usmle step 3: uworld practice test 2:

type 4 RTA

HYPERkalemia hypoaldosteronism

strongyloidiasis

ROUNDWORM infxn w/Strongyloides stercoralis -tropic/subtropic regions -skin penetration-->bloodstream-->lungs-->GI tract -mild &recurrent -cutaneous: pruritic raised *LINEAR* erythematous lesions, *urticaria* -GI: nausea, diarrhea, abd pain -Pulm: dry cough, wheezing, dyspnea *EOSINOPHILIA* -serology Tx: ivermectin or albendazole, recheck titers at 3-6 months to confirm response

what affects ventilation?

RR and TV

bowen disease

cutaneous SCC in situ -on penile shaft (follicle-bearing epithelium) -often asymptomatic -erythematous plaque -nonexudative

what can reduce risk of croup?

daily disinfection of surfaces & Toys at day care

muscular dystrophy(duchenne, becker)

elevated CK waddling gait or toe walking CHRONIC!!!! doesn't suddenly just appear like viral myositis

who has asymmetric moro reflex?

erb palsy (seen in large for gestational age infants)

heroin intoxication

euphoria *depressed mental status* *miosis* *respiratory depression* constipation

Cocaine intoxication

euphoria agitation/psychosis *CHEST PAIN* *SEIZURES* tachycardia/HTN *MYDRIASIS:DILATED PUPILS*

RF postop ileus

extensive bowel manipulation prolonged surgical time (debulking procedure for ovarian cancer) opiate use DM

why are spironolactone(mineralocorticoid receptor antagonists) contraindicated in pregnancy?

feminization of male fetus in early gestation and other endocrine problems in both male & female fetuses in late gestation

teratogenic effects of ACEI/ARBs

fetal renal toxicity persistent patent ductus neonatal death

Toxic synovitis

fever limp *YOUNG KIDS* -caused by acute inflammation of hip synovium after viral infxn -tenderness & limited ROM -NORMAL CK

hypertensive retinopathy

focal spasm of arterioles then progressive sclerosis & narrowing exam: AV nicking, copper or silver wiring, exudates, retinal hemorrhages

annual screening for lung cancer w/low-dose CT

for pts age 55-80 (earlier than AAA) who have >=30 Pack yr smoking hx & currently smoke or quit in last 15 yrs

meth intoxication

violent behavior psychosis, diaphoresis tachycardia/HTN choreiform movements tooth decay

chronic meth use

weight loss sleep disturbance mood changes paranoia poor dentition and skin excoriations psychotic sx: paranoia, persecutory delusions, visual and tactile hallucinations -skin picking due to tactile hallucinations of bugs crawling under skin(Formication)

hypophosphatemia

when serum levels are<1 -generalized weakness -diminished reflexes -paresthesias -ileus -metabolic encephalopathy

at what gestational time are tocolytics indicated?

preterm labor <34 wks gestation

COPD spirometry

"scooped out pattern" on expiratory curve FEV1/FVC ratio<0.7 -minimally reversible airway obstruction -if mild COPD: normal DLCO (reduced in interstitial lung dx, type of restrictive lung dx)

who gets screening for AAA?

*ANY SMOKING HISTORY* -men age 65-75 1 time abdominal duplex u/s

sx of neonatal polycythemia

*ASYMPTOMATIC* ruddy skin HYPOglycemia, hyperbilirubinemia Respiratory distress, cyanosis, apnea irritability, jitteriness abdominal distension

sx of rhino-orbital-cerebral mucormycosis

*Acute*/aggressive -fever, nasal congestion, purulent nasal discharge, HA, sinus pain -*Necrotic* invasion of palate, orbit, brain

Young man has 1 day hx pruritic rash over lower trunk & upper thighs near hair. recently went on vacation in puerto rico-hiked forest trails, eaten local cuisines, swam at resort pool. Bitten several times by insects during hike. Next step in management?

*Advise to stop swimming in pool* dx: folliculitis -*erythematous papules/pustules* around hair follicles -*pruritic* or painful -hot tub folliculitis due to *pseudomonas aeruginosa*(other folliculitis is staph aureus-face or scalp lesions) --this form develops in distribution of *wet bathing suit: buttocks, upper thighs* 8-48 hrs post swimming insect bites are more urticarial/wheals

2 week old girl has *asymmetric gluteal skinfolds&increased # thigh creases on right>left*. what else would be found?

*Apparent leg-length discrepancy* when pt lies supine w/knees flexed: affected leg looks shorter(Galeazzi test) DX: developmental dysplasia of hip -abnormal development of hip joint tht prevents femoral head from sitting properly in acetabulum -RF: *females, breech position, FH DDH, excessively tight swaddling* -instability during attempted dislocation&reduction if palpable clunk heard (Barlow and Ortolani maneuvers)

24 yo F found crouched under table in apartment to "avoid being shot." Says "govt is monitoring my movements&sent special agents to kill me."hears voices of ppl outside apt who are plotting against her. Recently fired from job&blames this on consipiracy against her. Hx of depression-takes paroxetine. Drinks beer on wkds&hx of MJ&Cocaine use. T 100F, BP 160/100, P112. Pt is diaphoretic, frightened, physically restless, tremulous. Pupils dilated&reactive to light. Tachycardia on exam. DX?

*COCAINE intoxication* -not alcohol withdrawal bc of dilated pupils and sporadic etoh use

4 yo M has difficulty stooling &Stool leakage. Has a small, hard BM every 4-5 days w/straining & pain. Frequently complains of abd discomfort, which is partially relieved by defecation. Father is embarrassed that he stools in underwear 1-2x/week & doesnt care abt accidents or fact that it makes him smell bad. sx started when pt started preschool at age 3 and worsened since then. pMH ototis media age 1, PNA age 2, occasional URIs. No FH GI dx. Height&weight 10th percentile last yr but this year weight &height 25th percentile. BMI 14.9. Exam: mass palpated LLQ, hard stool palpated rectal vault. CAUSE of encopresis?

*Chronic rectal dilation*-->intermittent relaxation of anal sphincter-->encopresis(fecal incontinence) dx: constipation -stool withholding STRETCHES Rectosigmoid colon to hold all that retained stool-->disrupts peristalsis-->colon can't fully empty during defecation-->retained stool becomes hard&impacted-->further dilates rectum -amt of impacted stool increases each day-->painful defecation -*sX STARTED when he started school* _NOT CYSTIC FIBROSIS BC NORMAL GROWTH OF INCREASING PERCENTILES RATHER THAN FTT -NOT HIRSCHSPRUNG BC STOOL WOULDN'T BE PRESENT IN RECTAL VAULT

a multinational research organization plans to conduct hospital-based case-control study to evaluate the association between 3 different site-specific cancers(cancers of corpus uteri, cervix uteri and ovary) & Evidence of past combined OCP. The study will be conducted in 10 participating centers in 8 different countries. A Random sample of women who were born after 1924 and had been living in the area served by participating hospital for at least a year will be selected and invited to participate in the case-control study. Which corresponds with proposed study design?

*Combined OC use rates should be compared between women with and without any of the 3 site-specific cancers* It's a case-control study so the case and controls have to be a disease or not a disease. The results should be related to risk factors. the case cannot be risk factor (OCP in this case)

78 yo F here for wellness visit. PMH b/l knee osteoarthritis limiting mobility recently by pain. Feels weak most of the time & gets tired easily. Lost several pounds over last yr. Lives alone but home health aide spends many hrs/day assisting w/shopping&household chores. Independent in ADLS, takes care of finances. BP 146/82. Knee exam: mild b/l joint line tenderness & Crepitus. Weak handgrip but symmetrical and slow gait. Which intervention will decrease risk of adverse health outcomes?

*Comprehensive exercise program*

what's the next step after u/s shows dislocated right hip w/flat acetabulum and positive barlow and ortolani tests?

*Consult orthopedic surgeon* --when ID within first 6 months of life, treat by maintaining hip in *flexed&abducted position in Pavlik harness for 3 months* -when hip extension & adduction are limited, the dislocated hip is reduced and/or stabilized and normal acetabular development is promoted --monitor pavlik harness closely by orthopedic surgeon b/c associated risks( avascular necrosis, femoral nerve palsy) w/excessive hip flexion & abduction >hip radiograph if >4 months old

82 yo M seen for initial physician evaluation at SNF. last colonoscopy age 70. For DM2: insulin glargine, sitagliptin. HgbA1c 6.5%. Appropriate intervention at this time?

*Decrease diabetes treatment regimen* b/c less stringent targets (hgba1c 7-8%) for those w/*limited life expectancy*, significant comorbidity or high risk of hypoglycemia, or w/longstanding DM w/chronic complications(nephropathy) -*Routine colon cancer screening NOT Recommended* for asymptomatic pts w/no personal or FH of colon cancer *past age 75 *or w/less than 10 yrs life expectancy

80 yo F had near-syncope. Feels excessively tired&breathless on moderate exertion &had occasional palpitations for 6 months. Several brief episodes of lightheadedness during last 2 wks& while walking in mall today, she felt weak&dizzy. ECG sinus bradycardia, RBBB. CAUSE?

*Degeneration of cardiac conduction system* dx: *SICK SINUS SYNDROME*=inability of SA node to generate enough/adequate heart rate --age-related degeneration occurs w/*fibrosis of sinus node* -other causes:sarcoidosis, amyloidosis -sx: *bradycardia*-->fatigue, DOE, lightheaded,confusion, syncope, presyncope -fibrosis can affect atria-->paroxysmal atrial arrhythmias like A.fib(likely caused palpitations in this pt) or bradycardia-tachycardia syndrome(bradycardia alternating w/SVT) -ECG: sinus bradycardia, *sinus pauses(delayed P waves)*, sinoatrial nodal exit block(dropped P waves) -w/bradycardia-tachycardia syndrome-long sinus pause observed on conversion from SVT To sinus rhythm -Pt w/*bundle branch block are at higher risk of high-grade atrioventricular block* dx: *holter or event monitor* to correlate sx w/episodes of bradyarrthymias tx: permanent pacemaker, then rate control meds if persistent paroxysmal tachycarrhythmias

38 yo F G3P3 is evaluated for heavy vaginal bleeding after spontaneous vaginal delivery. Labor was induced via oxytocin infusion at 38 wks gestation for gestational HTN. Delivery of placenta* assisted by traction on umbilical cord* &uterine massage occurred 30 minutes later. Immediately after placental delivery, profuse vaginal delivery & Severe lower abd pain began. 1st pregnancy ended at term w/C section due to fetal HR abnormalities. BP 90/60. Exam: profuse vaginal bleeding w/smooth round mass at introitus. Management?

*Discontinue oxytocin infusion & perform manual uterine replacement* DX: uterine inversion -*Hypotension, PPH, smooth ROUND Vaginal mass* -OB EMERGENCY!!!!!

56 yo M has fever, worsening HA, facial pain. Had nasal congestion&sinus HA for past several days. Prescribed oral augment 2 days ago but sx kept worsening. PMH AML w/stem cell transplant. Briefly admitted 6 wks ago for graft-vs-host disease. T 102F, P 110. Exam: right periorbital swelling, mild proptosis right eye, erythema of facial skin overlying right maxillary sinus. Thing, blood-tinged d/c present both nares & percussion of maxillary sinuses elicits pain. Area of decreased sensation over right cheek. CT scan: opacification & bony erosions of right maxillary sinus. Management?

*Endoscopic sinus surgery for debridement* DX: rhino-orbital-cerebral mucomycosis RF: DM(ketoacidosis), Hematologic malignancy, *Solid organ or stem cell transplant* Dx: *Sinus endoscopy w/bx & culture* Tx: *surgical debridement*, liposomal *amphotericin B*, eliminate RG(Elevated glucose, acidosis)

what are nonreactive(absent accelerations) nonstress tests indicative of?

*Fetal acidemia*-poor indicators tho-high false positive rate fetal sleep cycles fetal prematurity (<32 wks gestation) maternal tobacco use

71 yo F has 1 wk hx fever, dry cough, SOB. Over past year, 2 episodes shingles &feels tired constantly. Occasional loose stools, joint pains, 4.5 kg(10 lb) weight loss over past year. T 100.4F, R 24/min, Recently received pneumococcal and zoster vaccines. Drinks glass of wine w/dinner every evening. pulse ox 90% RA. Exam: enlarged LN in cervical & inguinal regions &small white patches in mouth, b/l crackles. Hgb 11.4,lymphocytes 22%, neutrophils 68% CXR b/l interstitial infiltrates. Antimicrobial therapy administered. next step in dx?

*HIV antigen/antibody testing: p24 antigen/HIV antibody assay* THERE CAN BE HIV IN OLDER PPL >50yo !!! -PCP PNA: dry cough, fever, dyspnea, b/l interstitial infiltrates weight loss, recurrent shingles, oropharyngeal candidasis (white patches) *annual HIV screening up to age 65* -NO LN bx bc thats invasive and u should r/o HIV 1st as thats more common cause of PCP PNA compard to non hodgkin and CLL

57 yo M w/PMH HIV has fever, chills, generalized weakness, dysuria & increased urinary frequency for the past several days. T 101F, BP 91/53, P 122, RR 20. Pulse ox 94% RA. Obese w/weight 80 kg, BMI 32. WBC 23000, plts 60,000,Na 131,BUN 46, SCr 2.2, UA: blood, LE,itrites, bacteria,WBC. Started on IVF&Antibiotics. 3 hrs later, he's agitated, diaphoretic, dyspneic w/T 99.7F, BP 104/70, RR 42, P 116. Pulse ox 70% on 100% O2 via nonrebreather mask. Lungs show b/l crackles. ECG sinus tachycardia. CXR diffuse b/l infiltrates. Mechanism responsible for pt's current decompensation?

*Increased pulmonary vascular permeability* b/c of DIFFUSE INJURY to pulmonary MICROVASCULAR ENDOTHELIUM & alveolar epithelium-->bloody&proteinaceous fluid escapes into alveoli and alveoli collapse b/c surfactant is lost & Diffuse alveolar damage results DX: ARDS -management: mechanical ventilation(low TV, high PEEP, high FiO2)

central hypothyroidism etiology

*Mass lesions* (pituitary adenoma) -pituitary surgery, trauma, irradiation -infiltrative d/o (Sarcoidosis, hemochromatosis) -pituitary infarction (sheehan syndrome) -empty sella syndrome

28 yo F has 3 day hx painless vulvar lesions. no intercourse pain, bleeding, pruritus or dysuria. Recently became sexually active w/new partner. Underwent LEEP 2 yrs ago for CIN 3. F/u pap WNL. 12 lifetime sexual partners. Exam: multiple small translucent raised labial lesions w/*Central umbilication*-nontender, nonfriable, no palpable inguinal lymphadenopathy. DX?

*Molluscum contagiosum* -viral infxn spread by skin-to-skin contact -esp in KIDS b/c contact sports &bath towels -*GENITAL LESIONS in sexually active adults are STIs* ---evaluate for *HIV* -molluscum contagiosum are found thruout body EXCEPT PALMS AND SOLES-can be pruritic or asymptomatic TX in adults: curettage, cryotherapy or topical medications (Cantharidin, podophyllotoxin)

57 yo F evaluated on surgical floor for *Continuous bilious emesis over last 12 hrs.* Had 10 episodes of vomiting which continued despite IV Antibiotics. Underwent TAH, b/l salpingo-oophorectomy, omentectomy, tumor debulking for epithelial ovarian cancer 4 days ago. During procedure, 2 L ascites was drained. Ate solid food yday for lunch & unable to hold down even small sips of water. Last BM was prior to surgery& not passed flatus. PMH Type 2 DM (metformin). PSH C/S x3. VSS. BMI 37. Exam: markedly distended abd w/vertical skin incision &ABSENT bowel sounds. Staples clean and dry. Labs: K 2.9(L), HCO3 30, BUN 26, glucose 58(L). Abd X ray: Dilated loops of bowel w/air in distal colon&rectum. Next step?

*NG tube placement* dx: Postop ileus: No return of bowel function >72 HOURS after intraabd surgery-->vomiting, lack of flatus, &inability to tolerate oral intake sx: increasingly distended abd w/ABSENT bowel sounds; abd nontender/mildly tender -persistent emesis-->HYPOchloremic met alkalosis&hypokalemia -X ray: *dilated loops of bowel BOTH SMALL& LARGE intestines, air in distal colon&rectum, gastric dilation* -NGT provides bowel rest for pts w/severe vomiting & alleviates abd distension by draining stomach contents & Decompresses small intestine -NOT EX-LAP b/c tht's for SBO when there's no air in RECTUM&DISTAL COLON on XRAY

what meds raise BP?

*NSAIDs* due to decreased renal clearance of sodium decongestants some antidepressants-venlafaxine OCPs systemic glucocorticoids stimulants-methyphenidate

PCP intoxication

*NYSTAGMUS(horizontal or vertical)* violent behavior dissociation hallucinations amnesia ataxia

84 yo M is evaulated in *ICU* b/c of fevers. admitted 5 days ago for copd exacerbation requring intubation. still intubated&on mechanical vent. recieving bronchodilators, steroids, iv cefepime. for the past 24 hrs, had high grade fever. T 102.4F, bp 100/60, hr 102. b/l breath sounds coarse.decreased bowel sounds, pt grimaces on abd palpation. 1+pitting sacral edema. hgb 9.8, wbc 21,000. bun 22, SCr 1, total bilirubin 2.1, alk phos 220,ast 62, ALT 74, CXR negative, CT abd: nonspecific bowel gas pattern w/gallbladder wall thickening w/mild pericholecystic fluid but no gallstones or biliary duct dilation. Next step?

*Perform percutaneous gallbladder drainage* DX: acalculous cholecystitis esp in *ICU pts w/no gallstones w/elevated alk phos, bilirubin, LFTs, unexplained fever, jaundice, leukocytosis,* -abd Ultrasound/CT abdomen shows: *Gallbladder wall thickening without choleliths* TX: *percutaneous cholecystostomy* &IV antibiotics after blood cultures*, cholecystectomy(for gallbladder perforation or necrosis-more severe stuff)

28 yo at 28 wks gestation has leakage of fluid-wakes up in AM W/damp underwear&had intermittent clear vaginal discharge.Elevated 1 hr glucose challenge test but 3 hr GTT normal. Exam: no pooling of fluid in vagina. Thin clear discharge present in posterior fornix&on cervix. cervix is visibly closed&no lesions. vaginal pH 4.0. Wet mount microscopy shows epithelial cells. CAUSE of sx?

*Physiologic leukorrhea* -due to increased estrogen levels(pregnancy, ovulation, combination hormonal contraception) -different from other vaginal discharge bc no odor, vulvar pruritus, vaginal spotting -no treatment needed

70 yo M W/COPD has SOB, dry cough&wheezing which started 6 hrs ago&worsened. Had 2 admissions this past yr for similar sx&both times also had A.fib w/RVR. Smoked 2 ppd daily for 40 yrs. ED: started on Noninvasive Positive Pressure ventilation due to increased work of breathing. P 125, RR 24. Pulse ox 92% on 40% FiO2. exam: diffuse wheezing thruout lung fields & prolonged expiration. Distant heart sounds & irregular. 1+ pretibial edema b/l. CXR: hyperinflation. Treated w/IV corticosteroids & antibiotics&inhaled albuterol. Diltiazem infusion for a fib. 6 hrs later: work of breathing improved & Transitioned to nasal cannula oxygen. On repeat exam, pt has bilateral face and neck swelling & palpation reveals creptius. Management?

*Repeat chest x ray*-->subcutaneous emphysema in this patient -Even tho Noninvasive positive pressure ventilation is usually low risk therapy w/fewer complications than invasive mechanical ventilation, those w/underlying lung disease(COPD) can develop pulmonary BAROTRAUMA due to sustained positive pulmonary pressures * -NOT DILTIAZEM INFUSION RELATED bc even tho it can lead to pulmonary edema-it doesn't lead to subcutaneous crepitus

AN active study of 30 pts w/spinal deformity underwent 3 column osteotomy procedures for deformity correction is evaluating the following outcomes at 3,6,12 months. Research proposal was approved by IRB but on week 2, health-related quality-of-life questionnaire which serves to evaluate additional study outcomes is added to the protocol. What's true regarding need to resubmit study protocol to IRB?

*Required b/c all modifications to an already-approved research protocol need new IRB approval* This includes: study design, study protocols, informed consent procedures, principal investigator team(new research assistants)

52 yo F with Hot Flashes. Hx DVT treated w/anticoagulation. PSH total abd hysterectomy w/o oophorectomy for symptomatic uterine leiomyoma.management?

*SSRI* NOT oral estrogen bc hx of DVT! other contraindications to estrogen: Coronary heart disease, breast cancer, endometrial cancer

38 yo F at 34 wks gestation hasn't felt fetal movement for the last 18 hrs. Complicated by fetal growth restriction at 28 wks when u/s showed estimated fetal weight at 3rd percentile. Since then, pt was followed w/serial biophysical profiles & umbillical artery doppler sonography which were normal. VSS. Cervix closed&posterior. Fetal heart tones NOT heard on doppler. bedside u/s shows no fetal cardiac activity. blood type is A rh negative, kleihauer betke test negative. She's informed about intrauterine fetal demise. Asks if any risks associated w/waiting for labor onset? appropriate response?

*awaiting spontaneous labor increases the risk of coagulopathy(DIC)*b/c of tissue factor release(thromboplastin) into maternal circulation from placenta-->tissue factor triggers maternal coagulation system leading to platelet & Coagulation factor consumption -delivery induced ASAP For unstable pts(eclampsia, hemorrhage) -spontaneous labor usually within 3 wks of diagnosis

15 month old boy w/trisomy 21 has chronic constipation. Has a small, hard BM once/4-5 days. Diet: fruits, veggies, meats, h20, 1-2 cups cow's milk/day. Meds haven't improved sx. Born at 40 wks gestation but remained in the hospital for 3 days b/c of difficulty feeding due to mild hypotonia. Ht&wt were at 10th percentile at birth&currently at the <5th percentile. Small VSD that's hemodynamically insignificantly. P 106. 3/6 holosystolic murmur at lower left sternal border. Abdomen slightly distended. Tightness in anal sphincter & no stool palpated in rectal vault.Tx of pt's constipation will likely require which?

*Surgical bowel segment resection* of aganglionic bowel segment & anastomosis of normal bowel w/anus Dx: hirschsprung disease(congenital aganglionic megacolon) -due to failure of neural crest cells to migrate to distal colon which causes dysmotility in affected segment&results in obstruction -higher risk w/trisomies -usually presents at birth w/*delayed passage of meconium of >=48 hrs*, abd distension, emesis, irritability BUT milder cases present later in life as *constipation, FTT(decreased growth <5th%tile)*, distended abd, *Tight anal sphincter* & *absence of stool in rectal vault*

21 yo M has episode of lightheadedness. He's a runner and training intensely for last several months. During 1 morning running session last week, he had lightheadedness & felt he was going to pass out. Had to stop&Sit on ground until feeling subsided. Attributed this to pushing himself too much. ADopted. Supine BP 133/78, stnading BP 130/75, pulse 60. ECG: increased voltage QRS complexes, 0.5 mm downsloping ST segment depression & Symmetic T wave inversion leads V4-6. management?

*TTE* DX: LVH: high voltage QRS complexes & lateral repolarization abnormalities(inverted T waves) -ATHLETE'S HEART= young athletes age <35 can develop physiologic increase in LV wall thickness, cavity size & Myocardial mass in response to intense CV training -HYPERTROPHIC CARDIOMYOPATHY can cause SIMILAR ECG FIndings tho--> ECHO TELLS THEM APART -so Young athletes w/ECG findings of LVH &*Unexplained sx(cp,palpitations, presyncope, syncope) should be evaluated for HCM or other structural heart disease (Aortic stenosis) w/ *TTE* -LVH<15 mm distinguishes athlete's heart from HCM

LSD

*VISUAL Hallucinations* euphoria dysphoria/panic tachycardia/HTN

Researchers are evaluating interim data from a randomized, placebo-controlled study of a new candidate vaccine against a life-threatening viral pathogen. Vaccine is expected to stimulate an immune response to either prevent infxn or reduce viral load in vaccinated subjects. On 1st evaluation of the interim data, the researchers conclude that there's no protection from infxn in the vaccine-inoculated volunteers after 1 vaccination when compared w/control group. They also found evidence of a potential vaccine-induced enhancement of infection. Course of action?

*Vaccine trial should be stopped & participants informed about the findings* -Data Safety Monitoring Board reviews trial protocols and data on ongoing basis to ensure that clinical trials are unethical

7 yo boy has 6 day hx fever, pharyngitis, myalgias, difficulty walking. Last week: sore throat, body aches, fevers Tmax 103F. Fever decreased for last 3 days&he started eating normally. Started to walk strangely & walking on his toes when he got out of bed this morning. Several kids will ill last week. T 102.6F and tenderness over calves b/l & weakness on dorsiflexion. CK 2000.UA:no blood, LE, RBCs. Dx?

*Viral myositis* or benign acute childhood myositis sx: calf pain, abnormal gait, elevated CK -influenza -most common virus which causes acute onset CALF pain-->abnormal gait (toe walking or wide based) -self-limiting condition! -no need for antiviral therapy if child doesn't meet typical criteria for tx(hospitalization, age<2) -NO HEMATURIA &NO renal dysfunction like w/rhabdomyolysis(more severe mm breakdown that causes AKI)!

how can perinatal transmission risk of HSV be decreased in pt who no longer has Herpes lesions and finished 7 day acyclovir course and is 16 weeks pregnant?

*acyclovir from 36 weeks to delivery w c-section if sx of herpes at term* -TO MAKE SURE THERE"S NO ACTIVE LESION CLOSE TO DELIVERY BC ACTIVE HERPES INCREASES RISK GREATLY OF TRANSMITTED TO NEWBORN

18 yo M has sudden onset CP, difficulty breathing & hoarseness 2 hrs after coughing. CP radiates into neck &worse w/deep breaths. For the last 3 days, nasal congestion, sore throat, persistent productive cough. Uses inhaled albuterol for asthma 2x weekly on avg due to wheezing w/exercise. VSS. Crunching sound heard over precordium during systole. CXR:Pneumomediastinum along left heart border & extends into upper mediastinum &lower neck. Next step in management?

*analgesics & supplemental O2* Dx: *spontaneous pneumomediastinum* -in young males w/hx of lung dx(asthma) or respiratory infxn(persistent cough) or who use inhalational drugs -occurs when air escapes the alveoli thru small tears in adjacent bronchovascular sheath -the air then travels along the vascular sheaths & can reach mediastinum&other nearby regions(neck, UE) -*resolves spontaneously* -Hamman's sign: crunching sound w/systole-occurs as the heart beats against air-filled tissues

50 yo M has episode of syncope. Brief episode of palpitations & lightheadedness yday evening which was attributed to tiring day at work. Today while eating bfast w/wife, suddenly slumped to table & lost consciousness for several minutes.Has been having HA&malaise for past several days. Wife adds that abt 1 month ago, he had a bright red rash on right calf for a week. Had a full medical evaluation 6 months ago when he turned 50. Exam normal. Pulse 46. recently took bird-watching trip to maine and likes anemials &nature and works in vet clinic. cbc wnl, bmp wnl. ECG sinus rhythm w/2:1 atrioventricular block. Which should be a component of treatment for this pt's arrhythmia?

*antibiotic treatment* dx: *LYME Carditis*-->went to MAINE and now has heart block -usually in Northeast and upper midwest US -sx: SKIN RASH: Erythema migrans -if NOT treated w/antibiotics: *early-DISSEMINATED* Dx develops which includes CARDIAC, neuro, muscular & Ocular involvement -LYME CARDITIS-->AV block-->SYNCOPE, CP, lightheadedness, dyspnea TX: IV Ceftriaxone _alternatives: cefotaxime and penicillin G ANSWER NOT PERMANENT PACEMAKER b/c this is related to lyme disease. temporary pacemaker may be placed tho until antibiotics resolve the sx.

management of pregnant lady with parvovirus

*antibody tests should be ordered to determine pt's immune and infection status=serologic testing* -fetus at risk for fetal anemia, hydrops fetalis, fetal demise-if immune: positive IgG antibodies and negative IgM antibodies

64 yo F: fundoscopic exam shows enlargement of optic cups w/increased cup:disc ratio b/l. Perimetry test shows mild peripheral visual field loss. CAUSE?

*open angle glaucoma* increased cup/disc ratio >0.6 increase in cup size over time thinning of disc rim pale disc(optic nerve atrophy)

17 yo F w/juvenile idiopathic arthritis has upper back pain. coughing after accidentally choking on popcorn &then back started hurting. Pain persisted overnight&only minimally relieved with Tylenol&applying heating packs.Pt takes etanercept after methotrexate failed to achieve dx remission of juvenile idiopathic arthritis&has frequent arthritis requiring glucocorticoid therapy. exam: overweight adolescent in mild discomfort when walking or climbing into exam table. TTP over midline of spine at T4-5 region. what additional findings is likely present?

*decreased bone mineral density* dx: vertebral compression fracture due to poorly controlled juvenile idiopathic arthritis-associated osteoporosis: *Frequent systemic glucocorticoid use & Continued joint destruction from unremitting disease leads to decreased bone mineral density(osteoporosis) -chronic >6 wk relapsing-remitting inflammatory condition causing pain, swelling& stiffness of multiple joints -tx: nsaids(naproxen), dmards(methotrexate)& glucocorticoids

17 yo girl has 3 week hx of rhinorrhea, paroyxyms of sneezing, nasal congestion, facial itching & Develops similar sx each spring. This yr, sx are more severe than usual &persistent. Pale nasal mucosa. Started on the most effective single treatment but what's a complication?

*epistaxis* dx: allergic rhinitis tx: *intranasal corticosteroids* (not antihistamines)-fluticasone, mometasone, budesonide -also give nasal saline rinses b/c they hydrate nasal mucosa &Can protect from steroid effect of epistaxis -second line: oral antihistamines(side effects acute angle-closure glaucoma, urinary retention, constipation, dry mouth)

2 yo boy is getting evaluated for a rash. Father first noticed a red rash on his stomach this AM & now spread to his arms. Last wk, the child had rhinorrhea, cough, fever 101F for 2 days. Yday, his* face appear flushed* but T is normal & Redness resolved w/o intervention. Received dtap but no other vaccines b/c parental preferences. Attends daycare during the week & other kids had fever & Rash and was admitted & Takes ASA everyday. Exam shows erythematous, nonblanching reticulated rash on UE &LE. Dx?

*erythema infectiosum/fifth disease* NOT measles Dx: parvovirus b19 Sx: flulike illness, slapped cheek rash, lacy&Reticular rash, small-joint symmetric polyarthritis, transient aplastic anemia TX: supportive, NSAIDs Prognosis: no long-term sequelae

3 yo M has a 8 day hx of 3-4 daily episodes of soft, *foul-smelling diarrhea*. Increased belching & Flatus, decreased appetite but drinks liquids without difficulty. 6 yr old sister has same sx. Fam went on cruise to Mexico last month so he tried new foods and went swimming at beach&in cruise ship pool. Went on wkd camping trip 3 wks ago and ate the fresh fish. After vacation, he went back to reg diet fruits, veggies 7 meats. P 108, hyperactive bowel sounds. negative stool occult blood. CAUSE of sx?

*giardia lamblia* -greasy, foul-smelling diarrhea, bloating, flatus/belching, weight loss -transmitted thru *fecal-oral route* or thru *contaminated food or water* -ingestion of unfiltered water while *camping* or hiking --drinking, swimming or consuming food from contaminated water -sx DON't present ASAP b/c takes time for cysts to mature into trophozoites in host intestines -tx: *metronidazole*

16 yo M has severe abd pain tht started suddenly on right side 6 hrs ago & Radiated to the groin for the apst 2 hrs. 3 episodes of emesis. 1 yr ago-similar episode w/hematuria&self resolved after 1 day. K 3.1, Na 140, Cl 110, HCO3 18, Calcium 9.5. Urine pH 6.1, SG 1.025&many RBC present, CAUSE of sx?

*hypercalciuria* dx:distal renal tubular acidosis/RTA, recurrent *nephrolithiasis/kidney stones* sx:flank pain, emesis, hematuria -Distal RTA occurs when kidneys can't excrete H+ ions into collecting tubules leading to elevated urine pH >=5.5 & decreased plasma HCO3(metabolic acidosis) -*hypokalemia & hyperchloremia* -*Hypercalciuria* 2/2 effects of chronic acidosis, including increased bone resorption & decreased tubular reabsorption of calcium-->the HIGH concentration of calcium in alkaline urine predisposes to calcium phosphate kidney stones & nephrocalcinosis** Tx: sodium bicarbonate to correct metabolic acidosis

15 yo M collapsed while playing bball At school. After CPR, he was brought back to life. Hospitalized twice in his life, once at age 4 for febrile illness that spontaneously resolved & once at age 10 for acute appendicitis. ECG ST segment elevations leads II, III, avF. Further cardiac w/u shows aneurysmal dilation, Myocardial thickening, calcification in proximal right coronary artery. Hx of what undiagnosed condition?

*kawasaki disease*-->MI*aneurysms w/calcification hypertrophic cardiomyopathy doesn't show aneurysms &calcifications-also there would be hypertrophy on ecg, echo

tx of central hypothyroidism

*levothyroxine*(adjust to keep free T4 in high-normal range* -get corticotropin(ACTH) stimulation test before tx

how can kidney stones be prevented besides hydration?

*limiting intake of foods rich in oxalate* -also limit sodium intake -reduce animal protein intake -*INCREASE DIETARY CALCIUM*: calcium binds oxalate in GI system & prevents GI oxalate absorption which reduces risk of calcium oxalate stones

Researchers plan to carry out a study to evaluate dynamic effects of CPAP on cognitive function and neurocognitive architecture & Function int pts w/OSA. All eligible pts w/moderate-severe OSA will be randomly allocated to either CPAP + supportive care group or supportive care group only by independent statistics committee andassessed at 3,6,12 months. Participants & intervention assistants, but not data collectors, evaluators or study statisticians will be aware of participants' intervention assignment. What's the purpose of controlling for awareness of intervention assignment in this protocol?

*maximize unbiased ascertainment of outcomes* Ascertainment bias: when results of clinical study are distorted by knowledge of which intervention the participants are assigned to.

Newborn girl was born 3 hrs ago at home via spontaneous vaginal delivery due to precipitous labor. *Umbilical cord was clamped in ambulance* & IM Vitamin K & opthalmic antibiotic ppx was administered at hospital. T 98.1F, P 120, R 24. Skin is slightly ruddy. WBC 11,000, Hgb 19, Hct 66%, total bilirubin 2.3, Management?

*monitor blood glucose levels&bilirubin* DX: neonatal polycythemia Defined as hct*>65% or hgb>22* in term infants CAUSES: increased erythropoiesis from intrauterine hypoxia: maternal DM, HTN, smoking, IUGR; erythrocyte transfusion: *delayed cord clamping liek w/some precipitous deliveries*, twin-twin transfusion; genetic/metabolic dx: hypothyroidism or hyperthyroidism, genetic trisomy(13,18,21)

prognosis for development dysplasia of hip

*most infants who are treated early have no long-term sequelae* -the need for surgical correction for DDH correlates w/increased age at diagnosis: <5% of pts dx & treated w/pavlik harness in early infancy require surgery

31 yo M has 3 month hx of progressive tiredness, weight gain, lethargy. Stopped going to gym a few wks ago due to fatigue&mm aches. ED&loss of libido. Sister has hypothyroidism treated w/levothyroxine. BMI 26. Delayed mm relaxation on DR testing. TSH 3.4, free T4 0.6(low), Testosterone 234(low), LH 4, cortisol 10, prolactin 36. management?

*order pituitary MRI* dx: central hypothyroidism -low free T4 w/low-inappropriately normal TSH -most common cause: pituitary mass -ACTH(Corticotropin) stimulation test should be done before initiating tx b/c levothyroxine can precipitate adrenal crisis in pts w/undiagnosed adrenal insufficiency

6 month old boy has 2 day hx fever. Difficulty sleeping, nonbloody nonbilious emesis yday & several loose stools today. Decreased appetite. T 101F, P 132, RR 26. Cranky. Management?

*otoscopy* Kids can have NONSPECIFIC(random) sx! dx: acute otitis media -abd u/s helps if abd pathology-but appendicitis is uncommon & unlikely w/o abd distension, tenderness or rebound -Otitis media is more common source of fever/infxn in kids compared to meningitis so r/o otitis media before meningitis!

64 yo M has worsening urinary sx. For past year, he had difficulty initiating urination, a weak urinary stream & increased urinary frequency. He wakes up 1-2x/night to urinate. He's a former smoker w/20 pack yr hx & Drinks 1-2 alcoholic beverages each evening. BMI 30, Rectal exam: symmetrically enlarged, nontender prostate w/smooth surface. 4 wks ago: hga1c 7%, serum creatinine 0.9. Next step in management of urinary sx?

*perform UA* NOT start finasteride already -UA to evaluate for hematuria(bladder cancer) & infxn -lower UTIs aren't specific for BPH and could also be due to prostate or bladder cancer -altho routine screening for prostate cancer in asymptomatic pts is not advised, PSA level indicated for *Symptomatic* pts unless life expectance <10 yrs

47 yo M has 6 month hx cough w/frequent episodes of paroxysmal coughing spells making it difficult to converse w/others. Small amts white sputum, no hemoptysis. Wheezing & Chest tightness too. Works as industrial welder after losing automechanic job abt 11 months ago. Lived w/wife in same house for past 20 yrs and recently traveled to Maine 2 months ago during which he felt well. Abd is protuberant. Office spirometry is normal, CXR normal. Management?

*perform bronchoprovocation test w/methacholine=bronchial HYPERresponsiveness* Dx: occupational asthma -every adult w/new onset asthma-like sx should be evaluated for occupational disease -clues: sx started after new job, no sx on vacation, normal chest x ray Esophageal manometry is for suspected GERD if UNRESPONSIVE TO PPIs

Preterm membrane rupture

*pool of vaginal fluid* that turns nitrazine paper blue, basic pH >7.0 -dried amniotic fluid crystallizes in a characteristic "fern" pattern on microscopy

18 month old girl: picky eater. Only eats fruit, bread, eggs&Cheese. Spits out food or refuses to open mouth when offered meat, nuts, veggies. Feeds herself w/fingers or spoon but sloppy. Dry erythematous patches of skin on cheeks and wrists. Management?

*provide reassurance and encourage introduction of new foods * -clinical feeding assessment & Swallow study can help ID anatomic (esophageal atresia) & Function(Vocal cord paralysis) d/o *if patient is coughing & Gagging during feeds*

36 yo M has itchy rash on buttocks&thighs. Pt had these sx intermittently over last year & tried OTC hydrocortisone cream w/little relief. 2 months ago: treated for urticaria w/loratadine. Sexually active w/2 female partners over the last year & used condoms consistently. Emigrated from Dominican Republic 10 yrs ago. Older brother has psoriasis. BMI 23. On the buttocks & upper thighs, there's a raised, erythematous *linear* rash w/excoriations. Negative HIV, eosinophils 16%, Dx?

*strongyloidiasis*: roundworm infection -LINEAR rash usually on buttocks -EOSINOPHILIA -tropical &subtropical regions: Dominican republic -NOT secondary syphilis b/c it causes palms & Soles rash that's papular, constitutional sx(fever), *lymphadenopathy*, diffuse symmetric macular or papular rash

rotavirus

*watery diarrhea* in kids age 2 and under -within 1-2 DAYS of exposure -also emesis, abd pain

67 yo w/metastatic breast cancer, dramatic hypercalcemia(Ca 14.3), low PTH 8, Parathyroid hormone-related peptide 1 (normal <2), & normal vitamin D levels(1-25 dihydroxycholecalciferol 25, 25-hydroxycholecalciferol 20). She has dry mucous membranes & mildly distended abd & has been constipated and takes oxycodone & Docusate.Tx besides IV Fluids?

*zoledronic acid* dx: hypercalcemia of malignancy -caused by tumor -produced hormones(PTHrP) and *bone metastases* -this pt prly has hypercalcemia due to osteolytic metastases -tx: short term calcium reduction w/IVF(increases renal excretion of calcium) & Calcitonin -for *long term reductions: bisphosphonates:zoledronic acid*

vestibular neuritis(labyrinthitis)

-*single episode* of severe vertigo that can last for days & is self-limited -*labyrinthitis when associated w/unilateral hearing loss* -normal MRI -after viral infection -feeling of imabalnce and unsteady gait -*positive head-thrust test*:pt focuses on examiner's nose while examiner quickly rotates their head 10-15 degrees to the side; normally the eyes remain fixed on the target but in pt w/peripheral vestibular d/o, the eyes initially rotate w/the head before voluntarily redirecting back to the target (corrective saccade)

subgaleal hemorrhage

-bleeding under galea aponeurotica -fatal complication of vacuum-assisted deliveries -rapidly expanding swelling leading to hypovolemic shock from blood loss

immune thrombocytopenia purpura (ITP)

-caused by acquired autoantibodies to plt antigens -preceding viral illness or ongoing medical problem (HIV, hep C, SLE) -sx: mucocutaneous bleeding (menorrhagia, epistaxis, petechiae) -*Thrombocytopenia-mild or severe but plt morphology on PBS is normal* -coag studies, leukocytes and erythrocytes unaffected

norovirus

-causes viral gastroenteritis -*cruise-ship* outbreaks -BRIEF duration: resolves within days -*VOMITING more common*rota

meta-analysis

-combines results of *several studies* to *increase statistical power* thru an *increased sample size* -ideally, the results are the same as produced by single study w/larger sample size -BUT *increase in statistical power may lead to *statistically SIGNIFICANT* effect sizes that maybe *CLINICALLY IRRELEVANT*=detects a very small effect(eg risk ratio)--not practical ---also, *validity depends on the design*-metanalysis isn't always more valid than other study designs

von willebrand dx

-inherited bleeding d/o -asymptomatic but can cause prolonged mucosal bleeding(menorrhagia, epistaxis) -easy bruising -*normal or mildly low plt counts*(unlike w/ITP) -*FH bleeding issues*

sx central hypothyroidism

-mild hypothyroid sx -other pituitary hormone deficiencies -mass-effect sx: headache, visual field defects if due to mass

dx septic arthritis

-moderately elevated WBC, ESR, CRP +/- positive BC unilateral u/s effusion *synovial fluid WBCs>50,000**

dx transient synovitis

-normal or mildly elevated WBC, ESR, CRP -Unilateral/bilateral ultrasound effusion -DX of exclusion

HIT Type 1 management

-occurs less than 2 days after heparin w/mild platelet reduction abt 100,000 -RESOLVES on its own! NO change in therapy needed! -continue heparin!!

subcutaneous emphysema

-sudden painless soft tissue swelling in upper chest, neck and/or face -DX: crepitus, CXR: radiolucent streaks thru subcutaneous tissue & muscle of affected area -self-limited usually or resolves when u stop Noninvasive positive pressure ventillation(if possible) and supportive care

uterine inversion

-when uterine fundus collapses into endometrial cavity & prolapses thru cervix into vagina -due to *Excessive umbilical cord traction* PRIOR to placental separation. Also due to *Excessive fundal pressure* sx: *Hemorrhage SHOCK*, lower abd pain, round mass thru cervix, uterine fundus NOT palpable transabdominally TX: Aggressive FLUIDS, manual uterus replacement, placental removal&uteroTONIC drugs(misoprostol, methylergonovine) are given AFTER uterine replacement bc uterine atony can occur leading to PPH but STOP UTEROTONICS(oxytocin, methylergonovine) WHEN TRYING TO MANUALLY REPLACE THE UTERUS!

defect in vertebral pars interarticularis

=spondylolysis -occurs as overuse injury often in athletes(gymnasts) -lower back pain, L4-5 tenderness 2/2 repeated hyperextension of back

physiologic Hgb levels in pregnancy

>=11 g/dL in 1st trimester >=10.5 g/dL in 2nd trimester >=11 g/dL in 3rd trimester

acute interstitial nephritis

CAUSES: antibiotics(penicillin), NSAIDs, PPIs, diuretics, infxns(legionella, strep), systemic/autoimmune dx(lupus, sarcoidosis, sjogren syndrome) SX: allergic sx (urticaria), new drug exposure Labs: AKI, pyuria, hematuria, *WBC casts*, eosinophilia, *urinary eosinophils*, renal bx: inflammatory infiltrate, edema MANAGEMENT: d/c offending drug, systemic glucocorticoids

coronary artery calcium score determination

CT coronary angiography w/calculation of a coronary artery calcium score can ID the presence of coronary atherosclerosis --but it's a poor predictor of functional coronary occlusion&not recommended in asymptomatic, low-risk pts

chancroid vs lymphogranuloma venereum

Chancroid: >=1 erythematous, PAINFUL papules that progress to ulcers w/deep, erythematous bases, well-demarcated borders Lymphogranuloma venereum: PAINLESS small ulcer in primary stage w/lymphadenitis during secondary stage

first line treatment for MDD w/psychotic features (esp if severely depressed, psychotic, suicidal, refusing to eat &Drink)

ECT!!! -not mirtazapine -its not enuf alone to treat MDD w/psychotic features -combine it w/antipsychotic

what's the cause of a patient w/generalized weakness &Hyporeflexia shortly after hospitalization w/hx of heavy etoh use?

HYPOphosphatemia --due to chronic malnutrition -esp noticed when IVF w/dextrose are given bc dextrose stimulates insulin secretion-->insulin drives serum phosphate into cells

tx neonatal polycythemia

IVF if symptomatic, glucose, partial exchange transfusion(withdrawal of blood & saline replacement) for short term sx relief in newborns w/symptomatic polycythemia=very invasive & has risks tho

management HIT type 2

LIFE THREATENING -platelet declines 30-50% 5-10 days LATER after heparin or <1 day if heparin recently *STOP HEPARIN, test for platelet factor 4 antibody (HIT)and alternative anticoagulation(argatroban)**

management of ARDS

MECHANICAL VENTILATION: -optimize ventilation & Arterial oxygenation while minimizing risk of alveolar barotrauma & Oxygen toxicity -sustain *partial pressure of arterial O2 at 55-80 mm hg* or the o2 sats 88-95% while also maintaining: --*low TV at 6-8 ml/kg predicted weight*: avoids overdistension of alveoli & Consequent barotruma but it comes at expense of reduced ventilation(reduced CO2 removal) --RR<=35/min --plateau pressure <=39 cm H20 --FiO2<=60%

is family hx of egg allergy a contraindication to immunization?

NO! -also vaccination schedules & Doses are SAME REGARDLESS OF GESTATIONAL AGE or premature status

what are the primary determinants of arterial oxygenation?

PEEP and FiO2 -increasing PEEP improves oxygenation by opening collapsed alveoli and allowing more alveoli to share the tidal volume, thereby decreasing shunting. -Prolonged FiO2 levels>60% are associated w/oxygen TOXICITY

manifestations of barotrauma induced by noninvasive positive pressure ventillation in those w/COPD

Pneumothorax pneumoperitoneum pneumomediastinum subcutaneous emphysema

SBO Vs ileus

SBO: *ACUTE ABDOMEN*, obstipation, HYPERactive BS or absent BS, X ray: air fluid levels, dilated proximal bowel w/collapsed distal bowel, little/no air in colon/rectum Ileus: NO flatus, abd distension, decreased BS or absent BS, dilated loops of bowel,*air in colon/rectum* -BOTH can have absent BS, n/v,

low pleural fluid/serum GLUCOSE Ratio<0.5

TB malignancy complicated parapneumonic rheumatologic (RA, SLE) esophageal rupture

HIT Type 2 (4 T's)

Thrombocytopenia: plts decline >30-50% Timing: onset 5-10 days after heparin initiation or <1 day w/prior recent heparin exposure Thrombosis: new thrombosis, progressive thrombosis or skin necrosis Alternative causes-no other sources for thrombocytopenia present or likely

3 yo sickle cell pt has sudden onset difficulty walking. UNable to get out of bed/walk across room when woke up. RIght hand feels clumsy. had 2 hospitalizations for severe UE & back pain. Weakness & Hypotonia of right arm&leg. BP 90/50. Whch screening test would have ID increased risk for acute dx?

Transcranial doppler ultrasound *STROKE *

measles

URI sx, then diffuse maculopapular rash -*Conjunctivitis* -ill appearing

what ppx is done for those w/stem cell transplants or leukemia?

acyclovir to prevent HSV for stem cell transplant or induction chemo for acute leukemia fluconazole ppx to prevent candida infxn for acute leukemia or those w/stem cell transplants isoniazid ppx for active tb-stem cell transplants, HIV w/close contact exposure to TB or w/latent dx

6 month old girl has fever&rash. 4 day hx of fever, dry cough, rhinorrhea. 2 days ago, she got rash on cheeks&forehead which slowly spread to rest of body. During Mexico trip, she had 2 day hx vomiting&drinking after smoothie. attends daycare 5 days/week. t 102.4f, bp90/60,hr 135,rr 20. tired appearing infant. b/l conjunctivae mildly erythematous. maculopapular blanching dark red rash covers entire body aside from palms&soles. route of transmission?

airborne -dx measles

what are umbilical artery doppler ultrasounds used for ?

assess fetal growth restriction -changes in umbilical artery resistance indicate uteroplacental insufficiency

tx of chancroid

azithromycin or ceftriaxone

cinacalcet

calcimimetic used to reduce PTH (And calcium) in pts w/primary hyperparathyroidism

cephalohematoma vs caput succedaneum

cephalohematoma: DOESN'T cross suture lines & resolves within WEEKS, *can lead to jaundice* b/c RBC breakdown&Calcification after resolution-located UNDER periosteum Caput succedaneum: like a CAP crosses suture lines&resolves DAYS after birth-serosanuineous fluid collection above periosteum/beneath scalp

NNT is 125 for a study abt effectiveness of adjusted dose warfarin in preventing stroke or systemic thromboembolic events within a year compared w/aspirin therapy. What best describes these results?

compared w/aspirin therapy, 125 pts need to be treated w/adjusted-dose warfarin therapy to prevent 1 additional stroke or systemic thromboembolic event during 1st yr of therapy

tx transient synovitis

conservative: oral NSAIDs -uncommon recurrence, full recovery 1-4 wks

what endocrine condition causes chronic constipation in pts with trisomy 21?

hypothyroidism

interstitial cystitis

idipathic bladder/suprapubic pain >=6 weeks -worse w/full bladder -relieved w/urination

selection bias

inappropriate (random or nonrandom) selection METHODS or thru different attrition rates between study groups

effect of glucosamine and chrondrotin sulfate

increased bleeding risk w/anticoagulants or antiplatelet drugs -glucosamine may raise glucose and insulin levels

Hidradenitis suppurativa

inflammatory nodules on vulva & other intertriginous areas -PAINFUL -can evolve into abscesses

causes of exudate pleural effusion

infxn(TB, PNA) malignancy -*lymphocyte predominant*-bloody/serosanguinous connective tissue disease PE *Neutrophil predominant* pancreatitis post CABG

bisphosphonates MOA

inhibit osteoclast-mediated bone reabsorption&can counter the cytokine-driven osteolytic effects of tumors

tx septic arthritis

joint drainage & antibiotics -MRI can be used to evaluate extent of infxn before surgical debridement

Tx peripartum cardiomyopathy/HF

lasix & *Direct acting arterial vasodilator(hydralazine reduces afterload) & Nitrate(isosorbide mononitrate-venous dilator reduces preload)* -safe pregnancy meds: lasix, BB, hydralazine, nitrates, cardiac glycosides (digoxin)

herniation of a intervertebral disk

lumbosacral region(L4-5,L5-S1) lower back pain sciatica

what tumors are prednisone used for?

lymphomas that make excess 1,25-dihydroxyvitamin D -blunts production of 1,25-dihydroxyvitamin D (Calcitriol)

condylomata lata

manifestation of secondary syphilis -large raised gray painless lesions of perineum or oral mucosa --other 2ndary syphilis features: diffuse lymphadenopathy, maculopapular rash w/palms&soles Lata~syphiLis: both have L's

behcet syndrome

multiple painful genital ulcers recurrent lesions occurs w/oral ulcers

who has sacral dimple?

neural tube defect (myelomeningocele)

tx ITP

observe if no bleeding & plts>30,000 *corticosteroids if plts <30,000* IVIG & plt transfusion if hemorrhage that is ONGOING only b/c effects slowly remits over 3-4 days

when should SBTs be done?

once pts demonstrate improvement of underlying condition & ability to maintain adequate ventilation (pH>7.25) & Oxygenation w/minimal ventilator support (FiO2<=40%, PEEP <=8)

tx TTP

plasma exchange

light criteria for exudate

pleural protein/serum protein>0.5 or pleural LDH/serum LDH>0.6 or pleural LDH>2/3 upper limit of normal of serum LDH

plateau pressure

pressure applied to small airways&alveoli -measured value that correlates w/lung compliance -should be kept <=30 cm H20 to minimize risk of barotrauma -increase in PEEP (or tidal volume) may increase plateau pressure

panic d/o

recurrent *UNEXPECTED* panic attacks at least >=4: -CP, palpitations, SOB, choking -trembling, sweating, nausea, chills -dizziness, paresthesias -derealization, depersonalization -fear of losing control or of dying -Worry abt additional attacks, avoidance behavior

allocation bias

results from the way subjects are assigned to treatment groups -may occur when subjects are NONRANDOMLY assigned to treatment groups of clinical study (Physicians may preferentially enroll sicker pts into a specific treatment group like Meredith grey with richard webber's wife)

1 day old boy genitalia shows ventrally positioned urethral meatus on shaft of penis and penis is curved downward. MANAGEMENT?

surgical correction at 6 months dx: hypospadias RF: advanced maternal age, maternal DM, FH hypospadias -AVOID CIRCUMCISION bc foreskin may be asymmetric which causes difficult circumcision and also foreskin might be needed for corrective surgical procedure *Pelvic ultrasound or karyotype only needed if cryptorchidism accompanies hypospadias*-->XX virilization/sex development disorder

why is desmopressin used w/von willebrand disease?

synthetic ADH that promotes release of vWF Factor -used in those w/vWF disease before surgery or to control mild bleeding episodes

besides HIV/AIDS pts, who else can get PCP pneumonia?

those on chronic glucocorticoids and azathioprine(immunosuppressive meds) --those w/HIV have indolent course w/sx over WEEKS but others have *Fulminant respiratory failure* W/dry cough and fever -PCP ppx: daily or 3x weekly if double strength BACTRIM--esp if >1 month daily prednisone(>=20 mg) if second source of immunocompromise(hematologic malignancy, additional immunosuppressive med)

TTP

thrombocytopenia-severe HEMOLYSIS(elevated bilirubin) anemia microangiopathy (Schistocytes) end-organ damage (CONFUSION-neuro, GI, renal) -acquired microangiopathy

when is ERCP done?

to diagnose & Treat choledocholithiasis after imaging shows dilation of CBD

transient synovitis versus septic arthritis

transient synovitis: *Well-appearing*, afebrile OR low-grade fever, able to bear weight--hip pain, limp, age 3-8, preceding viral illness Septic arthritis: *Ill-appearing*, MORE febrile, NON-weight bearing

high pleural fluid/serum glucose ratio~1

transudative effusions uncomplicated parapneumonic other infxn(viral) PE Post-CABG

when is anal sphincterotomy used?

treats chronic anal fissures(due to trauma like straining against hard stool) & results in strictures and tightness of anal sphincter -stool would be present in rectal vault