conjunctivitis bilaterally, a strawberry tongue, an erythematous truncal rash, and edema of the hands and feet. Which of the following is the most appropriate pharmacotherapy to prevent complications of this illness?

CMV Begin ganciclovir therapy

A 42-year-old man comes to the physician because of malaise, muscle and joint pain, and temperatures to 38.4°C (101.1°F) for 3 days. Three months ago, he underwent cadaveric renal transplantation resulting in immediate kidney function. At the time of discharge, his serum creatinine concentration was 0.8 mg/dL. He is receiving cyclosporine and corticosteroids. Examination shows no abnormalities. His leukocyte count is 2700/mm3, and serum creatinine concentration is 1.6 mg/dL; serum cyclosporine concentration is in the therapeutic range. A biopsy of the transplanted kidney shows intracellular inclusion bodies. Which of the following is the most appropriate next step in management?

Subarachnoid hemorrhage ruptured saccular aneurysms (berry aneurysms), arteriovenous malformation (AVM), and trauma to the circle of Willis. brupt-onset, intensely painful "thun- derclap" headache, often followed by neck stiffness (due to meningeal irritation). "theworstheadacheo my lie"with sudden onset.Migraine = a gradually worsening headache (peak intensity > 30 minutes). Immediate head CT without contrast LP if CT is - to look for RBCs, xanthochromia (yellowish CSF due to breakdown of RBCs), ↑ protein (from the RBCs), and ↑ ICP. Neurosurgery for definitive treatment! May perform angiographic coiling and/or stenting to stabilize aneurysm. Prevent rebleeding (most likely to occur in the rst 24 hours) by main- taining systolic BP < 150 mm Hg until the aneurysm has been clipped or coiled. Prevent vasospasm and subsequent ischemic stroke (most likely to occur 4-10 days after SAH) by administering calcium channel blockers (CCBs), such as nimodipine. Vasospasm is a major cause of delayed morbidity and mortality in patients with SAH. ↓ ICP by raising the head of the bed and instituting hyperventilation in an acute setting (< 30 minutes after onset). Treat hydrocephalus through a lumbar drain, serial LPs, or ventriculo- peritoneal shunt.

A 47-year-old man comes to the physician 12 hours after the sudden onset of a severe occipital headache and stiff neck. He has not had any other symptoms and has no history of severe headache. He has hypertension and gastroesophageal reflux disease. Current medications include hydrochlorothiazide and ranitidine. He is oriented to person, place, and time. His temperature is 36.7°C (98.1°F), pulse is 100/min, and blood pressure is 160/90 mm Hg. Range of motion of the neck is decreased due to pain. Neurologic examination shows no focal findings. Which of the following is the most likely diagnosis?

Aortic dissection Sudden tearing/ripping pain in the anterior chest (ascend- ing) or back (descending). Asymmetric pulses and BP measurements. murmur of aortic regurgitation CT angiography is the gold standard of imaging. Monitor and medically manage BP and heart rate as necessary. Avoid thrombolytics. Begin β-blockade before starting vasodilators to prevent re extachycardia.

A 47-year-old man is brought to the emergency department 2 hours after the sudden onset of shortness of breath, severe chest pain, and sweating. He has no history of similar symptoms. He has hypertension treated with hydrochlorothiazide. He has smoked one pack of cigarettes daily for 30 years. His pulse is 110/min, respirations are 24/min, and blood pressure is 110/50 mm Hg. A grade 3/6, diastolic blowing murmur is heard over the left sternal border and radiates to the right sternal border. Femoral pulses are decreased bilaterally. An ECG shows left ventricular hypertrophy. Which of the following is the most likely diagnosis?

CT scan of the abdomen with contrast

A 52-year-old woman comes to the emergency department because of a 1-week history of low-grade fever and increasing abdominal cramps that are exacerbated by bowel movements. She began a course of amoxicillin-clavulanate and metronidazole 2 days ago but has had no relief of her symptoms. She has had intermittent constipation for the past 12 years. She has not had nausea, vomiting, urinary symptoms, or bloody stools. She has a 3-year history of hypertension. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy 5 years ago because of leiomyomata uteri. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb); BMI is 32 kg/m2. Her temperature is 38.1°C (100.6°F), pulse is 75/min, and blood pressure is 150/80 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft, and there is tenderness to palpation of the left lower quadrant with guarding but no rebound. Bowel sounds are normal. The stool is brown, and test for occult blood is negative. Her hemoglobin concentration is 14.5 g/dL, leukocyte count is 15,000/mm3, and platelet count is 280,000/mm3; serum studies and urinalysis show no abnormalities. Which of the following is the most appropriate next step in diagnosis?

Herpes zoster Herpes zoster (shingles) represents the recurrence of VZV in a speci c nerve, with lesions cropping up along the nerve's dermatomal distribu- tion. Outbreaks are usually preceded by intense local pain followed by grouped blisters on an erythematous base (see Figure 2.2-16). Zoster can become disseminated in immunocompromised persons. Older patients with zoster can develop postherpetic neuralgia (severe nerve pain that persists for months at the infection site).

A 56-year-old man has had the painful weeping rash shown for 2 days. He underwent chemotherapy for non-Hodgkin lymphoma 1 year ago. His temperature is 36.7°C (98°F), pulse is 80/min, and blood pressure is 138/76 mm Hg. Examination shows no other abnormalities. Which of the following is the most likely diagnosis?

Toxic epidermal necrolysis

A 60-year-old man has had painful skin with exfoliation of the skin and mucous membranes for 1 day. He has been taking allopurinol and probenecid for 2 weeks because of gouty arthritis. There is diffuse exfoliation of the skin with oozing of serous fluid. The mucous membranes of the mouth are erythematous and exfoliated. There are no target lesions. Which of the following is the most likely diagnosis?

Phlebotomy A state of iron overload in which hemosiderin accumulates in the liver, pancreas (islet cells), heart, adrenals, testes, and pituitary. 1° hemochromatosis: An autosomal recessive disease characterized by mutations in the HFE gene that result in excessive absorption of dietary iron. Hx: Patients may present with abdominal pain, DM, hypogonadism, arthropathy of the MCP joints, heart failure, impotence, or cirrhosis. Examination: Bronze skin pigmentation, cardiac dysfunction (CHF), hepatomegaly, and testicular atrophy. Labs may reveal evidence of DM. ↑ serum iron, percent saturation of iron, and ferritin with ↓ serum transferrin. A transferrin saturation (serum iron divided by TIBC) > 45% is highly sug- gestive of iron overload. Perform a liver biopsy (to determine hepatic iron index), MRI, or HFE gene mutation screen. Tr e a Tm e n T Weekly phlebotomy to normalize serum iron levels, and then mainte- nance phlebotomy every 2-4 months. Iron chelating agents such as deferoxamine, deferiprone, or deferasirox can be used for maintenance therapy. ComPliCaTions Cirrhosis, hepatocellular carcinoma, restrictive cardiomyopathy, arrhyth- mias, DM, impotence, arthropathy, hypopituitarism.

A 62-year-old white man comes to the physician because of an 8-month history of progressive pain and stiffness of his hands. The stiffness is worse at the end of the day. He has a 1-year history of fatigue and increased urination. He has no history of serious illness and takes no medications. His last visit to a physician was 10 years ago. He does not smoke or drink alcohol. He is 185 cm (6 ft 1 in) tall and weighs 82 kg (180 lb); BMI is 24 kg/m2. His pulse is 84/min, and blood pressure is 136/82 mm Hg. Examination shows dark brown skin. S1 and S2 are normal. An S3 is heard at the apex. There is mild tenderness over the second and third metacarpophalangeal joints bilaterally without synovial thickening. Heberden nodes are present over the distal interphalangeal joints of the index and ring fingers bilaterally. Laboratory studies show: Hemoglobin 16 g/dL Leukocyte count 7700/mm3 Platelet count 332,000/mm3 Serum Glucose 182 mg/dL Albumin 3.4 g/dL Total bilirubin 1.1 mg/dL Alkaline phosphatase 52 U/L AST 55 U/L ALT 68 U/L Hepatitis B surface antigen -Hepatitis C antibody - Rheumatoid factor - Which of the following is most likely to have prevented this patient's condition?

Adjusting her medication regimen

A 67-year-old woman comes to the physician because of dizziness for 6 weeks. When she stands up suddenly, she becomes light-headed and has to steady herself for approximately 1 to 2 minutes before she is able to walk. She has hypertension and type 2 diabetes mellitus. Current medications include glyburide, a diuretic, a β-adrenergic blocking agent, and an angiotensin- converting enzyme (ACE) inhibitor. Her pulse is 55/min. Her blood pressure is 110/70 mm Hg in the right arm and 70/50 mm Hg in the left arm while supine; her blood pressure is 70/50 mm Hg in the right arm and 50/30 mm Hg in the left arm immediately after standing. Neurologic examination shows no focal findings. An ECG shows sinus bradycardia with no evidence of ischemia. Carotid duplex ultrasonography shows reverse flow in the left vertebral artery with no evidence of occlusion. Which of the following is the most appropriate next step in management?

Dermatomyositis

A 9-year-old boy is brought to the physician because of progressive weakness and a purple-red discoloration over his cheeks and upper eyelids over the past 8 weeks. His symptoms began shortly after a camping trip, and he now is unable to climb stairs, walk long distances, comb his hair, or dress himself. His mother says that she was careful to apply his sunscreen on the trip and can recall no tick bites or exposure to poisonous plants. His only medication is a topical corticosteroid for several dry, scaly patches of the skin. He appears weak and lethargic. He is at the 75th percentile for height and 25th percentile for weight; he has had no change in his weight since his last examination 9 months ago. His temperature is 37.7°C (99.8°F), blood pressure is 110/68 mm Hg, pulse is 105/min, and respirations are 28/min. Examination of the skin shows a purple-red discoloration over the cheeks and eyelids, periorbital edema, erythematous plaques and scales over the elbows and knees, and flat-topped red papules over all knuckles. There is generalized weakness and atrophy of the proximal muscles. Which of the following is the most likely diagnosis?

Selection bias Selection bias: Occurs when samples or participants are selected that dif- fer from other groups in additional determinants of outcome. Example: Individuals concerned about a family history of breast cancer may be more likely to self-select in entering a mammography program, giving the impression of a prevalence that is higher than it is in reality.

A cohort study is conducted to compare the incidence of adverse effects of a recently approved antihypertensive pharmacotherapy with that of conventional therapy. A total of 20,000 patients are enrolled. Twelve thousand are prescribed the recently approved therapy, and 8,000 are prescribed conventional therapy. Patients in the study and control groups are matched for baseline blood pressure, age, and gender. Data are collected from the records of the patients' ongoing clinical care. Results show that those receiving the newly approved treatment have twice the incidence of fatigue compared with those receiving the conventional treatment. The results are statistically significant (p=0.01). Which of the following potential flaws is most likely to invalidate this study?

Administer intravenous fluids

A previously healthy 15-year-old boy is brought to the emergency department in August 1 hour after the onset of headache, dizziness, nausea, and one episode of vomiting. His symptoms began during the first hour of full-contact football practice in full uniform. He reported feeling weak and faint but did not lose consciousness. He vomited once after drinking water. On arrival, he is diaphoretic. He is not oriented to person, place, or time. His temperature is 39.5°C (103.1°F), pulse is 120/min, respirations are 40/min, and blood pressure is 90/65 mm Hg. Examination, including neurologic examination, shows no other abnormalities. Which of the following is the most appropriate next step in management?

Arrange for the regional organ procurement organization to address the issue with the patient's family

A previously healthy 32-year-old man is brought to the emergency department after being found unconscious on the floor at his workplace. On arrival, he is obtunded. He is intubated and mechanical ventilation is begun. Examination shows flaccid paralysis on the right. A CT scan of the head shows a large evolving cerebral infarction on the left. Carotid duplex ultrasonography shows dissection of the left carotid artery. After receiving intensive medical care for 6 hours, the patient develops decerebrate posturing and becomes hemodynamically unstable. Vasopressor therapy is begun. A second CT scan of the head shows a massive left hemispheric cerebral infarction with severe edema and herniation. The physician determines that surgical intervention is not indicated because of the patient's poor prognosis. The patient's driver's license indicates that he wishes to be an organ donor. The physician meets with the patient's family and informs them about the patient's prognosis, and they are devastated. During the meeting, they say that they were unaware of his willingness to be an organ donor and agree that he should not receive cardiopulmonary resuscitation. Which of the following is the most appropriate next step with respect to organ donation?

Thrombotic thrombocytopenic purpura ADAMTS-13 Deficiency FATRN Fever Anemia Thrombocytopenia Renal Failure Neuro Symptoms

A previously healthy 34-year-old woman is brought to the physician because of fever and headache for 1 week. She has not been exposed to any disease. She takes no medications. Her temperature is 39.3°C (102.8°F), pulse is 104/min, respirations are 24/min, and blood pressure is 135/88 mm Hg. She is confused and oriented only to person. Examination shows jaundice of the skin and conjunctivae. There are a few scattered petechiae over the trunk and back. There is no lymphadenopathy. Physical and neurologic examinations show no other abnormalities. Test of the stool for occult blood is positive. Laboratory studies show: LOW Hematocrit HIGH Leukocyte LOW platelet LOW PT HIGH BUN HIGH Cr HIGH Total Bili HIGH LDH Blood and urine cultures are negative. A CT scan of the head shows no abnormalities. Which of the following is the most likely diagnosis?

Ventilation-perfusion mismatch PULMONARY EMBOLISM Hypoxia and hypocarbia are seen with resulting respiratory alkalosis.

A previously healthy 42-year-old man is brought to the emergency department 1 day after the sudden onset of shortness of breath and chest pain at rest; the pain is exacerbated by deep inspiration. His pulse is 100/min, respirations are 22/min, and blood pressure is 140/90 mm Hg. Breath sounds are normal. The remainder of the examination shows no abnormalities. Arterial blood gas analysis on room air shows: pH 7.49 PcO2 30 PO2 64 O2 Sat 91% An x-ray of the chest shows no abnormalities. Which of the following is the most likely mechanism of these findings?

Colonoscopy

A previously healthy 47-year-old man comes to the physician because of a 6.8-kg (15-lb) weight loss over the past 6 months. He spent 2 weeks in Mexico 3 months ago. Since returning, he has noticed that his stools have changed in size and consistency. He has not had fever, night sweats, or change in appetite. He takes no medications. He has smoked one pack of cigarettes daily for 20 years. He appears healthy and well nourished. His temperature is 37°C (98.6°F), pulse is 105/min, respirations are 16/min, and blood pressure is 130/78 mm Hg. Examination shows pale conjunctivae. The abdomen is soft with no organomegaly. Rectal examination shows a normal prostate with no masses. Test of the stool for occult blood is positive. Laboratory studies show: Hemoglobin 11 Mean corpuscular volume 72 Platelet count 300,000 Red cell distribution width 16% (N=13%-15%) Which of the following is the most appropriate next step in diagnosis?

Haemophilus ducreyi

A sexually active 20-year-old woman has had fever, chills, malaise, and pain of the vulva for 2 days. Examination shows a vulvar pustule that has ulcerated and formed multiple satellite lesions. Nodes are palpated in the inguinal and femoral areas. A smear of fluid from the lesions establishes the diagnosis. Which of the following is the most likely causal organism?

Chance of a type II error

A study is conducted to assess the effectiveness of a new drug for the treatment of type 2 diabetes mellitus. A total of 1000 patients with type 2 diabetes mellitus are enrolled. Patients are randomly assigned to receive the new drug or standard treatment. The alpha and beta values for calculating probability are 0.05 and 0.20, respectively. Results show that the new drug is significantly better than standard treatment. If this study had been performed in a population of only 500 patients, which of the following would have been most likely to increase?

Contrast Induced Nephropathy (CIN) acute rise in Creatinine within 24-48 hours of contrast administration. direct cytotoxicity causing acute tubular necrosis with muddy brown casts, and renal vasoconstriction causing prerenal injury

AKI following administration of radiologic contrast

Vagal Maneuvers increase parasympathetic tone and result in temporary slowing of conduction in the AV node and increases in the AV node refractory period lead to termination of AVNRT. Affects AV node Conductivity

AVNRT most common form of paroxysmal supra ventricular tachycardia and is caused by reentry mechanism due to presence of dual electrical pathway in AV node. Tx?

Proliferation of smooth muscle cells within the myometrium (leiomyomata Uteri (fibroids)) OCP can decrease bleeding duration and volume but may not completely resolve symptoms. Symptomatic anemia may require transfusion and more invasive fibroid treatment (myomectomy, uterine artery embolization, hysterectomy)

Abnormal uterine bleeding, with irregularly enlarged uterus.

paroxysmal supraventricular tachycardia (PSVT) AV Nodal Reentrant Tachycardia is the MOST COMMON form of PSVT young patients with palpitations and dizziness, SOB, or chest pain. Slow and fast pathways form a loop circuit with impulses traveling in an integrate direction through the slow pathway and returning through the fast pathway. Vagal Maneuvers (carotid sinus massage, cold water immersion or diving reflex, valsalva maneuver, eyeball pressure) increase parasympathetic tone in heart and result in a temporary slowing of conduction in the AV node and an increase in AV node refractory period leading to termination of AVNRT

Abrupt onset of tachycardia that resolves with cold-water immersion

Paroxysmal nocturnal hemoglobinuria red urine and normal RBC morphology

Absence of CD55 in RBC membranes

Decreased Esophageal Peristalsis and Increased lower esophageal sphincter tone.

Achalasia on esophageal manometry?

Respiratory Alkalosis from Hyperventilation

Acid base disorder in PE & Asthma

1. Elevated Aminotransferases 2. Hepatic Encephalopathy 3. Prolonged PT cirrhosis or underlying liver disease should not be present.

Acute Liver Failure is characterized by the triad of

M-Morphine O-Oxygen N-Nitrates-MOST IMPORTANT to reduce chest pain, by vasodilation (decrease preload, reduce ventricular volume and wall stress, decreased myocardial oxygen demand) A-Aspirin Beta Blockers LMWH Statins

Acute MI tx

Glucocorticoids (IV Methylprednisone) Plasmapheresis for those refractory to corticosteroid therapy disease modifying agents used for chronic maintenance therapy (INTERFERON BETA & GLATIRAMER ACETATE)

Acute MS exacerbation , treatment?

OBTAIN Serum AMYLASE & LIPASE Lipase is more useful and sensitive then amylase Imaging is not required if Amylase and Lipase are elevated.

Acute Pancreatitis binge drinking epigastric pain radiating to the back

Thromboembolic occlusion from left atrial thrombus due ti atrial fibrillation. IMMEDIATELY start HEPARIN Arterial Doppler study or Duplex US can identify the presence and location of acute arterial occlusion. But don't delay tx if clinical suspicion is high.

Acute arterial occlusion of lower extremity with signs of acute limb ischemia (pain, pallor, poikilothermic (cool extremity), paresthesia, pulselessness, paralysis) in a patient with a irregular heart beat

Both have Low Glucose, Elevated Protein Bacterial = Neutrophilic pleocytosis Tuberculosis = Lymphocytic pleocytosis

Acute bacterial vs TB meningitis

hypovolemia due to vomit, inability to tolerate oral fluids. Kidneys respond by releasing renin, causing vasoconstriction (efferent and systemic arteriolar), sodium and water reabsorption and aldosterone secretion.

Acute gallstone pancreatitis develop

pulmonary embolism Unilateral lower ext edema = DVT PE can cause rapid increase in PVR and RV pressure load. Result in acute RV dysfunction and sudden loss of CO. This results in Syncope.

Acute onset of dyspnea, chest pain, and tachycardia, in a patient who returned from a long trip. 2+ bilateral lower extremity edema, more pronounced on one side. T wave inversion in V1 to V3. Right bibasilar atelectasis.

Endoscopic CBD Stent for palliative symptom control

Advanced pancreatic cancer can cause jaundice and pruritus by obstructing CBD. Treatment?

Cholesterol Emboli causing acute pancreatitis Tx: Supportive care for acute pancreatitis most commonly improve in 4-7days

After cardiac catheterization patient presents with reticulated mottled discolored skin, blue toes, acute kidney injury and pancreatitis abdominal pain, nausea, elevated lipase.

Dapsone

Alternative to TMP-SMX prophylaxis for Pneumocystis pneumonia

Hypothyrodism

Amenorrhea Galactorhhea fatigure weight gain bradycardia anovulation

Class III antiarrhythmic used to manage ventricular arrhythmias in coronary artery disease & ischemic cardiomyopathy. cause CHRONIC INTERSTITIAL PNEUMONITIS baseline CXR and PFTs before starting medication

Amiodarone

Inhibit reuptake of Norepi & Serotonin Side effects: Anticholinergic symptoms (dry mouth, constipation, urinary retention) due to M1, Lethargy due to Histamine, Orthostatic Hypotension due to Alpha Diagnose orthostatic hypotension with orthostatic BP measurements (systolic >20 or diastolic >10

Amitriptyline

Pericardiocentesis

An 18-year-old man is brought to the emergency department 10 minutes after he sustained a stab wound to his chest. On arrival, he is unresponsive to painful stimuli. His pulse is 130/min, respirations are 8/min and shallow, and palpable systolic blood pressure is 60 mm Hg. He is intubated and mechanically ventilated, and infusion of 0.9% saline is begun. After 5 minutes, his pulse is 130/min, and blood pressure is 70/40 mm Hg. Examination shows a 2-cm wound at the left sixth intercostal space at the midclavicular line. There is jugular venous distention. Breath sounds are normal. The trachea is at the midline. Heart sounds are not audible. Which of the following is the most appropriate next step in management?

Ultrasonography

An 18-year-old primigravid woman comes for her initial prenatal visit at 16 weeks' gestation. She is not sure about the date of her last menstrual period but says that the pregnancy probably occurred immediately after she stopped taking oral contraceptives 5 months ago. Maternal serum α-fetoprotein (MSAFP) concentration is increased to 3 multiples of the median. Which of the following is the most appropriate next step in management?

Detrusor instability

An 82-year-old woman with a 20-year history of urinary incontinence has had a mild exacerbation of her symptoms over the past 3 months. Urine loss generally occurs when she is carrying out daily activities such as shopping or driving and is not affected by coughing or sneezing. She underwent appendectomy at the age of 24 years. She has one daughter. She takes no medications. Pelvic examination shows an atrophic cervix without palpable uterus or an adnexal mass. Which of the following is the most likely cause of this patient's urinary incontinence?

Pseudogout

An x-ray of the left knee shows calcification of the synovium. Which of the following is the most likely diagnosis?

caused by HPV associated with men sex with men and HIV anal bleeding, pain, sensation of fullness, anal mass or ulcerated lesion

Anal Cancer

no progesterone production (no corpus luteum development) no differentiation into secretory endometrium. Continued unopposed estrogen stimulation resulting in uncontrolled proliferation of the endometrium. Progesterone tx helps stabilize uncontrolled proliferation due to estrogen by casing differentiation into secretory endometrium. Cyclic progesterone withdrawal then causes menstraution.

Anovulatory Cycles with irregular, heavy menstrual bleeding due to an immature hypothalamic pituitary axis

Celiac Disease causing MALABSORPTION osteopenia due to vit D deficiency (fracture from ground level fall) Due to VILLOUS ATROPHY dx: assay of the stool for fat most sensitive intimal test for malabsorption syndromes

Antiendomysial antibodies

Autoimmune hepatitis

Antinuclear and Antismooth muscle Antibodies

Hashimoto's thyroiditis (hypothyroidism)

Antithyroid peroxidase antibodies and palpable goiter

compares groups based on the actual treatment received, performed to gauge effectiveness of a treatment itself, with less regard to potential confounders.

As-Treated Analysis

Results from an atypical population are extrapolated into entire population. type of selection bias.

Ascertainment Bias

Arachidonic Acid Pathway in NSAID-exacerbated respiratory disease pseudo allergic reaction to NSAIDs in patients with comorbid asthma, chronic rhino sinusitis with nasal polyposis or chronic urticaria. cough, wheezing, chest tightness, nasal and ocular symptoms (nasal congestion, rhonorrhea, periorbital edema) and facial flushing. due to increased pro inflammatory leukotrienes and decreased anti inflammatory prostaglandins. tx: d/c NSAID

Aspirin exacerbated respiratory disease

Antiplatelet (Aspirin) & Statin Therapy

Asymptomatic carotid stenosis (carotid atherosclerosis without recent TIA or stroke) with <80% lesions managed?

Temporal Arteritis, MS, SLE

Autoimmune diseases associated with sudden visual loss

Glucose-6-phosphate dehydrogenase deficiency X-Linked common in African Americans upper respiratory infection followed a few days later by hemolytic anemia (dark urine, scleral icterus, back/abdominal pain) G6PD generates NADPH, required to make glutathione. Without glutathione oxidative metabolites accumulate in erythrocytes and denature/precipitate hemoglobin into Heinz bodies. oxidative triggers: -infection -Meds (TMP-SMX, Nitrofurantoin) -Fava Beans

BITE CELLS & HEINZ BODIES (RBC inclusions)

FH of OVARIAN cancer at any age or personal/family hx of breast cancer <50 in first degree relative.

BRCA Mutation Testing

G6PD deficiency & thalassemia

Bite cells, Heinz bodies as peripheral blue inclusions with crystal violet stain

Osetosarcoma Spiculated Sun burst pattern and periosteal elevation known as conman triangle INCREASED Alkaline phosphatase and lactate dehydrogenase (due to turnover of damaged osteocytes) Tx: Tumor excision and chemo

Boy, 13-16yo, tender soft tissue mass.

BETA Blocker Overdose first step secure airway, give IV fluids, and IV atropine for intimal tx of hypotension and bradycardia. next step is IV glucagon (Increase intracellular cAMP helpful for beta blocker and calcium channel blocker toxicity)

Bradycardia, AV block, Hypotension, Diffuse WHEEZING. Overdose with what?

Irreversible cessation of brain activities. Absent cortical or brainstem function Spinal cord still may function = DTRs may be present.

Brain Death

irreversible loss of function of whole brain. Legally acceptable definition of death. Life support does NOT need to be continued. Therefore no further steps required to keep patient on ventilator.

Brain death

Endometrial glands within the myometrium (Adenomyosis)

Bulky, tender uterus that is UNIFORMLY enlarged

CMV colitis dx: Colonoscopy with biopsy (eosinophilic intranuclear and basophilic intracytoplasmic inclusions) tx: Ganciclovir All patients with active CMV should have an ocular exam to rule out concurrent retinitis

CD4<50, fatigue, low grade fever, weight loss, frequent low volume bloody stools.

Transudative pleural fluid

CHF, Hypoalbumin (Cirrhosis, Nephrotic) with LOW pleural protein, and minimal cells

Normal Preload Normal CO HIGH Afterload due to vasoconstriction from alpha-1 receptor stimulation

COcaine Preload CO Afterload

Mycoplasma pneumoniae tx with AZITHROMYCIN lack cell wall and gram stain is ineffective NO CULTURES NEEDED

CXR Diffuse reticulonodular opacities

CREST syndrome which is strongly associated with systemic sclerosis. These patients are at high risk for Pulmonary Arterial HTN, due to intimal hyperplasia of the pulmonary arteries and presets with progressive dyspnea. See RV heave which is an impulse palpated immediately to the left of the sternum that suggest RV enlargement.

Calcinosis Cutis, Raynaud phenomenon, esophageal dysmotility with reflux, scleordactyly, telangiectasia

amino acid derived hormones

Carcinoid (serotonin) & Pheochromocytoma (Norepi, Epi) due to overproduction of what type of hormones?

Symptomatic patients (TIA or Stroke in distribution of affected artery within the previous 6 months) with high grade carotid stenosis 70-100%.

Carotid Endarterectomy

Cross Sectional: Assess both exposure and outcome at a single point in time. Can show an association exist but cant establish causation. Case Control determines the outcome first and then looks for associated risk factors. Retrospective cohort first ascertains the risk factor exposure and then determines outcome. this allows calculation of RR. Stronger studies because ability to prove causation.

Case Control vs Cohort vs Cross Sectional

Gallstones, alcohol abuse, hypercalcemia, hypertriglyceridemia, trauma (most common cause of acute pancreatitis in children), drug side effects (thiazide diuretics), viral infections, post-ERCP, scorpion bites

Causes of Acute Pancreatitis

N S A I D NSAID Sickle Cell Analgesic abuse Infection (pyelonephritis) DM

Causes of papillary necrosis

Low arterial oxygen saturation due to congenital heart disease (peripheral cyanosis blue only in distal ext, normal arterial oxygen saturation, peripheral vasoconstriction, high venous pressure)

Central Cyanosis (lips, tongue, nail bed blue) tachypnea & diaphoresis while breastfeeding

subperiosteal hemorrhage occurs in neonates due to birth trauma (forecep or vacuum) presents as scalp swelling with fib, contender, NOT cross suture lines and no skin discoloration. resorb spontaneously few weeks to months. Possible to have hyperbilirubinemia requiring phototherapy due to blood breakdown from hematoma.

Cephalohematoma

subarachnoid hemorrhage need urgent non con Head CT showing blood in basilar cistern and within cerebral sulci from a ruptured arterial berry (saccular) aneurysm if CT negative then do a lumbar puncture see elevated opening pressure with xanthochromia (yellow-pink discoloration due to Hgb breakdown), and continued high levels of RBC from first to fourth tube.

Change in headache characteristic that is sudden, persistent, severe with vomiting

No pharmacotherapy is indicated

Child with ParvoB19 infection, tx?

halogenated hydrocarbons (occupational exposure to pollutant dioxin)

Chloracne inflammatory nodules and large comedones affecting head, neck and axillae associated with exposure to

Endometrioma

Chocolate cyst, severe dysmenorrhea and adnexal fullness

reduce LDL (bile acid binding resin)

Cholestyramine

fetal growth restriction, intrauterine fetal demise, cleft lip/palate

Cigarette use during pregnancy

Sertoli-Leydig Cell Tumor (Testosterone secreting sex cord stromal tumor) Testosterone excess results in: -Rapid onset virilization (clitoromegaly, male pattern baldness, voice deepening, increased muscle mass) -Estrogen Deficiency: Testosterone inhibits hypothalamic GnRH and Pituitary FSH/LH release, resulting in low estrogen. (breast atrophy, vulvovaginal atrophy, dyspareunia, oligomenorrhea) Tx: Surgical removal + Chemo for metastatic disease

Clitoromegaly (clitoris protruding from clitoral hood), large adnexal mass.

blocks adenosine diphosphate receptors on surface of platelet

Clopidogrel

grouping of different data point into similar categories randomization at the level of groups rather than at the level of individuals.

Cluster Analysis

best for incidence of a disease comparing incidence of disease in 2 populations with and without risk factor can calculate RR

Cohort Study

determine incidence of a disease. comparing incidence of disease in 2 populations. with and without a given risk factor. Allows calculation of RR.

Cohort Study

Everybody starting at age 50 if FH then 10 years before the age of the relative diagnosed or at 40yo which ever comes first.

Colon Cancer screening

CAP: Ceftriaxone + Azithromycin HAP: Vancomycin + Piperacillin-Tazobactam

Community acquired pneumonia vs hospital acquired tx difference

exacerbate asthma symptoms through micro aspiration of gastric contents lead to increased vagal tone and bronchial reactivity. dose throat, morning hoarseness, worsening cough only at night, increased need for albuterol after meals plus obesity PPI therapy improve both asthma symptoms and GERD

Comorbid GERD common with Asthma

Transposition o the great vessels is the most common cyanotic heart disease of newborns. Tetralogyo Fallot is the most common cyanotic heart disease of childhood.

Cyanotic Heart Diseases newborn vs child

a fluctuant mass that transilluminates. it is a congenital lymphatic malformation located in posterior triangle of the neck.

Cystic Hygroma will show

peripheral vascular disease obtain Ankle-Brachial Index Normal 0.9-1.3 <0.9 = disease <0.4= severe ischemia

DM, HTN, Obesity. Thin, shiny, hairless skin on extremity with non healing ulcer

Increased work of breathing there is reduced inspiratory and expiratory flow rates in COPD Elasticity decreased in COPD, Compliance Increases (therefore flattening of diaphragm)

Decreased alveolar capacity in COPD causes lung hyperinflation which results in increased TLC, FRC, rV as well as diaphragmatic flattening The flattening results in?

polymicrobial Gram +, Gram -, Anaerobic. Underlying osteomyelitis common due to contiguous spread wound debridement, evaluation of arterial insufficiency, and empiric IV Abx (Piperacillin-Tazobactam + Vancomycin)

Diabetic foot infections

CXR to show lobar, interstitial or cavitary infiltrate. Prior to tx with empiric abx.

Diagnosis of community acquired pneumonia requires

RA, Sarcoidosis, Hypothyroid, Amyloidosis

Diseases associated with Carpal Tunnel Syndrome

Hirschrung Disease, Alzheimer disease and Hypothyroidism

Down syndrome associated diseases

Amoxicillin Treat early disease with doxycycline (or amoxicillin in children < 8 years of age and in pregnant patients); more advanced disease (eg, CNS or arthritic disease) should be treated with ceftriaxone. Consider empiric therapy for patients with the characteristic rash, arthralgias, or a tick bite acquired in an endemic area. Prevent with tick bite avoidance. Prophylaxis: Lyme disease is not usually transmitted within the rst 48 to 72 hours of tick attachment. Give one dose of doxycycline if all the following apply: tick is Ixodes scapularis and has been attached for > 36 hours, prophylaxis is begun within 72 hours of removal, local rate of infection of ticks with B burgdorferi is > 20%, and doxycycline is not contraindicated. If criteria not met, observe and only treat if erythema migrans develops.

Early treatment of Lyme disease to prevent long term complications.

Calcium Disodium Edetate

Early treatment prevent worsening condition of Lead poisoning?

Unit of observation: Population Disease rates and exposures are measured in 2 or more population, association between disease rates and exposures is determined May not translate to individual level CANNOT determine incidence

Ecological Studies

Waldenstrom's macroglobulinemia dx: serum protein electrophoresis showing M-spike and bone marrow biopsy tx with plasma exchange to reduce blood viscosity

Elevated IgM, in an elderly with headaches, dizziness, and blurry vision due to hyperviscocity syndrome suffers from

ideal location is 2-6cm above carina if too far can enter into R main stem bronchus = overinflation of right lung, and under ventilation of left lung, and asymmetric chest expansion. decreased or absent breath sounds CXR confrims diagnosis Reposition the ETT by pulling back slightly

Endotracheal Intubation

Melanoma arising from nail matrix longitudinal bands in nail plate called longitudinal melanonychia

Enlarging Pigmented nail lesion

Sterol Vitamin

Excess production of Calcitriol (1,25 dihydroxyvit D) responsible for hypercalcemia in lymphomas and sarcoidosis this is what type of vitamin?

Preload LOW CO HIGH Afterload HIGH

Exercise Preload CO Afterload

short acting beta agonist (albuterol) 10-20 minutes before exercise, if only intermittent. Inhaled corticosteroids or antileukotriene if they exercise daily

Exercise Induced Bronchoconstriction

aortic regurgitation DEC CO, INC LA pressure dry cough = pulmonary congestion & edema due to primary mitral valve disease (rheumatic, IE, or trauma) or ischemic heart dz or hypertrophic cardiomyopathy.

Exertional dyspnea, dry cough, holosystolic murmur on auscultation at apex with radiation to axilla

Alveolar Hypoventilation

Explanation for Hypoxemia in OSA?

acute inflammatory disorder of eyelash follicle or tear gland erythematous, tender nodule at lid margin infection with staph aureus Tx: Warm compress

External Hordeolum (Stye)

prevents absorption of dietary cholesterol from the gut (DECREASES LDL)

Ezetimibe

facial movement, taste anterior 2/3 tongue, lacrimation, salivation eyelid closure, sensory to external ear and nasopharynx

Facial Nerve (VII)

Inhibitor development (frequent spontaneous bleeds as a complication of treatment) Autoantibodies that interfere with factor function. tx: bypassing products (recombinant activated factor VII, activated PT complex concentrates)

Factor VIII (Hemophilia A) deficiency on factor replacement therapy develops increased bleeding frequency or has hemorrhage refractory to treatment.

Randomization to different interventions with additional study of 2 or more variables

Factorial Design Studies

Randomization to different interventions with additional study of 2 or more variables

Factorial Design Study

Arteriovenous fistula

Five years after being shot in the right thigh, a 21-year-old man comes to the emergency department because of a buzzing sensation adjacent to the scar. At the time of the initial wound, he was discharged after 6 hours of observation with no fractures or soft-tissue swelling. A loud murmur is heard on auscultation; there is a thrill. He has dilated varicose veins with incompetent valves in the lower leg. Which of the following is the most likely diagnosis?

treat ethylene glycol or methanol ingestion through inhibition of alcohol dehydrogenase

Fomepizole

Femoral popliteal stenosis

For 8 weeks, a 52-year-old man with a 5-year history of type 2 diabetes mellitus has had deep burning pain in the ball of his right foot and big toe when the foot is raised above chest concentration. He also has cramping in his right calf when he walks more than 50 feet. He has smoked two packs of cigarettes daily for 30 years. Femoral pulses are palpable; pedal pulses are absent. Which of the following is the most likely diagnosis?

Progesterone challenge test would produce NO withdrawal bleed as low endogenous estrogen results in a thin endometrial lining that will not shed. Weight loss, strenous exercise, chronic illness, stress infertility, vagina dryness, stress fractures due to low estrogen. treat underlying problem and provide estrogen.

Functional Hypothalamic Amenorrhea

Normal from birth-2yo measure and observe.

Genu Varum (bowlegs) legs Symmetric, normal stature, no leg length discrepancy, no lateral thrust when walking

Dx: NAAT tx: CEFTRIAXONE + AZITHROMYCIN (Empiric tx of sexual contacts recommended)

Gonococcal Urethritis in Men (Dysuria, purulent Urethral Discharge)

due to effects of activated T cells and Thyrotropin Receptor Antibodies (TRAB) on TSH receptors on retro-orbital fibroblasts and adipocytes. Definitive treatment of Graves with Radioactive Iodine can cause worsening of the opthalmopathy. therefore Glucocorticoid administration with RAI to prevent worsening. Otherwise best option is Thyroidectomy for those with mod to severe opthalmopathy

Graves Opthalmopathy

Demyelination of Axons

Guillain-Barre Syndrome cause of muscle weakness?

prophylaxis for close contacts and vaccination in routine childhood vaccinations. infected patients completely recover in 3-6 weeks.

HAV Prophylaxis and vaccination

Hemochromatosis (iron overload) frequent transfusions for anemia

HIGH IRON, FERRITIN, TRANSFERRIN LOW TIBC

Dolutegravir (Integrase Inhibitor)

HIV med causing hyperglycemia and increased transaminases

Disseminated mycobacterium avium complex first line tx = Clarithromycin or Azithromycin. When CD4<50 AZITHROMYCIN prophylaxis

HIV patient with CD4 <50. fever, cough, abdominal pain, diarrhea, night sweats, weight loss, splenomegaly, elevated alkaline phosphatase.

Adverse effects of drug regimens for pneumocystis Pneumonia Dx: confirm with demonstration of organism in sputum or bronchoalveolar lavage aspirate. Tx: TMP-SMX + Corticosteroids (PaO2 <70, or Aa Gradient >35) Antiretroviral started after PCP tx

HIV patient with dry cough, exertion dyspnea, fever, CXR with bilateral interstitial infiltrates, Elevated LDH, CD4 <200.

paraneoplastic Cushing syndrome due to ectopic ACTH by small cell lung carcinoma. ACTH is a POLYPEPTIDE HORMONE

HTN, easy bruising, headaches, scattered lower extremity echymoses, symmetric proximal muscle weakness, Hyperpigementation, associated with a mediastinal mass

autoantibodies to platelet factor 4

Heparin induced thrombocytopenia leading to thrombocytopenia, arterial or venous thrombosis, and necrotic skin lesions at heparin injection sites within 5-10 days of therapy due to?

Alcohol consumption

High γ-Glutamyltransferase (GGT) can be explained by?

Melasma women of reproductive age, during pregnancy, as estrogen and progesterone also stimulate melanocyte proliferation. NO FURTHER EVALUATION minimize progression with sun avoidance and broad spectrum sunscreen resolves postpartum

Hyperpigmentation on sun exposed areas of face. irregularly shaped hyperpifmented macule of varying colors. Symmetric centrofacial, mandibular, molar distribution.

autonomous production of thyroid hormones from hyper plastic follicular cells. the radioactive iodine uptake scan reveals uptake only in the hyperactive nodule, with suppression of uptake in the rest of the gland.

Hyperthyroidism from toxic adenoma is due to

DEC PCWP INC SVR DEC Cardiac Index DEC MvO2

Hypovolemic Shock

Toxic Megacolon Medical emergency Tx: IV fluids, Broad spectrum Antibiotics, Bowel rest. IV Corticosteroids for IBD induced toxic megacolon. Emergency surgery if colitis doesnt resolve.

IBD (UC or Crohn), Ischemic colitis, Volvulus, Diverticulitis, C. Diff, Obstructive colon cancer. See on Plain Abdominal Xray. Diagnosis confirmed by Fever >100.4, Pulse >120, WBC > 10,500, Anemia. See dilated right or transverse colon (>6cm) multiple air fluid levels, thick haustral markings that dont extend across entire lumen.

brain abscess due to infective endocarditis

IVDU, fever, mitral regurgitation (blowing holosystolic murmur at apex), and neurologic symptoms.

spinal epidural abscess Due to Staph Aureus tx: Broad spec antibiotics (vancomycin + ceftriaxone) urgent decompression can prevent paralysis

IVDU, with fever, focal back pain, neurologic deficits HIGH ESR

Pruritic raised erythematous plaques

IgE mediated food allergies present with rapid onset of Urticaria.

Goodpasture Disease

IgG autoantibodies directed against glomerular and alveolar basement membrane, hematuria, proteinuria, as well as Dyspnea, cough, hemoptysis.

Benzo

Immediate relief of panic disorder?

To deal with selection bias by comparing the initial randomized treatment groups (the original intention) regardless of the eventual treatment to avoid counting crossover patients.

Intention to treat analysis

lung stiffening due to fibrosis & decreased lung compliance fine bibasilar "velcro-like" crackles reticular or nodular opacities on CXR chronic dust exposure, drug toxicity, CT disease

Interstitial Lung Disease Dec TLC FEV1/FVC >70 Dec DLCO

Aminoglycosides (Gentamicin)

Intrinsic AKI due to renal tubular toxicity

systolic >140 & disaatolic <90 due to increased stiffness or decreased elasticity of the aortic and arterial walls in elderly. reduced ability of arteries to dampen the systolic pressure and leads to increased pulse wave velocity and pulse wave reflection in systole.

Isolated Systolic HTN

G-6-PD deficiency

Jaundice Splenomegaly HIGH retic count NEGATIVE COOMBS LOW MCHC

Severe Combined Immunodeficiency (SCID) failure of T cell development. infection with Virus, Fungi, and opportunistic pathogens. STEM CELL TRANSPLANT only definitive therapy.

LOW CD19 (B-Cells) Absent CD3 (T-Cells)

iron deficiency anemia

LOW MCV Decreased Erythrocyte PENCIL CELLS

Anemia of chronic disease

LOW MCV LOW IRON LOW TIBC LOW TRANSFERRIN HIGH FERRITIN

hyponatremia due to hypovolemia

LOW serum osm HIGH Urine osm LOW urine sodium

primary polydipsia

LOW serum osmolality LOW urine osmolality HIGH urine sodium

Viral myocarditis

LV Systolic dysfunction in a young patient due to?

Multiple Myeloma

LYTIC lesions (not plastic), HYPERCALCEMIA, anemia and renal disease

-(+) Hydrogen Breath Test rise in measured breath hydrogen after ingestion of lactose. -(+) stool test for reducing substances -LOW stool pH -INCREASED stool osmotic gap

Lactose Intolerance osmotic diarrhea, abdominal cramps, bloating, flatulence test?

Two disease interventions are compared and one diagnosis the disease earlier than there other without an effect on outcome (survival) , makes it appears that the intervention prolonged survival when it really just diagnosed the disease sooner

Lead-Time Bias

Tetralogy of Fallot -RVOT obstruction -RV Hypertrophy -Overriding Aorta -VSD Exertion, feeding, and agitation increase pulmonary vascular resistance, result in complete RVOT obstruction. diversion of blood from RV into aorta results in hypoxemia and cyanosis (Tet spells) Harsh crescendo-decrescendo systolic murmur over left upper sternal border, due to pulmonary stenosis. Acute management = knee-chest position to increase SVR and inhaled Oxygen to stimulate pulmonary vasodilation.

Life threatening Tet Spells

Parinaud Syndrome from Pineal tumor pressure on pretectal region of midbrain

Limitation of upward gaze with downward gaze preference, bilateral eyelid retraction, light near dissociation.

Antiphospholipid syndrome PROLONGED PTT Anti-beta-2-Glycoprotein 1 Antiphosphatidylserine Anticardiolipin Abs

Livedo Reticularis, acute leg swelling due to DVT, hx of recurrent miscarriages

inhibit Na-K-2Cl carrier in loop of henle Increased loss of sodium, hydrogen, and potassium in urine. Volume contraction with increased aldosterone further promoting hydrogen secretion

Loop Diuretics function

Alzheimer disease

Loss of acetylcholine neurons in the nucleus basalis of Mynert Loss of Norepinephrine and degeneration of locus coeruleus

Parkinson's disease (PD)

Loss of dopamine producing neurons in substantial nigra

renal failure lead to phosphate retention and resultant secondary hyperparathyroid. PTH increases with declining GFR. in Vitamin D deficiency phosphate would be low to normal

Low Calcium, High Phosphate, High PTH

Cariogenic Shock

Low Cardiac index Normal MAP HIGH PCWP HIGH CVP

Cervical Cancer clinically staged through physical exam IV pyelogram or CT scan can be used to evaluate for hydronephrosis AIDS-defining illness immunosuppressed patients have persistent HPV that results in neoplasia

Lower back pain lower uterine segment mass hydronephrosis irregular vaginal bleeding postcoital spotting

Hereditary Nonpolyposis Colon Cancer AD germline mutation in a DNA mismatch repair gene -Colorectal Cancer -Endometrial Cancer (Annual endometrial biopsy 30-35) Ovarian Cancer (prophylactic hysterectomy and bilateral oophorectomy at age 40)

Lynch Syndrome

Congenital Toxoplasmosis

MACROCEPHALY & DIFFUSE PARENCHYMAL CALCIFICATIONS

Congenital Cytomegalovirus (CMV)

MICROCEPHALY & PERIVENTRICULAR CALCIFICATIONS

Mid-Diastolic murmur at the cardiac apex loud S1 Opening snap low pitched diastolic rumble apex with the bell while patient lying on left side and breath held in end expiration.

MITRAL STENOSIS

Primary Sclerosing Cholangitis (PSC) Associated with ULCERATIVE COLITIS: recurrent bloody diarrhea fatigue, pruritus, jaundice

MRCP: Multifocal short narrowing of the bile ducts with segmental dilations.

prevent further liver damage. Alcohol avoidance and HEP A and B vaccination. direct acting antiviral agents (Sofosbuvir-Velpatasvir)

Management of HCV

If initial X-ray is negative, get a CT or MRI of the wrist to confirm the fracture. As an alternative wrist can be immobilized briefly in a thumb spica splint followed by repeat imaging in 7-10days.

Management of a patient with tenderness in snuffbox due to possible scaphoid bone fracture From fallen on an outstretched hand.

Inhibitor of cortisol synthesis used in patients with Cushing Syndrome who are waiting for definitive surgical treatment.

Metyrapone

Aspirin toxicity

Mixed respiratory alkalosis & metabolic Acidosis pH 7.42 PacO2 25 Bicarb 14

DRESS Syndrome D-drug-Allopurinol, Phenytoin, Carbamazepine R-rash (morbilliform eruption) E-eosinophilia S-systemic S-symptoms- fever, malaise, diffuse LAD 2-8 week latency between drug initiation and manifestation of symptoms. Associated with antibody to HHV6 reactivation. tx: d/c drug and supportive care.

Morbilliform eruption starts on face or upper trunk and becomes diffuse and confluent, facial edema, Eosinophilia, Diffuse lymphadenopathy, fever.

Oral PTU

Most appropriate initial treatment for Hyperthyroidism?

E. COli tx is supportive and no need for abx if bloody due to enterohemorrhagic E Coli strain producing shiga toxin

Most common cause of bloody diarrhea in absence of fever?

postpartum endometritis Infection of the uterine decidua

Most common cause of postpartum FEVER, uterine tenderness and purulent lochia

Amytrophic Lateral Sclerosis (ALS)

Motor neuron degeneration and death

decreased acetylcholine receptors

Myathenia Gravis cause of muscle weakness?

Folic Acid Deficiency Carbamazepine is an anticonvulsant that has folic acid antagonistic properties.

Myelomeningocele (spina Bifida) a neural tube defect, commonly associated with?

Block prostaglandin induced dilation of the glomerular afferent arterioles

NSAID induced prerenal AKI

Acute pancreatitis most appropriate next step in management is aggressive volume resuscitation (ISOTONIC CRYSTALOIDS)

Nausea, vomit, constant epigastric abdominal pain partially relieved by leaning forward

Fournier's gangrene Rapid surgical intervention, DO NOT DELAY

Necrotizing fasciitis of perineal, scrotal, and lower abdominal skin. Rapid onset swelling, tenderness, crepitus, hypotension, high fever.

Probability of being free of a disease if test result is negative vary with pretest probability high probability of having disease = Low NPV

Negative Predictive Value

required by most states regardless of consent. discussion of patient concerns and risks and benefits id the first step in approaching hesitancy or refusal of an intervention.

Neonatal prophylaxis against gonococcal conjunctivitis

enlargement of lateral cerebral ventricles decreased volume of hippocampus and amygdala

Neuroimaging finding in Schizophrenia

start on empiric abx with anti pseudomonas (Cefepime, Meropenem, Piperacillin-Tazobactam)

Neutropenia (Absolute Neutrophil Count <1500)

secondary erythrocytosis increased immature erythrocyte (polychromasias) in response to hypoxia or tumor.

Normal MCV Increased Erythrocyte POLYCHROMASIA

Slipped Capital Femoral Epiphysis (SCFE) tx: Surgical pinning of the slipped epiphysis to lessen risk of Avascular Necrosis

Obese adolescent boys, hip or knee pain causing limping. loss of abduction and internal rotation of the hip.

eye movement (adduction via medial rectus, elevation via inferior rectus), eyelid opening, pupillary constriction. Pure motor nerve

Oculomotor Nerve (III)

visual information to brain and afferent limb of pupillary light reflex. monocular blondness and afferent pupillary defect.

Optic Nerve (II)

when contractions inadequate <200 Montevideo) in protracted labor cervical dilation <1cm/2h, but NOT arrested)

Oxytocin a uterotonic used to augment labor by increasing frequency and force of contractions.

Treatment of latent TB now

PPD skin test with 16mm induration, CXR shows no abnormalities. Sputum samples show no acid fast bacilli. next step?

Osteosarcoma pain, soft tissue swelling and Xray: Destructive bone lesion, sunburn periosteal reaction and woman triangle. higher risk for osteogenic sarcomatous transformation at sites of bone overgrowth

Paget disease of bone is associated with increased bone remodeling increases risk for

Randomizes one treatment to one group and a different treatment to other group (treatment drug vs placebo)

Parallel Study

HYPOKINETIC GAIT (festinating gait, shuffling) -Mask like immobile facial expression -bradykinesia -resting tremor -rigidity -Stooped posture Substantia Nigra decreased dopaminergic activity and increased cholinergic activity

Parkinson

decreased dopaminergic activity in the brain frontal lobe atrophy, dopaminergic neuron degeneration in substantia nigra pars compacta, Lewy bodies in affected neurons.

Parkinsons disease (festinating gait, slow speech, resting hand tremor, cogwheel rigidity) due to

appetite for items other than food like paper, dirt, etc. develops in iron deficiency anemia. Especially when its for Ice.

Pica

1. Ionized 2. Albumin bound 3. bound to inorganic and organic anions increase extracellular pH (Respiratory Alkalosis) causes hydrogen to dissociate from albumin thereby freeing up albumin to bind calcium. This results in decreased levels of ionized calcium. Decreased IONIZED calcium results in clinical manifestations of hypocalcemia (cramps pain, paresthesias, carpopedal spasm)

Plasma Calcium

improves outcomes in patients with Guillain barre syndrome.

Plasmapheresis

delivery within next week and indication for administration of antenatal corticosteroids (betamethasone)

Positive Fetal Fibronectin (FFN) is a strong predictor of

Hypoparathyroidism Tx Hypocalcemia with oral calcium & Calcitriol (active Vitamin D) Hyperphosphatemia treated with avoidance of phosphate rich foods. Deposition of calcium induced by hyperphosphatemia in the basal ganglia. Complication associated with chronic hypoparathyroidism leading to movement disorders. other manifestations are nephrocalcinosis and cataracts

Post Thyroidectomy Low Calcium High Phosphorus

administer varicella specific immunoglobulin (VZIG) (PASSIVE IMMUNIZATION WITH MONOCLONAL ANTIBODY) neonates, pregnant moms, and immunocompromised Infants are too young to receive live vaccine PEP is recommended in those who are not immune as in did not receive 2 doses of VZV vaccine or never had Varicella infection. If immunocompoteent PEP is immunization with live VZV vaccine.

Postexposure prophylaxis in a newborn to mother with varicella developing 5 days before to 2 days after delivery.

within 2 weeks of exposure <40 Hep A Vaccine >40 Hep A Immuneglobulin

Postexposure prophylaxis with Hep A vaccine or Hep A Immune Globulin

All women with postmenopausal bleeding require further evaluation. Pap test for cervical cancer regardless when the last Pap test was performed. endometrial biopsy or trasnvaginal US for endometrial cancer GOLD STANDARD = Endometrial Biopsy in postmenopausal women trans vag US may be performed initially if <4mm low likelihood of cancer, and requires no additional evaluation. But if >4mm then require biopsy. If diagnosed with Endometrial cancer than undergo TAH + BSO which treats and stages the cancer.

Postmenopausal Bleeding

increased urinary excretion of calcium

Primary Hyperparathyroidism can cause renal calculi due to?

Hypergonadotropic Hypogonadism (menopause) in <40 cause an ovulation and abnormal bleeding. There will be HOT FLASHES and ELEVATED FSH

Primary Ovarian Insufficiency

Torsades de pointes tx by MAGNESIUM SULFATE

Prolonged QT in setting of Hypomagnesium

Transjugular intrahepatic portosystemic shunt (TIPS)

Protein should be restricted in patients with cirrhosis who have had?

Pulmonary HTN Lung Biopsy: Hyperplasia of the intimal smooth muscle layer of the pulmonary artier leading to increased pulmonary vascular resistance. no infiltrates on CXR and normal FEV1 and FEV1/FVC ratio.

Pulmonary Arterial Pressure > 30 indicates and what do you see on lung biopsy?

Destruction of the thyroid follicles by RAI can cause unregulated release of thyroid hormones. Well tolerated by younger patients without cardiovascular disease. however elderly with cardiovascular disease may not tolerate the temporary rise in thyroid hormone and therefore benefit from antithyroid drugs to deplete existing thyroid hormone prior to RAI.

RAI therapy

>1 indicates a positive association (increased risk, higher odds) <1 indicates negative association (decreased risk, lower odds) when CI not contain 1 then statistically significant

RR & OR

Cohort Studies. But costly and time consuming. case control is inexpensive, less time consuming, popular for exploring exposure-disease associations. RR cant be directly calculated in case control studies, because don't follow over time and dont measure incidence. OR, measured in case control studies. Rare diseases where there is low prevalence, incidence will be low, and therefore OR generally approximates RR. this is called the RARE DISEASE ASSUMPTION OR also approximates RR when cases and controls used in study represent the population.

RR can be calculated in

plotting the true positive rate (sensitivity) against the false positive rate (1-Specificity) moving the curve UPWARD INCREASES SENSITIVITY and SHIFTING RIGHT indicates DECREASE SPECIFICITY ACCURACY (proportion of true results (TP & TN) out of all the results of a given test) INCREASES as the total area under the curve INCREASES

Receiver Operating Characteristic Curve (ROC)

Refeeding Syndrome constellation of pathologic derangements resulting from surge in insulin activity as body resumes anabolism. carbohydrate intake stimulates insulin activity, Insulin causes cellular uptake of phosphorus, potassium, magnesium. Phosphorus is the primary deficient electrolyte as it is required for energy. Deficiencies in potassium and magnesium causes cardiac arrhythmias, and cardiopulmonary failure.

Refeeding syndrome a fatal complication of nutritional rehabilitation in anorexia nervosa.

inflammatory condition that affects any cartilage in body most commonly the cartilaginous portion of the ear.

Relapsing Polychondritis

most common correctable cause of secondary HTN. Aggressive risk factor reduction (aspirin, Diabetes and hyperlipidemia control, smoking cessation) ACEis or ARBs Renal artery stunting or surgical revascularization is reserved for patients with resistant HTN or recurrent flash pulmonary edema and/or refractory HF due to severe HTN

Renal Artery Stenosis (renovascualr HTN)

EARLIEST: Glomerular Hyperfiltration First change to be Quantitated: Thickening of the GBM Followed by: Mesangial Expansion Later: Nodular Sclerosis (specific for diabetic nephropathy)

Renal abnormality seen in DM

Sliding hiatal hernia predispose to GERD Asymptomatic patients ONLY require OBSERVATION reflux symptoms medically manages with PPI refractory GERD can go for Antireflux surgery (Nissen Fundoplication)

Retrocardiac opacity with air fluid level within the thoracic cavity

Increased risk: -COPD -Smoking -OSA ->65 -Open thoracic Surgery decrease the risk by preoperative physical therapy (aerobic, inspiratory muscle training) to reduce the incidence of atelectasis and pneumonia. Smoking cessation as well.

Risk for Postoperative Pneumonia

Dementia with Lewy Bodies fluctuating cognitive function, visual hallucinations, Parkinsonism, REM sleep behavior disorder

Round eosinophilic and cytoplasmic inclusions within the neurons of substantia nigra

chronic severe mitral regurgitation, chronic aortic regurgitation, heart failure, high CO states such as pregnancy and thyrotoxicosis.

S3 heard in

small cell carcinoma

SIADH found with which lung cancer?

Heart failure due to myocarditis (Coxsackie B) Leading to dilated cardiomyopathy

SOB, paroxysmal nocturnal dyspnea, bibasilar crackles, pitting edema, displacement of point of maximal impulse. preceding Upper Respiratory tract infection.

Decreased libido, decreased arousal with erectile dysfunction in men anorgasmia in women and increased ejaculation latency in men. Tx: Decrease dose of SSRI, add PDE-5 inhibitor, and switch or argument with a non SSRI such as bupropion.

SSRI Sexual Side Effects

subacute stent thrombosis due to medication noncompliance. long term dual anti platelet therapy with aspirin and platelet P2Y12 receptor blocker (Clopidogrel, Prasugrel, Ticagrelor) to reduce risk of stent thrombosis. premature d/c of med is strong predictor of stent thrombosis within first 12 months.

STEMI in a patient who recently had a drug-eluting stent place. result of?

indicates how well as test can screen for a disease. HIGHER sensitivity makes it less likely that there are false negatives. meaning that a negative test better rules out the disease SNOUT

Sensitivity

Fenofibrate (DECREASES TRIGLYCERIDES)

Severe Hypertriglyceridemia (familial dysbetaliporoteinemia, striate palmar xanthomas, blood is milky and opalescent)

Waldenstrom's macroglobulinemia Lymphopasmocytic malignancy. Hyperviscosity Syndrome: Diplopia, Tinnitus, Headache, Dilated/segmented funduscopic findings), Neuropathy, hepatosplenomegaly, anemia, thrombocytopenia Confirm dx: Bone marrow biopsy >10% clinical B cells

Sharp IgM spike on serum protein electrophoresis

painless hematuria UTIs Renal Medullary Cancere Papillary necrosis can occur with massive hematuria, normal appearing RBCs on urinalysis also inability to concentrate the urine (vasa rectae damaged due to sickling in the vasa recta ) = HYPOSTHENURIA and distal renal tubular acidosis (tubular damage with impaired H+ secretion) HYPOSTHEnURIA: Polyuria low urine specific gravity normal serum sodium (intact ADH)

Sickle Cell trait renal complications

2-4 months with clinical breast exam, as cystic fluid can reaccumulate. If no further symptoms or signs of recurrence than annual screening can be resumed.

Simple breast cyst in a symptomatic patient that resolves post aspiration should be followed up when?

Before 65 positive ANTI-NUCLEAR ANTIBODY

Sjogren syndrome age of onset

Focal Nodular Hyperplasia (FNH) hyper plastic response to hyper perfusion caused by inappropriately large artery typically found at center of the lesion CT or MRI shows hypo or isodense lesion with arterial enhancement and a central stellate scar F>M Estrogen sensitive and larger in OCP users. Asympotmatic found incidentally no treatment no biopsy

Small <5cm solitary lesion ARTERIAL ENHANCEMENT & CENTRAL STELLATE SCAR

Bladder Dye Test Vesicovaginal fistula a complication of obstructed labor in small pelvis or limited or no prenatal care. obstructed labor is most common cause of fistula. excessive fetal head compression during obstructed labor causes injury and necrosis rot maternal vagina, rectum, and bladder. result in vesicovaginal or rectovaginal fistula with a vesicovaginal get continuous vaginal discharge with alkaline pH (URINE), malodorous due to surrounding necrotic tissue.

Small red area of granulation tissue on anterior vaginal wall, after a still birth. complaining of clear, slightly malodorous vaginal discharge. establish diagnosis?

Indicates how well a test can confirm the diagnosis. Higher the specificity the less likely there are false positives meaning that a positive test result better rules IN the condition. SPIN

Specificity

gaucher Disease AR Glucocerebrosidase deficiency -> Glucocerbroside accumulation in macrophages. Lysosoaml storage disease

Splenomegaly Hepatomegaly Anemia Thrombocytopenia Bone pain Delayed puberty

Increase endogenous insulin production

Sulfonylureas (GLIPIZIDE)

migraines and cluster NOT tension type headaches.

Sumatriptan indicated in treatment of

Mechanical prosthetic valve thrombosis strongest risk factor is inadequate warfarin anticoagulation dx: Echo

Symptoms of heart failure in a patient with prothetic heart valve

Grave's Disease/ hyperthyroidism

TSH receptor antibody, proptosis, periorbital edema

myocardial contusion

Trauma resulting in sternal fracture, and new onset tachycardia, and bundle branch block or arrhythmia.

Entamoeba histolytica Amoebic COlitis

Travelled to Philippines diarrhea bloody stools with mucus

Splenectomy

Treatment and prevention of symptoms in hereditary spherocytosis?

Imatinib (inhibits BCR-ABL Tyrosine Kinase)

Treatment for Chronic Myelogenous Leukemia (predominant neutrophils, t9,22, Philadelphia, BCR-ABL)

Oral Amxocillin/Clavulanic Acid

Treatment for Otitis Media (Bulging tympanic membrane)

Cholinesterase inhibitors (ie, donepezil) are first-line therapy for treatment of symptoms in mild to moder- ate disease but do not affect outcome. Memantine, an NMDA receptor antagonist, may slow decline in moderate to severe disease.

Treatment of Alzheimers

complex multilocular mass involving tube and ovary

Tube-Ovarian abscess on US

Dual Antiplatelet Therapy (DAPT): Aspirin + P2y12 receptor Blockers (Clopidogrel) significant reduction in recurrent MI, at least 12months in all its post drug eluting stent Beta Blocker ACEi/ARB HMG-CoA Reductase Inhibitor (Statin) Aldosterone Antag (Spironolactone)

Tx for Coronary Artery Dz

Type I (α) error: The probability of concluding that there is a difference in treatment effects between groups when in fact there is not (ie, a false positive conclusion)—in other words, rejecting the null hypothesis (of no effect) when it should not be rejected. The p-value is an estimate of the probability that differences in treat- ment effects in a study could have happened by chance alone if no true association exists. Often, differences associated with a p < 0.05 are statistically significant. A p-value alone does not give any informa- tion about the direction or size of the effect.

Type 1 error

Type II (β) error: The probability of concluding that there is no difference in treatment effects when in fact a difference exists (ie, a false negative conclusion)—in other words, not rejecting the null hypothesis (of no effect) when it should be rejected. Power is the probability that a study will find a statistically signi cant difference when one is truly there. Increasing the number of subjects in a study ↑ the power. Power = 1 - type II error (β)

Type 2 error

Alport Syndrome

Type IV collagen defect leads to glomerular disease with microscopic and gross hematuria in childhood. Also have sensorineural hearing loss and ocular defects.

can involve the kidneys (pyelonephritis) Risk factors: -girls any age -uncircumscribed boys <1 -underlying renal anomaly (vesicoureteral reflux, posterior urethral valves) Fever (>102) any child under 3 should prompt evaluation for occult UTI. BUN, Cr, Urinalysis are quick and noninvasive microscopic urinalysis more accurate than dipstick and a urine culture can identify bacteria type and antibiotic susceptibility.

UTI in infants and toddlers require prompt diagnosis and tx because?

Preterm labor and delivery

Ultrasonography shows a dichorionic-diamniotic twin intrauterine pregnancy. This patient is at increased risk for which of the following complications?

repeated microfacture at tendon insertion.

Underlying mechanism of Osgood-Schlatter? tenderness and swelling over the tibial tubercle.

Naloxone

Unresponse from heroin, Pulse 75, RR6, BP 100/60. Administer as initial step in management?

amyotrophic lateral sclerosis (ALS) diagnosed clinically and in patients >40yo.

Upper motor neuron (upgoing babinski and hyperactive reflexes) and lower motor neuron signs (atrophied hand muscles)

Warm autoimmune hemolytic anemia

Upper respiratory illness Jaundice Splenomegaly POSITIVE COOMBs HIGH Retic Normal MCHC

Down Syndrome (Trisomy 21)

Upslanting palpebral fissures, HYPOTONIA (poor feeding due to weak suck, protruding tongue)

Chlamydia trachomatis untreated can lead to infertility or ectopic due to PID, tubo-ovarian abscess.

Urethritis (dysuria, sterile pyuria (urine has WBC in absence of bacteriuria)) and nonmonogaus sexual contact.

swallowing, palate elevation, phonation, parasympathetic outflow to thoracoabdominal viscera. taste in epiglottis and sensation from parts of external ear. afferent lib of cough reflex and efferent limb of gag reflex.

Vagus Nerve (CN X)

cirrhotic patients need diagnostic upper endoscopy. those with medium or large varices should be started on nonselective BETA BLOCKER (PROPRANOLOL, NADOLOL) as prophylaxis if not actively bleeding. decrease adrenergic tone in mesenteric arterioles resulting in unopposed alpha mediated vasoconstriction and decreased portal venous flow endoscopic variceal ligation is an alternative if contraindications to beta blockers if actively bleeding then Octreotide (long acting somatostatin analog) causes splanchnic vasoconstriction and reduced portal blood flow by inhibiting release of glucagon. OR Endoscopic sclerotherapy.

Varices in Cirrhosis

most common cause of sudden cardiac death during an MI CPR & DEFIBRILLATION

Ventricular Fibrillation

deposition of sterile vegetation (immune complex, thrombus) on cardiac valves. occur in patients Wirth advanced malignancy or SLE. Patients are usually asymptomatic but may have symptoms of systemic embolization. (Focal weakness due to stroke)

Verrucous (Libman-Sacks) Endocarditis

Chronic pyleonephritis of the kidney resulting in severe renal scarring and blunted calyx. Gold standard for dx: Voiding Cystourethrogram first UTI at 2-24months should have renal and bladder US

Vesicoureteral reflux complication

GLP-1 agonists (Exenatide, Liraglutide)

Which anti-diabetic med most appropriate for reducing weight and controlling blood sugar?

Blastomycosis Great Lakes, Mississippi River and Ohio river basins (Wisconsin) Verrucous skin lesions can simulate SCC Forms granulomatous nodules

Wisconsin, fever, night sweats, productive cough, weight loss, multiple well circumscribed verrucous crested lesions, left upper lobe consolidation and two lytic lesions in anterior ribs.

cardioversion if unstable or procainamide or Ibutilide if stable AV node blockers such as beta blockers, CCBs, Digoxin, and adenosine should be avoided.

Wolff-Parkinson-White syndrome who develop Atrial Fibrillation with a rapid ventricular rate should be treated with?

Single round blue inclusions within RBCs on smear, consistent with Howell-Jolly Bodies (Persistent of RBC precursor nuclei) Due to asplenia (removed spleen) or Hyposplenism from splenic auto infarction (sickle cell disease)

Wright Staining

Lead poisoning Lab: Anemia, Elevated venous lead level, Elevated serum zinc protoporphyrin level, basophilic stippling on peripheral smear

abdominal pain constipation anorexia cognitive deficits peripheral neuropathy anemia

Whipple's Dz

abdominal pain, diarrhea, malabsorption with distention, flatulence, steatorrhea. migratory polyarthropathy, chronic cough, myocardial or valvular involved. ophthalmoplegia, myoclonus. pigmentation. LAD. PAS + in lamina propria

acute pancreatitis

abdominal pain, nausea, elevated lipase

Torsion of the sigmoid colon (Sigmoid Volvulus) colonic dysmotility and redundant sigmoid colon from chronic constipation increase risk of torsion of there sigmoid colon around its mesentery.

abdominal radiograph reveals distended bowel loop, without any haustra, extend from pelvis to RUQ in an inverted U shape. Several dilated small bowel loops with air fluid levels. No air in the rectum.

Choriocarcinoma type of gestational trophoblastic neoplasia follows after hydatidiform mole or any pregnancy. rapid metastasis to lungs and vagina.

abnormal uterine bleeding, pelvic pressure, symmetrically enlarged uterus, friable vaginal lesion (2x2cm, red, vascular nodule in the posterior fornix of the vagina bleeds when touched with cotton tip applicator)

Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome) 46XX

absence of uterus, cervix, upper 1/3 of vagina primary amenorrhea normal breast development ovaries and normal axillary and pubic hair

metabolic acidosis

acid base disorder in diarrhea

Respiratory acidosis due to hypoventilation (pickwickian Syndrome)

acid base disorder in obesity

metabolic Alkalosis

acid base disorder in vomiting

Bacterial meningitis. Most commonly Strep Pneumonia BUT >50yo or immunocompromised can have gram + bacillus (LISTERIA) raw meats/vegetables, UNPASTEURIZED MILK, prepackaged meats (hot dogs, deli)

acute fever, confusion, headache, neck stiffness, CSF evidence of Neutrophilic pleocytosis

Acute angle closure glaucoma precipitated by Decongestants, Antiemetics, Anticholinergics (TRIHEXYPHENIDYL-used in tx of Parkinson)

acute headache, nausea, blurry vision, sluggish/dilated pupil

Meniscal Tears locking or catching of knee, sensation of instability, exacerbation of pain with squatting. Tenderness AT joint line. Palpable locking or catching. PAINFUL CLICK DURING FLEXION AND EXTENSION. Dx: MRI Tx: Rest, decrease weight bearing.

acute knee pain, limited joint extension, from twisting injury. Sensation of knee giving away when walking.

Nerve root compression by a herniated disc radiation of pain to butt or posterior thigh, and more specific to sciatica calf and foot initial management = NSAID & Acetaminophen As it is self limiting.

acute lumbosacral radiculopathy (Sciatica)

Diffuse alveolar hemorrhage

acute onset cough, fever, hemoptysis, dyspnea. CXR: Interstitial infiltrates. In a patient with SLE.

pulmonary embolism Ventilation/Perfusion (V/Q) Mismatch. High alveolar-arterial gradient on arterial blood gas. Decreased PaCO2 due to hyperventilation

acute onset dyspnea and chest pain in setting of DVT given leg swelling in a patient with possible endometrial cancer given abnormal uterine bleeding and obesity.

pulmonary embolism pulmonary infarct leads to hemoptysis risk from HIV, hemoconcentration due to dehydration CT: WEDGE SHAPED PLEURAL OPACIFICATION CT with Contrast: Pulmonary artery filling defect

acute onset pleuritic chest pain, hemoptysis, tachycardia

acute angle closure glaucoma IV ACETAZOLAMIDE permanent cure with laser peripheral iridotomy

acute onset severe eye pain and blurred vision with N/V, following a pupillary dilation in darkened movie theatre, during time of stress or due to drug intake. Red eye with steamy cornea, pupil dilated and non reactive to light.

ruptured ovarian cyst only surgery if unstable otherwise analgesic on outpatient basis

acute onset unilateral pelvic pain, precipitated by strenuous activity or sexual intercourse. US confirms diagnosis by showing free fluid in pelvis.

drug induced acne (steroid induced folliculitis or steroid acne) uniform appearing erythematous ppaules across back, shoulders, upper arms

acute papular inflammatory rash

IV steroids

acute renal transplant rejection is best treated with?

Parvovirus B19 infection polyarticular, symmetric. Self limited resolves in 1-2 months. tx: NSAIDS

acute symmetrical arthralgia small joints of hands, morning stiffness and improves after use. NO other symptoms. and normal ESR. in person who works in a daycare.

first gen antihistamines have significant anticholinergic effects results in dry eyes, dry oral mucosa, urinary retention. urinary retention due to impaired detrusor muscle contraction, and impaired internal sphincter relaxation. Especially in elderly with BPH

acute urinary retention due to an adverse effect of diphenhydramine

androgen producing adrenal tumors

adulthood with rapidly progressive hirsutism and virilization. Serum DHEAS >700

iron deficiency anemia in young children excess cow milk is problematic due to low iron content. children should not be started on cows milk until 1 yo, and children >1 should consume <24oz/day. Typical glass is 8oz. no workup needed but rather treatment with empiric oral iron therapy, hemoglobin then rechecked in 4 weeks, if hemoglobin rises oral intake therapy continues for 2-3 months.

after 6 months inadequate dietary intake, most important cause of iron deficiency.

Tracheobronchial perforation (bronchial rupture) secondary to blunt thoracic trauma. Right main bronchus mist commonly injured. Confirm diagnosis with CT, Bronchoscopy, or surgical exploration. Operative repair indicated.

after MVA, persistent pneumothorax despite chest tube placement and pmneumomediastinum, subcutaneous emphysema.

Benzodiazepines Haloperidol would be a second line but contraindicated in seizure disorder.

agitation and aggression management in a patient with PCP intoxication (Agitation, disorientation, nystagmus)

pseudocyesis Hx of infertility and prior pregnancy loss. somatization of stress affects the hypothalamic-pituitary-ovarian axis and causes early pregnancy symptoms. Body changes misinterpreted. non psychotic patient who believes she is pregnant. can be such a strong belief that she misinterprets negative home pregnancy test as positive. Psychiatric evaluation and treatment.

amenorrhea, breast fullness, morning sickness, abdominal distention (symptoms of early pregnancy), however office exam (thin endometrial stripe, negative urine pregnancy test) excludes pregnancy.

prophylaxis of tension type headaches (constant pressure in temporal and occipital regions without nausea) and migraine headaches (unilateral, pulsatile throbbing headaches associated with N/V)

amitriptyline for what types of headaches

acute nephritic syndrome with fluid overload Poststrep glomerulonephritis, IgA neuropathy, Lupus nephritis, Membranoproliferative Glomerulonephritis, rapidly progressive glomerulonephritis Dec GFR

anasarca, pulm and facial edema, HTN, proteinuria and microscopic hematuria

Gaucher Disease

anemia thrombocytopenia splenomegaly hepatomegaly bone pain failure to thrive delayed puberty

Myelodysplastic Syndrome (MDS) Hematopoietic stem cell neoplasm leads to dysplasia and cytopenias. elderly, previous chemo, or radiation therapy Dx: BONE MARROW BIOPSY

anemia (weak, fatigue, dyspnea) granulocytopenia (infection) normocystic or macro cystic anemia

diabetic gastroparesis diabetic autonomic neuropathy of GI tract (delayed gastric emptying or gastroparesis) tx: increase fiber, small frequent meals, METOCLOPROMIDE

anorexia, nausea, vomiting, early satiety, postprandial fullness, impaired glycemic control, in a diabetic.

flattening of deltoid prominence, protrusion of acromion, anterior axillary fullness Axillary nerve most commonly injured. innervates teres minor and deltoid, and sensory to skin of lateral shoulder. Shoulder abduction weakness

anterior dislocation of the humeral head (blow to externally rotated and abducted arm)

urethral diverticulum abnormal localized out pouching of the urethral mucosa into surrounding tissues dysuria postvoid dribbling dyspareunia anterior vaginal wall mass dx: urinalysis, urine culture, MRI, transvaginal US CONFIRMED with MRI Tx: Surgical Excision

anterior vaginal wall mass presenting as dyspareunia or palpable mass on pelvic exam. purulent discharge, dysuria, or postvoid dribbling.

Glucagon by activating adenylate cyclase, increases intracellular calcium and improves cardiac contractility

antidote for beta blocker or calcium channel blocker

Primary biliary cholangitis

antimitochondrial antibodies

aortic root dilation

aortic regurgitation presenting with progressive exertional dyspnea and a decrescendo early diastolic murmur

atrial septal defect (ASD) with LEFT to RIGHT shunt

asymptomatic until adulthood, decreased exercise tolerance (fatigue, dyspnea), Atrial Arrhythmias (A fib or flutter), stroke due to paradoxical embolization, pulmonary HTN, Right heart Failure, or cerebral abscess. Wide fixed split of S2, does not change with inspiration or Mid systolic or ejection murmur over left upper sternal border or Mid diastolic rumble

Ataxia Telangiectasia

ataxia abnormal eye movements facial telangiectasia recurrent sinopulmonary infections.

mediastinal contents shift TOWARD atelectatic lung with compensatory hyperinflation of the opposite lung

atelectasis and collapse of large portion of lung

functional hypothalamic amenorrhea progestin challenge test (medroxyprogesterone acetate) confirm low estrogen levels as there is no withdrawal bleed due to estrogen not around to proliferate endometrium. No endometrium lining to shed. HYPOESTROGENEMIA: -Infertility -Breast Atrophy -Decreased bone mineral density

athletic patient with secondary amenorrhea, negative pregnancy, normal prolactin and TSH

Disseminated TB CKD is one of several immunosuppressed states (DM, HIV, Malignancies, immunosuppressant medications) increase risk of Mycobacterium TB reactivation. Lung apices (cavitary infiltrate in upper lung), affect bone (Collapse of L3 & L4 vertebral bodies)

back pain, subacute illness with intermittent fevers, night sweats radiographic evidence of pulmonary and spinal disease with lab results of normochromic anemia and chronic inflammation (HIGH ESR & Thrombocytosis)

Strep pneumoniae (third gen cephalosporins (Ceftriaxone), Vancomycin) Listeria (ampicillin)

bacterial pneumonia in an elderly >50 or immunocompromised

Frontotemporal Dementia

behavior and personality changes BEFORE memory deficits. Earlier age of 60.

Mucinous cystadenoma

benign surface epithelial ovarian masses that appear as thin walled locations of mutinous fluid

osteoma

benign, solitary area of bony overgrowth that form in outer ear. lead to hearing loss.

genetic testing XR show deletion of the dystrophin gene on Xp21

best test to confirm the diagnosis of Duchenne Muscular Dystrophy

C5 & C6 spinal nerves with muscular innervation vita musculocutaneous nerve (lateral cord of brachial plexus)

biceps reflex

terminal ill disease (Ileal resection, Crohn ileitis) increased bile salts in colon, resulting in diarrhea (cholerheic diarrhea)

bile salt diarrhea

midgut volvulus from intestinal malrotation dx: upper GI series tx: Surgery

bilious vomiting

Bullous pemphigoid autoimmune >60yo

biopsy shows sub epidermal cleavage, with linear IgG deposits at basement membrane on immunofluorescence

Chronic Pancreatitis usually due to alcohol use.

bloating, frequent bulky foul smelling stool = steatorrhea malabsorption lead to weight loss epigastric abdominal paina nd DM Multiple calcifications within the pancreatic duct

Rupture of aorta Transesophageal Echo or CT with contrast if stable exploratory thoracotomy if unstable

blunt chest trauma, chest pain, upper extremity HTN, wide mediastinum

pulmonary contusion blood filling the alveoli <24 hours after trauma and resolve in a week tx: pain control, pulmonary hygiene (nebulizer tx, chest physiotherapy) and supplemental oxygen until contusion resolves

blunt thoracic trauma, hypoxia, lower right bronchial breath sounds, opacity on CXR, tachypnea.

hemothorax

blunting of costophrenic angle

Osteoclastoma (Giant Cell Tumor of Bone) benign but locally aggressive tumor in long bone epiphysis Soap bubble appearance

bony trabecular within lesion of long bone epiphyses

Holt-Oram Syndrome (heart-hand)

both upper limb defects (deformities of radius and carpal bones) and ASD

Legg-Calve-Perthes Disease (idiopathic osteonecrosis of the femoral head)

boys 3-12 antalgic gait dull chronic. lower ext pain referred thigh or knee pain normal initial xray limited internal rotation and abduction of the hip

Mammogram every 2 years 50-75

breast cancer screening

Asthma

bronchoconstriction and small airway inflammation occur in patients with

Meralgia Paresthetica compression of lateral femoral cutaneous nerve at the waist

burning pain and paresthesias at lateral thigh

pagets disease markers of bone resorption (telopeptides) markers of bone formation (alk phos and osteocalcin)

c-telopeptide and n-telopeptide and alk phos, and osteocalcin are elevated in?

inexperienced athletes from high impact exercise program. pain at heel that os worse with weight bearing. pain can be elicited by firm palpation at side of heel. (Sqeeze test)

calcanea stress fracture

malabsorption of fat (Crohns) leads to increased binding of calcium by fat, less calcium available to form insoluble oxalate complexes, facilitating increased intestinal absorption of oxalate. renal clearance of excess oxalate leads to calcium oxalate kidney stones.

calcium oxalate kidney stones

scalp swelling superficial to periosteum, crosses suture lines. identified at birth. edema involves the portion of head presenting doing vertex delivery.

caput succedaneum

Obstructive Shock HIGH PCWP LOW Cardiac Index HIGH SVR LOW MvO2 distant heart sounds JVD

cardiac tamponade can cause what type of shock

subjects with the disease of interested compared to those similar groups disease free. Look for exposure to risk factors. Measure Odds ratio, NOT incidence.

case control study

Lymphatic network dysgenesis from congenital lymphedema dysfunctional lymphatic system causes accumulation of protein rich interstitial fluid in the hands, feet, neck. severe obstruction of lymphatic vessels can result in CYSTIC HYGROMA of the neck and fetal hydros. non pitting edema at birth due to high protein continue t in interstitial fluid.

cause of swelling in Turner syndrome

optic neuritis central scotoma and afferent pupillary defect, pallor of optic disc.

cause of visual loss in a patient with MS?

Coagulase negative staph, Staph aureus, and CANDIDA (colonize skin, mucus membranes and GI tract)

central venous catheter infection

Macular degeneration atrophic (dry): slow, bilateral exudative (wet): unilateral, agressive DRUSEN and patchy depigmentation

central vision loss.

ipsilateral (fall toward side of lesion), nystagmus, hypotonia, dysarthria, loss of coordination, inability to perform, rapid, alternating movements.

cerebellar ataxia

Preterm labor risk factors: -short cervical length -hx of preterm delivery -multiple gestations in the absence of contraindications to vaginal delivery patient who present in preterm labor >34 weeks gestation can be managed expectantly. However due to an increased risk of fetal injury a vaginal delivery is contraindicated for a breech. best option would be C section. Active labor is a contraindication for external cephalic version.

cervical dilation, painful contractions <37 weeks

pulmonary embolism (PE) LOW CO HIGH RA pressure HIGH RV pressure HIGH Pulmonary Artery Pressure NORMAL PCWP (Left Atrial Pressure) increased resistance between pulmonary artery and pulmonary capillaries and left ventricle.

chest pain, SOB, hypotension, tachycardia, hypoxia, but Clear lungs on exam

Cholesteatoma secondary to chronic middle ear disease complications: -hearing loss -cranial nerve palsies -vertigo -brain abscess or meningitis CT and or surgical visualization to confirm diagnosis.

child with continued ear drainage for several weeks despite appropriate antibiotic therapy. retraction pocket in tympanic membrane fill with granulation tissue and skin debris.

cystic fibrosis (CF) CFTR gene chronic airway inflammation eventually causes BRONCHIECTASIS bronchial airway dilation and erosion lead to hemoptysis

child with hemoptysis, multiple pulmonary infections, pancreatic insufficiency (chronic diarrhea treated with pancreatic enzymes)

Down Syndrome

childhood acute lymphoblastic leukemia, and Brushfield Spots (white-grey spots on periphery of iris) seen in?

Langerhans cell histiocytosis

children <3, single or multiple punched out lytic bone lesions.

irritant induced inflammation leading to hyper secretion of mucus and structural changes of the tracheobronchail tree. Productive cough for >3m over 2 consecutive years. This is a form COPD. FEV1/FVC <70% NORMAL DLCO CXR: prominent bronchovascular markings and mildly flattened diaphragm.

chronic bronchitis

chronic inflammation of the conducting airways and hyperexpasnion of the lungs due to alveolar wall destruction

chronic bronchitis and emphysema of COPD FEV1/FVC <70

Neurocognitive deficits psychosis neuroimaging: atrophy of medial temporal, temporal pole, parahippocampal cortex, amygdala, orbitofrontal cortext

chronic cannabis use

suspect asthma Get PFTs if no bronchodilator response seen can do a methocholine challenge test can also treat empirically with inhaled glucocorticoids for 2-4 weeks. If cough improves a diagnosis of asthma can be made

chronic cough that worsens overnight and not improve with antihistamine

Crohn Disease 15-40 weight loss microscopic bleeding stricture formationm malabsorption mouth to anus fistulas due to transmural bowel inflammation cause sinus tracts arthritis, uveitis, scleritis, erythema nodosum

chronic diarrhea abdominal pain fever enterovaginal fistula (passing gas or feces from vagina)

post nasal drip symptom relief by antihistamines to reduce nasal secretions

chronic dry cough in a patient with allergic rhinitis

Phymatous Rosacea

chronic irregular thickening of the skin involving the nose

Secretory Diarrhea large daily stool volumes, even during fasting or sleep.

chronic non bloody diarrhea and weight loss after multiple abdominal surgeries

Adenomyosis Endometrial glands and storm accumulate within the uterine myometrium >40 new onset dysmenorrhea heavy bleeding chronic pelvic pain BOGGY, TENDER UTERUS, SYMMETRICALLY ENLARGED UTERUS pelvic US and or MRI definitive dx via hsitologiclly after hysterectomy which is also the treatment for those who don't improve with conservative management (OCP, progestin-releasing IUD)

chronic pelvic pain, heavy menstrual bleeding, boggy uterus.

open angle glaucoma Elevated IOP Decreased vision in peripheral visual fields Optic Disc Cupping increased cup:disc ratio due to loss of ganglion cell axons decrease IOP with meds

chronic progressive loss of peripheral vision

microscopic colitis Nocturnal Diarrhea >50 F Smoking NSAID stool studies should be performed to rule out other etiologies diagnosed based on Colonoscopy revealing inflammatory infiltrates with a mononuclear predominance tx by avoiding NSAID, starting antidiarrheal agents.

chronic watery diarrhea without evidence of lactose intolerance or systemic symptoms

Symptoms & Signs of Adrenal Insufficiency Primary adrenal insufficiency (Addison Disease) initial eval should include 8AM serum Cortisol and Plasma ACTH. Low cortisol <5 with High ACTH confirms primary adrenal insufficiency Low Cortisol & low ACTH = central adrenal insufficiency (pituitary or hypothalamic) High cortisol >15 rules out primary adrenal. Csyntropin is a synthetic ACTH analog, infusion normally triggers a rapid increase in cortisol, but primary adrenal insufficiency will. not have rise.

chronic weakness, weight loss, hyponatremia, hyperkalemia, low-normal cortisol

SLE, Post strep glomerulonephritis

circulating immune complexes in glomerulonephritis

Spontaneous Bacterial Peritonitis (SBP) dx: PARACENTESIS

cirrhosis + ascites + fever and lethargy

celiac disease dermatitis herpetiformis.

clusters of intensely pruritic plaques and vesicles on dorsal forearms, knees, butt. diarrhea, neuropsychiatric disease.

manic type symptoms during intoxication depression during withdrawal

cocaine causes substance induced mood disorders

fetal growth restriction and abrupt placentae.

cocaine use during pregnancy

Vitamin C Deficiency (Scurvy) decreased connective tissue strength needed for hydroxylation of proline and lysine residues during collagen synthesis poor wound healing in children have hemorrhages, bony deformities and subperiosteal and joint hematoma.

coiled hairs perifollicular hemorrhages petechial hemorrhages mucosal bleeding periodontal disease

myelofibrosis

collagen or reticulin deposition in bone marrow presenting with fatigue, fevers and hepatosplenomegaly from extra medullary hematopoiesis.

Laryngomalacia

collapse of supraglottic structures during inspiration presents with chronic inspiratory stridor that begins in the neonatal period WORSE in SUPINE

ALL patients 50-75 FOBT annually, or flexible sigmoidoscopy every 5 years, or combined with FOBT every 3 years, or colonoscopy every 10years

colon cancer screening

Thiazide diuretics

common cause of erectile dysfunction

peripheral edema due to dilation of precapillary vessels (arteriolar dilation) headache, flushing, dizzy Risk of peripheral edema is decreased by adding ACEi/ARB

common side effect of dihydropyridine CCB (AMLODIPINE & NIFEDIPINE)

cause increased intrapleural pressure and displace mediastinal structures leading to tracheal deviation and neck vein distention due to SVC compression. High intrathoracic pressure IMPEDED VENOUS RETURN to the RA by compressing vena cava. Tx: needle decompression followed by placement of tube thoracostomy to increase venous return

complication of tension pneumothorax

decreased LV preload secondary to hemothorax

complication of thoracentesis, now presenting with lack of breath sounds, dullness to percussion, and hypotension.

ZIKA VIRUS

congenital seizures, microcephaly, hypertonia, contractures, ocular abnormalities, hearing loss

milk-alkali syndrome hypercalcemia from excess calcium intake for patients with osteoporisis as an alternative to bisphosphanets. HIGH CALCIUM LOW Phosphate LOW MAG Metabolic Alkalosis AKI DEC PTH causes renal vasoconstriction and decreased glomerular blood flow, inhibit Na-K-2Cl cotransport due to activation of calcium sensgin receptors in thick assending loop impaired ADH leads to loss of sodium and free water, results in hypovolemia and increased reabsorption of bicarb. medications that can cause this: Thiazide, ACEi/ARB, NSAID

constipation, abdominal pain, urinary frequency and constant thirst

multiple myeloma Hypercalcemia leads to fatigue, constipation, and depression bone marrow infiltration by neoplastic cells, alters normal leukocyte population and causes HYPOGAMMAGLOBULINEMIA = Increased risk for infection dx: serum/urine protein electrophoresis (M-spike), peripheral blood smear (rouleaux) and serum free light chain analysis. confirm diagnosis by bone marrow biopsy.

constipation, back pain, anemia, renal insufficiency, hypercalcemia Osteolytic lesions, fractures, Hypercalcemia (from bone destruction) and Anemia excess monoclonal protein can clog renal tubules causing renal insufficiency

delayed growth spurt, delayed puberty and delayed bone age. once reaches puberty a normal growth spurt will occur and will attain a normal adult height. schedule followup visit in 6 months.

constitutional growth delay

patent ductus arteriosus (PDA)

continuous machine like murmur associated with congenital rubella syndrome.

coarctation of the aorta

continuous rumbling murmur in the back over the interscapular area

primary dysmenorrhea First line = NSAID in non sexually active, in sexually active OCP

cramps bilateral lower abdominal pain 1-2 days prior to menses and resolves a few days after onset of menses. NORMAL pelvic exam.

Pyoderma gangrenosum (rare neutrophilic dermatosis)

cutaneous papule or nodules that mature into a painful purulent ulcer with violaceous borders. without fever. in a patient with IBD and arthropathies.

spermatocele

cystic epididymal accumulation of sperm that form superiorly to testicle

Contralateral Hemiballismus

damage to sub thalamic nucleus seen in

ventilation of areas of the lung that are not perfused with blood as in pulmonary embolism

dead space ventilation

Botulism

decreased acetylcholine release from motor neurons

Urethral sricture fibrotic narrowing of urethra obstructive type voiding symptoms idiopathic, pelvic fracture, iatrogenic instrumentation, sexually trasnmitted urethritis, radiotherapy. elevated postvoid residual urethrography (voiding cystourethrogram or cystourethtoscopy can confirm the diagnosis. mild strictures can be observed but significant structures require correction with urethral dilation or surgical urethroplasty

decreased urinary flow, incomplete emptying. in a young man.

long thoracic nerve injury causing scapular winging. as it innervates serrates anterior.

deep lacerations to the axillary region and axillary lymphadenectomy are common cause of

Membranoproliferative glomerulonephritis persistent activation of the alternative complement pathway. caused by IgG antibodies (termed C3 nephritic factor) directed against C3 convertase of the alternative complement pathway.

dense intramembranous deposits that stain for C3

duration of 6months and lifelong chronic anxiety if <6months and lack of psychiatric hx = major depression (>2weeks)

diagnosis of generalized anxiety

Complete Atrioventricular Septal Defect most common in Down Syndrome Both VSD & ASD defect heart failure due to blood mixing between chambers and severe AV valve regurgitation leading to volume overload and excessive pulmonary blood flow. at around 6 weeks as pulmonary vascular resistance falls. Fixed split S2 (Delayed pulmonary valve closure from flow across ASD) Systolic Ejection murmur (increased flow across pulmonary valve due to left to right shunt across ASD) Holosystolic murmur of VSD Holosystolic apical murmur depending on degree of AV valve regurgitation

diaphoresis and dyspnea with feeds and crackles around age 6 weeks in a child with Down syndrome

pathologic Further eval with echocardiogram. Aortic Regurgitation leads to an early and gradual; decreasing decrescendo diastolic murmur. high pitched, blowing in quality. best heard along left sternal border at 3rd and 4th intercostal space. with patient sitting up and leaning forward while holding breath in full expiration.

diastolic and continuous murmurs are

scleroderma Tx Raynaud with first prevent fingers from getting cold, second CCB (NIFEDIPINE)

difficult swallowing with food sticking in throat = Esophageal dysmotility cold induced vasospasm leads to paleness of fingers = Raynaud Phenomenon

acute pericarditis

diffuse ST elevation and PR depression

pneumocystis pneumonia

diffuse interstitial pattern

Interstitial lung disease due to Asbestosis. cor pulmonate eventually develops with peripheral edema, hepatojugular reflux, JVD, RV heave. CXR: Interstitial abnormalities of lower lung fields and PLEURAL PLAQUES RESTRICTIVE Pattern (Decreased lung volumes with normal or elevated FEV1/FVC ratio >80%, DECREASED DLCO & Pulmonary compliance)

digital clubbing, bibasilar end inspiratory crackles in a plumber

Psoriasis worsening of symptoms occurs in local skin trauma (koebner phenomenon) infections, withdrawal from glucocotritocs, antimalrialis, indomethacin, propranolol

distal onycholysis (distal separation of nail plate from nail bed) & pitting (focal areas of abnormal keratinization of the nail plate) in association with dermal erythematous plaques on knees and elbows

serum Alpha-Fetoprotein (AFP)

distinguish hepatocellular carcinoma from other types of liver lesions

stool osmotic gap. Osmotic Diarrhea: HIGH gap: Lactose Intolerance Secretory Diarrhea: LOW gap: Bacterial infections, viral infections, congenital disorders (CF), early ileocilitis, and post surgical changes (bowel resection or cholecystectomy)

distinguishing osmotic from secretory diarrhea

fetal alcohol syndrome (FAS) deficits in development of corpus callosum, cerebellum, basal ganglia results in abnormal reflexes, tones and coordination difficult writing and clumsiness. decrease volume of frontal lobe and dysfunction of amygdala defect in executive functioning, impulse control, emotion regulation. features of ADHD cognitobve imparement, seizures, learning disabilities, social skill deficits.

distractibility, emotional reactivity, growth retardation

Benign Paroxysmal Positional Vertigo displacement of otoliths from normal location. Diagnosed by Dix-Hallpike Maneuver (place head in positions to observe for nystagmus) Tx: maneuvers to reposition the displaced otoliths (epley maneuver)

dizziness with complaint of spinning sensation =Vertigo Intermittent, short episodes = peripheral etiology occurs when rolling over in bed

Chronic Lymphocytic Leukemia (CLL) diagnosed by: FLOW CYTOMETRY (Clonality of mature B cells)

dramatic leukocytosis with predominant lymphocytes in a 65 yo M. as well as hepartosplenomegaly, lymphadenopathy, anemia, thrombocytopenia.

penicillins, cephalosporins, sulfonamides fever, rash, arthralgia peripheral eosinophilia, hematuria, sterile pyuria, eosinophilia. WBC casts tx is to d/c offending agent.

drug induced interstitial nephritis

Efavirenz (non-nucleoside reverse transcriptase inhibitor) resolve within first few weeks of treatment careful in its with previous psych hx

drug reaction with HIV med: Dizzy, insomnia, vivid or bizarre dreams, depression, anxiety, confused, aggression.

glucocorticoids, beta blockers, oral cholecystography contrast agent, PTU

drugs that inhibit conversion of T4 to T3

Croup due to parainfluenza subglottic edema (Steeple Sign) on xray Tx: DEXAMETHASONE for mild cases and nebulized racemic epinephrine for patients with stridor at rest

dry bark seal cough, hoarseness, inspiratory stridor (high pitched noise on inspiration)

acute decompensated heart failure from LV Systolic Dysfunction due to cardiotoxic effects of chemoradiation therapy tx: Diuresis, Oxygen, Nitroglycerine early used of noninvasive ventilation in hypoxemia and respiratory distress provides rapid improvement to prevent need for mechanical ventilation.

dyspnea orthopnea JVD bibasilar crackles

clinical features of acute decompensated heart failure pulmonary edema due to acute decompensated HF. due to LV systolic or diastolic dysfunction. Or due to normal LV function but severe HTN, renal artery stenosis, severe renal disease with fluid overload. tx: Supplemental O2, IV Furosemide, IV Nitroglycerine if no hypotension

dyspnea orthopnea paroxysmal nocturnal dyspnea bibasilar crackles hypoxemia

acute decompensated heart failure from LV systolic dysfunction due to cardiotoxic effects on chemoradiation therapy. initial management includes IV diuresis, Oxygen supplementation, Nitrates and NONINVASIVE VENTILATION in hypoxemia and respiratory distress.

dyspnea, orthopnea, JVD, bibasilar crackles. In patient with recent chemo radiation. patient sitting up at edge of bed appears restless, using accessory muscles to breathe.

CHF Systolic LV dysfunction Tx: ACEi/ARBs Beta-Blockers (Metropolol, Carvedilol, Bisoprolol) Aldosterone Antag Hydralazine + Nitrates (In African American)

dyspnea, orthopnea, LE edema, bibasilar crackles.

involuntary, sustained twisting movements of limbs and trunk

dystonic gait

Acute cystitis

dysuria, frequency, urgency, suprapubic pain with no systemic manifestations

Aortic regurgitation due to aortic root dilation due to ascending aortic aneurysm from atherosclerosis.

early decrescendo murmur that begins immediately after A2, accentuated with patient sitting up and leaning forward while holding his breath in full expiration and puts hands behind head. left sternal border third and fourth intercostal space. radiates to right side along right sternal border.

Focal segmental glomerulosclerosis Especially in Obese, African American, HIV partial sclerosis limited to a segment of the glomerulus increased risk of infection (loss of immunoglobulins), thrombosis (loss of antithrombin and plasminogen), protein malnutrition.

edema, proteinuria >3.5, hypoalbuminemia, NO HEMATURIA = Nephrotic Syndrome Most common cause in adults

Fibromyalgia 1st line treatment = AMITRIPTYLINE (TCA) if not responding alternative therapy = pregabalin, duloxetine, milnacipran

effective initial therapy in patients who are young to middle age women with fatigue, widespread pain and cognitive/mood disturbance.

Malignant Otitis Externa due to infection by pseudomonas Aeruginosa CT or MRI can be used to confirm the diagnosis tx: CIPROFLOXACIN

elderly diabetic, ear pain and ear drainage with granulation tissue inside the ear canal. lead to osteomyelitis skull base and cranial nerve damage. result in facial drooping sue to damage of facial nerve.

pulmonary HTN and Cor pulmonale Loop diuretics are often used to lower right ventricular filling volumes and reduce peripheral edema. however, they can lead to HYPOVOLEMIA, LOW CO, and renal HYPOperfusion. Resulting in Prerenal Azotemia/Acute Kidney Injury.

elevated JVD, hepatomegaly, peripheral edema in presence of clear lungs suggest

after ethanol, methanol, or ethylene glycol ingestion

elevated plasma Osmolal gap seen

pituitary adenoma TSH has an alpha subunit common to TSH, FSH, LH and hCG and thyroid specific beta subunit HIGH TSH, HIGH T4, normal or increased radioiodine uptake.

elevated ratio of serum alpha subunit to TSH suggests

Alpha-1-antitrypsin deficiency

emphysematous lung disease, chronic hepatitis, cirrhosis, panniculitis (painful, erythematous nodules and plaques on thighs of butt)

homogenous cyst with internal echoes (ground glass)

endometrioma on US

chronic pancreatitis nonreversible exocrine and endocrine function damage leads to diarrhea, steatorrhea, wirhgt loss glucose intolerance with overt diabetes. pancreatic calcification seen on abdominal plain films or CT scan

epigastric abdominal pain that can radiate to back and partially relived by sitting up and leaning forward. chronic alcohol consumption. intermittent pain free intervals.

Acute Pancreatitis if not alcohol, and not gallstones next most common cause HYPERTRIGLYCERIDEMIA Serum TG >1000 to be considered a potential cause yellow red papule on arms and shoulders suggestive eruptive xanthomas (subcutaneous fat deposits) fasting serum lipid profile can confirm.

epigastric pain, vomiting, markedly elevated lipase

carcinoid syndrome neuroendocrine tumors found in distal small intestine, proximal colon, lung, metastasis to liver. episodic flushing (Pounding sensation in neck) associated with Hypotension and tachycardia.

episodic pounding sensation (FLUSHING), chronic DIARRHE, weight loss, valvular heart disease with tricuspid regurgitation,

Diffuse esophageal spasm (DES) Resolution after Nitrates is consistent with diagnosis. because it can relax smooth muscle cells in esophagus. Esophageal motility studies (manometric Recordings) shows repetitive, non peristaltic, high amplitude contractions.

episodic retrosternal pain that radiates to inter scapular region. precipitated by emotional stress, hot to cold food. Regurgitaes food intermittently. revolution of chest pain after NITROGLYCERINE

Erythematotelangiectatic Rosacea

erythema and facial flushing telangiectasia, roughness or scaling and burning discomfort.

Atopic Dermatitis (Eczema)

erythematous, scaly, pruritic rash on flexural surfaces

systemic sclerosis (scleroderma) & CREST syndrome

esophageal dysmotility, sclerodactyly, calcinosis cutis, telangiectasia

small intestine disease (Crohn or Celiac)

excess fecal loss of thyroid hormone can occur in

Hypertrophic Cardiomyopathy (HCM)

exertion lightheadedness and syncope, systolic murmur over left sternal border that is accentuated by moving from supine to standing. Inverted T waves on ECG.

Alpha Thalassemia normal hemoglobin is a heterotetramer composed of 4 chains: 2 alpha, 2 beta in children and adults 2 alpha, 2 gamma in fetuses and infants Hemoglobin H disease Result in chronic hemolysis, elevated erythrocyte count, microcytic, hypo chromic, target cells

extra band representing gamma tetramers on hemoglobin electrophoresis

chylothorax lymphatic flow through thoracic duct is disrupted, leading to direct leakage of chyle (lymphatic fluid) into pleural cavity. traumatic causes (cardiothoracic surgery), congenital malformations, Down syndrome, Noonan syndrome, malignancy. drain via thoracentesis or chest tube placement, limit dietary fat, and possible thoracic duct ligation.

exudative effusion. increased work of breathing, tachypnea, hypoxia, dullness to percussion. Milky white fluid with lymphocyte predominance and increased triglycerides.

Tuberous sclerosis

facial angiofibromas, hypo pigmented macules (ash leaf spots), shagreen patches, Renal angiolipoma

Ramsay Hunt Syndrome due to Herpes Zoster Infection

facial nerve palsy and vesicles in the auditory canal and auricle.

1-sensitivity

false negative ratio

1-specificity

false positive ratio

clinical features of chronic Hep C mixed cryoglobulinemia syndrome (palpable purpura, arthralgia, glomerulonephritis, low complement), lichen plans, Porphyria HCV is strongly associated with porphyria (Increased plasma and urine porphyrins) tx: Serial phlebotomy or hydroxychloroquine

fatigue elevation in LFTs arthralgia ulcers on back of hands (Porphyria Cutanea Tarda)

Hereditary Hemochromatosis IRON OVERLOAD HFE gene mutation AR increased intestinal iron absorption and iron deposition in tissues resulting in multi system end organ damage tx: Serial phlebotomy to deplete excess iron stores

fatigue hypogonadism (testicular atrophy, decreased sexual drive) arthropathy hepatomegaly

Acute Promyelocytic Leukemia (APML) a form of Acute Myeloid Leukemia (AML) APML will have coagulopathy due to DIC (prolonged PT/PTT/Hypofibringogenemia) Atypical promyelocytes on BM biopsy

fatigue, prolonged bleed, easy bruising, pancytopenia, coagulopathy, elevated LDH

Hyperthyroidism Most common = Graves due to autoantibodies to the TSH receptor casing diffuse goiter and proptosis, periorbital edema. High radioactive iodine uptake either graves with diffuse increase uptake or toxic nodular disease (nodular uptake). low radioactive iodine uptake suggest release of preformed thyroid hormones )thyroiditis) or exogenous hormone intake. SERUM THYROGLOBULIN, if HIGH endogenous, if LOW exogenous.

fatigue, sweating, palpitations, weight loss. Elevated T4, Suppressed TSH.

Hypothyroidism Myxedema maddness High TSH, Low T4 Tx: Levothyroxine

fatigue, weight gain, cold intolerance, myalgia, constipation, DEPRESSED MOOD, PARANOID, HALLUCINATIONS

Multiple Myeloma

fatigue, weight loss, bone pain, renal insufficiency with GRANULAR casts. Hypercalcemia, anemia.

Multiple Myeloma monoclonal light chain clog renal tubules causing intratubular cast and toxicity (myeloma cast nephropathy) high risk for bacterial upper respiratory and UTIs.

fatigue, weight loss, normocytic anemia, renal insufficiency, hypercalcemia

Grave's Disease/ hyperthyroidism

fatigue, weight loss, palpitations, diaphoresis, amenorrhea, SCLERA SEEN ABOVE IRIS ON DOWNWARD GAZE, SEPERATION OF DISTAL PART OF FINGERNAIL FROM NAIL BED, BULBOUS ENLARGEMENT OF FINGERTIPS

-prolonged pain >1hr -postprandial symptoms -heartburn or dysphagia -relief with antireflux

features suggestive of an esophageal origin of chest pain

Choriodecidual Interface (+) in vaginal sampling 24-34 weeks = High risk for preterm delivery

fetal Fibronectin (fFN)

infective endocarditis Mitral valve prolapse is #1 and Aortic regurgitation is #2 Tricuspid regurgitation is associated with IE in IV drug users

fever chills malaise heart murmur splinter hemorrhage small petechiae on palatal mucosa

Pyelonephritis in Pregnancy may be complicated by ARDS and preterm labor during 2nd trimester elevation in progesterone causes urinary stasis and hydronephrosis which predisposes to pyelonephritis

fever flank pain dyspnea hypoxia diffuse crackles infiltrates on CXR

Kawasaki disease strawberry tongue, cracked lips, bilateral nonexudative conjunctivitis, cervical lymphadenopathy, polymorphous rash, erythema or edema of hands and feet. self limiting resolves in 1-2 weeks. Tx: IV Immunoglobulin administered within 10 days of fever onset decrease incidence of Coronary Artery Disease. & Aspirin to prevent coronary artery thrombosis.

fever (103) everyday for >5days, bilateral eye redness, raised erythematous rash on ext, bilateral bulbar conjunctival erythema with limbal sparing, tongue erythematous and prominent papilla, bilateral cervical lymphadenopathy.

cyclic bone marrow suppression (cyclic neutropenia)

fever and illness occur at predictable pattern every 2-5weeks associated with oral lesions (aphthous ulcers)

BILE LEAK Leukocytosis Elevated Bili, Alk phos 2-10 days post procedure normal biliary ducts on imaging

fever, RUQ pain, nausea, vomiting after laparoscopic cholecystectomy

Tube-ovarian abscess (TOA)

fever, abdominal pain, complex multiloculated adnexal mass with thick walls and internal debris. increased nonspecific indices (Leukocytosis, CRP, CA-125)

Septic Arthritis in joints with preexisting abnormalities (Osteoarthritis, RA), or prosthetic joints. >50,000 leukocytes, >90% neutrophils

fever, acute monoarticular arthritis with a background hx of RA

Complications of BPH Acute Pyelonephritis common in men with urethral obstruction such as BPH causing elevated post void residual volumes.

fever, costovertebral angle tenderness, leukocytosis, bacteriuria/pyuria

Acute bacterial prostatitis due to acute urinary retention from prostatic swelling suprapubic catheter required to decompress 6 weeks tx with fluoroquinolone (LEVOFLOXACIN) or TMP-SMX

fever, dysuria, leukocytosis, tender swollen prostate

suppurative (infectious) thyroiditis Children and immunocompromised

fever, erythema, severe pain at thyroid gland. asymmetric goiter.

HSV encephalitis anosmia, gustatory hallucinations, bizzarre or psychotic behavior. CSF: Lymphocytic pleocytosis, elevated protein, elevated RBC, normal Glucose. WBC-125 Neyrophils-5% Glucose-65 RBC-700 Protein-90

fever, headache, seizures, confusion, stupor, over a few days. CT/MRI high amplitude slow waves over the left temporal and frontal lobes.

Infections in sickle cell disease Septic Shock Empiric abx: Ceftriaxone + Vancomycin

fever, hypotension, lethargy, petechiae

chorioamnionitis

fever, maternal or fetal tachycardia uterine tenderness

Subacute thyroiditis (de Quervain's) resolves in <8weeks

fever, neck pain, thyroid tenderness, high ESR

Retropharyngeal abscess strep pyogenes, staph aureus, preceeded. by URI 6m-6yrs CT with contrast CONFIRMS dx antimicorbial therapy + surgical drainage for larger abscesses are essential

fever, odynophagia/dysphagia, neck pain with extension, muffled voice, widened prevertebral space on XRAY

Effects of positioning in a patient with pneumonia consolidation causes impaired alveolar ventilation in affected portion, hypoxemia due to right to left shunting of blood and extreme ventilation perfusion mismatch.

fever, pleuritic chest pain, hypoxemia, dullness to percussion with bronchial breath sounds in the left lung field

community acquired pneumonia by Strep Pneumonia "rusty sputum"

fever, pleuritic pain, dyspnea, productive cough. Lobasr, interstitial, or cavity infiltrate on CXR.

septic shock due to pneumonia. Causes increased tissue metabolic acid production, leading to buildup of lactic acid. lactic acidosis causes metabolic acidosis in hospitalized patients.

fever, tachycardia, hypotension, bronchial breath sounds in right lung base, metabolic acidosis

Steven Johnson Syndrome and Toxic Epidermal Necrolysis tx: supportive with aggressive fluid support, wound care similar to that of burns.

fever, tachycardia, hypotension, seizures, coma

Systemic Sclerosis (Scleroderma)

fibrous tissue replacement of smooth muscles

galactosemia (Galactose-1-phosphate uridyl transferase deficiency)

first few days after birth with jaundice, hepatomegaly, failure to thrive after consumption of breast milk or regular infant formula.

warfarin induced skin necrosis due to Protein C deficiency. Stop Warfarin immediately and administer protein C.

first few days after starting warfarin therapy. this is due to?

Beta blocker (propranolol)

first line treatment for essential tremor

ulnar nerve injury claw hand due to paralysis of intrinsic muscles of the hand as well as sensory loss of medial hand.

fracture of the medial epicondyle of humerus or deep laceration of anterior wrist

Entamoeba histolytica tx: Metronidazole, luminal agent (paromomycin) is also required. Drainage is NOT recommended.

from Mexico, abdominal pain, fever, leukocytosis, and hx of bloody diarrhea.

intracranial tumor affecting motor cortex. Increased ICP with n/v, focal Neuro manifestations, symptoms worsen during night, pailledema. MRI of brain for further eval

gait dysfunction, headache with nausea worse in morning, focal left sided weakness

laparoscopy for direct visualization and biopsy.

gold standard for diagnosis of endometriosis (dysmenorrhea and chronic pelvic pain)

Central line associated blood stream infection within 7-10days. Coagulase negative staph, Staph aureus, klebsiella, pseudomonas, candida Cholestasis occurs after >2weeks.

greatest risk related to Parenteral nutrition?

Femoral Hernia: contender groin bulge below inguinal ligament risk: chronic cough, constipation, smoking nonpulsatile mass in older women. when bowel loops are present, tympanic to percussion. substantial risk of incarceration and strangulation. Asymptomatic hernias are referred for elective surgery. inguinal hernias are lower risk for incarceration and strangulation due to wider orifice. therefore most can be managed with reassurance and followup.

groin hernias

IgA nephropathy

gross or microscopic hematuria with minimal proteinuria after an URI.

male hypogonadism secondary (central) hypogonadism Low levels of testosterone should increase LH and FSH, therefore abnormal hypothalamic pituitary response. in men with prolactinoma gynecomastia is rare and galactorrhea is uncommon. therefore patient should have a prolactin level checked. pituitary imaging if prolactin levels elevated, visual defects, very low testosterone, disruption in other pituitary hormones.

gynecomastia testicular atrophy low testosterone levels normal LH and FSH

hypertensive retinopathy

hard exudates, arteriovenous nicking, silver wiring of arterioles. flame hemorrhage. headache, eye pain, visual field defects.

Croup (laryngotrachitis) edema and narrowing of proximal trachea (subglottis)-Steeple Sign

harsh cough inspiratory stridor

hypertrophic cardiomyopathy

harsh crescendo-decrescendo systolic murmur best heard at apex and lower left sternal border increase intensity with valsalva and with standing

ratio of an event rate occurring in the treatment group compared to an event rate occurring in the non treatment group <1 indicates tx group had a significant lower event rate >1 tx group had a much higher even rate

hazard ratio

lactate dehydrogenase-secreting germ cell tumor (Dysgerminoma)

hcg and estrogen secreting tumor (solid adnexal mass)

Superior vena cava syndrome due to small cell lung cancer RADIATION THERAPY

headache that os worse with leaning forward, JVD (WITHOUT Peripheral edema = not cardiac cause), Facial and upper extremity swelling. In a smoker.

Waldenstrom's macroglobulinemiaB-cell malignancy excess production of monoclonal IgM antibody. hyperviscocity syndrome screening: SERUM PROTEIN ELECTROPHORESIS (SPEP) identify monoclonal IgM spike. if positive then get bone marrow biopsy (lymphocytic infiltration with certain immunophenotype markers) urgent plasmapheresis may be required.

headache, dizzy, blurry vision, large gamma gap (difference. between total protein and albumin) and a retinal changes (dilated, segmented and tortuous retinal veins=Sausage-link changes) HIGH ESR

Alport syndrome X linked defect in collagen IV formation.

hearing loss, ocular abnormalities, hematuria, progressive renal insufficiency, thinning of GBM.

Von Willebrand Disease impaired platelet adhesion diagnosis confirmed by vWF testing (vWF antigen, Ristocetin cofactor activity, factor VIII levels) tx: Desmopressin, vWF replacement therapy, Antifibrinolytics (Tranexamic Acid)

heavy regular menses, anemia, and normal coagulation studies

paravalvular regurgitation evidenced by holosystolic murmur at cardiac apex. result in significant intravascular hemolysis with fatigue, dyspnea, tachycardia. Mild jaundice, dark urine, elevated LDH, decreased haptoglobin, increased indirect bili, thrombocytopenia.

hemolytic anemia due to intravascular hemolysis, due to mechanical prosthetic valve. Malfunction of the valve can result in.

splenectomy

hereditary spherocytosis is treated via

Epiglottitis swollen epiglottis (thumb sign)

high fever, drooling and stridor

radial nerve extensor muscles of wrist and digits and sensory of posterior arm, forearm, and dorsolateral hand.

humeral mid shaft fractures or improperly fitted cruches

Bacterial Meningitis in children (>1month) Inflammatory damage to the cochlea, CN VIII, and labyrinth. most common with strep pneumonia meningitis therefore audiologic testing for all patients with bacterial meningitis intellectual disability (due to global hypoxia), cerebral palsy (due to necrosis of motor cortex)

hx of bacterial meningitis and now ignoring voices, raising concern for hearing loss secondary to her infection.

chronic pulmonary aspergillosis Tx: -Iraconazole, Vorizonazole -Surgery -Bronchial artery embolization

hx of cavitary TB, >3months of fever, weight loss, fatigue, cough, hemoptysis, or dyspnea. Cavitary lesions containing debris, fluid or fungus ball.

selective IgA deficiency recurrent sinopulmonary (sinusitis, pneumonia) and GI infections (Giardia) due to absence of secretory IgA as a mucosal barrier. when transfused with blood products have IgE antibodies directed against IgA, result in anaphylaxis during transfusion. therefore need blood products washed of IgA.

hx of recurrent pneumonia, atopy (asthma, eczema) and anaphylactic reaction during blood transfusion.

Osteosarcoma Sunburt Periosteal rection inherited genetic mutation to tumor suppressor gene RB1 (retinoblastoma) and TP53 (Li Fraumeni Syndrome-Adrenocortical tumors), leukemias, breast tumors, brain tumors. Also in older adults in areas of previous bone damage due to pages disease, irradiation, benign bone tumors

hx of retinoblastoma, lytic bone lesion in distal femur with concentric layers of reactive bone

fluid collection within the tunica vaginalis, painless scrotal swelling. large hydrocele can cause irritation and ulceration of overlying skin. congenital Hydrocele associated with increased risk of torsion.

hydrocele complications

chronic kidney disease resulting in real osteodystrophy.

hyperphosphatemia, hypocalcemia, secondary hyperparathyroidism, increased bone turnover with radiographic evidence of widespread osteopenia and subperiosteal bone reabsorption.

cerebellar tonsillar herniation neck tilt, flaccid paralysis, coma, BP instability, Resp arrest

hypertensive hemorrhage can occur in the cerebellum

release of preformed thyroid hormone radioactive iodine uptake in these cases is reduced

hyperthyroidism in subacute (de quervain) thyroiditis, silent thyroiditis, and transient hyperthyroid phase seen in chronic lymphocytic (hashimotos) thyroiditis is due to

Tumor Lysis Syndrome (TLS)

hypocalcemia, Hyperphosphatemia, Hyperkalemia, elevated uric acid n/v/low urine output, acute renal insufficiency, seizures, tetany, arrhythmias

Secondary hyperparathyroidism in CKD decreased production of calcitriol (1,25 dihydroxyvit D) leads to decreased calcium absorption from GI. As GFR decreases kidney cannot excrete phosphate. low calcium and high phosphate leads to parathyroid glandular hyperplasia to release more PTH. Renal Osteodystrophy (pain and increased risk of fracture) Tx: Low phosphate diet, phosphate binders (calcium carbonate, calcium acetate, sevelamer) and supplement calcium and Vitamin D.

hypocalcemia, hyperphosphatemia in setting of CKD

Primary adrenal insufficiency (Addison's disease) most common cause is due to Autoimmune Adrenalitis common to have other autoimmune diseases as well such as thyroid, parathyroid, and ovaries.

hypotension, pigmentation, hyponatremia, hyperkalemia, eosinophilia, elevated ACTH, low Cortisol

cerebral salt wasting

hypovolemia, hyponatremia, high urine sodium. post injury or surgery.

Alveolar hypoventilation

hypoxia and dyspnea in patients with extrinsic restrictive lung disease (obesity) Dec TLC FEV1/FVC >70 Normal DLCO

Dubin-Johnson syndrome Due to defect of hepatocyte bilirubin excretion OCP, illness, preganancy can trigger jaundice. Black liver with dark lysosomal pigments on histology

icterus, positive urine bilirubin (Elevated conjugated bilirubin), Normal AST, ALT, ALK Phos. Liver biopsy shows dark granular pigment in hepatocytes

1-NPV

if a test result is negative the probability of having the disease is

1-PPV

if a test result is positive the probably of not having the disease

long acting opioids (sustained release morphine, transdermal fentanyl) may be needed.

if severe cancer related pain is requiring frequent dose of short acting agents or if bedtime dosing does not provide adequate relief through the night then need?

Ecthyma granulosum Pseudomonas aeruginosa

immunocompromised (Chemotherapy) patient who develops a erythematous and edematous lesion that developed into bulla surrounded by erythema eventually ruptured leaving a painless ulcer with a black center.

CMV causing pneumonitis, gastroenteritis, hepatitis dx: PCR tx: Stop immunosuppressant and initiate Ganciclovir

immunosuppressed patient presenting with dyspnea on exertion, dry cough, abdominal pain, diarrhea, hematochezia, pancytopenia, mild hepatitis, and interstitial infiltrates on CXR.

Alzheimer's disease (AD) slow and gradual with neuropsychiatric symptoms later in course

impaired acetylcholine synthesis

leukocyte adhesion defieincy 'recurrent infections including staph aureus, but NO pus

impaired neutrophil chemotaxis

abdominal US and if non diagnostic go to MRI

in assessing appendicitis in a pregnant patient start with?

Noncardioselective Beta Blockers (Propranolol, Nadolol)

in esophageal varices to decrease portal vein blood flow to prevent progression of varies and risk of vatical bleeding

kidney biopsy

in order to evaluate for glomerulonephritis which can present with nephrotic range proteinuria need to obtain a

patients with renovascular HTN (renal artery stenosis) important cause of secondary HTN. Increase in both systolic and diastolic BP.

increase in plasma renin activity

increases precision of the study. but not affect accuracy

increasing sample size

Sarcoma botryoides

infancy and early childhood as a NON friable nodule protruding from vagina that resembles cluster of grapes.

neonatal herpes simplex virus lumbar puncture will yield a bloody tap. empiric ACYCLOVIR while await HSV PCR results

infant with fever, seizure, patchy areas of increased attenuation in cerebral cortex and edema and hemorrhage in the left temporal lobe and brainstem.

CMV additional findings are periventricular calcifications and microcephaly as well as sensorineural hearing loss.

infant with growth restriction, hepatosplenomaegaly, jaundice, petechiae

Congenital Torticollis postural deformity in which SCM Muscle is tight and contracted, due to intrauterine crowding (breech, multiple gestation, oligohydramnios) evident at 1-6months with head preference to one side. When infant lies down with head facing the preferred side positional plagiocephaly occurs (flattening of the head on side as well as anterior displacement of ear and forehead) tx: positioning (inched tummy time) passive stretching, PT. Missed or delayed diagnosis can lead to craniofacial asymmetry.

infant with neck mass, ipsilateral head tilt, contralateral chin deviation

Aldolase B deficiency hereditary fructose intolerance. introduction of fruits and vegetables into diet followed by accumulation of fructose-1-phosphate.

infant with vomit, poor feed, lethargy. Seizure and encephalopathy following addition of fruits and vegetables into diet.

Septic Shock (Distributive shock) DEC SVR Dec (or Normal) PCWP Elevated MvO2 sat Inc Cardiac Index

infected foot, hypotension, tachycardia, leukocytosis, High Lactate, AKI

inability to conceive after 6 months of unprotected sex in >35 or after 12 months <35

infertility

epiglottitis severe infection caused by H. Influenza type B. ill, high fever, difficult swallowing, drooling

inflammation of epiglottis and aryepiglottic fold

Uveitits

inflammation of the uveal tract (iris, ciliary body, choroid) intense pain and photophobia in one eye

retinitis pigmentosa

inherited degeneration of retinal photoreceptors causing bilateral tunnel vision and eventually binocular blindness

exclude metabolic with basic laboratory tests exclude toxic with urine drug screen ECG then brain MRI or CT scan EEG

initial diagnostic evaluation of a first time seizure in an adult

serum chemistry panel hemoglobin/hematocrit urinalysis in addition patients should be screened for major atherosclerotic risk factors with a lipid panel and either fasting serum glucose or hemoglobin a1c

initial evaluation of HTN focuses on identifying complications or comorbid conditions such as

plaque psoriasis Topical High potency glucocorticoids or Vit D derivatives (calcipotriene)

initial treatment for this?

mechanically induced neuropathic degeneration of the interdigital nerves numbness and pain at distal forefoot between 3rd and 4th toes.

interdigital (Morton) Neuroma

muscle cramps due to exertion induced ischemia in lower ext in setting of atherosclerotic peripheral artery dz. similar mechanism to typical angina atherosclerotic arterial narrowing

intermittent claudication

Multifocal Atrial Tachycardia. supra ventricular tachyarrhythmia occurs due to atrial conduction abnormalities triggered by disturbances such as right atrial enlargement, catecholamine surge (sepsis), or electrolyte imbalance (hypokalemia), exacerbation of COPD elderly >70 tx: Correct underling disturbance, AV nodal blockade (VERAPAMIL) if persistent

irregular narrow complex tachycardia with 3 different P-wave morphologies, and variable PR interval.

Hyperthyroidism Screen with TSH & T4 levels.

irregularly irregular rhythm likely due to atrial fibrillation causing dizziness as well as unintentional weight loss. HTN. can be explained by?

congenital hypothyroidism

jaundice decrease activity poor feeding hoarse cry

Hereditary spherocytosis defect in RBC membrane proteins (Spectrin, Ankyrin) splenomegaly and hemolytic anemia **pigment gallstones** HIGH MCHC HIGH Metic Count NEGATIVE COOMBS

jaundice splenomegaly FH of hemolytic Anemia requiring splenectomy

neutropenia most common complication is a bacterial infection

just began chemotherapy with a leukocyte count of 600

granulose cell tumor

large adnexal mass + Hyperestrogenism (precocious puberty, endometrial hyperplasia, postmenopausal bleeding)

malignant pleural effusion EXUDATIVE Low pH <7.2 Low Glucose <60 High LDH most common causes: BREAST & LUNG cancer

large, non painful, unilateral pleural effusion, in the setting of a cancer hx and rapid weight loss.

ventricular aneurysm mural thrombus is present in most and lead to systemic embolization

late complication of MI, persistent ST elevation along with deep Q waves.

Constrictive pericarditis inelastic pericardium diuretics can provide temporary relief and pericardiectomy is definitive tx.

late complication of radiation therapy. inelastic pericardium prevents venous return to right heart during inspiration and leads to right heart failure. peripheral edema, ascites, hepatic congestion with hepatomegaly. JVD,

wound dehiscence

leakage of serosanguineous fluid between incision staples.

DVT immobilization from RA and RA itself can predispose to DVT Trauma Hypercoagulable state (malignancy) Medications (OCP) compression US is the preferred initial test Clinical evidence of PE should be stated on anticoagulation while undergoing diagnostic evaluation. Those with DVT only should abbe diagnosis confirmed prior to starting anticoagulation.

left leg pain, asymmetric swelling (swollen, warm and tender, pitting edema)

Blount Disease Pathologic cause of bowlegs due to abnormal cartilage growth.

leg length discrepancy, asymmetrical bowing, lateral thrust with ambulation

treat the allergic response in asthma that lead to bronchospasm

leukotriene antagonists

slipped capital femoral epiphysis

limp and insidious hip pain, adolescent and obese, X-ray shows posterior displacement of the femoral head.

tremor, hyperreflexia, ataxia, seizures, vomiting, diarrhea

lithium toxicity

Polyarteritis Nodosa Necrotizing vasculitis

livedo reticularis, purpura, kindey disease, abdominal pain, muscle aches or weakness. Elevated CRP.

Acute exacerbation of COPD most common trigger is URI.

long smoking hx, cough, sputum production, dyspnea. Inc JVD during expiration. Distant heart sounds.

Rett Syndrome MECP2 gene mutation Girls develop normally first 6 months then regress.

loss of communicative skills, deceleration in head growth, hand clapping without evidence of purposeful movement and gait abnormalities

pulmonary cachexia leads to impaired balance, increase susceptibility to lung infections, and increased mortality. Development of disorder correlates with disease severity. Seen in patients with severe COPD. CXR to suggest COPD shows Hyperinflation of lung fields with small cardiac silhouette

loss of lean muscle mass associated with chronic pulmonary disease (COPD)

Euthyroid sick syndrome T4 made in thyroid gland T3 made by peripheral conversion of T4 LOW T3 syndrome of Euthryroid Sick syndrome is due to decreased conversion of T4 to T3, Due to High Cortisol, Inflammatory cytokines, starvation, glucocorticoids or amiodarone.

low T3, Normal T4 & TSH in setting of acute illness

compression fracture

low back pain, dull ache, present all day and night, difficult to find comfortable sleeping position. prolonged course of prednisone. cushingoid and hirsute appearance. tenderness from T11-L2. Normal CK and ESR.

Ankylosing Spondylitis (AS)

low back pain, present throughout the day, most severe when awaken and after physical activity. Dull ache with stiffness. walk with stooped gait, tenderness of sacroiliac joint. decreased flexion at the waist. Increased ESR. Diagnosis?

-increased potassium entry into cells -renal potassium wasting -GI fluid loss COPD treated with inhaled beta 2 agonist (albuterol) EXOGENOUS and ENDOGENOUS BETA AGONISTS cause a potassium shift INTO cells. Also stimulate release of insulin which further promotes intracellular potassium shift, causing HYPOKALEMA

low serum potassium result from

neurogenic claudication due to lumbar spinal stenosis from degenerative osteoarthritis MRI of spine definitive (confirm narrowing of lumbar canal)

lower extremity pain with extension of the spine (walking, standing), spine flexion (leaning forward, walking uphill) relieves the pain.

ELEVATED protein with normal leukocyte count (ALBUMINOCYTOLOGIC DOSSOCIATION)

lumbar puncture findings of Guillain-Barre Syndrome

yearly low dose CT 55-80, have >30 pack year smoking, and are currently smoking or quit last 15 years.

lung cancer screening

Chronic Lymphocytic Leukemia (CLL) >70yo SMUDGE CELLS dx: flow cytometry of peripheral blood, monoclonal B cell Lymphocytes symptomatic patients require treatment RITUXIMAB a monoclonal antibody against CD20 first line

lymphadenopathy, splenomegaly, anemia, thrombocytopenia, marked lymphocytic predominant leukocytosis. in an elderly.

Chediak-Higashi syndrome

lysosomal defect leading to impaired phagocytosis albinism peripheral neuropathy recurrent skin and soft tissue pyogenic infections

Acute graft-versus-host disease Activation of donor T lymphocytes (host HLA antigen recognition by donor T cells causing cell mediated immune response)

maculopapular rash palms, soles, face, bloody diarrhea, abnormal LFTs. 2 weeks post bone marrow transplant.

normal under age of 6 yo. become anxious about physical harm or death

magical thinking and incomplete understanding of death in children

Psychotherapy + SSRI SERTRALINE & ESCITALOPRAM lowest risk of drug reaction with cardiac meds. (Citalopram avoided due to QT prolongation, paroxetine can cause anticholinergic effects, drug drug interaction through CYP450, and weight gain)

major depressive episode post MI, tx?

1. Hepatic Cysts 2. Valvular heart Dz (MVP or Aortic Regurgitation) 3. Colonic Diverticula 4. Abdominal Wall and Inguinal Hernia 5. intracranial berry aneurysm

major extra-renal complications of ADPKD

Mefloquine begin 2 weeks prior to travel and continued during the stay and d/c 4 weeks after return. protective clothing, insect repellent and insecticide treated bed netting.

malaria prevention

Burkitt's lymphoma

mass involving the mandible or abdominal viscera associated with EBV. Starry sky appearance on histology.

pulmonary HTN Pulmonary Venous HTN due to LH disease, Chronic lung disease or hypoxemia, Chronic thromboembolic disease. see exertion dyspnea, edema, JVD, loud P2, murmur of tricuspid regurgitation.

mean pulmonary arterial pressure >25

volvulus

mechanical obstruction from torsion of a mobile cecum and ascending colon, with progressive abdominal pain with episodes of cramping.

Reveals myocardial ischemia constant with obstructive CAD. Adenosine causes coronary vasodilation and increased myocardial blood flow. this is a several fold augmentation of blood flow in non obstructed coronary arteries. this blood flow difference causes detectable reduction in radioactive isotope uptake by myocardial cells in areas supplied by a stenotic coronary artery.

mechanism of coronary artery vasodilator stress test (adenosine, dipyridamole)

Hodgkin's lymphoma

mediastinal mass, pancytopenia, elevated LDH, fever, night sweats and painless LAD

spironolactone, triamterene, amiloride, ACEIs, trimethoprim, NSAIDs

medications that can cause Hyperkalemia

Herpes Simplex Encephalitis

meningitis in a patient with MRI brain showing BITEMPORAL HYPERINTENSITIES

both cause anion gap metabolic acidosis and increased osmolar gap Methanol: Eye damage (optic disc hyperemia) Ethylene Glycol: Kidney damage

methanol vs ethylene glycol

Folate deficiency alcoholic and poor nutrition become deficient in 5-6weeks. (Cobalamin B12 deficiency would have a HIGH METHYLMALONIC ACID)

microcytic anemia, hypersegmented neutrophils. NORMAL METHYLMALONIC ACID

Radial nerve injury Wrist drop

mid shaft Humeral Fracture

radial nerve stretched limited wrist extension and sensory deficits resolve after management tx: CLOSED REDUCTION and ARM IMMOBILIZATION open reduction and internal fixation only if open, segmental, inadequate closed, polytruama, shortening, pathologic

midhaft humerus fracture

Bisphosphonates to inhibit osteoclastic activity of bone, stabilizing destructive bony tumors and reduce risk of skeletal related event.

mild hypercalcemia in setting of metastatic breast cancer to bone

Lymphonodular hyperplasia (inflamed lymphoid tissue)

milk-induced colitis mild, painless, hematochezia

papilledema associated with increased ICP with headaches in the mornings. common in young, obese due to idiopathic intracranial HTN (pseudo tumor cerebri) next step CT or MRI

momentary vision loss that varies according to changes in head position

Lamotrigine (valproate & Carbamazepine is teratogen causing neural tube defects, lithium can cause ebstein anomaly)

mood stabilizer for patients with bipolar disorder to switch to in order to be safe during pregnancy

HBsAg & IgM anti-HBc both elevated during initial infection and HBc will remain elevated during window period

most appropriate diagnostic tests for acute Hep B infection

nasogastric intubation

most appropriate initial step in a patient presenting with distended, tympanic abdomen with diffuse tenderness and hypoactive bowel sounds. had a hysterectomy 12 years ago.

Hypercalcemia of malignancy secretion of PTHrp by malignant cells associated with SCC PTHrp does NOT induce conversion of 25-hydroxy D to 1,25 so those levels will be normal. Other causes: bony destruction by osteolytic metastasis (breast, non small cell, non Hodgkin, Multiple Myeloma), increased production of 1,25 due to lymphoma, increased IL-6 due to Multiple Myeloma.

most common cause of PTH-independent hypercalcemia with >14 hypercalcemia, polyuria, constipation, nausea. in a smoker, with fatigue and poor appetite. HIGH Ca, LOW PTH

Pernicious Anemia Accompanied by Autoimmune Thyroid Disease & Vitiligo Shiny tongue = atrophic glossitis , shuffling broad based gait, loss of position and vibration sense. Autoantibodies to gastric intrinsic factor. which is required for Vit B12 absorption. (it would take 4-5 years for a pure vegan diet to cause dietary vitamin B 12 deficiency)

most common cause of Vitamin B12 deficiency in whites of Northern European background

Streptococcus pneumoniae bacterial meningitis: -Headache -Fever -Nuchal rigidity -Altered mental status CSF: -High opening pressure >350 -Low glucose <40 -High protein >200 -Neutrophilic leukocytosis >1000 URGENT tx: Ceftriaxone, Vancomycin, and Dexamethasone If >50yo add AMPICILLIN due to Listeria

most common cause of community acquired bacterial meningitis

Metatarsus adductus No treatment necessary

most common congenital for deformity. Medial deviation of forefoot. Bilateral. first born infants. flexible feet that correct both passively and actively.

Immune thrombocytopenia course is usually self limited with spontaneous recovery within 3 months

most common in children 2-5 petechiae and purpura

CMV atypical lymphocytes multiple large shallow erosions or ulcers on colonoscopy tx: Ganciclovir

most common opportunistic infection following renal transplantation

Agranulocytosis Once patient presents with sore throat and fever to d/c the med. Administer broad spec IV Abx especially for pseudomonas

most feared side effect seen with PTU and Methimazole

Folate deficiency anemia due to chronic hemolysis

most likely cause of microcytic anemia in a sickle cell patient.

neonatal varicella zoster infection passive immunization with monoclonal antibody (VZV immunoglobulin) recommended for those not immune as well as neonates, pregnant women and immunocompromised patients. effective for neonates who's mom developed 5 day before to 2 days after delivery

mothers fever, intensely pruritic vesicular rash consistent with VZV

clinical features of Ehlers-Danlos & Marfan

multiple joint dislocations easy bruising poor wound healing wide atrophic scars

Zollinger-Ellison syndrome (Gastrinoma) Gastrin producing tumor in pancreas or duodenum. excess gastric acid in small intestine can cause diarrhea and steatorrhea due to inactivation of pancreatic enzymes and injury to the mucosal brush border. dx: Serum gastrin >1000 if gastrinoma confirmed patients should be screened for MEN1 with assays for PTH, ionized calcium, and prolactin.

multiple peptic ulcers and diarrhea

Basophilic stippling due to precipitation of ribosomal ribonucleic acid in lead poison, thalassemia, heavy metal poison.

multiple scattered blue granules within RBC cytoplasm

primary hyperparathyroidism. bones, stones, abdominal moans, psychic groans due to parathyroid adenoma. HTN, Arhythmias, ventricular hypertrophy, vascular and valvular calcification.

muscle weakness, recurrent nephrolithiasis, neuropsychiatric symptoms, hypercalcemia

Synchronized Cardioversion

narrow or wide QRS tachyarrhythmia (Atrial Fib, Atrial flutter, V tach with a pulse)

Vasovagal Syncope BRADYCARDIA with SINUS ARREST peripheral vasodilation and abrupt hypotension recurrent episodes requires trigger avoidance and training in counterpressure techniques (leg crossing, hand grip) to try to avert a syncope episode once prodromal symptoms occur

neurocardiogenic syncope due to alteration in autonomic drive.

small cell carcinoma

neuroendocrine tumor of the lung that causes central (hilarity, perihilar) mass, with mediastinal lymphadenopathy.

overflow incontinence urinary frequency, nocturne, frequent leakage of small volumes. High postvoid residual volumes (>150 F, >50 M) Nonpharm: Suprapubic pressure, timed voids, double voiding Pharm: Cholinergic Agonist (Bethanechol) Severe cases may need intermittent self cath.

neurogenic bladder due to longstanding DM. Bladder voiding dysfunction due to detrusor under activity.

Dopamine

neurotransmitter most likely responsible for Neuroleptic Malignant Syndrome

Myelodysplastic Syndrome (MDS) ovalomacrocytosis and reduced segmentation. Dx: Bone Marrow Biopsy hematopoietic stem cell neoplasm risk increases with old age and previous chemo/radiation Cytopenias (anemia causing weakness and fatigue), leukopenia causing infections, Thrombocytopenias causing bruising/bleeding. Dysplastic RBC & WBC on peripheral smear tx: transfusion for symptomatic cytopenias, chemotherapy and hematopoietic stem cell transplantation

neutrophils with decreased segmentation and decreased granulation

-Aminoglycosides -Chemo -Aspirin (VERY HIGH DOSES) -Loop Diuretics (FUROSEMIDE)

new onset bilateral hearing loss from medication induced ototoxicity

Ruptured Abdominal Aortic Aneurysm (AAA) referred pain from aorta, Hypotension, pulsatile abdominal pain

new onset intense back pain unaffected by movement and hypotension

TCA overdose still used for major depression QRS prolongation due to inhibition of fast sodium channels

new onset seizure, anticholinergic toxicity (dilated pupils, hyperthermia, flushed skin, decreased bowel sounds) and QRS widening most likely due to?

age, functional status, and tumor grade (DEGREE OF ANAPLASIA)

new onset seizures are a common presentation of brain tumors. Most common of which in adults are ASTROCYTOMAS. most important prognostic factor for Astrocytomas?

Henoch-Schonlein Purpura (HSP) skin biopsy of lesions can confirm (small vessel vasculitis with extensive deposition of IgA)

non blanching palpable purpura over buttocks and lower extremities, abdominal and knee pain, hematuria, preceded by upper respiratory infection.

Cell Free DNA If abnormal follow up with Chronic Villus Sampling at 10-12 weeks or Amniocentesis 15-20 weeks. Women >35 at increased risk for fetal aneuploidy therefore should receive cell free DNA testing. if not high risk can undergo combined test (plasma protein A, b-hCG, Ultrasound nuchal translucency) in first trimester. then in the second trimester with quad screen (MSAFP, b-hCG, Estriol, Inhibit A)

noninvasive highly sensitive and specific screening test for aneuploidy ordered at >10 weeks gestation

Acute Bronchitis cough >5days characteristic of acute bronchitis, and viral URI usual cause. blood in sputum can occur due to inflammation and epithelial damage wheezing and crackles that clear with cough, suggest secretions are easily mobilized unlike pneumonia. if fever think bacterial pneumonia or influenza. self limiting symptomatic tx only.

nonsmoking, recent upper respiratory infection and persistent cough productive of yellow blood tinged sputum

Testicular cancer majority due to malignant transformation of seminiferous germinal epithelium (germ cell tumor)

nontender nodule in the testis that does not transilluminate

Leiomyomata Uteri due to abnormal proliferation of MYOMETRIUM very heavy or prolonged bleeding. best diagnostic study to confirm = SONOHYSTEROGRAPHY (saline infusion ultrasound) tx: OCP or venorogesterel containing IUD, myomectomy for those who failed conservative management and dont want hysterectomy. Definitive treatment is hysterectomy.

nontender, slightly enlarged uterus with an IRREGULAR contour and heavy menstrual bleeding

first stage of labor begins with onset of regular contractions and lasts until 10cm dilation. 2 phases of first stage: -latent: 0-6cm when cervix dilates slowly and has no defined expected rate of cervical change -active: >6-10cm cervix dilates rapidly with progression >1cm every 2 hours Section only if active phase labor arrest (no cervical change for >4hours with adequate contractions or >6hrs with inadequate contractions) or category 3 fetal heart rate tracing when cervical change slows to <1cm/2hr (labor protraction) an intrauterine pressure catheter placed to measure contraction frequency and force. if contraction is inadequate labor augmented with oxytocin An operative vagibal delivery when category 3 ytacing or maternal exhaustion during the second stage of labor.

normal labor progression

AV Conduction Block (Mobitz Type 1 Wenckebach) second degree AV Block

normal p-waves PR interval that increases with successive beats until a P wave fails to conduct with absence of QRS

15months

normal to not walk independently until

Parkisnon's disease

nucleus accumbent and substantia nigra are affected in

Colonic pseudo-obstruction (Ogilvie's syndrome) men > 60 nonoperative trauma severe illness 3-7 days after surgery dx: abdominal CT

obstipation, abdominal pain and distention, colonic dilation without anatomic obstruction on imaging. Dilated colon from cecum to splenic flexure. Oral contrast visualized up to the distal colon = no anatomic obstruction

biliary atresia

obstructive jaundice, Acholic stools

stress induced (takotsubo) cardiomyopathy Apical ballooning Syndrome Broken Heart Syndrome

older adults in response to intense physical or emotional stress or acute medical illness resulting in cardiomyopathy

Age-related sicca syndrome Age related exocrine gland atrophy also corneal epithelial erosions leading to impaired vision. tx: Artifical tears

older patient with dry eyes and mouth

Fetal hypoxia due to placental dysfunction (placental insufficiency) risk factors: advanced maternal age, tobacco, HTN, DM requires prompt delivery due to high likelihood of fetal demise

oligohydramnios (single deep poket <2cm or amniotic fluid index <5) and BPP score of 0-4/10 indicates?

intraabdominal carcinomatosis which can lead to small bowel obstruction dx based on air fluid levels on abdominal X-ray and dilated loops of bowel on CT.

omental caking on CT consistent with

dialysis or renal transplant transplant has better survival and quality of life

once end stage Renal disease develops only 2 treatment options available

during second stage of labor (10cm dilation until fetal delivery) to expedite delivery. For Category III tracings or maternal exhaustion.

operative vaginal delivery (vacuum-assisted)

Respiratory acidosis DEC RR DEC TV Hypothermia DEC Bowel Sounds INC CO2 Low pH Miosis

opioid intoxication

Herpangina due to coxsackievirus A Clinical dx supportive tx

oral vesicles on uvula, soft palate, tonsillar pillars in a child

Kingella kingae (gram - bacillus)

osteomyelitis and septic arthritis in 2m-4yr

Acute Cerebellar Ataxia (acute post infectious cerebellar ataxia) follows a viral illness (coxsackie, or HHV) 1-3 weeks after infection, resolve spontaneously after 2 weeks.

otherwise healthy child, acute onset of ataxia, staggering gait, intention tremor, nystagmus

De Quervain's Tenosynovitis provocative maneuvers (Finkelstein Test)

overuse of extensor policies Brevis and Abductor Pollicis Longus Tendons. pain at base of thumb, common after pregnancy due to lifting newborn (baby wrist)

Peyronie Disease fibrous plaques in tunica albuginea reduce tissue elasticity and expansion during erection. US sometimes necessary pain and deformity spontaneous resolve in 1-2 years active or progressive PD require NSAID, Pentoxifylline to reduce fibrosis, and intralesional injections of collagenase

pain and penile curvature with erection

Endometriosis

pain that begins few days prior to and persist throughout the entire menstrual cycle. Uterosacral ligament tenderness, culdesac modularity, adnexal enlargement on exam.

Balanitis or Phimosis due to candida infection

painful or pruritic erythematous rash with foul-smelling, thick discharge of the penis.

Meckel's diverticulum remnant of persistent vitelline duct within 2 feet of ileocecal valve ectopic gastric mucosa

painless GI bleed Technetium-99m pertechnetate scan (+)

cataract vision impairing oxidative damage of the lens. Increase with age, smoking, excess sunlight exposure, DM, glucocorticoid use. LOSS of RED REFLEX tx: Surgery

painless blurring of vision, glare, and halos around lights.

penile cancer

painless penile ulcer for several months

mixed cryoglobulinemia (vasculitis characterized by immune complex deposition in small and medium sized vessels) dx: cryoglobulins (immunoglobulins that precipitate in colder temps), Rheumatoid factor (IgM against IgG) and polyclonal IgG bx: small vessel leukocytoclastic vasculitis.

palpable purpura, peripheral neuropathy (hyporeflexia), liver involvement (elevated LFTs, hepatomegaly), arthralgia, fatigue, weakness. Glomerulonephritis (HTN, renal failure, proteinuria, hematuria, RBC casts). Strongly associated with Hep C. LOW Complement.

VSD smaller the murmur the louder the sound

palpable thrill, loud harsh holosytolic murmur in fourth left intercostal space

aplastic anemia Anemia (severe fatigue, pallor) Leukopenia (Infections such as pneumonia) Thrombocytopenia (mucocutaneous bleeding) dx: Bone marrow biopsy hypo cellular marrow with a few normal hematopoietic cells and no myeloid infiltration or fibrosis. and predominantly storm and adipocytes.

pancytopenia (decrease in all 3 blood cell lineages) no splenomegaly no abnormal cells on peripheral smear

Cat Scratch Disease (Bartonella Henselae)

papular skin lesion, fever and >1 enlarged regional lymph nodes. Nonspecific lymphoid hyperplasia and areas of necrosis on histo.

Piebaldism AD

patchy absence of melanocytes noticed at birth confined to head and trunk

Methotrexate Inhibits dihydrofolate reductase. Folate depletion is the reason. Therefore supplement folic acid while on med. routine peripheral blood counts every 3months. other side effects: Nausea, Stomatitis, rash, hepatotoxicity, Interstitial lung disease, alopecia and fever.

patient being treated for RA, presenting with Macrocytic Anemia, likely due to what medication?

Ecthyma gangrenosum infection by pseudomonas aeruginosa. In immunocompromised patients on chemo.

patient on Chemotherapy, trunk has several indurated, contender macule and pustules, some the lesions have become gangrenous ulcers.

Acute Appendicitis due to obstruction of the appendix lumen

patient supine in bed with hips flexed and reports worsening of the pain when. hips are extended. Fever. RLQ Abdominal pain. Vomiting.

Epidural Spinal cord Compression IV GLUCOCORTICOIDS given without delay, it decreases vasogenic edema help alleviate pain and restore neurologic function. MRI next

patient with advanced prostate cancer presenting with subacute back pain with lower extremity motor weakness, hyperreflexia, and bladder dysfunction.

Hepatic Encephalopathy recent melena, positive stool occult test, anemia and elevated BUN/Cr suggest upper GI bleed leading to hepatic encephalopathy

patient with cirrhosis has confusion, lethargy, asterixis (Flapping hand tremor)

Hyperoxaluria due to increased oxalate absorption in the gut. normally, calcium binds oxalate in the gut and prevents its absorption, in fat malabsorption calcium binds fat leaving oxalate unbound and free to be absorbed into bloodstream.

patient with crowns disease presenting with nephrolithiasis due to?

most likely has glomerular cause of hematuria due to IgA Nephropathy. hematuria within 5 days of an URI (Synpharyngitic Glomerulonephritis)

patient with proteinuria, transient gross hematuria following acute pharyngitis.

IV saline bolus to increase RV preload and improve CO due to cariogenic shock. RVMI when inferior wall STEMI (II,III,avF) and clear lungs on auscultation. AVOID Nitrates as venous dilation can cause decrease in RV preload and lead to profound HYPOTENSION.

patients with RV MI can experience profound hypotension due to inadequate RV preload from nitroglycerine administration. Manage with?

elevated BUN/creatinine ratio due to increased urea production from intestinal breakdown of hemoglobin and increased urea reabsorption in proximal tubule due to hypovolemia

patients with upper GI bleeding will likely have what lab abnromalities

risk for CAD therefore aggressive risk factor modification with smoking cessation, lipid lowering therapy, evaluate and tx HTN and diabetes. Start on low dose aspirin, and statin. as well as enroll patient in supervised exercise program. goal is to produce claudication symptoms during each session.

peripheral artery disease

Smoking (Centriacinar) or Alpha-1-antitrypsin deficiency (panacinar)

permanent enlargement of airspaces distal to terminal bronchioles describes the alveolar destruction that occurs in

hookworm infection (ancylostoma duodenale, nectar americanus) dx: 3 stool specimens for ova and parasite on separate days

persistent GI Discomfort, malabsorption (chronic diarrhea, weight loss, nutrient deficiency) and eosinophilia from recourse limited country after a self limited pulmonary infection.

Adenoid Hypertrophy Mucopurulent nasal discharge, postnasal drip, elongated/flattened facial features concurrent tonsillar hypertrophy is common.

persistent nasal obstruction during childhood. Affected patients have nasal congestion refractory to medical management. recurrent sinus and ear infections, mouth breathing, sleep disturbance/snoring.

bronchopulmonary dysplasia (Chronic lung disease of the neonate) due to repeated insults to the neonatal lung from mechanical ventilation, prolonged oxygen exposure and inflammation. risk factors: -premature -low birth weight -RDS -mechanical ventilation surfactant therapy does not prevent but may reduce mortality. Improve over 2-4 months. May develop pulmonary arterial HTN.

persistent oxygen requirement with tachypnea, rhonchi, and radiographic findings of haziness and decreased lung volumes in a neonate

platelet disorder NOT hemophilia where bleed into muscle or joints.

petechia (pinpoint red spots) mucosal bleeding

47 XYY

phenotypically male nodulocystic acne at puberty increased incidence of learning disability, behavior problems, developmental delay

horizontal nystagmus, cerebellar ataxia, confusion

phenytoin toxicity

test myocardial function and perfusion. normal tracer uptake at both rest and exercise have excellent prognosis with <1% annual risk of CAD decreased tracer at both rest and exercise indicates scar tissue with decreased perfusion and CAD. Decreased with stress but normal at rest indicates inducible ischemia and likely ACD. Antiplateelt therapy (Aspirin) for prevention of MI, beta blockers, and modification of risk factors (smoking cessation, lipids, diabetes)

photon elision CT scan after treadmill exercise using technetium 99 labeled perfusion agent.

Otitis Externa (Swimmer's Ear) most common risk factor: WATER EXPOSURE Pseudomonas Aeruginosa most common pathogen implicated in OE. patients instructed to keep ear dry until infection resolves.

pinna tenderness pruritis painful swollen external auditory canal

Psoriasis T cell mediated immune disorder, characterized by keratinocytes hyper proliferation erythematous plaques with a silvery scale over extensor surfaces.

pitting distal onycholysis and hyperkeratosis

Transudative and bilateral with signs of volume overload

pleural effusion due to CHF

Tuberculous Exudative Effusion

pleural fluid High protein >4, Lymphocyte predominance, Low Glucose <60, High LDH >500, Low pH

Acute Pericarditis First line is NSAID If contraindication to NSAID (renal Insufficiency) then Corticosteroids

pleuritic chest pain that can radiate posteriorly to bilateral trapezius ridges Fever triphasic pericardial friction rub (scratchy sound between S1&S2) T wave inversions

Necrotizing Enterocolitis (NEC)

pneumatosis on xray

traumatic esophageal rupture

pneumomediastinum, left sided pleural effusion, abnormal contour of mediastinum

IV magnesium sulfate

polymorphic VT associated with acquired QT prolongation (torsades de pointes)

Allergic bronchopulmonary aspergillosis hypersensitivity to inhaled aspergillus fumigatus. In undderlying asthma or CF. peripheral eosinophilia tx oral corticosteroids for several month in combination with anti fungal agent itraconazole

poorly controlled asthma with recurrent exacerbations, infiltrates fever cough productive of browsing sputum and hemoptysis.

Subacute (deQuervain) granulomatous thyroiditis patients are thyrotoxic due to release of preformed thyroid hormones. elevated ESR.

post acute viral illness, fever, neck pain, tender diffuse goiter.

acute epididymitis

posterior testicular pain and swelling, improves with elevation (Prehn sign)

transverse myelitis

postinfectius condition resulting in abnormal gait, weakness and flaccidity.

Epithelial Ovarian Carcinoma pelvic US with CT abdomen/pelvis Baseline CA-125 thoracocentesis with cytology for pleural effusion tx: Exploratory laparotomy and tumor debulking followed by platinum based chemo

postmenopausal woman with urinary frequency or urgency, pain, bloating, abdominal distention, nodularity along rectovaginal septum. Pleural effusion.

incentive spirometry and deep breathing exercises by promoting lung expansion

postoperative measure to prevent postoperative pneumonia

fetal dysmaturity syndrome due to age related placental changes and resultant utter-placental insufficiency

postterm >42 weeks, neonates are small, thin body with loose skin and have meconium stained amniotic fluid

measure of random error in the study. study is precise if the result is not scattered widely. reflected by a tight Confidence Interval.

precision

urinary stasis

pregnant woman with multiple UTIs. Most likely cause?

Intra-amniotic infection (Chorioamnionitis) broad spec abx: Ampicillin, Gentamicin, Clindamycin immediate delivery via augmentation of labor

premature rupture of membranes, before onset of contractions or prolonged membrane rupture >18hrs. N/V, uterine fundal tenderness. Maternal fever, fetal tachycardia, maternal leukocytosis, maternal tachycardia, Abnormal contraction pattern.

Primary CNS Lymphoma MRI: Weakly ring enhancing mass, solitary and periventricular.

presence of EBV DNA in CSF is specific for

promote pneumocyte development and induce surfactant production = corticosteroid (betamethasone) to decrease risk RDS magnesium sulfate (fetal neuroprotection) tocolytics (nifedipine, indomethacin)

preterm labor (regular contractions, cervical change <37 weeks)

frontal release signs seen in frontally based dementias (frontotemporal dementias)

primitive reflexes (rooting, sucking, glabellar) are

Class IA antiarrhythmics to treat supra ventricular and ventricular arrhythmias. Especially Wolff-Parkinson-White.

procainamide

Juvenile Myoclonic Epilepsy (JME)

progression from absence seizures beginning around 10 to myoclonic seizures around 15, finally generalized tonic clonic around 16. limb jerking (myoclonus), worsened by sleep deprivation. postictal state with confusion. and urinary incontince.

Tick-borne paralysis Neurotoxin release, tick needs to feed for 4-7 days for release of neurotoxin. Once tick found and removed results in improvement within an hour and complete recovery in days.

progressive ascending paralysis over hours to days. localized or more pronounced in 1 leg or arm. No fever, normal sensation, no autonomic dysfunction (HR, Urinary retention, arrhythmias). normal CSF.

Aortic Stenosis -Diminished and delayed carotid pulses (Pulsus Parvus and Tardus) due to blood flow obstruction -mid to late peaking systolic murmur from turbulence -presence of SOFT & SINGLE S2 thickening and calcification of the aortic leaflets leads to reduced mobility and causes soft S2 (sudden aortic valve closure), as a result of reduced mobility A2 is delayed and occurs simultaneously with pulmonic valve closure (P2) leading to single S2.

progressive fatigue, exertion lightheadedness and presyncope, delayed carotid pulses, midsystolic murmur over right sternal border

Interstitial Lung Disease (ILD) Increased Alveolar-arterial (A-a) Gradient

progressively worsening exceptional dyspnea, persistent dry cough, crackles, clubbing, CXR: reticular or nodular opacities.

persistent complex bereavement disorder (complicated grief, prolonged grief, complex grief) tx: Psychotherapy

prolonged grief >1yr, difficulty accepting the death, persistent yearning for the deceased, avoidance of reminders of the deceased

Cryptosporidium Parvum Cyclospora Giardia

prolonged, profuse, WATERY diarrhea

Azithromycin for mycobacterium Avium Complex

prophylaxis for CD4<50

Osteoarthritis (OA)

proximal and distal interphalangeal joint

Dyshidrotic Eczema (Pompholyx)

pruritic vesicles and erythema on palms and soles

Secondary Polycythemia. Cerebral microcirculation slugging and ischemic events. primary polycythemia: malignant transformation of erythrocyte progenitor cells result in unregulated erythrocyte production. EPO that stimulates RBC production will be low due to negative feedback. Require bone marrow aspiration/biopsy with JAK2 mutation testing. Secondary polycythemia due to elevated EPO. Due to chronic hypoxia (cardiopulmonary Dz, OSA) stimulates EPO secretion or by EPO producing tumors (Renal cell carcinoma) with normal BMI, pulse ox, CXR, chronic hypoxia unlikely. kidney is primary site of EPO production, to diagnose renal cell carcinoma an abdominal CT scan first test of choice.

pt with acute ischemic stroke presenting with Hematocrit >49% in M and >48% in F. Elevated EPO.

arterial pulse with decreased amplitude and delayed peak seen in SEVERE AORTIC STENOSIS

pulses parvus et tardus

PID Intramuscular ceftriaxone and oral doxycycline

purulent cervical discharge, cervical motion tenderness, and bilateral adnexal tenderness. Which of the following is the most appropriate pharmacotherapy?

thickening and fibrosis of the pericardium

radiation therapy to the chest for patients with Hodgkin lymphoma can lead to

INCREASE specificity (True negative) DECREASE Sensitivity (True positive)

raising the cutoff point (increasing inclusion criteria) as in fewer people being identified with the disease.

ischemic hepatic injury or shock liver diffuse livery injury due to hypotension (Septic shock, heart failure)

rapid and severe increase in transaminases (AST & ALT >10,000)

Thyroid Lymphoma higher incidence in patients with preexisting chronic lymphocytic hashimots thyroiditis. CT: diffuse enlargement of the thyroid around the trachea (doughnut sign) core or excisions biopsy may be required and flow cytometry can confirm monoclonal lymphoma cells.

rapid enlarging, firm goiter associated with compressive symptoms, as well as fever, night sweats, weight loss. mild pain and tenderness with fixed gland. retrosternal extension result in venous compression with distended neck veins and facial plethora. raising arm causes compression of subclavian between the clavicles and enlarged thyroid.

pneumothorax Tension pneuma should have needle thoracotomy or direct emergency tube thoracostomy ASAP, in unstable patients. second intercostal space in mid clavicular line or fifth intercostal space in mid axillary life

rapid onset severe SOB, tachycardia, Tachypnea, Hypotension, Distention of neck veins due to superior vena cava compression.

acute angle closure glaucoma

rapid onset severe eye pain, see halos, eye appears injected pupil dilated and poorly responsive to light, tearing and headache with subsequent n/v. In setting of recent pupillary dilation from medications like anticholinergic such as tolterodine, sympathomimetics and decongestants.

bacterial pneumonia

rapidly progressing chest pain, fever, chills, cough, dyspnea alveolar infiltrates following bronchial distribution

cytokines that promote platelet production driven by inflammatory state (infection, recent surgery, malignancy)

reactive (secondary) thrombocytosis

Glomerular vs non-glomerular hematuria Primary glomerular pathology likely post strep glomerulonephritis, redish brown (cola-color). Dysmorphic erythrocytes, red cell cast and white cell casts. 10 or more days post strep. IgA nephropathy similar presentation but 5 days post viral upper respiratory tract infection

recent bacterial pahryngotonsilittis has proteinuria, hematuria with dysmorphic RBC

Bronchiectasis disease of bronchial damage and dilation triggered by underlying impairment of host defense. inability to clear bacteria from airway results in recurrent cycles of bacterial overgrowth, neutrophilic infiltration, inflammation, tissue damage. cough with mucopurulent sputum that may be streaked with blood, dyspnea, fatigue and weight loss may be common. CXR: bronchial dilation and irregular peripheral opacities. Definitive diagnosis with high resolution CT scan. permanent destruction and dilation of the airway.

recurrent cycle of infection, inflammation, tissue damage that leads to bronchial dilation and airway destruction.

Hemophilic Arthropathy Joint damage caused by intra-articular bleeding. Hemosiderin deposition within the joint triggers synovial inflammation, which leads to fibrosis and destruction of cartilage and bone. MRI allows for earlier detection early prophylaxis with factor concentrates can significantly reduce the risk of developing arthropathy.

recurrent hemarthroses in a patient with hemophilia can result in

Adult still's disease

recurrent high fevers, arthritis/arthralgia, salmon colored macular or maculopapualr rash Elevated ESR

Behcet Syndrome diagnosed by pathergy Test

recurrent oral aphthous ulcers and systemic symptoms raise concern for and diagnosed by?

Granulomatosis with polyangiitis (Wegener) QUALITATIVE SERUM AUTOANTIBODIES = serum antineutrophil cytoplasmic antibodies (ANCA), proteinase 3-ANCA (c-ANCA)

recurrent sinusitis & otitis, auditory canal ulceration, fatigue, anemia, microscopic hematuria

Hypersecretion of IgE (hyper IgE or Job Syndrome)

recurrent skin abscess pulmonary infections Staph aureus infection broad nose scolioisis

Chronic Granulomatous Disease (CGD) abnormal NADPH oxidase (Respiratory Burst-Formation of superoxide radicals), decreased production of peroxide anions susceptible to fungal and catalase positive bacteria tx: Prophylaxis against bacterial infection.

recurrent skin abscesses staph aureus infection

job syndrome HYPER Ig-E

recurrent skin and lung infections in addition to purpuric rash

cutaneous arteriovenous malformations. Seen in hereditary telangiectasia and AD disorder characterized by recurrent epistaxis and telangiectasia.

red papules on trunk and lips

causes include: -Inappropriate sinus tachy -atrial tachy -atrial flutter -Atrioventricular nodal reentrant tachycardia Manage with immediate synchronized direct current cardioversion. If hemodynamically stable Adenosine or Vagal Maneuvers (bearing down, squatting, breath holding) can be considered.

regular narrow complex tachycardia (Supraventricular Tachycardia), causing Hypotension and signs of poor perfusion (cool extremities). Causes? tx?

if RR = 1 = no association between exposure and outcome RR>1 indicates that exposure is aasscoaited with increased risk fo disease RR<1 exposure is associated with decreased risk of disease. when 95% CI not include null value (1) p value <0.05 and association is statistically significant The wider the CI likely due to smaller sample size which decreases study power increasing sample size would increase power and make CI narrower.

relative risk

resistant HTN, Recurrent flash pulmonary edema, abdominal bruit, acute kidney injury after initiation of ACE inhibitors. older adults with widespread atherosclerotic disease and young women with fibromuscular dysplasia.

renal artery stenosis suspected in patients with?

Membranous glomerulopathy Loss of Antithrombin 3 (inhibitor of coagulation factors) in the urine increases risk of venous and arterial thrombosis. Abdominal pain, fever and hematuria due to thrombosis of the renal vein.

renal vein thrombosis and other thromboembolism complications of nephrotic syndrome, most commonly associated with?

atelectasis of the lung due to bronchial mucus plug. surgery (under anesthesia) and smoking increases risk of mucus plugging. chest physiotherapy useful in preventing mucus plugging and can be used to treat minor atelectasis. Large volume atelectasis requires bronchoscopy to remove mucus plug.

respiratory distress(dyspnea, tachypnea, tachycardia), Hypoxemia, dullness to percussion and absence of breath sounds. opacification of the affected lung with mediastinal shift TOWARD side of opacification. rib spacing becomes narrower.

amyloidosis, sarcoidosis, hemochromatosis

restrictive cardiomyopathy caused by?

isolated ambulatory HTN (masked HTN) normal BP readings during clinic visit but average BP through out the day and night is elevated. present with hypertensive end organ damage (HTN retinopathy, increased QRS voltage consistent with LVH) Dx: Ambulatory BP monitoring. BP cuff worn throughout 24 hours period and BP measured and recorded at routine intervals (every 20min while awake and every 60min while sleeping) Average 24 hour BP>135/85 is diagnostic

retinal arteriovenous nicking = retinal vanules are narrowed at the intersection points with arterioles and appear to bulge on either side , increased QRS complex voltage consistent with LVH. normal BP reading in clinic.

von Hippel-Lindau disease

retinal hemangioblastoma, renal cell carcinoma

Diabetic retinopathy due to poor glycemic control over long period of time dot and blot hemorrhages, exudates, and macular edema with to without neovascularization.

retinal neovascularization

Cardiac tamponade as a result of viral pericarditis (Coxsackie Virus) Pericarditis can cause retrosternal chest pain radiating to left arm and shoulder. Current symptoms of weakness, dizzy, and syncope best explained by severe depressed CO that occurs due to cardiac tamponade. pulses paradoxus = decrease in systolic BP on inspiration. significant for cardiac tamponade.

retrosternal chest pain that radiates to left arm and shoulder, weakness, dizzy, syncope. following a viral infection. thready pulses over both radial arteries that disappear with deep inspiration.

testicular torsion from twisting of spermatic cord due to inadequate fixation of the testis to the tunica vaginalis twisting leads to compression of the pampiniform plexus and reduced venous outflow. bell-clapper deformity (shortening of spermatic cord cause testis to ride high in the scrotum with long axis oriented horizontally) cremasteric reflex absent dx confirmed with doppler US lead to lack of blood flow in affected testicle

right scrotum erythematous, swollen, tender and cremasteric reflex absent.

Congenital Clubfoot karyotype due to associated chromosomal anomalies tx: orthopedic evaltuation, serial manipulation and casting soon after birth.

rigid medial and upward deviation of both forefoot and hind foot in a new born.

Obesity, DM, Hypothyroidism, pregnancy (3rd trimester)

risk factors for Carpal Tunnel Syndrome

nulliparity, fetal macrosomia, placenta accreta, rapid labor and delivery

risk factors for uterine inversion

Nummular (discoid) Eczema

scattered round eczematous plaque on back and extremities

primary ovarian insufficiency lack of ovarian function results in low estrogen levels, evidence by lack of withdrawal bleed after a progesterone stimulation challenge. The low estrogen levels limit endometrial proliferation, therefore there is no endometrium to slough off with progesterone stimulation. Fragile X syndrome permutation carrier (generalized anxiety, autism) and family hx of Fragile X.

secondary amenorrhea (lack of menses >6m in a previous irregular cycle). Elevated FSH. Negative progesterone challenge.

Shigella febrile seizure from infection or toxins MUCOID diarrhea not always bloody

seizure in the setting of an acute bacterial gastroenteritis (rapid onset, high fever, profuse diarrhea with mucus)

psychogenic non-epileptic seizures a type of CONVERSION disorder video-electroencephalogram is monitoring gold standard for diagnosis. A psychiatric assessment is crucial

seizure with forceful eye closure, absence of self injury, incontinence, or postictal confusion

IV calcium gluconate to stabilize cardiac cell membrane, this is temporary then need to add Insulin, bicarb, and or cation exchange resins like sodium polystyrene sulfonate (kayexylate) to reduce serum potassium levels

seizure, lack of responsiveness, urinary incontinence (poetical state) HIGH CPK and Cr (Rhabdomyolysis consequence of seizure, as well as release of POTASSIUM) Elevated Potassium from release from intracellular stores, with ECG showing flat P waves, PR and QRS prolonged. Tx?

hypovolemia hypokalmiea hyponatremia urinary sodium will be low as kidneys try to conserve water by resorbing sodium and water.

self induced vomiting may lead to

transient ischemic attack due to thromboembolism in setting of atrial fibrillation Warfarin or NON vitamin K Antagonist Oral Anticoagulanta (RIVAROXABAN, DABIGATRAN, APIXABAN, EDOXABAN) Reduce risk of systemic thromboembolism in patients with atrial fibrillation and mod-high risk thromboembolic events.

self limited epidote of right hand weakness and slurred speech, with hx of atrial fibrillation

Ocular Rosacea involve the cornea, conjunctiva, and lids with burning and foreign body sensation, blepharirits, keratitis, conjunctivitis, corneal ulcers and recurrent chalazia. tx with lid scrubs, topical abx (metronidazole, erythromycin) and ocular lubricants.

sensation of dirt in my eyes, erythema and tearing. increased vascularity, and mild erythema of the conjunctivae. erythema and scattered pustules involving the cheeks and nose.

Toxic Megacolon

series complication of Clostridium Difficile Colitis

incisional hematoma risk: Obesity, Hypocoagulability

serosanguinous drainage and incisional pain

(2xNa)+(BUN/2.8)+(Glucose/18) Increased serum osmolality >295 = Hyperglycemia, Advanced renal failure, alcohol intoxication

serum osmolality

serum Quantitative: (+) in 4 days Urine Pregnancy Test: (+) in a week

serum quantitative pregnancy test vs urine pregnancy test?

Metastatic Prostate Cancer prostate cancer causes pure osteoblastic lesions. leads to normal or low serum calcium, elevation in alk phos, and imaging evidence of focal sclerotic bone lesions.. radionuclide bone scan and PSA is required, and prostate biopsy.

several months of progressive back pain, focal lumbar tenderness, increased alkaline phosphatase and L1/L2 sclerotic lesions (osteoblastic)

Iron Toxicity later finding = lactic acidosis, hepatotoxicity, and organ failure. Bowel obstruction.

severe colicky abdominal pain with dizzy, N/V (bloody), Diarrhea (dark green), hypovolemic shock, in a child.

tracheitis

severe croup like symptoms including fever and stridor. Neck X-ray shows tracheal narrowing.

Transposition of Great Arteries.

severe neonatal cyanosis, tachypnea within first 24hrs. Single s2. In a patient with DiGeorge Syndrome.

Vaso-occlusive pain crisis due to SCD, caused by microvascular occlusion from sickled RBCs severe pain at multiple sites, triggered by viral, dehydration, cold, stress. Tx: Hydration, NSAID, opioids

severe pain in setting of anemia, leukocytosis, signs hemolysis (High LDH, High Indirect Bili) in African American patient

Complication of Roux-en-Y Gastric Bypass Surgery Gallstone disease with possible Cholecystitis this is due to RAPID WEIGHT LOSS which promotes gallstone formation likely from increased bile concentration of mucin and calcium prophylactic URODEOXYCHOLIC ACID administered for 6months postop to reduce risk. DUMPING SYNDROME (Rapid Gastric Emptying) cramps abdominal pain, vomit, diarrhea, flushing, palpitations

severe postprandial RUQ pain radiating to right shoulder following bypass surgery

Myasthenic Crisis

severe respiratory muscle weakness leading to respiratory failure. generalized or bulbar muscle weakness.

testicular torsion, urgent surgery required

severe testicular pain and negative cremaster reflex

Uremic pericarditis Dialysis is the most effective treatment for uremic pericarditis can resolve symptoms and decrease size of pericardial effusion. (Post MI pericarditis (DRESSLERS) occurs within 1-6 weeks after MI)

sharp, pleuritic chest pain, pericardial friction rub, uremia. BUN>60.

Acyclovir or Famciclovir or Valacyclovir decreases duration of symptoms and incidence of post hepatic neuralgia if initiated within 72 hours of onset.

shingles treatment

abacavir and lamivudine (Nucleoside reverse transcriptase inhibitors)

side effect of HIV meds causing insomnia and depression

Akathisia inner restlessness or internal sense of unease and need to walk or pace. Dystonia Cogwheeling Parkinsonism

side effect of antiemetics (prochlorperazine, promethazine, metoclopramide) and antipsychotics

pancreatitis, liver toxicity, dose dependent bone marrow suppression

side effect of azathioprine

Hypotension due to vasodilation (venous pooling), decreased venous return to right side of heart, and decreased CO. Prevent by aggressive intravenous fluid volume expansion poor to epidural placement.

side effect of epidural anesthesia during labor

GI distress, Visual Disturbance, Hemolysis in G6PD deficiency

side effects of Hydroxychloroquine

Frontotemporal Dementia (Pick Disease) early personality changes and later memory impairment and compulsive behavior

silver staining cytoplasmic inclusions within hippocampus

tight BP control. <140/90 ACEi /ARBs are first line

single most effective intervention for slowing diabetic nephropathy

consistent condom use majority of transmission of genital HSV is during asymptomatic viral shedding.

single most effective strategy to prevent herpes infection

ACEi reduces urine albumin excretion and decline in creatinine clearance. recommend in patients with microalbuminuria

slowing the progression of diabetic nephropathy requires

interstitial lung disease due to idiopathic pulmonary fibrosis DEC TLC NORMAL FEV1/FVC DEC DLCO evaluate for autoimmune dz, medications like amiodarone, occupational exposures, therapeutic radiation, asbestosis exposure CXR: nonspecific reticular infiltrates CT: peripheral or basilar reticular infiltrates and honeycombing are more helpful in establishing diagnosis.

slowly progressive dyspnea, dry cough, fine crackles in absence of smoking. End inspiratory squeaks, digital clubbing and abnormal S2, due to pulmonary HTN.

osteoarthritis (degenerative joint disease) progressive destruction of articular cartilage. >40, obesity, DM large weight bearing joints of lower ext Xray: loss of joint space, osteophyte formation and subchondral sclerosis

slowly progressive pain relieved by rest, worse with activity or weight bearing

Benzodiazepines overdose normal vitals, normal pupil size (2-4mm), respiratory depression if congestion (opioids or alcohol) used for tx of anxiety, insomnia, seizures, and alcohol withdrawal.

slurred speech, unsteady gait, drowsy

Idiopathic Guttate Hypomelanosis

small macule in sun exposed areas of an elderly

papulopustular rosacea

small papule and pustules resembling acne

bed bugs

small punctate lesions with surrounding erythema, in linear tracks or clusters.

SCC of the lung

smoker, weight loss, cough, chest pain, hemoptysis, single upper lobe cavitary lesion

chronic lymphocytic leukemia

smudge cells (fragile lymphocytes)

Olecranon Bursitis causes by pressure, friction, overuse, autoimmune disease (RA) normal pain-free range of motion

soft fluctuant swelling at elbow, with minimal tenderness and no warmth.

Galactocele milk retention cyst occurs weeks to months after cessation of breastfeeding. US first line imaging Aspiration confirms diagnosis and curative Asymptomatic: no tx Symptomatic: needle aspiration

soft, mobile, non tender subaerolar mass

Infectious epiglottitis thickened epiglottis on lateral neck radiograph risk factors: DM, Obesity, preceding upper respiratory infection.

sore throat, hoarseness, stridor, pooled oral secretions, drooling

UMN (spinal cord injury or cerebral palsy), slow stiff and effortful

spastic gait

amyotrophic lateral sclerosis (ALS)

spasticity, bulbar symptoms, exaggerated DTRs (UMN lesion) Fasciculations (LMN lesion) Weakness and wasting of muscles (UMN & LMN)

validity

specificity and sensitivity are measure of

CHILDREN <6yo

staphylococcal Scalded Skin Syndrome is seen in

complex partial seizures leg dragging = Todds paralysis TEMPORAL LOBE EPILEPSY common cause of complex partial seizures

stare blankly for several minutes and engage in automatisms such as lip smacking or chewing. confusion after episode, with leg dragging for 20-30 minutes.

single seizure lasting >5min resulting in Cortical Laminar Necrosis especially common in those noncompliant with medical therapy

status epilepticus in setting of seizure disorder

Leiomyomata Uteri (fibroids) best test to confirm = US enlarged anteverted and ante flexed uterus exerts direct pressure on bladder and decreases capacity. Subserosal and pedunculated fibroids are especially likely to compress adjacent organs.

stress urinary incontinence, IRREGULARLY enlarged uterus with anteverted and anteflexed uterus, due to?

OCD (Obsessive Compulsive Disorder)

structural abnormalities seen in orbitofrontal cortex and basal ganglia associated with

blood between periosteum and aponeurosis due to shearing of the emissary veins during delivery. fluctuant scalp swelling that can move cross suture lines and expand for days after delivery. tachycardia and pallor due to excess blood loss.

subgaleal hemorrhage

vitreous hemorrhage due to diabetic retinopathy upright position during sleep

sudden loss of vision, onset of floaters, dark red glow with loss of fungus details

central retinal artery occlusion retinal pallor with a cherry red fovea ulcerated plaque in internal carotid artery need carotid imaging to evaluate for atherosclerotic disease.

sudden monocular vision loss due to atherosclerotic, cardioembolic, vasculitis

Arrhythmia Torsades de Pointes a ventricular arrhythmia a side effect of sotalol (used to treat Atrial fibrillation) Atrial fibrillation alone cannot cause syncope

sudden onset syncope without prodrome in a patient with atrial fibrillation on Sotalol

failure of brane attack complex (C5-C9 defieicny)

susceptible to neisseria infections

Vitamin D and Calcium supplementation to treat rickets.

symmetric bowing and short stature in toddlers.

most common neuropathy in DM. Axonopathy of Small fibers (Pain, paresthesia, allodynia) Axonopathy of Large Fibers (numbness, loss of proprioception and vibration sense, diminished ankle reflexes)

symmetric distal sensorimotor polyneuropathy

Polymyositis

symmetric proximal muscle weakness, elevated muscle enzymes (CK, Aspartate aminotransferase, aldolase)

Pericardial effusion and cardiac tamponade due to pericarditis from URI. Tachycardia, distended neck veins, pulses paradoxus, muffled heart sounds. ECG shows Electrical Alternans pathognomonic for pericardial effusion. Due to swinging of heart in pericardial cavity causing beat to beat varian in QRS axis and amplitude. Tx: Emergency PERICARDIOCENTESIS

syncope getting out of bed, feels weak, complains of dyspnea and chest discomfort. URI 2 weeks ago.

Aortic Stenosis common in elderly due to degenerative calcifications of aortic valve leaflets in younger patients BICUSPID aortic valve is most common cause In non developed countries Rheumatic valve disease is most common cause

systolic ejection murmur at R upper sternal border that radiates to carotids

Malignant Hyperthermia excessive calcium release following exposure to succinylcholine

tachycardia, dyspnea, generalized muscle rigidity, dark urine after general anesthesia

entrapment and compression of tibial nerve where it passes under the flexor retinaculum at medial aspect of ankle. Numbness and paresthesia at toes and distal sole. pain provoked by percussion at tarsal tunnel.

tarsal tunnel syndrome

Bartholin Gland Abscess MRSA or E. Coli Tx: Incision & Drainage and culture Word catheter to help prevent recurrence

tender, fluctuant mass at base of labium majus, protrudes into vagina causing pain

acute epididymitis

testicular pain that resolves with elevation of the testis (positive Prehn Sign).

Lichen Simplex Chronicus (Neurodermatitis)

thickened excoriated plaques due to persistent scratching and rubbing associated with anxiety disorders and occurs in easy to reach areas.

Microangiopathic Hemolytic Anemia (MAHA) seen in association with DIC Schistocytes on peripheral smear

thrombocytopenia, decreased fibrinogen, increased INR + Elevated LDH, retic count, bilirubin (Hemolysis)

tympanovstomy tubes for recurrent Acute Otitis Media, smoke induced dysfunction of the cilia in upper respiratory tract.

tobacco smoke exposure in a child Is linked to increased need for

Actinic keratoses and superficial basal cell carcinoma

topical 5-Fluorouracil is treatment for

Cryptosporidium parvum contaminated water microscopy with specialized stain healthy adults have spontaneous resiltuon in 10-14days chronic disease in immunocompromised

travelers diarrhea that is prolonged, profuse, and watery.

Unfractioned Heparin or LMWH. continued for at least 3 months (throughout remainder of pregnancy and first few weeks postpartum)

treating DVT in pregnancy

Systemic Glucocorticoid (methylprednisolone) Mobilization of marginated neutrophils, stimulation of release of immature neutrophils from bone marrow, inhibition of neutrophil apoptosis. decrease number of circulating lymphocytes and eosinophils through increased apoptosis, increased emigration into tissue and decreased production.

treating for asthma exacerbation now has leukocytosis with neutrophilic predominance common effect of?

aimed at underlying cause. in patients wit infective endocarditis IV antibiotics significantly reduces risk of septic cardioembolism within weeks of initiating therapy.

treatment for ischemic stroke

surgery + chemotherapy + radiotherapy Chemo = Cisplatin + Etoposide + Docetaxel or Carboplatin + Paclitaxel Cisplatin adverse effects: Tinnitus and hearing loss, N/V, Neurotoxicity

treatment for non small cell carcinoma

Topical Ciprofloxacin Water exposure wither from swimming or washing the ear out can alter pH cause maceration of skin and introduce bacteria into canal. pseudomonas most common pathogen. second most common staph aureus. Both covered with topical therapy (ciprofloxacin +/- Glucocorticoid drops) systemic therapy only if patient immunosuppressed.

treatment for otitis externa?

Cholinergic (bethanechol) stimulates muscarinic receptors to increase bladder contractility

treatment for overflow incontinence due to urinary retention (neurogenic bladder)

Ciprofloxacin

treatment for travelers diarrhea (E. coli, Campylobacter Jejuni, Shigella, Salmonella)

Carbamazepine SE: N/V and Leukopenia and aplastic anemia therefore CBC to monitor whole on drug. if fail treatment with medication then surgical decompression of trigeminal nerve.

treatment for trigeminal neuralgia

detrusor overactivity involuntary and uncontrolled contraction of the bladder muscle. Bladder training and pelvic floor muscle exercises Antimuscarininc (OXYBUTYNIN, TOLTERODINE) inhibit involuntary detrusor contractions and added when behavior therapy is unsuccessful.

treatment for urge incontinence

Muscarinic antagonists Beta Agonist (Mirabegron) relaxing the bladder

treatment for urge incontinence (Detrusor Overactivity)

occurs during rest and improves with activity. frequency of 4-5hz, first manifestation of Parkinson's disease. starts in one hand then involves both. tx: TRIHEXYPHENIDYL (used in younger patients where tremor is there predominant symptom)

tremor of Parkinson's

Dysgerminoma

tumor in adolescents secreting LDH

otorrhea, persistent tympanic membrane perforations and cholesteatoma

tympanostomy tube placement can increase risk of

impaired renal bicarb reabsorption and associated with Hypokalemia and non anion gap metabolic acidosis

type 2 renal tubular acidosis

basal cell carcinoma low risk lesions on trunk or extremities treat with electrodessication and curettage nodular on trunk or extremities managed with surgical excision 3-5mm margins. mohs for face

ulcerated early nodule with a rolled border on sun exposed skin

for growth restricted fetuses to evaluate for placental insufficiency and progressive fetal hypoxemia.

umbilical artery doppler US

Hypertensive hemorrhage most commonly occurs in basal ganglia and results in uncle herniation. RIGHT BASAL GANGLIA HEMORRHAGE resulting in UNCAL HERNIATION Dilated, nonreactive ipsilateral pupil (due to compression of CNIII), contralateral extensor posturing, coma, respiratory compromise.

uncontrolled HTN and Crack cocaine use is at risk for hypertensive vasculopathy.

pathophysiology of submissive/massive Pulmonary Embolism massive PE can result in syncope and hemodynamic collapse Echo: Bowing of septum into the LV (due to RV pressure exceeding LV diastolic pressure) and RV free wall hyperkinesis with sparing of the apex.

underlying malignancy, acute presentation of dyspnea, chest pain, tachycardia, hypoxia, clear lungs

Fragile X Syndrome (FMR1 gene) most common inherited form of intellectual disability. With Autistic behavior, less commonly ADHD, and anxiety. elongated face, large ears, enlarged testes

unstable trinucleotide repeat (CGG) on X chromosome

pulseless cardiac arrest who have a shockable rhythm (V fib, Pulseless Ventricular tachy)

unsynchronized cardioversion (defibrillation) is used for?

Coarctation of aorta confirm dx with ECHO

upper extremity HTN, headaches, epistaxis, lower extremity claudication. brachial femoral pulse delay. sustained apical impulse. Confirm the diagnosis with?

Prothrombin Complex Concentrate (2,7,9,10) + Vitamin K If PCC not available give FFP (takes longer to prepare and more volume necessary)

urgent reversal of Warfarin

protamine sulfate

urgent reversal of heparin

elevated serum uric acid levels due to gout, or tumor lysis syndrome and or acidic urine pH precipitate uric acid kidney stones. chronic diarrhea which leads to GI loss of bicarbonate and water with resultant acidic, hyperconetrated urine leads to uric acid stones. tx: urine alkalization with potassium bicarb or potassium citrate

uric acid stones

nephropathy

urine microalbumin to creatinine ratio is a good screening method for

cause fetal compromise (hypoxemia, acidemia) due to interruption of intervillous blood flow and inadequate recovery time between contractions. management is with supportive measures and DISCONTINUE UTEROTONIC AGENTS (OXYTOCIN)

uterine tachysystole with >5 contractions in a 10 min strip

Yellow Fever

vaccination for travel to subsaharan Africa and South America

vaccine strain versus wild type varicella attenuated vaccine virus can replicate after immunization and cause mild infection, or wild type VZV can cause classic varicella if acquired before immunization patients who develop rash after receiving VZV vaccine should avoid contact with high risk individuals who are susceptible to varicella until rash completely crusted over.

vesicular rash 2 weeks after receiving live attenuated VZV vaccine.

contralateral hemiparesis hemisensory loss homonymous hemianopsia gaze deviation toward side of lesion

vision problem seen in MCA occlusion

contralateral hemianopsia with macular sparring macula receives collateral circulation from middle cerebral artery

vision problem seen in PCA occlusion

muscular dystrophy

waddling gait

Clostridium difficile (C. diff) in Adults antibiotic use disrupts the normal colonic flora gastric acid suppression also alter colonic microbiome Advanced age >65 diminished colonic immunity and greater exposure to antibiotics FIRST LINE = VANCOMYCIN (po)

watery diarrhea (>3stools/day), abdominal cramping, vomiting, low grade fever, leukocytosis

significant hypokalemia in the setting of persistent HTN = Primary Hyperaldosteronism metabolic alkalosis mild hypernatremia best screening = early morning aldosterone concentration our plasma renin activity elevated aldosterone >15 with PAC/PRA ratio >20 = Primary hyperaldosteronism CT image the adrenal glands if unilateral take it out if bilateral manage with aldosterone antagonists (SPIRONOLACTONE, EPLERENONE)

weakness and leg cramps after starting a thiazide diuretic

Management of Hypercalcemia smoking hx + mass in lung = humoral hypercalcemia of malignancy due to secretion of PTHrp. Hypercalcemia results in volume depletion due to polyuria and decreased oral intake. severe hypercalcemia requires aggressive hydration with normal saline to promote urinary calcium secretion.

weakness, GI distress, neuropsychiatric symptoms (confusion, stupor, coma) Volume depleted due to polyuria from hypercalcemia induced nephrogenic DI

Hypokalemia due to Potassium wasting diuretic (HYDROCHLOROTHIAZIDE) can also occur due to diarrhea, vomiting, anorexia, hyperaldosteronsim

weakness, fatigue, muscle cramps, flaccid paralysis, hyporeflexia, tetany, rhabdomyolysis, arrhythmias. Broad flat T waves, U waves, ST depression, premature ventricular beats.

toxic megacolon due to Ulcerative Colitis key to diagnosis of toxic megacolon = colonic distension >6cm of right colon on ABDOMINAL XRAY tx: BOwel rest, nasogastric suction, Corticosteroids with broad spec antibiotics due to IBD or targeted against C. Diff.

weeks of lower abdominal pain, bloody diarrhea, and fecal urgency

glucocorticoid induced myopathy. improves once glucocorticoids are d/c'd

weeks to months after treatment of temporal arteritis patient develops painless proximal muscle weakness, more prominent in lower extremities. no muscle inflammation or tenderness and CK and ESR are normal.

Renal Cell Carcinoma dx: Abdominal CT with and without contrast, followed by staging imaging (CT chest) Nephrectomy or partial Nephrectomy provides a tissue diagnosis

weight loss smoking hard flank mass

Erythrasma Cornybacterium Minutissimum

well demarcated thin red brown plaques with wrinkling and a fine scale coral red appearance under woods lamp

MITRAL VALVE PROLAPSE

what murmur is seen in Marfan syndrome?

Obstructive Shock Normal or Low PCWP & Cardiac Index Increased SVR Increased MvO2 dyspnea tachycardia

what type of shock from Pulmonary Embolism

Susceptibility Bias (confounding by indication)

when the treatment regimen selected for a patient depends on the severity of the patients condition, this is a form of selection bias called?

Physiologic leukorrhea

white odorless cervical discharge, increased mid cycle (10-14days after previous menses), as estrogen levels increase prior to ovulation.

ASD

wide and fixed splitting of S2, mid systolic ejection murmur and mid diastolic rumble

aortic rupture

widening of mediastinum abnormal knob contour left apical cap lef sided hemothorax

Benzodiazepines withdrawal. especially in patients who take Benzos chronically for insomnia and or anxiety. withdrawal symptoms in 24-48 hours. tx: re-initiation of long acting benzodiazepines that can be gradually tapered down over weeks to months.

worsening agitation, impaired attention, disorientation following surgery. tremulousness, hallucinations, HTN, Tachycardia. in a non alcoholic. Delirium due to?

Cholesterol embolization to the retina from carotid artery or aortic arch caution acute transient monocular vision loss amaurosis fugax

yellowish refractive plaques at arterial bifurcations (hollenhorst plaques)

Thromboangiitis obliterans (Buerger disease) HEavy SMOKERS, smokeless tobacco and marijuana nonatherosclerotic, inflammatory thrombosis ischemia and fibrosis affecting small and medium sized vessels peripheral pulses are diminished angiography confrims segemntal occlusion of small and medium arteries. only definitive treatment is complete smoking cessation

young smoker with gangrene and painful ulceration involving distal lower extremity

Fibromyalgia Low impact exercise regimen can improve pain and provide long term benefit. inflammatory and serological markers are normal.

young to middle age woman with widespread pain, fatigue, cognitive/mood disturbance. Trigger point tenderness in areas such as mid trap, lateral epicondyle, costochondral junction, greater trochanter. perceive worsening after excercise.

Diuretic abuse leads to hypovolemia elevated urine sodium which suggest salt wasting (diuretic, cerebral salt wasting, adrenal insufficiency) renal potassium wasting (diuretic, hyperaldosteronism, renal tubular acidosis) Hypochloremia result of diuresis and contraction alkalosis

young woman with orthostatic hypotension, hyponatremia, hypokalemia, hypochloremia and increased urinary Na and K.

Idiopathic Intracranial HTN (Pseudotumor Cerebri) associated with some meds: Isoretinoin, Tetracyclines, GH, Excess Vitamin A dx: MRI + Magnetic Resonance Venography EMPTY SELLA present in 70% of patients but NOT diagnostic causes communicating hydrocephalus LP: Opening pressure >250

young, obese women with headache, vision changes (blurry, diplopia) and pulsatile tinnitus.

Neurofibromatosis type 1 -Cafe-Au-Lait spots -Clustered freckles -Lisch Nodules -Neurofibromas (Nerve sheath tumors) -Optic Glioma

young, uniformly pigmented macular skin lesions on trunk