UWorld Step 3

Chikungunya fever - What - Presentation - Tx

C/S America, Africa, Asia Aedes mosquito Incubates 3-7 days High fever Severe distal POLYarthralgia HA, myalgia, conjunctivitis, mac-pap rash LOW WBC, platelets; high LFTs Supportive care 1/3 have chronic joint sx - MTX

Well controlled DM still at risk for?

CAD - even with normal lipid panel Progression to overt DM

Alcohol abuse screen - CAGE - Single question - AUDIT-C

CAGE: cut down, annoyed, guilty, eye-opener Single item: how many times in past year had 5+ drinks in a day (four for women) AUDIT-C - How often, how many, how often do you have 6 (4) or more

Routine labs for progressive cognitive decline

CBC, CMP, TSH, B12 If have risk factors then test - Folate - alcoholism - Syphilis - Vit D

Old man with insomnia. Tx?

CBT is 1st line

Intubated -> pneumothorax - Next step

CHEST TUBE if only tachycardia, tachypnea, hypoxemia, decreased/absent breath sounds on that side NEEDLE DECOMPRESSION if signs of tension pneumothorax - compression of mediastinal structures, marked hypotension

Non-gonococcal urethritis - Bugs - Urethral fluid characteristic - Urethral gram stain - Tx

CHLAMYDIA, ureaplasma, mycoplasma, trichomonad Water, scant Aseptic with leukocytes Azithromycin - if doesn't work, have to treat for other non-g bugs

CMV vs. HSV esophagitis?

CMV - large deep ulcers; tx ganciclovir HSV - multiple coalescing ulcers; tx acyclovir

TCA overdose - Presentation - Management

CNS sx Anticholinergic effects Cardiotoxic effects (sinus tach, hypotension, arrhythmias) - killer O2, IVF Activated charcoal if w/in 2 hr IV sodium bicarb if QRS widening or ventricular arrhythmia

Delay surgery to prevent postoperative pulmonary complications if in COPD exacerbation

COPD, smoking, sleep apnea, and heart failure all increase risk of pulmonary complications

Cardiac arrest - Do what first? - Shockable vs non-shockable rhythm

CPR!!! - And O2 and attach monitor/defibrillator Shockable: VF and pulseless VT NOT SHOCKABLE: PEA/asystole

Anti-centromere antibodies

CREST scleroderma

Acute pancreatitis -> improves w/ supportive management -> increased sx 3 days later - Next step?

CT abdomen w/ contrast - do if: - Severe AP - Signs of sepsis - Evidence of complications >72 hr after presentation Complications: pancreatic necrosis, acute necrotic collection, acute pancreatic fluid collection, pancreatic infection

Smoker with LLL PNA then three weeks later have same thing. Next step?

CT chest - Concern for endobronchial neoplasm leading to non-resolving PNA If CT not helpful, do bronchoscopy

CXR -> lung mass -> sputum w/ squamous cell carcinoma - Next step?

CT for staging Resect stage I and some stage II non-small cell lung cancer - Stage II needs adjuvant chemo/rad

Sudden onset very severe HA, HTN, and vomiting - Next step

CT head w/o contrast - Look for SAH

Metastatic medullary thyroid cancer -> thyroidectomy and neck dissection 0> TSH normal, persistently elevated calcitonin - Next step?

CT neck and chest - still has metastatic disease - Surgery of resectable - CT and bone scan if no lesion identified MTC is from parafollicular C-cells so iodine scan not helpful

RF for AAA rupture

CURRENT SMOKING >6 cm Expand >0.5 cm in 6 months (Not DM, HTN, or HLD)

COPD now with increasing cough, green sputum, streaked hemoptysis. - Next step? - Tx if workup is normal

CXR Likely COPD exac. 2/2 bronchitis. Steroids, inhaled albuterol Oral abx recommended if inc sputum volume/purulence or inc dyspnea

Right facial droop, hepatomegaly, nontender LAD - Best initial test - What is it

CXR - b/l hilar adenopathy, interstitial infiltrates Sarcoidosis - Papular/nodular lesions or erythema nodosum - Uveitis, keratoconjuctivitis sicca - Acute polyarthritis - Facial nerve palsy - HSmegaly, LAD

Kid swallows button battery - Next step? Then what?

CXR - circular, radiopaque object with double ring 2/2 bilaminar design If in esophagus, endoscopic removal immediately If in stomach/intestines, serial XR and remove if not progressing or sx develop

Work up for active TB

CXR - upper lobe cavitation, hilar LAD, pleural effusion Sputum sample series (3) sent for AFB smear, mycobacterial culture, and NAAT - Smear has low sensitivity (high false negatives) and can't tell b/w T and nonT mycobacterium PPD or interferon-gamma release assay - do one but can't tell b/w active and latent dx

Full term infant doesn't pass meconium w/in 48 hr -> abd distention, poor feeding, bilious emesis -> Next steps?

CXR to r/o free air and eval bowel gas pattern -> Multiple dilated loops and no rectal air -> distal bowel obstruction -> contrast enema -> normal recosigmoid caliber than dilated descending colon = Hirsprungs - Dx w/ rectal mucosal suction bx -> absence of ganglion cells

History of latent TB - testing?

CXR! Will have positive PPD and interferon-gamma release assay for life

Porcelain gallbladder

Calcification of gallbladder - Increase cancer risk - Ppx chole if sx or PUNCTATE calcifications but not curvilinear

CREST syndrome

Calcinosis cutis Raynaud phenomenon Esophageal dysmotility Sclerodactyly Telangiectasias pHTN w/ CREST, ILD w/ diffuse - Get PFTs

Screen for medullary thyroid cancer

Calcitonin

Test for complete Achilles tendon rupture

Calf squeeze doesn't plantar flex the foot (Not active plantar flexion because they may use accessory muscles) MRI best imaging tool

Severe SIADH with Na <120 -> seizure/coma

Can give hypertonic saline

In carbon monoxide poisoning, pulse ox will be normal. Why?

Can't tell the difference between oxy- and carboxyhemoglobin GIVE HIGH FLOW 100% O2

SGLT2 inhibitor - Example - Mechanism - SE

Canagliflozin Reduces reabsorption of glucose in the kidney EUGLYCEMIC KETOACIDOSIS GU - vulvovaginal candidiasis, UTI Fluid loss - hypotension, AKI Metabolic - hyperkalemia, HLD Low trauma fracture, amputation

Request for euthanasia - What kind of dx - Why

Cancer Loss of autonomy and control Loss of dignity Loss of ability to engage in pleasurable activities More associated with fears of future suffering rather than current

Oropharyngeal cancer -> chemo -> neutropenia -> ventral venous catheter -> high fever, eye pain, white lesions extending from chorioretinal surface into vitreous - What - Tx

Candida endopthalmitis - Fundoscopy shows focal, glistening, white, mound-like lesions on retina that exerted into the vitreous with resultant vitreous haze All 3 of these: Systemic amphotericin B Intravitreal antifungal injection Vitrectomy

Aphthous stomatitis

Canker sores Recurrent ulcers on ANTERIOR oral mucosa NO FEVER or systemic sx

Most reliable method to verify proper ET tube placement

Capnography - Graph of CO2 in exhaled breath - Can also use colorimetric EtOC2 detector (litmus paper)

Prolonged labor or vacuum-assisted delivery -> baby has swelling at vertex - What - Tx

Caput succedaneum - scalp swelling above periosteum that crosses suture lines, may have petechiae or echymoses Nothing - resolves in a few days

Fire -> smoke inhalation - What kind of poisoning - Presentation - Dx - Sx

Carbon MONOXIDE Mild/mod: HA, AMS, malaise, dizziness Severe: seizure, syncope, coma, MI, arrhythmia ABG: carboxyhemoglobin level ECG Cardiac enzymes if ischemia/CAD Pulse ox will show 100% High flow 100% oxygen Intubate/hyperbaric oxygen

Stimulant therapy for ADHD - Check this before - Potential side-effect

Cardiac history/exam, baseline weight and vitals - Routine ECG not indicated Appetite suppression and weight loss Treat with nutrient-dense meals

Hypotension and neck vein distention

Cardiac tamponade

What type of syncope? - Exertional lightheadedness - Palpitations

Cardiogenic - Structural - Arrhythmia

Abrupt onset of syncope w/o prodrome in setting of underlying structural heart disease (ischemic scar, CMO w/ low EF) - What - Next step - Tx

Cardiogenic syncope 2/2 ventricular tachycardia Admit, telemetry and echo Med (amio), catheter ablation, or defibrillator

Odds ratio used in what study type? Formula?

Case control = (a/c) / (b/d) = (a*d) / (b*c)

Recall bias - Common in what studies? - Leads to what?

Case-control Leads to misclassification of exposure

Study design to investigate outbreak of infectious disease

Case-control - quick localization of outbreak source -Not correlational studies because they look at multiple variables and helps develop but not test hypotheses

Pasteurella multocida

Cat or dog bite - Can cause osteomyelitis or infxn

MMC (2) of decreased vision in elderly

Cataracts and associated macular degeneration

Rubella - Presentation - Workup

Cataracts, deadness, heart defects, blueberry muffin spots (extramedullary hematopoesis) Maternal rubella immune status negative or unknown? Check rubella IgM

Squamous cell carcinoma - Imaging - Sx - Lab

Cavitary lesion in bronchus Cough, dyspnea, wheezing, hemoptysis Hypercalcemia 2/2 parathyroid like hormone production

CAP requires hospitalization - abx?

Ceftriaxone and azithromycin - Strep pneumonia and Mycoplasma pneumonia

Bacterial meningitis tx

Ceftriaxone and vancomycin - Ampicillin if >50 2/2 increased Listeria risk

Anti-tissue transglutaminase

Celiac

Young person with hypocalcemia, vitamin D and iron deficiency anemia, high alk phos and vitiligo

Celiac disease - MAY NOT HAVE ABDOMINAL PAIN OR DIARRHEA - Often have associated autoimmune conditions - Check anti-endomysial and TTG antibodies Dermatitis herpetiformis, anemia, vitiligo, depression, neuropathy, osteopenia/porosis

Insect bite then after a couple days notices tender, warm erythema with ill-defined, flat borders - What - Cause - Tx

Cellulitis 2/2 strep pyogenes (group A strep) Involves deep dermis and subQ fat, no fluctuant or purulent drainage. Indolent and +/- fever. Cephalexin for 5+ days - if afebrile, tx as outpatient

Low sodium, low/normal TSH, low free T4, borderline low/normal AM cortisol - What - Check what

Central hypothyroidism -> get MRI (r/o mass lesion of pituitary) -> ACTH stim test before tx Must then assess for other pituitary hormones Borderline cortisol test -> further testing with ACTH level and stim test for central adrenal insufficiency - All adrenal insuff. will have subnormal cortisol response - Central: low ACTH - Primary: high ACTH Can cause adrenal crisis if treat hypothyroidism w/ levothyroxine (monitor fT4 not TSH which will remain low) while adrenally insufficient (accelerate cortisol metabolism -> adrenal crisis)

Sudden vision loss w/ temporal sparing and pale fundus w/ cherry red spot on fundoscopy - What - Tx

Central retinal artery occlusion - May have hx amaurosis fugax - Decrease intraocular pressure - ocular massage, acetazolamide - Ophthalmology consult

Acute painless monocular vision loss w/ fundoscopy showing retinal pallor and cherry red spot at macula

Central retinal artery occlusion - Usually 2/2 carotid atherosclerosis - Consider cardiac embolism, small vessel dx, or vasculitis (giant cell) (Central retinal vein occlusion shows tortuous dilated veins, diffuse hemorrhages, disk swelling, cotton wool spots)

Treatment of asymptomatic bacturia or UTI in pregnancy

Cephalexin Amoxicillin-clvulanate Fosfomycin Nitrofuantoin Repeat urine culture 1 week after abx finished NOT... Cipro - disrupts fetal cartilage development TMP-SMX - NTD in 1st tri, kernicterus in 3rd tri

ADPKD - Extra-renal features - Dx - Tx

Cerebral aneurysms (berry) Hepatic/pancreatic cysts Mitral valve prolapse, aortic regurgitation Diverticulosis Ventral/inguinal hernis US Follow BP and renal function Aggressive control of CV RF ACEi for BP meds Statins for lipid control ESRD: dialysis, transplant

Born at 35 weeks with increased LE tone, hyperreflexia and clonus - What - Dx - Tx

Cerebral palsy - RF: prematurity, low birth weight - Features: delayed motor milestones, hypertonia, hyperreflexia, seizures, intellectual disability - MRI +/- EEG vs genetic/metabolic testing PT, OT, speech; nutrition support; antispasmodics

ADHD -> stimulant tx -> HA, moodiness and still having sx -> next step?

Change to a different med - Norepi reuptake inhibitor atomoxetine - Alpha-2 adrenergic agonist clonidine

Isolated elevation of anti-HBc

Check IgM anti-HBc and LFTs 1. "Window period" of acute hep B, high IgM anti-HBc 2. Years after recovery from acute HBV, all other labs negative 3. Many years after chronic HBV, IgM anti-HBc negative, high LFTs If LFTs high and IgM negative, or if evidence of chronic liver dx, check HBV DNA

Young person with submandibular/cervical LAD and white oral plaques easily removable

Check KOH prep of mucosal scraping to confirm Candida If no abx, ICS, or chemo, concern for HIV - Check p24 antigen and HIV-1/HIV-2 antibody

Screen for thyroid function in pregnancy - Labs - Why

Check TSH - In normal pregnancy: free T3/T4 are high-normal, TSH low - - Increased thyroxine-binding globulin (TBG) -> HIGH total T3/T4 - hCG stim binds TSH receptors -> increased thyroid hormone production - Trimester specific ranges - Total hormone approx =1.5x non-pregnant level

Pt with liver disease has low calcium - Next step

Check albumin and recalculate calcium Corrected Ca = Ca + 0.8(4.0 - measured albumin)

When to instill methylene blue in bladder

Check for vesicovaginal fistula - Painless continuous leakage of urine from vagina

Epileptic on med but has breakthrough seizure. Next step?

Check med level - Increased risk of noncompliance in stressful life situations - EEG, electrolytes if level normal

Old person with lethargy, apathy, decreased appetite, weight loss or muscle weakness and a fib requiring increasing dose of beta blocker - Next step

Check thyroid - Old people get apathetic hyperthyroidism - Beta blocker may be preventing tachycardia

Start on thyroid meds. Labs?

Check total T3 and free T4 after 4-6 weeks TSH remains suppressed for months Meds cause agranulocytosis (CBC if fever, sore throat) or hepatotoxicity (PTU - don't have to check LFTs unless sx)

Many head and neck cancers are inoperable at time of dx - Tx?

Chemo and radiation both

Epididymitis - Bug - Presentation - Exam

Chlamydia in sexually active boys Scrotal pain and swelling Increased blood flow to epididymis on doppler US Pain RELIEF with scrotal elevation (Prehn sign)

High gamma-glutamyl transferase (GGT)

Cholestasis - Differentiate if elevated alk phos is from liver or bone

Intrapartum uterine infection - Name - Tx

Chorioamnionitis Ampicillin plus gentamicin

Uterine fundal tenderness - What - Dx

Chorioamnionitis - intrauterine infection G and C nucleic acid amplification testing

Hashimoto thyroiditis - (HYPOTHYROIDISM) - Presentation - Dx

Chronic autoimmune thyroiditis - Hypothyroid features - Diffuse goiter - Positive TPO antibody - Variable radioiodine uptake

Worsening of dully cramps epigastric pain after eating, endoscopy negative, carotid bruit - What - Dx

Chronic mesenteric ischemia CT angiogram, MRA (or duplex US)

Weight loss, bulky smelly stools that are hard to flush, drinks EtOH, hx of abdominal pain - What - Test - Tx

Chronic pancreatitis - Fat malabsorption - Amylase/lipase often normal - Often see with DM MRCP (or abd CT) - Pancreatic calcification - Enlarged pancreas, ductal dilation, pseudocyst Lifestyle modifications - No smoking or drinking - Small, low-fat meals - Fat soluble vitamin supplements - Pancreatic enzyme supplement

Episodic well-circumscribed, raised erythematous plaques with central pallor and intense pruritus - What - How long - Workup - Tx - How long will it last

Chronic urticaria Episodes enlarge over minutes/hrs and go away w/in 24 hr. Lasts >6 weeks to be chronic. Dx clinically, no testings 2nd gen H1 blocker - loratadine or cetirizine Spontaneous resolution w/in 2-5 yr

Seborrheic dermatitis - What - Tx

Chronic, superficial inflammation in areas with sebaceous glands - erythema and fine scale Tar-based creams

Who gets leukoreduced RBCs for transfusions?

Chronically transfused CMV seronegative at-risk pts (AIDS, transplant) Potential transplant recipient Previous febrile non hemolytic transfusion reaction - Lowers risk of HLA alloimmunization and CMV transmission

Recurrent sinusitis in otherwise healthy person 2/2 ?

Cigarette smoke Air pollution Inadequately treated acute sinusitis Structural abnormalities of septum Allergic rhinitis

Type II immune reaction

Circulating antibodies against RBCs - Autoimmune hemolytic anemia -

Dog bite - who gets what tx?

Clean/minor wound and... - Imm > 10 yrs ago = booster - ? or not imm = booster Dirty/severe wound and... - Imm >5 yr ago = booster - ? or not imm = booster AND *tetanus immune globulin*

Comedonal acne - 2/2 - Pharm tx - Lifestyle tx

Increased sebum, follicular hyperkeratinization, bacterial colonization Topical retinoids and organic acids (salicylic, azelaic) pH-neutral cleaners BID applied gently (NO VIGOROUS SCRUBBING), water-based makeup

Breast milk jaundice

Indirect hyperbilirubinemia Over first few WEEKS No anemia

PCP pneumonia - Presentation - Workup - Tx - Prevention

Indolent (HIV) or ACUTE (immunocompromised) respiratory failure - Fever, dry cough, hypoxia (worse than lung exam suggests) High LDH DIFFUSE reticular/ground glass infiltrate on CXR Induced sputum or BAL stain Tx: TMP-SMX (plus prednisone if hypoxic) Prevent: TMP-SMX (plus antiretrovirals in HIV)

DVT after surgery/pregnancy/OCP use/trauma -> how long to anticoagulant? How long for idiopathic?

Induced by reversible or time-limited RF - warfarin at least 3 months, not more than 6 months Idiopathic - at least 6 months, re-eval at end for further use

Why mild indirect hyperbilirubinemia in B12 deficiency?

Ineffective erythropoiesis - Defective DNA synthesis w/ megaloblastic transformation of bone marrow and intramedullary hemolysis - Reticulocyte count often normal

Infant with non-bloody, non-bilious projectile vomiting after feeding - What - Who/when - Exam - Labs - Dx - Tx

Infantile hypertrophic pyloric stenosis Boys age 3-6 weeks +/- Olive-shaped mass in RUQ, peristaltic waves L to R on abd Hypokalemic hypochloremic metabolic alkalosis from volume contraction/vomiting High BUN/Cr - prerenal azotemia Abd US IV fluids, pyloromyotomy

Bronciolitis - who and what - presentation - tx - complications - ppx

Infants with RSV Nasal congestion, rhinorrhea, coarse breath sounds, low grade fever, wheezing +/- crackles If have respiratory distress (increased WOB, retractions, nasal flaring), hospitalize and out on contact and droplet precautions with supportive treatment - inhaled bronchodilators don't help If <2 months, apnea or respiratory failure, Recurrent wheezing (keep away from allergens) Pavalizumab if <29 weeks, premature lung dx, hemodynamically significant congenital heart dx

Pylephlebitis - What - Why - Presentation - Eval - Tx

Infective suppurative portal vein thrombosis Complication of untreated appendicitis or intraabdominal or pelvic infection (diverticulitis) Fever, RUQ pain, jaundice, hepatomegaly High alk phos, GGT, CT/US shows thrombus, polymicrobial bacteremia Broad-spectrum abx to present ischemic bowel, portal HTN or abscess

Uveitis

Inflammation of middle eye (choroid, vitreous, iris, ciliary body) 2/2 autoimmune dx (juvenile idiopathic arthritis, Reiter syndrome) or systemic infection

Scombroid poisoning

Ingestion of improperly stored seafood - Histidine decarboxylated to histamine - Histamine -> HA, flushing, palpitations, abd cramps, diarrhea, wheezing, tachycardia, hypotension - Fish may taste bitter or sour - Self limited

Fire -> facial burns - Worry about what? Next step?

Inhalation injury -> edema and airway narrowing

McCune-Albright syndrome

Peripheral precocious puberty Fibrous dysplasia, cafe-au-lait macules w/ irregular borders Rare in boys, usually have testicular abnormalities

Microcytic anemia, normal folate and LOW B12, abd pain/distention - What - Next step - Endoscopy findings

Pernicious anemia Anti-intrisic factor antibodies - Also caused by anti-parietal cell antibodies but much less specific - Schilling test - classic test but second line - radio-labeled B12 Gland atrophy, intestinal metaplasia and inflammation - See atrophy of mucosa and absent rugae of the gastric body and fundus

Borderline personality disorder - Presentation - Tx

Persistent pattern of unstable relationships and self-image, mood instability, impulsivity, recurrent suicidal behavior - Transient mood shifts 2/2 situational stressors rather than sustained Dialectical CBT

Amiodarone and 4 thyroid disorders and tx

Inhibit T4 to T3 conversion - High T4, low T3, normal/high TSH - Clinically euthyroid - NO TX Iodine inhibits hormone synthesis - High TSH, low T4 - Levothyroxine Iodine ups hormone synthesis - Low TSH, high T3/4, low RAIU - Increased vascularity on US - PTU and methimazole Destructive thyroiditis - Low TSH, high T3/4, NO RAIU - Decreased vascularity on US - Steroids

Organophosphate poisoning - Mechanism - Tx

Inhibit acetylcholinesterase -> CHOLINERGIC TOXICITY Both: ATROPINE - competitive mACh receptor antagonist and decreases cholinergic activity PRALIDOXIME - AChesterase reactivator

When to place ear tubes

Persistent tx failure Persistent effusion >3 months 3+ episodes in 6 months 4+ episodes in a year

Organophosphate poisoning - Mechanism - Tx

Inhibit acetylcholinesterase -> cholinergic toxicity Fluid out of everywhere, weak, respiratory failure Garlic order from clothes ABCs ATROPINE (competitive inhibitor) & PRALIDOXIME (cholinesterase activator) Activated charcoal if w/in 1 hr

STEMI - Cath timeline - ECG findings

PCI w/in 90 minutes of medical contact or 120 minutes if transferred - Fibrinolytics w/in 30 min New St elevation 2+ contig. leads - >1 mm except V2/V3 - >1.5 in women; >2 in men >40 and >2.5 if <40 in V2 and V3 - New LBBB and presents w/ ACS

65+ gets what pneumococcal vaccine?

PCV13 followed by PPSV23 after 6-12 mo Can get flu shot and PCV13 at same time

Non-shockable rhythm

PEA and asystole SHOCKABLE: VF and pulseless VT

RA - What hand joints - Labs - What correlates w/ disease activity?

PIP, MCP, MTP - spares DIP + rheum factor and anti-CCP ab CRP and ESR correlate w/ disease activity

Routine labs at... - Initial prenatal visit - 24-28 weeks - 35-37 weeks

Initial - Rh(D) antibody screen - H&H, MCV - HIV, VRDL/RPR, HBsAg - Rubella & varicella immunity - Pap test - Chlamydia PCR - Urine cx and protein 23-28 weeks - H&H - Antibody screen if Rh(D) neg - 50g 1-hr GCT 35-37 weeks - GBS culture

Outpatient tx acute pyelonephritis

PO cipro for 7 days

Varicose veins tx

Initially: leg elevation, weight loss, and compression stockings If fail at least 3-6 months of tx, consider injection sclerotherapy Surgical ligation/stripping for large sx vv with ulcers, bleeding, or recurrent thrombophlebitis

Subacute thyroiditis (de Quervain)

POSTVIRAL inflammation Fever, HYPERTHYROID sx (release stored hormone) PAINFUL goiter High ESR and CRP Low radio iodine uptake Self limited - NSAID & b-blocker

Positive predictive value Negative predictive value

PPV = TP / (TP + FP) NPV = TN / (TN + FN)

Pregnant. What thyroid med?

PTU - less birth defects, does have hepatotoxicity risk Not methimazole because of risks of scalp defects, TE fistula, and chantal atresia - After first trimester, switch from PTU to methimazole

Eczema of nipple and areola with pruritic and nipple retraction

Paget dx of the breast

Pain/decreased ROM hip, thick outer cortex femur with bowing, sclerotic lesions on ischial bone, bone scan increased uptake frontal bone, scapula, ischium, proximal femur, normal Ca and Cr - What - Tx

Paget's dx Alendronate (bisphosphonate)

Acute limb ischemia - 6 P's

Pain Pallor Paresthesia Pulselessness Poikilothermia Paralysis

Acute aortic dissection tx

Pain control IV beta blocker - Esmolol (short 1/2 life), labetalol, propranolol +/- Sodium nintroprusside if SBP >120 if beta blocker not working Emergency surgery for ascending dissections

Anterior uveitis = irits

Pain, redness at junction of cornea and sclera, variable vision loss, constricted and irregular pupil On slit lamp, leukocytes seen in anterior segment - May see hazy "flare" indicative of protein accumulation 2/2 damaged blood-aqueous barrier

Poison ivy - Presentation - Prevent further spread - Tx

Painful and pruritic linear papules and clear, fluid-filled vesicles in exposed areas Remove contaminated clothing Cool compress and topical steroids - Oral steroids if severe or on face/genitals - NOT antihistamines - Topical abx if bacterial superinfection (honey-crusted, exudates)

Mixed cryoglobulinemia - Presentation - Labs - Dx - Associated condition - Tx

Palpable purpura, weakness, arthralgia Glomerulonephritis - RBCs, RBC casts, proteinuria High RF, low complement level Serum cryoglobulin level Chronic hepatitis C (hx IVDU) Initial immunosuppression to stop end-organ damage Tx underlying dx - hep C

Quality-adjusted life years Disability adjusted life years

Person with illness says 5 sick years is equal to 1 health year so this means a QUALY of 1 Years of life lost due to premature mortality plus years of life with disability

bcr/abl

Philadelphia chromosome - Translocation of 9 and 22 - CHRONIC MYELOID LEUKEMIA Tx with tyrosine kinase inhibitor - IMATINIB - Doesn't cure but controls dx

Coarse, deep wrinkles on rough skin surface with actinic keratoses, telangiectasisas and brown (liver) spots - What - Tx

Photoaging Tretinoin - all-trans-retinoic acid

Thyroid nodule first step

Physical exam, check TSH, US If high CA risk (fam hx, radiation exposure, cervical LAD), do FNA next Low TSH -> iodine scintigraphy - "Hot" = hyperthyroidism - "Cold" = FNA for cancer Normal/high TSH -> FNA

Drunk person with ? life-threatening injuries wants to go AMA

Physically restrain and treat

MEN type 1

Pituitary adenoma - Prolactin, growth hormone, ACTH; mass effect HA, vision change Primary hyperparathyroidism - Hypercalcemia Pancreatic/GI neuroendocrine tumor - Gastrinoma, insulinoma, VIPoma, glucagonoma

High TSH, high T3, high T4, high alpha subunit - What - Tx

Pituitary adenoma secreting TSH - Thyrotoxicosis, diffuse goiter +/- mass effect sx - High other hormones (growth hormone -> acromegaly) - High sex hormone-binding globulin - High alpha subunit is give-away Somatostatin analog Transsphenoidal surgery

Herald patch

Pityriasis rosea - Acute post-viral rash with initial "herald patch" on trunk followed by smaller pink/tan lesions on trunk and proximal extremities

RF for breech presentation

Placenta previa Multiple gestation Polyhadramnios Advanced maternal age >35

Abrupt placentae - What - RF - Presentation - Dx - Complications

Placental detachment HTN, preeclampsia, abd trauma, prior hx, smoking, cocaine use Sudden-onset vaginal bleed, abdominal/back pain, rigid and tender uterus, high frequency and low intensity contractions Clinical dx but can see on US Fetal hypoxia, preterm birth, mortality Maternal bleed, DIC if severe - Do Kleihauer-Betke test in an RhD-negative

Reversed (or absent) umbilical artery end-diastolic flow on umbilical artery US

Placental insufficiency -> fetal hypoxia -> DELIVER

TTP-HUS tx

Plasma exchange

History suggests pheochromocytoma. Next step?

Plasma free metanephrines or 24hour carecholamines and metanephrines Wait until confirmation before giving alpha blocker because it can falsely raise labs Also stop TCAs and OTC decongestants two weeks before testing If normal, recheck during episode If high, then image with CT or MRI Consider MIBG scan if imaging negative or if positive and concerned about cancer

Hypoglycemia

Plasma glucose <60 Normal person can be 45 w/o sx

Medullary thyroid CA and RET proto-oncogene - Next step

Plasma-free metanephrine - Look for MEN2A/B

Renal failure -> increased bleed time but normal PT and PTT - What - Tx

Platelet dysfunction IV desmopressin - increases release of factor VIII:von Willebrand factor from endothelium

Anti-citrullinated peptide antibodies

Polyarticular juvenile idiopathic arthritis - Multiple symmetrical joints

JAK2 mutation - What dx - Presentation and lab

Polycythemia Erythrocytosis Aquagenic pruritus, HTN, arterial or DVT

Stimulant toxicity

Insomnia, decreased appetite, irritability Dilated pupils, tachycardia, HTN, diaphoresis Look for family member or patient with ADHD

Acrochordons = skin tags - Associated with what?

Insulin resistance Pregnancy (Crohn dx if perianal)

Scabies appearance and tx

Intensely pruritic papules and vesicles b/w fingers, volar wrists, elbows, axillae, lower abdomen, genitalia Permethrin cream

Factitious disorder

Intentionally making up symptoms in absence of external reward

Immigrant, got BCG vaccine, test for TB?

Interferon-gamma release assay - No false positives with BCG like PPD

Meconium ileus

Intestinal obstruction of distal ileum with meconium 2/2 inspissated GI secretions - Pathognomonic for CYSTIC FIBROSIS May see dilated loops small bowel, absent air fluid levels, right sided ground glass mass (mixed air bubbles & meconium in ileum)

Intussusception -> air enema -> acute onset severe abd pain - What and exam - Next step - Tx

Intestinal perforation - rebound, guarding Upright or lateral decubitus x-ray to show free air Surgery

Tx gout in renal failure or post-transplant

Intra-articular steroids Contraindicated: - Allopurinol: only used for chronic prevention - NSAIDs: decrease renal prostaglandin production, which is also decreased by cyclosporin - Colchicine: when used with azathioprine -> leukopenia

C diff w/ significant ileus tx?

Intracolonic vancomycin - careful 2/2 perforation risk

Keloid treatment

Intralesional steroid injection - May require excision or might come back Silicone gel sheeting helps with sx but doesn't actually tx keloids

Maternal DM -> fetal high glucose and insulin -> ?

Polycythemia - high metabolic demand -> hypoxemia -> erythrypoesis Organomegaly Neonatal hypoglycemia Macrosomia -> shoulder dystocia -> brachial plexus inj, clavicle fx, perineal asphyxia Hypertrophic cardiomyopathy -> increased glycogen -> deposition in inter ventricular septum - Outflow obstruction -> CHF -> fluid management & propranolol - Resolves spontaneously in weeks

Human bite - Bug - Tx

Polymicrobial Eikenella corrodes (anaerobe) Viridans strep (alpha hemolytic) Staph aureus Local wound care + irrigation No primary closure Amoxicillin-clavulanate - cover anaerobes +/- Tetanus booster

Torsades de pointes

Polymorphic VT in setting of prolonged QT - Cyclic alteration of QRS axis/morphology - Premature beats then compensatory pauses (short-long RR intervals) initiate it - Bradyarrhythmias, low mag or potassium, SSRIs, hypothermia, HIV Terminates spontaneously but can have repeat episodes -> death - GIVE IV MAGNESIUM even if mag level normal - Consider temp. transvenous pacing if don't respond to mag

Progressive, painless proximal muscle weakness, elevated CK, LFTs, and CRP/ESR - What - Other sx - Dx - Tx - Watch for

Polymyositis Difficulty climbing stairs/working with arms above head, joint pain or swelling, dysphagia Skin findings = dermatomyositis ANA and anti-Jo-1 antibodies Muscle bx - edomysial infiltrate Steroids, methotrexate, azathioprine Interstitial lung dx, paraneoplastic

Respiratory failure from asthma exacerbation - Next steps?

Intubate Also will give inhaled beta agonist and ipratropium, IV steroids, IV magnesium

Central line, neutropenia and clusters of painless pustules on erythematous base +/- necrotic center

Invasive candidiasis - Can cause endopthalmitis and require optho eval

Immunosuppressed, cough, pleuritic chest pain, hemoptysis CT chest: nodules or cavitation with ground-glass opacity - What - RF - Workup - Tx

Invasive pulmonary aspergillosis - Stem cell/organ transplant - Prolonged neutropenia (immunosuppressed) - Chronic steroid use CT findings Serum biomarkers: beta-D-glucan, Galactomannan Sputum fungal stain/culture Voriconazole Decrease immunosuppression

Large retrosternal multinodular goiter -> compressive sx - Cause - Tx

Iodine deficiency Surgical removal - Radioiodine ablation may cause further enlargement of the goiter

Hypochromic microcytic anemia in kids - Most common cause cause - Why get it?

Iron deficiency - Low meat, grain, veggies, fruit - High fatty snacks, sweets, soft drinks

Hypochromic microcytic anemia cause? In kids?

Iron deficiency and iron deficiency

Presentation of infant with septic arthritis

Irritable, poor feeding, don't want to be held, pseudoparalysis (not moving leg), fever - Fever may be absent - High ESR is red flag - >50,000 WBC on joint aspirate - Effusion on MRI or US <3 mo = S aureus, GBS, gram negative bacilli >3 mo = S aureus, GAS, strep pneumo Joint drainage, IV vancomycin (plus cefoxatime if <3 mo)

BP goal - Ischemic stroke - Hemorrhagic stroke

Ischemic - 220/120 - <185/105 if get thrombolytics Hemorrhagic - SBP around 140

Thrombolytic therapy for stroke - Give if...

Ischemic stroke w/ measurable neurodeficits Sx onset <3-4.5 hours before tx

Idiopathic premature pubarche presentation

Isolated pubic hair development

Tx latent TB? When back to work?

Isoniazid and rifampentine weekly 3 weeks Isoniazid 6-9 months Rifampin 4 months Non-infectious, go back to work now

Latent TB tx

Isoniazid for 9 months OR Rifampin for 4-6 months Only need to do sputum or gastric lavage AFB testing and cx for active pulm TB, not latent

Positive interferon-gamma release assay but asymptomatic and normal CXR. Tx?

Isoniazid for 9 months OR rifampin for 4 months OR isoniazid and rifapentine for 3 weeks under direct observation (not used in HIV) He has latent TB

RA on tx -> acute knee pain, no trauma, now has fever, swelling and hyperemia - Next step?

Joint aspiration - Joint aspiration - Monoarticular arthritis in RA + systemic signs of infxn = septic arthritis until proven otherwise

Teen with absence seizure, morning myoclonus, and generalized tonic-clonic seizure - What - Dx - Tx

Juvenile myoclonic epilepsy EEG: bilateral polyspike and slow wave activity Valproic acid - lifelong Avoid triggers - EtOH, sleep deprivation

Anosmia and hypogonadotropic hypogonadism

Kallmann syndrome - Cryptorchidism and micropenis

Drunk person threatens suicide -> denies SI in ED -> next step?

Keep in ED and reassess suicidality when sober

Sequelae of bacterial conjunctivitis - What - Why - Presentation Next step and tx

Keratitis - Inflamed cornea - Most common if wear contact lenses improperly or immunocompromised Photophobia, blurry/impaired vision, foreign body sensation w/ difficulty opening eye Urgently to optho - Dx w/ slit lamp exam to see ulcer under fluorescein - Corneal scrapings for abx - Empiric topical, combo abx for gram + and -, including pseudomonas -> scarring, ulceration and blindness

SE of TMP-SMX in breastfeeding

Kernicterus - Med is excreted in milk

Nursemaid's elbow - radial head subluxation - Who - Findings - Tx

Kid pulled, lifted by arm - Axial traction on forearm with elbow extended - annular ligament slides over radial head and trapped in radiohumeral joint Arm held extended and pronated No swelling, deformity, or focal tenderness Hyperpronation of forearm OR supination of forearm and elbow flexion - DON'T NEED X-RAY

Herpangina

Kids in the SUMMER Coxsackie group A virus Painful esicles and ulcers on POSTERIOR oropharynx FEVER Tx: sx relief w/ saline gargles, analgesis, antipyretics - No antivirals - Handwashing to prevent spread

Epistaxis - Where - Management? If first step doesn't work?

Kiesselbach plexus in anterior nasal septum Nostril pinching - Topical vasoconstrictor on cotton pledget (oxymetazoline in kids) - Older pt gets posterior epistaxis tx with posterior nasal packing

High-grade squamous intraepithelial lesion on PAP - Treatment algorithm

LEEP (not if pregnant, postmenopausal, or <25) OR Colposcopy - CIN2, 3 - per guidelines (?) - No CIN2, 3 then... 21-24 yo: repeat colposcopy and cytology at 6 mo interval for 2 yr >25: per guidelines

Acute stress disorder

LESS THAN 1 MONTH BUT LONGER THAN 3 DAYS - Exposure to actual/threatened trauma - Nightmares/flashbacks - Amnesia or detachment Tx - CBT >1 month = PTSD

Check what with valproic acid

LFTs

Pregnant but has valve replacement. Anticoag?

LMWH in 1st trimester Warfarin in 2nd/3rd UFH in last few weeks Hold all at labor Warfarin during breastfeeding

Major orthopedic surgery (arthroplasty) increases post-op DVT risk - tx?

LMWH, rivaroxaban, dabigatran, fondaparinux, or warfarin - Start 8-12 hr after procedure once hemostatis achieved - Continue >10 days

Hypoparathyroidism labs

LOW calcium HIGH phosphorus

17 alpha-hydroxylate deficiency - Hormone levels - Labs and presentation

LOW cortisol and TESTOSTERONE HIGH mineralocorticoids HIGH corticosterone (weak glucocorticoid) All are phenotypically FEMALE Fluid and salt retention, HTN

CSF for herpes encephalitis

LYMPHOCYTIC PLEOCYTOSIS Increased number RBCs Elevated protein (Temporal lobe brain abnormalities on imagine)

Mechanism of emphysema in A1AT deficiency

Lack of A1AT allows neutrophilic elastase to break down lung tissue

Next step if pain 2/2 breastfeeding

Lactation consultant - likely 2/2 poor positioning or latching

Fever, breast pain in 1 quadrant, focal inflammation without fluctuance while breastfeeding 1. What 2. When 2. Tx, can she still breastfeed? 3. Worry about what developing? Next step?

Lactational mastitis - staph a First 3 months Oral dicloxacillin or cephalexin Yes Abscess - breast US then FNA and abs

Pt can have sigmoidoscopy for colon cancer screen. What is abnormal enough to require colonoscopy right away?

Large >1.0 cm adenomatous polyp Multiple adenomatous polyps Villous or tubulovillus polyps

Large cell carcinoma

Large peripheral mass Cough, dyspnea Painful if parietal pleura or chest wall infiltrated

Increase power with...

Larger sample size

Extubated -> stridor, respiratory distress - What - Next step

Laryngeal edema 2/2 mechanical damage to mucosa -> inflammation Reintubate if signs of impending respiratory failure - pH <7.35, paCO2 >45 - Clinical signs of resp failure - RR >25 for 2 hr - Hypoxemia

BCG vaccine, immigrant, PPD 16 mm, upper lung fibrosis - What??? - Any tx?

Latent TB 9 months of isoniazid OR 4 months rifampin If had evidence of active infection, get sputum cx for AFB then start RIPE abx

+PPD and calcified pulmonary nodule - Next step - Then what

Latent TB - Tx with 9 months of isoniazid - If asx after tx, no additional evaluation or tx needed

First stage of labor

Latent phase - from beginning of regular contractions to 6 cm cervical dilation - slow change Active phase - 6-10 cm (complete) cervical dilation, rapid (>1 cm/2 hr)

Positive syphilis serology w/out signs/sx

Latent syphilis - Early latent (<12 mo) - 2.4 million units benzathine penicillin G IM 1 dose - Late latent (>12 mo), ?duration - 2.4 million units benzathine penicillin G IM weekly for 3 weeks

Wallenberg syndrome - Where in brain - Vestibulocerebellar sx - Sensory sx - Ipsilateral bulbar muscle weakness - Autonomic dysfunction

Lateral medullary infarct Vestibulocerebellar sx - Vertigo, ataxia - HORIZONTAL and VERTICAL nystagmus Sensory sx - Abnormal facial sensation/pain -Lose pain/temp ipsilateral face & contralateral trunk/limbs Ipsilateral bulbar muscle weakness - Dysphagia & aspiration - Hoaresness (ipsilateral vocal cord) Autonomic dysfunction - Ipsilateral HORNER'S (kiosks, ptosis, anhydrosis) - Intractable hiccup

Cause of shoulder pain - Lateral - Anterior

Lateral: rotator cuff (abduction too) or frozen shoulder Anterior: AC or glenohumoral joints or biceps tendon

Kid with anorexia, decreased activity, irritability, gauge abdominal pain, insomnia, eats random things - What - Tests

Lead poisoning CBC, iron, ferritin, reticulocyte count, blood lead level

Lead time vs length time bias

Lead: a test diagnoses dx earlier than another test does - time to death appears prolonged even though no actual improvement in survival Length: subjects w/ rapidly progressive form of dx are less likely to be detected by screening than with slowly progressive - gives impression screening improves surival

Bite wound w/ high infxn risk - Crush - Bites on hand/feet - Wound on body >12 hr or face >24 hr - Cat or human bites (except on face) - Bite wounds in immunocompromised How to treat these?

Leave open to heal with secondary intention Amoxicillin-clavulanate - Gram-negative Pasteurella - Gram-positive S progenies - Oral anaerobes

Young person with acute LE arterial occlusion, apical diastolic murmur, regular rhythm. What?

Left atrial myxoma - Mitral valve obstruction -> diastolic murmur and "tumor plop", heart failure, new onset a fib - Dx on echo - Tx is surgical excision

Vessel that supplies - Lateral wall of left ventricle - Anterior wall of left ventricle RCA supplies

Left circumflex LAD RV and inferoposterior LV

Carotid endarterectomy -> tongue debates to left - What?

Left hypoglossal nerve transection (vagus nerve also at risk)

MS and pregnancy

Less symptoms during pregnancy, more symptoms in postpartum period Still use steroids for exacerbation treatment More likely to have c-section or assisted delivery

Qualification for home health

Lets people receive SKILLED care (PT, OT, med compliance monitoring, wound care) 1. Serious illness or injury 2. Homebound: 1+ of.... - Use supportive device for mobility - Can only leave home with help of someone else - Medical contraindication to leaving home

Lead toxicity clinical

Levels as low as 10-20 associated with cognitive impairment and ADHD, may not appear until school starts

Subclinical thyrotoxicosis - Suppressed TSH, normal T4 - Causes - Next step - What if pt had sx?

Levothyroxine tx, nodular thyroid dx, Graves' dx, thyroiditis Repeat TSH in 6-8 weeks If sx, RAIU then low dose methimazole. If improves, radioactive iodine ablation

Shiny, pruritic papules and plaques on flexural surfaces - What - Other thing you see - Dx - Test for what

Lichen plans - middle-aged adult Wickham striae - whitish, lacy pattern Mucosal lesions - papular, atrophic, erosive lesions OR lace like, reticular Wickham striae on tongue/mucosa Genitals - pruritic violaceous papule on glans or vulva Dx is clinical but sometimes do a punch biopsy Hepatitis C

Skin findings with Hep C

Lichen planus Porphyria cutanea tarda Cryoglobulinemia causing leukocytoclastic vasculitis

Hospice criteria

Life-limiting illness with prognosis <6 months Can leave hospice for life-prolonging treatments and can return if criteria still met Can have palliative tx but not aggressive

PCP -> large blood, low RBCs -> prevent adverse outcome how?

Likely has rhabdo w/ very high CK - Major complication is AKI 2/2 myoglobinuria IV isotonic saline - volume resuscitation and prevent intratubular casts

Acute pancreatitis, no EtOH, stones or dilation on US. Next step?

Lipid panel - ERCP and MRCP are for gallstone or obstruction at ampulla of Vader pancreatitis

Acute paronychia - What - Tx

Localized bacterial nail fold infection Warm soaks, topical antibiotics - Adrain abscess

Prevent spread of zoster with these precautions - Localized - Disseminated (also what's the treatment?)

Localized: standard precautions and lesion covering until lesions crusted over Disseminated: standard precautions plus CONTACT and AIRBORNE precautions - Hospitalize for IV acyclovir - increased risk of complications (ocular infection)

Tx of pediatric functional constipation

Long term: High fiber, low dairy, osmotic laxative Acute: stimulant laxative, phosphate enema (lyte abnormalities)

Intistitial cystitis presentation, tx

Long-standing dysuria, aseptic pyuria, discomfort worse when bladder full and improved when voiding, usually women tx: improve qual of life, behav modification (avoid triggers, PT), amitriptyline, pentosan polysulfate sodium, analgesics for acute exacerbatio

S2-S4 spinal cord injury

Lose anal sphincter tone

L5-S2 spinal cord injury

Lose dorsiflexion and plantar flexion

Spinal cord injury at L1-L2

Lose hip flexion and adduction Lose cremasteric reflex

CKD and calcium

Low 1,25 dihydroxy vit D -> decreased Ca intestine absorption Phosphate retention -> high serum phos binds serum Ca These increase PTH synthesis -> secondary hyperparathyroidism Can lead to autonomous PTH secretion and tertiary HPTH requiring parathyroidectomy if... - Persistently elevated Ca, phos, or PTH (>800) - Soft tissue calcification or calciphylaxis (vascular calcification w/ skin necrosis) - Intractable bone pain or pruritus

Euthyroid sick syndrome

Low T3, normal TSH and T4 - Decreased peripheral conversion of T4 -> T3 - Usually precipitated by acute illness or certain meds (TNF, steroids, amiodarone) - No tx unless persists after back to baseline

Primary hyperthyroidism - First labs - Next steps

Low TSH, high free T3 and T4 Signs of Graves (goiter, ophthalmopathy)? - Yes = Graves - No = do RAIU .... High RAIU -> - Diffuse = Graves - Nodular = toxic adenoma or multi nodular goiter .... Low RAIU -> check thyroglobulin - Low = exogenous thyroid hormone - High = thyroiditis, iodine exposure

Subclincial HYPERthyroidism - Labs - Causes - Tx indications

Low TSH, normal T3/4 +/- sx Exogenous T3/4, Graves dx, nodular thyroid dx TSH persistently <0.1 TSH 0.1-0.5 AND.... - >65 YO - Heart dx - Osteoporosis - Nodular thyroid dx

Delirious elderly patient fighting restraints. Next step?

Low dose haldol Not benzos b/c they can worsen confusion and sedation - But can help reduce EPS of antipsychotics

Whipple's triad

Low glucose, sx of hypoglycemia, sx relief w/ glucose administration

Critically ill -> TPN -> what lab abnormality? Why?

Low phosphate IV dextrose in TPN simulates insulin -> serum phos into cells -> phos used for ATP -> low serum level Refeeding syndrome - risk of seizures, rhabdo, arrhythmia, CHF

PPV and NPV vary based on disease prevalence Sens/spec/LR don't

Low prevalence -> PPV likely low 2/2 high false positive

MI -> when can resume having sex?

Low risk (most people) - resume sex when can do light-intensity exercise w/o sx - Usually 3-4 weeks after MI High risk - detailed assessment before resuming

Lung cancer screen - What - When - Age - Eligibility

Low-dose CT chest Annually 55-80 >30 PYH AND current smoker or quit w/in last 15 yr

Lung cancer screening and smokers - Test and when? - Eligibility - When to stop

Low-dose CT chest annually age 55-80 >30 pack year hx AND current smoker or quit w/in last 15 yr Stop if >80 OR quit >15 years ago OR limited life expectancy/refuses 20% relative reduction in mortality FALSE POSITIVE RATE of 96%

Cancers that met to the brain

Lung, breast, unknown primary, melanoma, and colon cancer Hx cancer and see multiple brain tumors, it is a met!

Mono -> sx resolve but still have rubbery, firm LAD after 2 months - Next step?

Lymph node biopsy - LAD usually resolves after 3-4 weeks - Have to look for lymphoma

Cystic hygroma

Lymphatic formation that may be ID'd prenatally or present at birth as soft mass at posterior base or lateral aspect of neck

New HIV dx and tuberculosis pleural effusion - Labs - Dx - ART tx

Lymphocyte-predominant, exudative effusion High ADA - adenosine deaminase Pleural biopsy - Histopath: pleural granulomas - Pleural fluid smear aseptic Delay ART tx 1-2 weeks - Reduce risk of immune reconstitution syndrome

APL - associated with and tx

M3 APL associated with DIC ATRA +/- arsenic

RA and has anemia of chronic disease - Iron studies - Tx

MCV - normal/low Iron - low TIBC - low (high in iron def) Ferritin - normal/high Transferrin sat - normal/low Epo - high Treat RA with anti-TNF-alpha antibody infliximab - Won't respond to epo if level already high

Mentzer index

MCV / RBC - If >13, suggests iron deficiency in kids - If <13, suggests thalassemia

Bipolar II disorder

MDD (2+ weeks) AND hypomanic episodes (4+ days)

Timelines for depressed mood disorders - MDD - Persistent depressive d/o (dysthymia) - Adjustment d/o w/ depressed mood

MDD - >2 weeks Dysthymia - 2+ years Adjustment w/ depressed mood - WITHIN 3 months of initial stressor Or can just have normal stress response

Cough, coryza (rhinitis), and conjunctivitis

MEASLES

Active RA -> start DMARD even if sx improve w/ ibuprofen - First choice? Start what with it? - Others?

METHOTREXATE - folic acid Hydroxychloroquine, sulfasalazine, leflunomide, azathioprine

Live vaccines contraindicated in HIV except....

MMR and varicella zoster can be given if CD4 >200 and no hx AIDS-defining illness

Routine workup of dementia/cognitive impairment

MMSE CBC, B12, folate, TSH, CMP - Sometimes folate, syphilis, vit D or CSF CT or MRI brain - Sometimes EEG

Cushings syndrome, high urinary cortisol, non suppressible high-dose dexamethasone suppression test, undetectable ACTH - Next step

MRI of adrenals

Staph aureus bacteremia -> back pain -> next steps?

MRI spine for osteomyelitis - If positive, open/CT-guided bx

Dx with stroke, what other imaging?

MRI/CT angiogram or just doppler US carotids EKG Echo

SE of anabolic steroids

MSK: increased muscle mass Reproductive - Low T, FSH, and LH - Testicular atrophy - Decreased spermatogenesis - Normal libido and ED - Decreased libido and impotence during withdrawal - Gynecomastia Endocrine: low HDL, high LDL Hematologic: erythrocytosis Psych: affective sx, aggression Derm: acne

Kaposi sarcoma

MSM w/ HIV Red/purple papules w/o necrosis

Pelvic inflammatory disease - Biggest RF - Other RF - Tx - Complications

MULTIPLE SEXUAL PARTNERS - Also age 15-25, previous PID, inconsistent condom use, partner w/ STD Outpatient: Ceftriaxone & doxy Inpatient: Cefoxitin & doxy Tubo-ovarian abscess, infertility, ectopic pregnancy, perihepatits

B12 deficiency anemia

Macrocytic Hypersegmented neutrophils Neuro sx unlike folate deficiency

Bacterial conjunctivitis tx

Macrolide drops (erythro, azithro) or polymyxin-trimethoprim drops Wear contacts? Fluoroquinolone drops (cipro) for pseudomonas

Effect of strict glycemic control in T2DM on... - Macrovascular complications (MI, stroke) - Microvascular complications (nephropathy, retinopathy)

Macrovascular complications (MI, stroke) - NO CHANGE Microvascular complications (nephropathy, retinopathy) - Decrease risk

Traveler with fever from sub-Saharan Africa - What - How to prevent

Malaria 2/2 Plasmodium falciparum PPx - Susceptible P fal - hydroxychloroquine - Resistant P fal - atovaquone-proguanil, doxy, mefloquine - W/o P fal - primaquine

Cluster HA

Male > female (only one) No fx hx Onset during sleep Behind one eye Excruciating, sharp 15-90 minutes Sweating, facial flushing, nasal congestion, lacrimation, pupillary changes

Differentiate Mallory-Weiss tear from Boerhaave syndrome

Mallory-Weiss presents after hematemesis following n/v Boerhaave also has FEVER, CHEST PAIN, MEDIASTINITIS, LEFT PLEURAL EFFUSION, and HEMODYNAMIC INSTABILITY

Breast cancer screening recs

Mammogram q2yr women 50-75 Genetic counseling +/- testing for women with high risk family hx ?benefit - mammogram before 50 DO NOT DO: self-breast exam, genetic testing w/o high family risk

Severe malnutrition - Types - Tx - Watch for

Marasmus - wasting Kwashiorkor - edematous ORAL rehydration (IV if in shock) - Do OG or NG tube if poor PO Rewarming for hypothermia Abx for presumed systemic infxn Refeed cautiously Heart failure - IV rehydration Refeeding syndrome - low phos

Uterine (apical) prolapse

Mass protrudes past hymenal ring on valsava - Can develop vaginal or cervical erosions leading to abnormal vaginal bleeding - Tx: pessary or surgical correction Vaginal estrogen to tx erosions

Tibial stress fracture - Starts w/ medial tibial stress syndrome (shin splints) - Further activity -> actual fracture with tibial TTP Dx? Tx?

Clinical - pain at specific area that increases w/ jumping/running and associated w/ local swelling and point tenderness Initial XR initially negative - MRI can be used if need official dx Pneumatic splinting, reduced weight bearing, graduated exercise program

Gas gangrene - Technical name - Presentation

Clostridial myonecrosis Fever, severe muscle pain, purple bullae

Caloric stimulation of vestibular apparatus - What - Responses

Cold water in external auditory canal Normal: transient, conjugate, slow deviation of gaze to side of stim then saccadic correction to midline - Can't fake this! They are faking the coma if it's normal (psychogenic coma)

Cervical insufficiency - RF - Features - Tx

Collagen defects, uterine abnormalities, cervical cone 2+ painless 2nd trimester losses Painless cervical dilation Cerclage placement at 12-14 weeks

64 YO male w/ microcytic anemia, +FOBT, weight loss and fatigue

Colonoscopy to exclude colon cancer - EGD if negative

Decision making capacity

Communicates choice Understands info provided Appreciates consequences Rationale given for procedure

2-sample t-test

Compare 2 group means Use 1-way ANOVA for 2 or more group means These can't simultaneously adjust for other variables

Pearson chi-squared test

Compare association b/w categorical variables

McNemar test

Compares difference b/w 2 pair proportions when patients are their own control - Success/failure before and after tx in same subject

Intention-to-treat analysis

Compares intervention groups in randomized trial by including all subjects as initially allocated after randomization Provides conservative but more valid estimate of intervention effect Preserves benefits of randomization in superiority trials

LE thrombectomy -> LE pain, ant-crawling and burning sensation - What

Compartment syndrome - After trauma or postischemic 2/2 interstitial edema and intracellular swelling after ischemia and subsequent reprofusion Pain out of proportion, pain with passive stretch, rapid, paresthesias - Rare: sensation change, weak, paralysis, decreased pulses

Breast cyst on ultrasound if young or mammogram if old, next steps if simple vs complex

Complex - biopsy Simple - if asymptomatic, observe - tender then FNA: bloody then biopsy, imaging Nonbloody then repeat US in 4-6 weeks and if returns then biopsy

Knee pain, allodynia, swelling, decreased ROM, bluish mottled skin discoloration, increased warmth and sweating of the leg

Complex regional pain syndrome - After recent injury - Pain OOP to injury Stage 1 - during pain, edema, vasomotor changes Stage 2 - progressive edema, skin thickening, muscle wasting Stage 3 - limited ROM, bone demineralization Dx - autonomic testing shows increased resting sweat output or MRI shows above findings Tx - sympathetic nerve block or IV regional anesthesia

Chronic portal vein thrombosis

Complication of cirrhosis - Portal HTN w/ esophageal AND gastric varices

Young/middle-aged woman with isolated transaminitis - Check what?

Concern for autoimmune hepatitis - ANA and anti-smooth muscle antibodies - Often seen with arthritis, erythema nodosum, thyroiditis, pleurisy, pericarditis, anemia, sicca syndrome

URI sx for days then worsening fever, productive cough

Concern for secondary pneumonia - go to ED Increased risk if >65 YO Women preggo or 2 weeks after Underlying chronic medical dx Immunosuppressed Morbidly obese Native American Live in nursing home/facility

Trauma with blood at tip of meatus and hematuria

Concern for urethral injury and do retrograde urethrogram

New patient reports history of ADHD, requests high dose stimulant. Next step?

Confirm diagnosis and assess current functioning before prescribing

Acute otitis media -> delay in treatment -> worsening - What develops - Findings - Tx

Mastoiditis - Strep pneumo infection of mastoid air cells Kid <2YO with protrusion of ear, post auricular erythema, swelling, and tenderness over mastoid process - Swelling may high erythematous, bulging tympanic membrane - Clinical dx but see pacification of mastoid air cells on CT or MRI Culture middle ear to guide tx Empiric IV vancomycin and drain middle ear

Adolescent pregnancy <19 YO - Maternal complications - Fetal complications

Maternal - Hydatidiform mole - Preeclampsia - Anemia - Operative vaginal delivery - Postpartum depression Fetal - Gastroschisis/omphalocele - Preterm birth - Low birth weight - Perinatal death

Contraindications to breastfeeding

Maternal HIV (unless in resource-poor country) Active untreated TB Herpetic breast lesions Active varicella infection Chemo or radiation Active substance abuse Baby: galactosemia

Neonate with uni/bilateral breast hypertrophy with firm, disc-like tissue under areolae and galactorrhea - Why - Tx

Maternal estrogen crossed placenta - no more after birth so pituitary produces prolactin - Girls also get swelling, leukorrhea, uterine withdrawal bleeding Reassurance If purulent or blood discharge, concern for abscess or mastitis requiring abx (or drainage)

What are measures of central tendency? What types of variables are they used for?

Mean, median, mode Continuous variables

High maternal serum AFP - When to measure in first place - Suggests what - Next steps

Measure at 15-20 weeks High (>2.5) in neural tube defects, ventral wall defects, and multiple gestations (and improper dating of pregnancy) 1. Repeat test 2. Obstetric ultrasound - detailed anatomic survey 3. Amniocentesis if still no answer. Measure amniotic fluid AFP and AChesterase. Both high = NTD

Tumor at lung apex - Think about what - Presentation

Pancoast tumor - non-small cell lung cancer Shoulder pain - presenting sx Horner syndrome - ipsilateral ptosis, mitosis, enopthalmos, anhidrosis) - sympathetic chain and inferior cervical ganglion C8-T2 involved - weakness or atrophy intrinsic hand muscles; pain/tingling 4th/5th digits, medial arm and forearm Supraclavicular lymphadenopathy Weight loss Spinal cord met and compression

4+ Recurrent/unexpected episodes of ... and worry about additional attacks, avoidance behavior - CP, palpitations, SOB, choking - Trembling, sweating, nausea - Dizziness, paresthesias - Derealiziation, depersonalization - Fear of losing control or dying

Panic disorder Tx: - Immediate: benzos, - Long term: SSRI/SNRI and/or CBT

Central face flushing, telangiectasis - What - Tx if mild vs mod/severe (pustules) -Common complication

Papulopustular rosacea - Mild: topical brimonidine, avoid triggers - Mod/sev: topical metronidazole (oral if refractory) - Comp: ocular sx (burning, chalazion)

MCC croup

Parainfluenza

Loss of pupillary reaction, impaired upward gaze, loss of optokinetic nystagmus, ataxia - What

Parinaud's syndrome 2/2 pineal gland tumor - HA 2/2 obstructive hydrocephalus - May secrete HCG -> precocious puberty

Regular, narrow QRS tachycardia - What - Next step

Paroxysmal SVT Hemodynamically unstable? Sychronized cardioversion Stable? Adenosine or vagal maneuver to slow down AV node conduction

Abrupt, intermittent palpations and narrow-complex tachycardia with regular R-R intervals +/- retrograde P waves - What - Tx

Paroxysmal SVT - Usually 2/2 secondary conduction pathway (AVNRT or AVRT) - If stable, vagal maneuver or adenosine to slow AV node - Unstable, synchronized cardioversion - Cardiac ablation

Child choking algorithm

Partial = coughing, gagging - Allow spontaneous coughing Complete = can't talk or cough, cyanosis, difficulty breathing - <1 YO, turn face down and 5 back blows then face up and 5 chest thrusts - >1 YO, Heimlich/abd thrusts or alternate back blows and abd CPR if become unconscious

N/V/abd pain, distended tender abd, tympanic BS. XR w/ multiple air fluid levels in SI and some air in distal colon - What - Tx

Partial SBO Admit for observation, tx w/ IVF, NG suction, correct electrolytes - If no improvement in 12-24 hr, consider surgery

Intention to treat principle in trials

Participants should be analyzed in the groups they were randomized in, regardless of whether they received/adhered to the allocated intervention or if they withdrew from treatment PRESERVE RANDOMIZATION by preventing crossover and dropout effects

Flu-like sx w/ fever, myalgias then kid w/ slapped cheek malaria rash or adolescent w/ acute onset symmetric joint pain, swelling, and stiffness in PIP and PCP joints - What - Dx - Tx - Prognosis

Parvovirus B19/ erythema infectiosum Dx clinically but can confirm w/ B19 IgM antibodies Supportive, NSAIDs No long term sequelae

Angiodysplasias = small, flat, cherry red spots in colon - Increased bleeding with?

Pathogenesis: chronic occlusion of submucosal veins -> vascular congestion and dysplastic AV collaterals Increased bleed with: - ESRD -> uremia -> platelet dysfxn - von Willebrand dx - decreased vW factor -> less platelet aggregation - Aortic stenosis - acquired vWD 2/2 mechanical disruption

Selective survival bias

Patients selected from entire disease population (prevalent cases) instead of newly diagnosed (incident cases) - Patients w/ more aggressive disease die sooner and are less likely to be enrolled

Line of small, flesh-colored, dome-topped papules on penile corona or sulcus - What - Tx

Pearly penile papules - Normal variant Reassurance only (condylomata acuminate are dark/skin colored)

Rectocele sx and tx

Pelvic pressure, LBP, constipation, fecal incontinence Posterior vaginal mass increases w/ valsalva Surgical repair or pessary placement

Give if in preterm labor and 34-36 6/7 weeks

Penicillin (GBS unknown or +) and IM steroid NO tocolytic (nifedipine) after 34 weeks Add mag sulfate if <32 weeks

Ureteral stone with proximal obstruction -> hydronephrosis, infection, and hemodynamic instability - Next step

Percutaneous nephrostomy OR Retrograde ureteral stent Not shock-wave lithotripsy b/c not necessarily giving immediate relief

Benzo withdrawal - Sx - Tx

Confusion, restless, tremor, psychosis, tachycardia, HTN, high temperature - Sx peak after several days if long acting benzo or w/in 24 hr if short Diazepam - Give IV if severe withdrawal - Taper gradually

Rubella - Presentation in congenital vs children vs adults - Dx - Prevention

Congenital - sensorineural hearing loss, cataracts, patent ductus art., low birth weight, microcephaly Kids - fever, cephalocaudal rash spread (blueberry muffin) Adults - same as kids + arthralgias Serology Live attenuated vaccine

Low serum 21-hydroxylase

Congenital adrenal hyperplasia - Hyperkalemic metabolic acidosis

Fetal growth restrictions (weight <10th percentile) caused by...

Congenital infections - CMV, syphilis Chromosomal abnormalities Mom's HTN or DM - PRE-ECLAMPSIA

HTN, polyuria, and hypokalemia - What - Test

Conn's syndrome - primary hyperaldosteronism Plasma aldosterone to renin ratio >30 suggests high aldo from adrenal gland, renin suppressed from high aldo Polyuria 2/2 hypokalemia - difficultly concentrating urine

High nonresponse rate reduces statistical power How to fix?

Pool data and do meta-analysis - Helpful for studying rare things or if unethical to induce

Lupus causes pericarditis Does NOT cause tamponade

Positional substernal chest pain with friction rub

Effects on measures of central tendency of ..... skewed distribution 1. Positively 2. Negatively If there's a skew, use what measure of central tendency?

Positively skewed: mean > median > mode - right shift Negatively skewed: mode > median > mean If there's a skew, use median (it's always in the middle) instead of mean

Black cohosh - Tx - SE

Postmenopausal sx Hepatic injury

Black cohosh - Used to treat... - Side effect

Postmenopausal sx Hepatic injury

Fever, uterine fundal tenderness >24 hr after c-section - What - Increased RF - Tx

Postpartum endometritis - MCC postpartum fever - Purulent vaginal discharge, boggy uterus, vaginal bleeding - Polymicrobial from vaginal flora RF: PROM & PPROM, c-section, chorioamnionitis, GBS, operative vaginal delivery IV clinda and gent

Asbestosis - Who/when - Sx - Imaging

Construction or shipyard - 20 yrs later DOE, cough, chest tightness, wheezing Pulmonary fibrosis

Contact vs. candid diaper dermatitis

Contact - Spares skin folds - Tx is topical barrier or paste (petroleum, zinc oxide) - No powder 2/2 aspiration risk Candida - "Beefy" red rash involving skin folds - Satellite lesions - Tx is topical antifungal

Lithium may induce hypothyroidism - Tx

Continue lithium and start levothyroxine

Chvostek sign

Contraction of facial muscles when facial nerve tapped HYPOcalcemia

Medial mid-pontine infarct

Contralateral ataxia Hemiparesis of face, trunk, limbs (ataxic hemiparesis) Sometimes loss of contralateral tactile and position sense

Viral conjunctivitis often has viral prodrome of pharyngitis rhinorrhea, fever, sandy/burning sensation - Tx - How long contagious

Cool compress, lubricating drops Contagious until drainage stops

Emergency contraception

Copper IUD - up to 5 days after - >99% efficacy - NOT if acute pelvic infxn (STD), Wilson's, complicated organ transplant failure Ulipristal - antiprogestin pill - up to 5 days after - 98-99% efficiency and no contra. - Efficacy DOESN'T decrease w/ time like plan B or OCPs Levonorgestrel - plan B - up to 3 days after - 59-94 % - non contra. OCPs - up to 3 days after - 47-89%, no contra.

Adrenal cortex vs medullary tumor

Cortex: steroid hormones + androgens = Cushing syndrome or aldosteronism Medulla: catecholamines = pheochromocytoma - episodic HA, flushing, sweating, tachy, paroxysmal HTN

Crohns vs UC

Crohns - Prolonged diarrhea - Abd pain - Weight loss - C-scope: focal ulceration - COBBLESTONE WITH SKIP LESIONS UC - Bloody diarrhea - Tenesmus - Abd pain - C-scope: COLITIS w/ inflammation and friable mucosa

Failure to thrive

Crossing 2+ major percentiles MCC is inadequate calorie intake 2/2 psychosocial stressors (poverty, lack of knowledge) Get detailed hx w/ diet history

Excise squamous cell skin cancer - If can't then what?

Cryosurgery or electrosurgery - Can do in office Radiation - Multiple visits and increases future cancer risk - used in old patients who refuse surgery

Long-term travel diarrhea - Cryptosporidium - Cyclospora - Giardia

Cryptosporidium - Chronic illness in immunosuppressed Cyclospora - Prolonged, relapsing infection Giardia - Wilderness - Foul smelling, fatty stools - Asx pts may shed for months

Young patient with DM, osteoporosis, HTN, hypokalemia - What - Test

Cushing's syndrome Overnight dexamethasone suppression test or 24-hour urinary free cortisol

Signs of intracranial HTN

Cushing's triad - bradycarida, HTN, respiratory depression Early stages: HA, n/v, blurred vision, papilledema Later: AMS, ipsilateral pupil dilation, 3rd CN palsy, decerebrate postutring INTUBATE! Then CT head and consider mannitol

Untreated HIV patient has skin papule with umbilication and central hemorrhage/necrosis - What - Dx - Tx

Cutaneous cryptococcosis - Encapsulated yeast - CD4 <100 - Meningoencephalitis is most common manifestation - Arise quickly in head/neck Bx the lesion 2+ weeks IV amphotericin B and oral flu cytosine then 1 yr oral fluconazole

Mycosis fungoides - What - Tx

Cutanous T-cell lymphoma casing slowly progressive skin lesions that appear as patches, plaques, tumors or erythroderma Skin directed steroids, chemo, phototherapy, or radiation

Endometriosis presentation/exam

Cyclic pelvic pain w/ heavy menstrual bleeding Fixed, immobile uterus; rectovaginal nodularity; adnexal mass

Management of NSTEMI

DAPT Nitrates Beta blocker Statin Anticoagulation (hep, LMWH, DTI) DO NOT DO EMERGENT CATH LIKE WITH STEMI

Dupuytren contraction (fibrosis of palmar fascia) - Associated with - Tx

DIABETES MELLITUS Male, >50, fam hx Smoking and drinking Modify hand tools Needle aponeurotomy Steroid shot Surgery if advanced

T1 vs T2 DM - DKA associated with? - C-peptide level - Pancreatic autoantibodies

DKA = type 1 usually Low c-peptide in T1 and high in T2 See pancreatic autoantibodies (glutamic acid decarboxylase) in T1

RF that predict future cardiac events - CAD risk equivalents - Other RF

DM, CKD, non coronary atherosclerosis (carotid, PAD, AAA) Age, male, family hx, HTN, HLD, smoking, obesity

Renal cysts on CT - Management? - What if there is a bunch of cysts?

DO NOT ENHANCE WITH CONTRAST Simple - nothing Complex - surveillance w/ repeat imaging Polycystic kidney disease - multiple b/l cysts - test for PKD gene mutations and treat with ACEi

Recent pregnancy, contender goiter, low TSH, high T4 - What - Presentation - Lab - RAIU result

Postpartum thyroiditis (PT) - Within 1 year of pregnancy - Variant of Hashimoto chronic lymphocytic thyroiditis - Similar to silent thyroiditis Transient hypothyroid phase then euthyroid (unlike classic Hashimoto which says hypo) Thyroid peroxidase antibody RAIU - low in PT - high in Graves dx

Pulmonary HTN - Sx - Signs - Dx - Tx

DOE, fatigue, exertional angina, palpitations, syncope, abd pain Left parasternal lift, RV heave Loud P2, right sided S3 Pansystolic TR murmur Right heart failure: JVD, ascite, peripheral edema, hepatomegaly CXR - big pulmonary arteries Echo - estimates PA pressure, RV or valvular dysfunction Right heart cath for definitive dx - PA pressure >25 mm Hg Endothelin receptor antagonist (vasodilates) - bosentan, ambrisentan - delay progression - Consider sildenafil (phos-5 inh.) or epoprostenol (prostacyclin ag)

Fecal impaction - What - Tx

DRE - hard stool, decreased anal sphincter tone, overflow incontinence Manual disimpaction THEN enema or suppository

Elderly person fall - don't forget to check this

Postural stability - "get up and go" test

ACEi -> face/tongue swelling, ABDOMINAL PAIN

Decreased breakdown of bradykinin -> angioedema and dry cough Switch to ARB

Mechanism of anemia in ESRD

Decreased epo production Iron deficiency Severe hyperparathyroidism -> epo resistance Folate deficiency Systemic inflammation Aluminum toxicity

ATN

Decreased perfusion to kidney BUN/Cr ~10-15 FENa >2% - intrinsic Urine osms 300 Muddy brown casts Supportive care FENa <1% or BUN/Cr >20 suggests pre renal

Mechanism of exercise-induced amenorrhea

Decreased pulsatile secretion of LH -> decreased estrogen Can lead to osteopenia/porosis, vaginal/breast atrophy, HLD, infertility

Causes of stress incontinence

Decreased urethral sphincter tone - Different from intrinsic sphincter deficiency which is 2/2 neuromuscular damage during pelvic surgery or vaginal delivery Urethral hypermobility - Inadequate urethral support 2/2 trauma, age-related connective tissue loss, high impact exercise increased intraabdominal pressure - Obesity, increased parity, increased age, smoking, caffeine

Oligohydramnios ->

Potter sequence - pulmonary hypoplasia, flattened facies

Pragmatic study vs explanatory study

Pragmatic - determine if intervention works in real-life conditions Explanatory - determine if intervention works in optimal conditions - randomized trials are usually explanatory

Initial Parkinson's tx

Pramipexol or bromocriptine - Dopamine agonist Levodopa is most effective but limited response period and increased SE, especially if <65 YO - Save for later

Rabies ppx - Pre-exposure - Post-expsure - Post-exposure, previously unvaccinated

Pre - Vaccine Post - Vaccine (4x) - IMMUNOGLOBULIN day 0 Post, previously vaccinated - Vaccine only (2x)

Actinic keratosis - What/why - Leads to? - Tx

Pre-malignant small, rough, erythematous papules/plaques 2/2 excess sunlight SQUAMOUS CELL CARCINOMA Liquid nitrogen, surgical excision, curettage - Field therapy for numerous small lesions (5-FU cream, topical diclofenac, imiquimod)

Bell's palsy presentation

Preceding URI -> facial asymmetry

Stages of change and what to do

Precontemplation - encourage to think about consequences Contemplation - same plus promote new behavior Preparation - encourage small initial steps Action - identify strategies Maintenance - f/u support, develop relapse prevention plan Identification - praise chages

Kappa

Measure of inter-rate reliability - Two people evaluating, how much do they agree on -1 to +1 scale

Recent ear pain and coughing and aspiration during swallowing initially solids but now liquids too - where is issue - dx

Mechanical obstruction of pharynx or proximal esophagus Nasopharyngeal laryngoscopy - Can also do barium esophogram and if no dx then EGD

Positive stress test - Next steps

Medical therapy If high risk features, percutaneous coronary angiography - >1 mm ST depression - ST deletion w/ minimal exertion - ST elevation in leads w/o Q waves - Ventricular arrhythmias

BRAF gene mutation associated with?

Melanoma

Osteolytic cancer lesions - What cancers - Next steps

Melanoma, non-small cell, non-Hodgkin lymphoma X-ray or PET

Hyperpigmentation of face during pregnancy - What - Why - Tx

Melasma - occurs on sun exposed face Pregnancy -> inc estrogen, progesterone and MSH cause melanocyte stimulation Minimize sun, broad spectrum sunscreen - Can use skin-lightening hydroquinone or azelaic acid (topical retinoids work too but NOT in pregnancy)

Ginseng and ginkgo biloba - Tx - SE

Memory/mental enhancement Increased bleed risk

Early neurosyphilis - Presentation - When after initial infection?

Meningitis sx, ocular and hearing abnormalities, subacute (prodrome of a couple days) vs acute meningococcal May start in 2ndary syphilis (mac-pap rash, lymphadenopathy)

Multiple, well circumscribed brain tumors with large vasogenic edema compared to lesion size

Metastatic cancer to the brain

Overweight guy with mild LFT and alk phos elevations and diabetes - What med for DM?

Metformin - Causes some weight loss and increases HDL, decreases triglycerides Thiazolininediones, insulin, and sulfonylureas cause weight gain

ALL tx

Methotrexate

Cancer patient on chemo now having slow movement and unstable gate. Think about what?

Metoclopromide - D2 central/peripheral blocker - Tx/prevent chemo-induced emesis - Side effect is EPS like akathisia, dystonia, parkinsonian-like sx Zofran doesn't have these SE

CMV - Presentation - Workup

Microcephalic with periventricular calcifications, petechiae with thrombocytopenia, sensorineural hearing loss

Small intestinal bacterial overgrowth - findings

Microcytic anemia, B12 deficiency Positive lactose breath test

Hairy Cell Leukemia - who - tx

Middle aged (50) Cladribine

Dermoid cyst

Midline neck mass of cutaneous structures (hair follicles, sebaceous glands) Located in subQ tissue and tone move with tongue protrusion or swallowing

Bicuspid aortic valve - Murmur - Complications - Tx

Midystolic murmur at left lower sternal border Infective endocarditis Severe regurg or stenosis Aortic root/ascending aorta dilation Dissection F/U echo every 1-2 yr First-degree relatives get echo Balloon valvuloplasty or surgery if: - Sx - Planning to become pregnant or participate in sports and asx but have aortic stenosis, no AV calcification or aortic regurg, peak gradient >55 mmHg

Absolute contraindication to OCPs

Migraine w/ aura - increased ischemic stroke risk - BP >160/100 - >35 YO and smoke 15+ cigarettes per day - Heart dx - DM w/ end organ damage - Hx DVT or anti-phospholipid - Breast cancer - Liver cirrhosis/cancer - Prolonged immobilization - <3 weeks postpartum

Neonatal hyperbilirubinemia tx

Mild (physiologic): breastfeed every 2-3 hours Moderate: phototherapy - Consider formula supplement and IV fluids Severe >20, worsening on phototherapy, or bile-induced neuro dysfunction: Exchange transfusion

Tinea pedis treatment

Mild - 1-4 wks topical terbinafine, miconazole, or clotrimazole Severe or if onychomycosis - 12 wk oral terbinafine, itraconazole, fluconazole NOT griseofulvin

Management of mild scrotal trauma vs significant pain and swelling

Mild - oral pain meds Swelling, bruising, marked pain requiring strong meds requires a scrotal ultrasound to assess for trauma or hemorrhag

Gallstone pancreatitis - When to have lap chole?

Mild - w/in 7 days of clinical improvement, during same hospitalization Severe - organ failure and local or systemic complications - wait a while - also need ERCP to ensure no gallstones remain Pre-op ERCP reserved for persistent biliary obstruction

Elderly with delirium tx

Mild confusion - environmental interventions (reassurance, reorientation, sitter) Severe (pulling IV, hitting, falling) - low dose haldol

Glucagonoma presentation

Mild diabetes "Necrolytic migratory erythema" - Red, itchy, painful, borders elevated and crusty Angular cheilosis Usually malignant w/ mets to liver Dx: Elevated glucagon Tx: surgery

Delayed hemolytic transfusion reaction

Mild fever and hemolytic anemia w/in 2-10 days Positive direct Coombs, new positive antibody screen 2/2 anamnestic antibody response

Statin myopathy

Mild muscular pain No joint pain Occurs within first few months

Physiologic anemia of pregnancy

Mild normocytic, normochromic anemia 2/2 dilution - Nadir in last 2nd/early 3rd trimester

Labyrinthitis

Mild, vertigo, tinnitus, nausea, low of balance Follows viral illness (influenza)

Psoriasis tx

Mild-mod plaque: topical high-potency steroids, topical vit D derivatives Severe plaque: phototherapy, methotrexate, biologics Facial/intertriginous: topical tacrolimus, low potency steroids Guttate psoriasis: observation, phototherapy

Asthma exacerbation - Mild-mod - Severe

Mild-moderate - PEF or FEV1 >40% baseline - Inhaled SABA (albuterol) +/- PO steroids if no response or hx recent steroid tx Moderate-severe - PEF or FEV1 <40% baseline - Inhaled SABA + ipratropium 1 hr - PO or IV steroids

St John's wort - Use - Potential SE

Mild-moderate depression Drug interactions - induces P450 isozymes - Decrease effectiveness of OCPs, anti-retrovirals, anticoagulants, narcotics, immunosuppressives,

Acute urticaria treatment

Mild: 1st or 2nd gen H1 blocker Moderate: both Severe: add oral steroids

When and how to treat lead toxicity

Mild: lead 5-44 - repeat level in 1 month, NO TX now Mod: lead 45-69 - DMSA succimer Severe >70 - dimercaprol PLUS EDTA May see lead lines on x-ray but imagine not routinely indicated and doesn't change tx

Illness anxiety disorder

Minimal or no actual sx but is preoccupied with having a dx If somatic sx actually present, pt has somatic sx d/o

Gestational transient thyrotoxicosis - What - Tx

Minimal sx, mild hyperthyroidism on labs, resolves w/ hCG decline after 12 weeks Mild: no tx Severe: may occur w/ hyperemesis gravid arum or molar preg

MELAS

Mitochondrial encephalomyopathy w/ lactic acidosis and stroke-like episodes - Maternally inherited through mitochondria

Rheumatic fever effects what valve? What does murmur sound like?

Mitral stenosis Opening snap then soft, low-pitched rumble over cardiac apex - Hear best with bell if patient exhales and lies in left lateral decubitus

Heart valve causing hemoptysis

Mitral stenosis raises pulmonary capillary pressure

Systolic click at apex

Mitral valve prolapse

Linear regressin

Models linear relationship b/w DEPENDENT variable and 1 or more INDEPENDENT variables - Effects of EtOH, smoking on gastric cancer incidence

Colonic ischemia - Clinical features - Dx - Management

Moderate abd pain Hematochezia, diarrhea Leukocytosis, lactic acidosis CT: colon wall thickening and fat stranding, pneumatosis Endoscopy: edematous friable mucosa IVF, bowel rest Abx w/ enteric coverage Colonic resection if necrosis

Benefits of breastfeeding - Mom - Baby

Mom - Less postpartum bleeding - Faster return to normal weight - Natural contraceptive - Decreased breast/ovarian CA - Bonding w/ kid Baby - Better GI fxn - Lower risk necrotizing enterocolitis - Fewer infxns (ear, GI, respiratory) - Less childhood CA

Post-infarct pericarditis - pleuritic chest pain worsens with inspiration and decreases sitting up, diffuse PR depression and ST elevation - 2 types - Tx

Peri-infarction pericarditis - With 4 days of MI - Delayed reperfusion ups risk - Tx: High dose aspirin for severe Dressler syndrome - Weeks after MI - Immune mediated

Desmoid tumors

Deeply seated sometimes painful tumors in turn, intraabdominal bowel or wall - Can cause obstruction or ischemia - High recurrence rate even after surgery

Hemophilia A - What - Inheritance

Deficit in factor VIII X-linked recessive

Nausea, bloating, postprandial fullness, succussion splash - What - Next step - Tx

Delayed gastric emptying EGD Check for DM, drugs with antimotility effects, TSH, ANA Tx DM Frequent, small meals Metoclopramide (promotility med causes QT prolongation and EPS)

Delirium vs dementia

Delirium is acute onset and reversible Dementia is the opposite

Visual hallucinations plus parkinsonism features

Dementia with Lewy bodies - Fluctuating progressive cognitive decline - Visual hallucinations - Parkinsonism (after dementia) - REM sleep behavior disorder - Severe antipsych sensitivity leading to worsening confusion, parkinsonism, autonomic dysfunction (orthostatic) - Low dopamine transporter uptake at basal ganglia - Repeated falls, autonomic dysfunction - More common in men

Postmarketing surveillance

Monitoring of safety of meds after released to market If small # of study have adverse effect more often compared to control but not statistically significant, monitor with postmarked surveillance, NOT a randomized control trial

Rash after amoxicillin

Mono It's not a real allergy, can use in future

Chronic lymphocytic leukemia - What - Indicator of poor prognosis - Complications

Monoclonal B-cell lymphoma with severe lymphocytosis and smudge cells on peripheral smear and dx with flow cytometry Lymphadenopathy, HSmegaly, and thrombocytopenia/anemia indicate poor prognosis Infection, autoimmune hemolytic anemia, secondary malignancy (Richter transformation)

Trastuzumab - Use - SE

Monoclonal antibody targeting HER2 - used in breast cancer tx Cardiotoxicity w/ low EF - NOT dose dependent (doxorubicin is) - Reversible w/ stopping the med

Steroid psych sx - What - When - Tx

Mood changes, psychosis, anxiety - Also sleep disturbance, restless, memory loss High doses for long periods but can occur any time More common in women Decrease steroid dose

Metformin - side effects and use around surgery

Most common: GI sx like nausea, diarrhea, abd pain B12 malabsorption LACTIC ACIDOSIS - Contraindicated with alcohol abuse, sepsis, renal or liver dysfunction Hold day of surgery and restart after 48 hours - risk of lactic acidosis with IV contrast

Basilar artery occlusion

Motor weakness, ataxia, incoordination, AMS, facial weakness, dysphagia or dysarthria

Transverse myelitis - What - Tx - Increased risk of

Motor weakness, paresthesias, autonomic dysfunction (bowel/bladder), sensory level High dose steroids Increased risk for multiple sclerosis

Diabetic with black nasal eschar - What - RF - Presentation - Dx - Tx

Mucormycosis 2/2 Rhizopus DM (DKA), hem CA, transplants Acute and agressive Fever, HA, sinus pain, nasal congestion/discharge Necrotic invasion of palate/orbit Sinus endoscopy w/ bx/cx Surgical debridement Liposomal amphotericin B

Female with absent uterus -> karyotype and serum testosterone levels - Possible results?

Mullerian agenesis - 46 XX - Normal FEMALE testosterone level Androgen insensitivity syndrome - 46 XY - Normal MALE testosterone level - Breast development 2/2 testosterone conversion to estrogen

Osler-Rendu-Weber syndrome

Multiple telangiectasias CNS vascular lesions

Compartment syndrome may lead to what?

Muscle cell necrosis & rhabdo -> myoglobin filtered/broken down by kidney -> heme pigment -> toxic to proximal tubule cells, forms cats, induces vasoconstriction -> acute renal failure

Hypothyroid myopathy

Muscle weakness, elevated CK Myalgias, delayed reflexes, hypothyroid sx

Isotretinoin used for nodulocystic acne - Test for this first - Therapy timeline

Must have 2 negative pregnancy tests If sexually active, must have 2 forms of contraception Acne may initially flare then improves in first few weeks - Permanent improvement over 4-6 months STOP other systemic meds if using - pseudo tumor cerebra with doxy at same time

"Incidentaloma" found on adrenal gland on CT - Next step?

Must work-up for hormone hypersecretion or malignancy even if no sx BMP, dexamethasone suppression test, 24-hour urine catecholamine, metanephrine, vanillylmandelic acid and 17-ketosteroid levels Remove all functional, malignant, >4 cm tumors - Serial image all others

Cystic fibrosis - Pathogenesis/inheritance - Presentation - Dx - Abx

Mutation in CFTR gene - Autosomal recessive Recurrent sinupulm infxn, intestinal obstruction (meconium ileus), pancreatic insufficiency and DM, male infertility Elevated sweat chloride, CFTR mutation, abnormal nasal potential difference Cover STAPH AUREUS - vanco and PSEUDOMONAS (2 meds) - cefepime/ceftazidime, amikacin/tobramycin, carbapenem, fluoroquinolone, aztreonam, or colistin

Antibodies against ACh receptor - What - Sx

Myasthenia graves - postsynaptic NMJ Fatigable, fluctuating weakness (arms > legs), ptosis, diplopia, dysarthria, dysphagia - Can have purely bulbar variant - Autonomic dysfunction rare - Sensation normal

Acute cervicitis - Cause - Tx

N gonorrhoeae and C trachoma's Ceftriaxone plus azithromycin

Anemia in pregnancy <11 in 1st tri <10.5 in 2nd tri <11 in 3rd Microcytic hypothermic anemia - Small RBC with central pallor

N/V from hyperemisis gravidarum leads to iron deficiency - Increased iron requirement in pregnancy

Acute fatty liver of pregnancy

N/V, RUQ pain, significant transaminitis (300-500) Third trimester

Uremia - Signs/sx - Who

N/V, neuropathy, lethargy, seizure, coma ESRD

Hypopigmented spots and family history of bilateral deafness

NF2 - Autosomal dominant - Hypopigmented cafe-au-lait spots (hyperpigmented in NF1) - B/l acoustic neuromas

Incidence in exposed group: 18 per 1000 Incidence in unexposed: 16 per 1000 Number needed to harm?

NNH is inverse of absolute risk increase ARI = 18/1000 - 16/1000 = 2/1000 NNH = 1/ (2/1000) = 1000/2 = 500

Number needed to treat formula

NNT = 1 / absolute risk reduction (ARR) ARR = relapses in tx group - placebo group

Number needed to treat

NNT = 1/absolute risk reduction = 1 / (control group rate - event group rate)

Birth control in pt with lupus-anticoagulant

NO ESTROGEN - Progestin IUD or implant - Can use copper IUD but NOT IF HEAVY BLEEDING

Pt diagnosed with Huntingtons. Do you tell the father, sister, or wife since it can impact future pregnancy?

NO NO NO NO - Can encourage disclosure to family but since HD is incurable and not modifiable, not obligated to report Only obligated to report if harm to identifiable individual is evident

Pt's customs have man make medical decisions. Who signs consent for procedure?

NO ONE! Mark as verbal - Husband not "surrogate" because she still has capacity to make her own decisions

Breast mass -> FNA -> lobular carcinoma in situ - Next step?

NONMALIGNANT - Do have increased risk of invasive lobular/ductal cancer Excisional biopsy - Remove the whole thing, may be upstaged - After this, surveillance w/ annual mammogram, sometimes SERMS (tamoxifen, raloxifine)

Mamograms with breast implants

NORMAL schedule Start getting at 40-50 YO (unless other RF) USDA recommends MRI every 2-3 yr for asymptomatic implant rupture eval - can cause scarring

PFTs in asthma patient with no current symptoms

NORMAL!!!!!! See >20% decrease in FEV1 and low FEV1/FVC ratio after methacholine challenge

DKA - when to switch to subQ insulin

NOT UNTIL ANION GAP IS CLOSED and glucose <200 If gap open but glucose <200, cut infusion rate 1/2 and add dextrose to IVF

Negative predictive value Positive predictive value

NPV = TN / (TN + FN) PPV = TP / (TP + FP)

Acute gout tx

NSAIDs - not if renal failure or GI bleed history Colchicine - not if renal failure Intra-articular steroids are next best - exclude septic arthritis first - Oral steroids if multiple joints

Viral or idiopathic pericarditis tx

NSAIDs plus colchicine

Med tx for alcohol use disorder

Naltrexone - Mu opioid antagonist - Not if acute hepatitis or liver failure or currently taking opioids Acamprosate - Glutamate modulator Disulfram only if highly motivated or if take in supervised setting (aldehyde dehydrogenase inhibitor)

Warfarin SE on baby?

Nasal and limb hypoplasia at 6-12 weeks and can cause fetal bleeding throughout pregnancy

SSRI -> improve depression but have side effects - What are common SE? - Next step?

Nausea, anxiety, insomnia - resolve with time so continue for 6 weeks then reassess Sexual dysfunction - change med as doesn't go away with more time

Progressive multifocal leukoencephalopathy cause and symptoms

Demyelinating illness of CNS in immunocompromised like HIV with reactivation of JC virus Hemiparesis, gait ataxia, visual sx, AMS

St. John's work - Used to treat... - SE

Depression GI distress, dizziness, fatigue, photosensitivity, dry mouth - Long term studies: anorgasmia, urinary frequency swelling

Postpartum depression vs postpartum blues

Depression - SIGECAPS >2 weeks Blues - milder, less impact on functioning, peaks at 5 days postpartum and resolves w/in 2 weeks

St. John's wort - Tx - Se

Depression, insomnia Drug interactions - SSRI -> serotonin syndrome, OCPs, anticoagulants (lower INR), digoxin HTN crisis

Disseminated gonococcal infection - Presentation - Testing

Dermatitis - painless pustular lesions on distal extremities Tenosynovitis - swelling & pain w/ PASSIVE EXTENSION of tendons Polyarthralgia - asymmetric, large and small joints NAAT - Also test for other STDs (HIV, chlamydia)

Skin finding in celiac dx and it's tx

Dermatitis herpetiformis Dapsone + gluten free diet

Tinea barbae

Dermatophyte infection in distribution of beard in men - Spread by shared razors - Scattered folliculitis with erythematous papule, pustules

Med to tx von Willebrand dx

Desmopressin (ddAVP) increases von Willebrand factor and factor VIII

Standardized incidence radio

Determine if occurrence of dx in small population is high or low relative to expected value = cases observed / expected cases

IgA deficient pt gets normal transfusion

Develop antibodies against IgA which reacts with IgA in donor product Causes anaphylactic reaction - angioedema, hypotension, respiratory distress WASH RBCs before giving to IgA deficient

Hx multiple RBC transfusions -> trouble finding cross-matched blood. Why?

Developed ALLOantibodies to RBCs - E, L, and K antigens on RBC

Corpus luteum cyst

Develops after ovulation and produces progesterone until placenta can Adnexal mass on US WILL SEE INTRAUTERINE PREGNANCY

Mean, median and mode if - Negatively skewed - Positively skewed

Negative skew - tail on left - Mean > median > mode Positive skew - tail on right - Mode > median > mean

Cushing causes b/l adrenalectomy then has hyper pigmentation, bitemporal hemianopsia - Name of syndrome - Why vision sx - Next steps

Nelson syndrome Pitiuitary microadenoma with suprasellar extension 2/2 decreased feedback to pituitary after adrenalectomy MRI head and ACTH (will be high)

Varicella in congenital/newborn - Presentation - Workup

Neonatal: PNA Congenital: limb hypoplasia, cutaneous scars, seizures, MR Initial: IgM Specific: PCR of amniotic fluid

Brief shooting back pain worsened with bending forward, coughing and decreased lying down

Nerve root irritation - Positive straight-leg raise test at 60 degrees

Nested study

Nested case-control study - Retrospective observational study - Subsets of controls are matched to cases and analyzed for variables of interest

MCC death in tuberous sclerosis

Neuro impairment -> tumor (mass effect) or impairment 2/2 tumor (status epileptics, aspiration PNA) Get brain MRI and EEG at initial dx Renal failure is 2nd MCC death

Dantrolene used for what dx/sx?

Neuroleptic malignant syndrome - AMS, high fever, autonomic instability, diffuse muscle rigidity

Glyburide overdose -> give what?

Dextrose for hypoglycemia Octerotide - somatostatin analogue that decreases insulin secretion

Borderline personality disorder - what kind of CBT?

Dialectical

Acute radiation proctitis

Diarrhea, mucus discharge, and tenesmus during or w/in 6 weeks of pelvic radiation Chronic if sx >9 weeks to years after radiation - strictures, fistulas, rectal bleeding Dx of exclusion

SE of cholinesterase inhibitors (donepezil)

Diarrhea, vomiting, bradycardia

Absolute risk reduction (ARR)

Difference in risk between exposed and unexposed groups = risk exposed - risk unexposed

Pericarditis EKG

Diffuse ST elevation, PR depression

On digoxin, gets new HTN med -> n/v, anorexia, confusion, visual disturbances - What - What med was started?

Digoxin toxicity Verapamil, spironolactone, quinidine, amiodarone

Raynaud's - Tx - Labs to consider if other sx present

Dihydropyridine CCB - Nifedipine, amlodipine ANA, RF, CBC, BMP, UA, complement level

Peripheral edema 2/2 med

Dihydropyridine CCB (amlodipike, nifedipine) - Dilation of pre capillary vessels -> increased hydrostatic pressure and fluid extravasation - Combining ACEi w/ CCB lowers risk

Sporotrichosis - Type of bug - Who - Presentation - Dx - Tx

Dimorphic FUNGUS Gardeners or landscapers Subacute/chronic Skin papule -> ulceration/ non purulent, odorless drainage Proximal lesions along lymphatic chain - Rare to have lymphadenopathy or systemic sx Cultures - aspirate fluid or bx Itraconazole oral of 3-6 months

Pyoderma gangrenosum

Neutrophillic dermatosis associated w/ IBD or arthritis Inflammatory nodule/pustule/vesicle -> painful ulcer Painful as opposed to painless ecthyma gangrenosum

Preeclampsia - Define - Severe features - Management

New HTN (>140 or >90) at 20+ weeks gestation PLUS proteinuria and/or end organ damage S>160, D>110 - 2x, 4hr apart Thrombocytopenia High Cr or LFTs Pulm edema Visual/cerebral sx W/o severe: delivery at 37+ wk W/ severe: delivery at 34+ wk Mag sulfate - seizure ppx Antihypertensives (hydrazine, labetalol) - stabilize mom then deliver

PE -> RV strain - What findings on EKG? - Finding seen on echo?

New RBBB, atrial arrhythmias, Q-waves or ST-changes in inferior leads (II, III, aVF) Pulm HTN may lead to dilated TV annulus -> TRICUSPID REGURG. - Also RV dysfunction, decreased RV contractility, RV thrombus

Preeclampsia - Define - Severe features - Tx

New onset HTN (>140, >90) at >20 weeks gestation Proteinuria and/or end-organ damage >160 or >110 (2x, 4+ hr apart) Thrombocytopenia, high CK and LFTs, pulmonary edema, visual sx, hyperreflexia W/o severe - deliver 37+ wk Severe - deliver 34+ wk Give MAGNESIUM - seizure ppx AntiHTN

Sickle cell -> acute chest syndrome - Diagnostic criteria - Tx

New pulmonary infiltrate PLUS 1+: - Increased WOB, cough, tachypnea, wheezing - Fever - Hypoxemia - Chest pain - Ceftriaxone (strep pneumo) PLUS azithromycin (Mycoplasma pneumo) - IVF - Pain control - morphine

Pellagra

Niacin deficiency Diarrhea, dermatitis, dementia, stomatitis, cheilosis Rash is symmetrical, sun-exposed areas, vesicles or blisters

B3 deficiency

Niacin deficiency associated with pellagra - photosensitive dermatitis, diarrhea, dementia

Carpal tunnel syndrome tx

Nightime splint Steroids for short term relief if splinting not working Surgery reserved for mod-severe sx for 6+ months

ACS - Initial med management - .... contraindicated if ....

Nitrates, cardioselective beta blocker (metoprolol, atenolol), DAPT, anticoagulant, high intensity statin No nitrate if hypotensive or RV/inferior infarct No beta blocker in acute decompensated heart failure and bradycardia

Cyanide toxicity - Who - Signs/sx - Tx

Nitroprusside for HTN emergency (rapid on/offset), increased risk in CKD Skin: cherry-red flushing CNS: HA, AMS CV: arrhythmia Resp: tachypnea -> resp dep, pulm edema GI: abd pain, n/v Renal: metabolic acidosis 2/2 lactic acidosis, renal failure Stop nitroprusside and give sodium thiosulfate

Preferred antiarrhythmic in A Fib - No CAD or structural heart dx - LVH - CAD w/o HF - HF - A fib sx refractory to meds

No CAD or structural heart dx - Flecainide, propafenone LVH - Amio, dronedarone CAD w/o HF - Sotalol, dronedarone HF - Amio, dofetilide A fib sx refractory to meds - Radiofrequency ablation

Arrest of labor - Define - Tx

No cervical change in active phase for: >4 hr with adequate contractions OR >6 hr w/out adequate contractions C-section

HIV with positive VRDL and RPR and HA, blurred vision - Next step

No neuro sx: just treat Neuro sx (HA, blurry vision): LP and CSF analysis for neurosyphilis HIV increases neurosyphilis risk - Especially if CD4 <350, RPR >1:128 - Dx confirmed on CSF w/ elevated leukocyte count >5, positive VDRL or fluorescent treponema antibody absorption (FTA-ABS) False + RPR w/ HIV but normally low <1:16 and negative FTA-ABS

MC adverse events if - No surgery - Surgery

No surgery - adverse drug event Surgery - wound infection, bleeding, DVT

Increased cancer risk in lupus

Non-Hodgkin lymphoma - especially diffuse large B-cell lymphoma - Rapidly enlarging symptomatic mass in neck or abdomen

MVP murmur

Non-ejection click and/or mid-to-late systolic murmur of MR at apex Standing or Valsalva - longer, softer, earlier

Presentation of lesion to - Nondominant parietal lobe - Dominant temporal lobe

Nondominant parietal lobe - Apraxia - construction (drawing) and dressing difficulty Dominant temporal lobe - Homonymous upper quadrantanopia - Aphasia - Wernicke's (comprehensive aphasia)

Nurse had chicken pox as a kid but wasn't vaccinated and is taking care of herpes zoster patient - Tx

None - Don't need post-exposure ppx if had varicella or had 2 shots of vaccine If not immune, get varicella vaccine w/in 5 days of exposure - If pregnant or immunocompromised, get immune globulin (or antiviral therapy) too

Endoscopy for GERD and concern for Barrett esophagus. Next steps if... - No dysplasia - Low grade dysplasia - High grade dysplasia Stratified squamous -> simple columnar

None - PPI & repeat endoscopy 3-5 yr Low grade - PPI, repeat endo 6-12 mo OR endoscopic eradication High grade - Endoscopic eradication

GERD -> endoscopy -> next steps? - No Barrett's esophagus (BE) - BE w/out dysplasia - BE w/ low grade dysplasia - BE w/ high grade dysplasia

None: no further screening BE w/o dys: endoscopy in 3-5 yr BE low dys: ego q6-12mo or endoscopic eradication (ablation, mucosal resection) BE high dys: endoscopic eradication

Mitral valve prolapse - Murmur - Depends on what? What other murmur is like this?

Nonejection click and systolic murmur of MR Depends on LV end-diastolic volume - Occurs later (or disappears) as LVEDV increases - Earlier and more intense with increased venous return (squatting, supine leg raise) - Decrease with standing/valsalva Hypertrophic cardiomyopathy is the OPPOSITE - high LVEDP decreases intensity

Metoclopramide -> torticollis -> tx?

Diphenhydramine or benztropine - Anticholinergics Acute dystonic reaction 2/2 dopamine receptor antagonist wi

Fever, malaise, sore throat, LAD, PSEUDOMEMBRANOUS pharyngitis - What - Look out for... - Dx - Tx

Diptheria - Kids <15 YO, not vaccinated Toxin-mediated MYOCARDITIS, neuritis, kidney dx Resp secretion cx, toxin assay Erythromycin or penicillin G - Antitoxin if severe

Acute DVT treatment

Direct factor Xa inhibitor (rivaroxaban) for 3+ months - Oral and don't need labs - If have cancer LMWH 1st choice

No medical reason pt can't be discharged. Wants to stay but insurance only covered through today. - Next step?

Discharge and try to set up outpatient support DO NOT ASK INSURANCE FOR MORE DAYS

Secondary prevention of hemorrhagic varices

Nonselective beta blocker - propranolol, nadolol Can also add an oral nitrate but beta blocker most important

Findings of active TB

Nonspecific - weight loss, anorexia, night sweats, fever, fatigue Lung: cough >3 weeks, hemoptysis, chest pain CXR: cavitation or infiltrate in upper lobes (fibrosis in latent)

Guillain-Barré CSF

Normal WBC 0-5 Normal glucose 40-70 HIGH protein 45-1000

Intelligence/intelectual disability level in Turner syndrome

Normal intelligence but increased risk of learning disabilities

Next step for thyroid nodule >1 cm on US and - Normal/high TSH - Low TSH

Normal/high TSH - FNA w/ cytology Low - RAIU scan - Hot nodule = benign hyperT - Cold nodule = CA risk, do FNA

Breast cancer screening guidelines

Normal: mammogram q2y started at 50 YO (some say 40) Genetic testing if... - 2 1st degree relatives (1 before 50) - 3 1st or 2nd degree - 1st or 2nd w/ breast AND ovarian - BC in male relative

Vomiting predominant gastroenteritis and negative stool culture

Norovirus - Nursing homes, restaurants, cruise ships - Sx last 48-72 hr - Tx is supportive Enterotoxigenic E coli - less frequent causes diarrhea in outbreaks, + stool culture, and is more diarrhea than vomiting

Pregnant woman with incidental gallstone, asx - Next step?

Nothing - increased risk in pregnancy, go away w/in 2 months of delivery If sx, IVF and pain control. Can do cholecystectomy in second trimester.

Seizure hx -> phenytoin -> toxicity - Sx? - Tx?

Nystagmus on far lateral gaze - Blurry vision, diplopia, ataxia, slurred speech, drowsy, dizzy, lethargy - Increased clearance of OCPs by the liver Decrease the dose

Persistent thoughts about killing her kids , anxious as kid

OCD - Takes up >1 hr/day or causes distress/impairment - SSRI, CBT as tx

Postmenopausal pt stable with acute uterine bleed tx

OCP w/ high dose estrogen - Estrogen must be used - IV if can't tolerate oral or if still bleed after OCP

Contraception SE - OCPs - Depot medtroxyprogesterone - Progestin subdermal implant - Progestin IUD - Copper IUD

OCPs - BREAKTHROUGH BLEED, tender breasts, nausea, bloating DMPA - initial irregular bleeding, amenorrhea, REVERSIBLE BONE LOSS, DELAYED RETURN TO FERTILITY, +/- weight gain Progestin subdermal - irregular bleeding Progestin IUD - irregular bleeding, amenorrhea Copper IUD - HEAVY MENSES, dysmenorrhea

Baker cyst rupture - Who - Presentation

OLD Pain and swelling of posterior knee and calf - May resemble DVT - No knee effusion or hemarthrosis

CLL - Who - Smear - Tx

OLDER >50, asymptomatic Smudge cells Initial stages: no tx Advanced: fluderabine + rituximab

Next step for newborn of mom who didn't get GBS ppx? What if infant >37 weeks or prolonged ROM >18 hr?

Observation for 48 hr CBC, blood culture - LP and abx only if baby is ill appearing

Standardized mortality ratio

Observed deaths / expected deaths Used in occupational studies to see if exposure specific RF increases number of deaths vs. not exposed Confidence interval that doesn't include null value (1.0 for SMR) = statistically significant

Observer bias

Observers misclassify data 2/2 individual perceived differences in interpretation or preconceived expectations

OCD - Dx - Tx

Obsessions and compulsions >1 hr/day or causing significant distress SSRI CBT - exposure and response prevention therapy - reduce sx through habituation (Clomipramine is 2nd line 2/2 orthostatic hypotension, anticholinergic, cardiac conduction delay)

PFTs in asthma

Obstructive pattern - Reduced FEV1 - Reduced FEV1/FVC ratio - TLC and DLCO usually normal (sometimes high) - Bronchodilator improves FEV1 >15% If no active symptoms, NORMAL PFTs - give methacholine, see >20% reduction in FEV1

COPD PFTs

Obstructive pattern - Low FEV1/FVC - DLCO reduced (normal in asthma!!!)

Old obese person with mild cognitive impairment, irritability, poor concentration and memory - What - RF - Next step

Obstructive sleep apnea >50, male, neck circ >43.2 cm, high BP, BMI >30, chronic HA, poor sleep Polysomnography

Medial medullary syndrome

Occlusion of branch of vertebral or anterior spinal artery Contralateral paralysis of the arm and leg - Tongue deviation toward the lesion

Supracondylar (distal humerus) fracture from fall on outstretched hand and now with elbow pain and limited ROM - Tx

Occult, non displaced (fat-pad displacement on XR) - Splint and sling Displaced - surgical reduction and pinning

Familial or benign essential tremor

Distal extremities - More pronounced with outstretched arm - Increases at end of activity - May have head tremor - Worsens with time - No other neuro signs s/o Parkinson's - No significant disability - Normal life expectancy - Tx w/ propranolol

HIV presentation

Distinctive features: - Painful mucocutaneous ulcer - Maculopapular rash on palms/soles Fever, nontender LAD, sore throat, HA, fatigue, myalgias Leukopenia, thrombocytopenia

When to measure reverse T3

Distinguish euthyroid sick syndrome (high) and central hypothyroidism (low)

Drug induced pancreatitis

Diuretics! - ACEi/ARBs - Tylenol, NSAIDs, opiates - Isoniazid, tetracyclines, flagyl, TMP-SMX - Valproate, carbamazepine - Antivirals - Azathioprine, mercaptopurine, steroids - Estrogens

2 episodes of painless hematochezia and hx diverticulosis - What - Tx

Diverticular bleeding - as mucosa and submucosa herniate through muscular layer, penetrating artery injured from erosion or trauma Bleeding self-limited, may need fluids or blood transfusion Colonoscopy for cauterization or tamponade of vessel - Can do angiography with embolization

LLQ pain, fever, n/v, ileus (peritoneal irritation) - What - Dx - Tx - Not improved in 3 days?

Diverticulitis CT abdomen w/ oral and IV contrast Abx (cipro, metronidazole) Bowel rest Repeat CT to eval for abscess, obstruction, perf

Eval for chronic diarrhea

Do all of these: - History - CBC, CMP - Stool analysis for leaks, parasites, occult blood, pH, fat, electrolytes for osmotic gap

Previously undiagnosed hypothyroidism found on labs before cardiac cath - Next step

Do the surgery - Hypothyroidism only mildly increases preoperative risk in absence of myxedema coma or severe sx Levothyroxine increases myocardial O2 demand -> infarct, angina, arrhythmias - Started slowly in cardiac patients - Do urgent surgery first

Chronic hep B diagnosed if...

Don't clear hep B surface antigen within 6 months Occurs in 5% of cases - More frequent in kids 2/2 immature immune system (90% if perinatally acquired)

Pramipexole

Dopamine agonist used for long-term tx of Parkinson's

Prolactinoma treatment

Dopaminergic receptor agonist - Bromocriptine, cabergoline Tumor size reduces quickly and vision improves Surgery rarely required

Anthracycline chemo cardiac toxicity

Dose-dependent decline in EF -> dilated cardiomyopathy

Inflammatory acne -> med -> photosensitivity - What med? - Other options

Doxycycline -> photosensitivity - Dose dependent Benzoyl peroxide, topical azelaic acid, dapsone, erythromycin, topical retinoids

Eosinophils in urine

Drug-induced interstitial nephritis - 3-5 days after abx

TCA overdose sx

Dry skin/mucosal surface, dilated pupils, hot, ventricular tachyarrhythmias Also with some plants and mushrooms

Gastrectomy -> diarrhea, cramping abd pain, postprandial n/v, dizziness, diaphoresis, SOB, increased BS, mildly distended and tender abd - What - Tx

Dumping syndrome - Pass through stomach into jejunum faster High protein, low carb diet with small but frequent meals

Acute asthma exac in pregnant pt - Tx

Duonebs -> ORAL steroids -> IV MgSO4 or subQ terbutaline - ICS safe in preg but not used in acute asthma - Goal SaO2 95%+ (90% in non-preg) - Steroid risk of premature birth outweighed by tx asthma

Most common allergen causing asthma

Dust mites

Biopsy an actinic keratosis if...

Dx unclear >1 cm diameter Indurated Ulcerated Tender Rapidly growing Don't respond to appropriate tx If bx shows SCC - Mohs or excision w/ 4 mm margins

Obesity hypoventilation syndrome

Dyspnea Right sided heart failure -> LE edema, hepatomegaly, JVD NOT pulmonary edema, chronic cough

Mitral stenosis - Presents with - Exam - Dx

Dyspnea, hemoptysis, PND Hx rheumatic heart dx years ago A fib, systemic thromboembolism Hoarse voice - LAE compression of recurrent laryngeal nerve Loud S1, opening snap, low pitched mid-diastolic rumble at apex, loud P2 if pulm HTN EKG: broad notched P waves, atrial tachyarrhythmias, RVA

Bug for mono

EBV

Infectious mononucleosis - Bug - Presentation - Dx - Tx

EBV Fever Tonsillitis/pharyngitis +/- exudate Posterior or diffuse LAD FATIGUE +/- HSmegaly RASH AFTER AMOXICILLIN + heterophiles antibody (1/4 false negative in 1st week of illness) Atypical lymphocytosis Transient hepatitis Avoid sports 3+ weeks (4+ if contact) Supportive care Fatigue may persist for months

Mono - Bug - Presentation - Dx - Tx

EBV (sometimes CMV) Fever, fatigue Tonsillitis/pharyngitis +/- exudates Lymphadenopathy +/- HSmegaly +/- Rash after amoxicillin + Monospot heterophile antibody (25% false-negative in 1st week) Atypical lymphocytosis Transient hepatitis Supportive - NSAIDs, etc. No sports >3 weeks, no contact >4 weeks 2/2 splenic rupture

Small 8 mm diameter and raised 1 mm, densely pigmented lesion with irregular borders in peripheral right choroid on fundoscopy - What - Tx

Ocular melanoma - from melanocytes in urea (iris, ciliary body, choroid) If <10 mm diameter, <3 mm thick then repeat exam in 3 mo. then every 6 months If large or sx, radiation therapy

Ethambutol SE

Ocular toxicity

Measure of association used in case-control study - What - How to calculate it

Odds ratio = (a/c) / (b/d) = (a*d) / (b*c)

First trimester vag bleeding, positive pregnancy test, elevated (but normal for pregnancy) beta-hCG, transvag US shows left adnexal complex cystic structure and thickened endometrium - What - Presentation - Dx - Tx

ECTOPIC pregnancy Abd pain, amenorrhea, vag bleed +/- cervical motion, adnexal, abd tenderness; palpable abd mass Hypovolemic shock if ruptured Positive hCG Transvag UC shows adnexal mass, empty uterus with thick endometrium - MAY NOT SAY "EMPTY" but won't say anything seen Stable: methotrexate Unstable: surgery

Hematochezia and hemodynamic instability, orthostatic hypotension, NSAID use - Next step

EGD - assumed upper GI unless strong suggestion of lower source

WPW - EKG - Potential sx - Tx

EKG: short PR, wide QRS, delta wave (slurring slow rise at beginning of QRS!) - in V2 on question - PSVT is most common arrhythmia (regular, narrow complex) - Risk of a fib (may be precipitated by EtOH) and can causes syncope Catheter ablation - a fib can turn into v fib

Functional hypothalamic amenorrhea - Other name - Presentation - Labs - Consequences - Tx

EXERCISE-INDUCED hypothalamic amenorrhea - Strenuous exercise, relative caloric deficiency, stress fractures, amenorrhea, infertility, breast atrophy LOW GnRH, LH, FSH, estrogen Low bone density, high LDL and triglycerides Increase caloric intake, estrogen, calcium , vit D

Compartment syndrome (pressure >20-30 mm Hg) - Presentation

Early - tightness, swelling, weakness, pain with passive flexion, pain out of proportion to injury Late - decreased arterial blood flow -> absent distal pulses

Pancreatitis -> abd pain afterward -> pancreatic inflammatory fluid collection (pseudocyst)

Early <4 weeks - Peripancreatic fluid collection or acute necrotic collection Late >4 weeks - Pancreatic pseudocyst or walled-off necrosis Management is supportive unless significant sx -> surgical/endoscopic drainage

Traveler returning, has fever. Causes for... - Early incubation (<10 days) - Medium (1-3 weeks) - Long (>3 weeks)

Early incubation (<10 days) - Thyphoid, dengue, chikungunya, influenza, legionellosis Medium (1-3 weeks) - Malaria, typhoid, leptospirosis, schistosomiasis, rickettsial dx Long (>3 weeks) - TB, leishmaniasis, enteric parasite

Lyme disease features at: - Early localized (days - 1 mo) - Early disseminated (weeks - months) - Late (months - years)

Early localized (days - 1 mo) - Erythema migrans, fatigue, HA, myalgias, arthralgias Early disseminated (weeks - months) - Multiple erythema migrans, CN palsy (VII), meningitis, carditis (AV block), migratory arthralgias Late (months - years) - Arthritis, encephalitis, peripheral neuropathy

Sarcoma botryoides

Ebryonal rhabdomyosarcoma Presents as infant/early childhood Nonfriable nodules with cluster of grapes appearance and protrudes from vagina

Usually still use lithium during pregnancy but what is the potential side effect?

Ebstein anomaly - Apical displacement of tricuspid valve leaflets and atrialization of the RV

DVT -> stroke - Do what test?

Echo with bubble study - look for PFO or ASD

Rapid evolution of skin lesion from erythematous macule to pustule or bullae then to painless gangrenous ulcer in immunocompromised pt - What - Cause - Tx

Ecthyma gangrenosum Pseudomonas aeruginosa bacteremia in immunocompromised pt IV abx Painless as opposed to the painful pyoderma gangrenosum (IBD or arthritis)

Endometriosis - What - Presentation - Exam - Dx - Tx

Ectopic implantation of endometrial glands Unilateral pelvic pain and tender adnexal mass (endometrioma) Dyspareunia, dysmenorrhea, chronic pelvic pain, dyschezia Immobile uterus, cervical motion tenderness, adnexal mass, ligamentous NODULES Dx w/ direct visualization and bx Medical: OCPs, NSAIDs Surgical resection MAY CAUSE INFERTILITY

Positive urine hCG, lower abd pain and/or vaginal bleed. Next steps if hemodynamically - Unstable + peritoneal signs - Stable

Ectopic pregnancy Unstable -> emergent laparoscopy Stable -> transvaginal US - Adnexal mass = tx ectopic - Intrauterine preg - Nondiagnostic - depends on hCG >1500 = repeat hCG and US 2 days <1500 = repeat hCG alone 2 days

Mom doesn't want to vaccinate kid even after long discussion. Next step?

Educate again at next appointment Don't offer passive immunoprophylaxis - only for high risk and not a good substitute

Serous otitis media

Effusion of middle ear but no infection or inflammation - Follows suppurative otitis media

MCL/LCL injury characteristics

Effusion uncommon Tx with RICE

Berry aneurysms associated with?

Ehlers-Danlos 2/2 increased fragility of cerebral artery walls

Cases of emancipated minor and medically emancipated minor

Emancipated: homeless, parent, married, military, financially independent, high school grad Medically emancipated: emergency, STI, substance abuse, pregnancy, contraception

Branchial cleft cyst

Embryologic remnant Lateral neck mass anterior to sternocleidomastoid muscle +/- sinus tract or fistula

Tx for... - Suspected G & C - Confirmed G - Confirmed C

Empiric - ceftriaxone and azithromycin Confirmed chlamydia - azithro Confirmed G & C - ceftriaxone AND azithro

Endometriosis - What - Sx - Exam - Dx - Tx

Endometrial gland implantation outside uterus Dyspareunia, dysmenorrhea, dyschezia Immobile uterus, adnexal mass, modularity along posterior cul-de-sac Laparoscopy - "powder-burn" lesions, endometrioma

Adenomyosis

Endometrial tissue within the uterine myometrium - Dysmenorrhea, heavy bleeding, chronic pelvic pain, +/- uterine tenderness - DIFFUSE uterine enlargement Thickened myometrium on US/MRI - Confirm w/ pathology Tx: hysterectomy

Chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia - What - Workup/tx

Endometriosis Do laparoscopy if... - Contraindication to medical tx - Hx infertility - Concern for adnexal mass/CA If none of those... - NSAIDs +/- OCPs - decrease endometrial shedding->less pain, inflammation

Incidental cystic lesion in pancreas on CT. Labs normal. - Next step?

Endoscopic US and aspiration High CEA from cystic fluid would be suggestive of malignancy but not a first step

Well differentiated adenocarcinoma in head of peculated colon polyp w/o involvement of stalk or resected margins

Endoscopic removal Repeat colonoscopy 2-3 months

Cervical lymphadenitis

Enlarged tender lymph notes in lateral neck Triggered by inflammation from bacteria/viruses Associated with upper respiratory sx (sore throat, rhinorrhea)

Basal cell carcinoma

Enlarging fleshy nodule with ulceration Sun exposure - but not from AK!

Untreated celiac -> abdominal pain, weight loss, fatigue, fever, GI bleed - What?

Enteropathy-associated T-cell lymphoma (EATL) - Proximal jejunum - Present late and tx limited

Travel to poor country, eat street food, develop watery diarrhea, cramps abd pain 1-3 days after ingestion and resolves in 3-4 days w/ supportive care

Enterotoxigenic E coli

Meralgia paresthetica - What - Tx

Entrapment of lateral femoral cutaneous nerve - Purely sensory to anterolateral thigh - Direct branch of lumbar plexus through abdominal cavity, under inguinal ligament - Reassurance, weight loss, avoid tight fitting clothes

Churg-Strauss - Other name - Manifestations

Eosinophilic granulomatosis - autoimmune vasculitis Allergic rhinitis w/ nasal polyps, asthma, chronic sinusitis, mononeuropathy multiplex, granulomas, palpable purpura

Unvaccinated child with acute onset fever, respiratory distress, dysphonia, and stridor sitting forward with neck extended - What - Next step

Epiglottitis 2/2 H influenze B - Stridor, tripod plus drooling INTUBATE - Abx after airway secure - See thumbprint sign on XR but don't need it to dx (Croup has barking cough, no fever or drooling, and gets racemic epinephrine and IM steroids)

Biliary colic - Sx, radiate where - Dx

Episodes of epigastric/RUQ pain radiating to back and right shoulder +/- nausea, vomiting, diaphoresis RUQ US

HbSC disease

Equal HbS and HbC on hgb electrophoresis

Baby born with adduction and internal rotation of the upper extremity, pronated forearm, and asymmetric Moro reflex - What - Mechanism - Why - Tx

Erb-Duchenne palsy Stretching of brachial plexus (neck traction) during deliver stretches C5-C7 Gestational diabetes -> macrosomia -_ shoulder dystocia during birth Resolves over time

SJS - Presentation - Causes

Erosions of mucous membranes, small blisters on purpuric macule, atypical target lesions Abx: sulfa, aminopenicillins, quinolones, cephalosporins Anticonvulsants: lamotrigine, phenytoin, carbamazepine

Abrupt onset of red, painful, edematous, elevated rash with sharp demarcation of border - What - Where - Bug

Erysipelas - May have fever, malaise - Usually on LE but can be on face and have butterfly pattern Group A strep (pyogenes)

Sarcoidosis -> anterior uveitis. What does that look like?

Erythema at limbus (junction of cornea and sclera) Constricted pupil Blurry vision Moderate eye pain Need to see ophthalmologist

Irritant diaper dermatitis

Erythema spares skin folds, may have papules - Looks less angry than candida Tx: frequent diaper changes, avoid tight fitting diapers, expose skin to air, apply barrier cream like zinc oxide or petrolatum

Cause and tx of rhinitis with - Erythematous nasal mucosa - Pale/bluish nasal mucosa

Erythematous = non-allergic - Mild: intranasal antihistamine or steroid - Mod/severe: combo Pale/bluish = allergic - Intranasal steroids - Antihistamines

Intertrigo - What - Bug - Tx

Erythematous plaques and erosions in intertriginoous regions sometimes with satellite papules (inguinal, genital, intergluteal, under breasts) Candida Topical antifungals

Confluence of pruritic, reddish brown, finely wrinkled papule 2/2 infection - Name of disorder and the bug - Testing - Makes appearance worse

Erythrasma - Corynebacterium minutissimum Wood lamp - coral-red fluorescence 2/2 Corynebacterium porphyrins Smoking

Boerhaave syndrome - What/why - Sx - Dx - Tx

Esophageal TRANSMURAL tear 2/2 forceful vomiting Esophageal air/fluid leaks into mediastinum and pleura - Retching, n/v - CHEST PAIN, abd pain - Dyspnea from pleural effusion - Fever (may not initially be present), septic shock Water-soluble contrast esophagogram Surgery

Achalasia

Esophageal dysmotility - Trouble with solids AND liquids

Multiple logistic regression

Estimate association b/w 2 or more independent variables and 1 dichotomous dependent variable

OCPs ant thyroid meds

Estrogen increases TBG, increasing TOTAL T4 and decreasing FREE T4 - Normal thyroid can adjust If hypothyroid, INCREASE med dose - Check TSH after 12 weeks

Thyroid hormones and first trimester

Estrogen increases thyroxine-binding globulin -> more T4 bound -> increased TOTAL T4 hCG stimulates TSH receptors -> increased thyroid hormone production and feedback suppression of pituitary TSH release LOW TSH, HIGH TOTAL T4 - Free T4 unreliable

Restless, tremulous, diaphoretic, elevated LFTs during first night of hospitalization

EtOH withdrawal - Lorazepam Seizures 12-48 hr after last drink Delirium tremens 48-96 hr after

Antifreeze intoxication - Bad component? Why? - Sx - Tx

Ethylene glycol - broken down by alcohol dehydrogenase to glycolic acid, glyoxylic acid, and oxalic acid AG acidosis -> Kussmaul breathing (rapid and deep) Early: n/v, slurred speech, ataxia, nystagmus, lethargy Late: tachypnea, agitation, confusion, flank pain/renal failure, pulm edema, AMS, coma Fomepizole infusion (better than ethanol)

DM -> abd pain, n/v, high HR & RR Glucose 160 UA - + for glucose and ketones pH 7.28, low PaCO2 What? Causes?

Euglycemic diabetic ketoacidosis - 2/2 SGLT2 inhibitor - Triggered by prolonged fasting, major illness, intense exercise, excessive EtOH - These low the insulin-glucagon ratio and exacerbate relative insulin deficiency -> ketogenesis - glucose <250 - Tx: IVF, stop med, give insulin

Multiple linear regression

Eval association b/w quantitative dependent variable and independent variables while controlling for effects of other factors (adjustment variables)

When to use hysterosalingography

Evaluate for infertility - checks potency of fallopian tubes - Obstruction may be 2/2 endometriosis or PID due to adhesion formation

Hypothermia tx

Everyone - warmed crystalloid for hypotension, intubate if comatose Mild (32-35 C) - Passive external warming (remove wet clothing, cover w/ blankets) Moderate (28-32 C) - Active external warming (warm blankets, heating pads, warm bath) Severe (<28) - Active INTERNAL rewarming (warmed pleural/peritoneal irrigation, warmed humidified O2)

STD testing in men 35-65 with or without risk factors Additional testing for men

Everyone gets fourth generation HIV test (P24 antigen and HIV antibody) Asymptomatic men who have sex with women and no sex workers get no more testing MSM and symptomatic men get chlamydia screening

Primary dysmenorrhea

Excess prostaglandins stimulate uterine contraction -> pain, bloating, n/v Tx: NSAIDs (OCPs 2nd line)

Somatic symptom disorder

Excessive anxiety and preoccupation it 1+ somatic sx for 6+ months Schedule regular f/u, same provider, limit unnecessary workup and referrals, focus on reducing stress and better coping

Pesticide OD

Excessive salivation

Suspicious for melanoma - next step

Excisional bx - entire lesion w/ 1-3 mm margins plus subQ fat If no LAD but increased risk (>0.75 mm thick, tumor ulceration), do sentinel node bx too

Old guy with SOB, lightheadedness fatigue, S4, no murmur, no JVD or peripheral edema - Next step? For what?

Exercise ECG - Stable angina - old people more likely to get anginal sx rather than chest pain Pharm stress test with adenosine perfusion study or dobutamine echo if can't exercise

Thought behind 2 step PPD test

Exposure to TB antigens May have initial negative PPD 2/2 waned immunity then have positive second "booster PPD weeks later 2/2 anamnestic response following initial test

Effect modification

External variable modifies the effect of a risk factor on the disease of interest in different groups

Effect modification bias How is it different from confounding bias?

Extraneous variable changes direction/strength of effect the independent variable has on the dependent - Stratification based on the modifier helps detect this In confounding, extraneous variable effects both the independent and dependent variables - No change with stratification

Glasgow Coma Scale - Categories - When to intubate

Eye opening - 4 Verbal response - 5 Motor response - 6 Intubation recommended if <8

Tension HA

F > M No fam hx Onset under stress Band-like pattern around b/l head Dull, tight, persistent 30 min - 7 days Muscle tenderness of neck/shoulder Tx: Tylenol, stress-reducing

MVA -> blunt thoracic trauma -> tachycardia hypotension - Next step? Worried about what?

FAST (bedside ultrasound) Cardiac contusion -> decreased contractility and heart failure Arrhythmia Myocardial rupture -> pericardial effusion, tamponade, cariogenic shock

Microcytic, hypochromic anemia with low-normal ferritin - Next best test

FOBT - Likely has iron deficiency - Most people with ferritin up to 30 are iron deficient too - Usually to c-scopy before EGD unless suspect UGI bleed

False positive False negative

FP = 1 - specificity FN = 1 - sensitivity Not as good as LR for individual patients

Repeated polymicrobial bacteremia with no history of malignancy or immunosuppression - What - Who

Factitious disorder - inducing/feigning sickness w/o external benefit - Inject exogenous material Women and health care workers

Most common cause of inherited thrombophilia

Factor V Leiden

Viral gastroenteritis - Transmission - Presentation - Dx - Tx

Fecal-oral Emesis and/or watery diarrea Clinical dx REGULAR DIET for age with limited sugars which can worsen diarrhea (doesn't need to be bland) Oral fluids (IV if can't tolerate oral or significantly dehydrated)

Migraine HA

Female > male Often family hx Often unilateral Pulsating, throbbing 4-72 hr Aura, photo/phonophobia, nausea

Neonatal displaced clavicle fx - RF - Presentation - Dx - Tx

Fetal macrosomia (DM, post-term) Instrumental delivery Shoulder dystocia Pain w/ passive motion of arm Crepitus over clavicle Asymmetric Moro reflex XR Reassurance, pain med, pin arm sleeve to chest w/ elbow 90 deg.

Febrile nonhemolytic transfusion reaction

Fever and chills w/in 1-6 hr 2/2 cytokine accumulation during blood storage

Spontaneous bacterial peritonitis - Presentation - Dx - Tx - Predictor of mortality

Fever, abd pain, AMS, hypotension, hypothermia, - Paralytic ileus w/ severe dx Paracentesis - PMN >250 + culture (E coli or Klebsiella) - Protein <1 - SAAG >1.1 - IV albumin - decrease renal failure and mortality - Empiric abx - 3rd gen cephalosporine (cefotaxime) - Fluoroquinolone for SBP ppx MELD - bili, INR, creatinine, Na

B symptoms - What are they - Associated with what

Fever, fatigue, pruritus Hodgkin's lymphoma

Acute hemolytic transfusion reaction

Fever, flank pain, hemoglobinuria, ARF, DIC w/in 1 hr Positive direct Coombs, pink plasma ABO incompatibility

Acute bacterial rhinosinusitis - Sx - Dx criteria - Tx

Fever, nasal congestion, PURULENT nasal discharge, maxillary tooth pain, face pain increased leaning forward Sx >10 days w/o improvement Severe sx 3+ days Double sickening - URI sx -> better -> then worsening sx 1st: Amoxicillin-clavulanate 5-7 d 2nd: doxy, fluoroquinolone

Pain with ulnar deviation and thumb held in opposition across the palm - Name of test - What's wrong

Finkelstein test DeQuervain tenosynovitis - overuse of extensor policies brevis and abductor policies longs tendons - sharp pain at base of thumb

Mutlifocal atrial tachycardia: 3+ P wave morphologies, irregular R-R intervals, atrial rate >100 - Tx

First stabilize with O2 if needed Correct underlying disturbance - Hypokalemia - COPD exacerbation - Sepsis -> catecholamine surge Then can use AV nodal blocking agents (verapamil, beta-blocker) if persistent

RF for pyloric stenosis

First-born boy Macrolydes (erythromycin, azithromycin) - ppx for pertussis Bottle feeding

Amlodipine SE

Fluid retention and urticarial rash

Benzo overdose - tx

Flumazenil

Pregnancy induced skin changes

Focal pruritus but no rash 2/2 hormone changes Normal labs +/- mild high LFTs Tx oatmeal baths, UV light, antihistamines

Methotrexate -> antifolaxe effects -> tx?

Folinic acid - leucovorin

Pyelonephritis in pregnancy tx

Follow these steps: 1. Admit to hospital and start empiric broad-spectrum beta-lactam abx: ceftriaxone, cefepime 2. Afebrile 48 hr, start oral abx for 10-14 days 3. Daily low-dose cephalexin or nitrofurantoin until 6 weeks postpartum

Antifreeze ingestion tx

Fomepizole - Competitive inhibitor of ADH - Also for methanol intoxication - Prevents toxic metabolite formation - Better inhibitor than ethanol

Nonclassic congenital adrenal hyperplasia

Form of peripheral precocious puberty - Autosomal recessive - Reduced 21-hydroxylase deficiency -> increased androgen - Acne and early pubic hair - Boys w/ normal testes (large in central PP) - Girls w/ hirsutism, menstrual irregularities - Tall as kid but premature fusion of growth plates -> short adult - No salt wasn't (still have some 21-hydrox) so not caught on newborn screen - High 17-hydroxyprogesterone on ACTH stim test - Tx w/ hydrocortisone

Pick dx

Frontotemporal dementia - Onset in 50s-60s - Personality changes - Worsening executive dysfunction

Rectal prolapse - Exam - Mangement If untreated can lead to strangulation and gangrene

Full thickness mass extending through anus with concentric rings of the rectum Medical if not full thickness - Reduce with digital pressure - Fiber and fluids - Pelvic floor muscle exercises Surgical if... - Full thickness or sensation of prolapse - Prolapse with fecal incontinence and/or constipation

Histoplasmosis

Fungal Usually lung but can spread Disseminated - nodular, papular, or plaque-like skin lesions with systemic sx

Coccidiodomycosis

Fungal Community acquired PNA CNS manifestations May have soft tissue abscesses

Positive beta-D-glucan test

Fungal cell wall component - elevated in aspergillosis and candidiasis

Blastomycosis

Fungal infection Pneumonia Occasionally verrucous skin lesions with heaped borders

Abx then hemolysis

G6PD deficiency Got sulfa (TMP-SMX)

Gonorrhea treatment Chlamydia treatmetn

G: ceftriaxone C: azithro or doxy

Oioid withdrawal - Presentation - Management

GI: n/v/d, cramping, inc BS Cardiac: tachy, HTN, diaphoresis Insomnia, yawning, dysphoric Myalgia/arthralgias, lacrimation, rhinorhea, piloerection, mydriasis Opioid agonist: methadone (preferred) or buprenorphine (not for acute 2/2 partial antagonist) Nonopioid: clonidine or adjunctive meds (antiemetic, antidiarrheal, benzos)

Buspirone used to tx?

Generalized anxiety disorder

Intrahepatic cholestasis of pregnancy

Generalized pruritus w/ hand/foot involvement and no rash High bile acids and transaminitis Increased risk intrauterine death Deliver at 37 weeks Tx urodeoxycholic acid, antihistamine

Positive HIV screen. Now test for what?

Genotypic drug-resistance testing, CD4 count, viral load Hepatits B - some meds have dual activity against hep B and HIV so we use them in these cases Screen for TB, hep C, STDs Don't routinely test for CMV (reactivations occur w/ CD4 <100)

Mild asymptomatic thrombocytopenia during pregnancy - What - Tx

Gestational thrombocytopenia -2nd/3rd trimester -No hx, no associated fetal low platelet count Spontaneous resolution after delivery Management - serial CBC, re-eval postpartum to ensure resolution (self-resolves)

Post-exposure ppx for sexual assault

Get all of these HIV - 3 drug (tenofovir-emtricitabine w/ raltegravir) Hep B - vaccine +/- IG Chlamydia - azithro Gonorrhea - ceftriaxone Trichomonas - metronidazole If immune, no Hep B If no trich on wet mount, no flagyl HIV ppx up to 72 hr after assault

Suspect peripheral arterial dx - do what?

Get ankle-brachial index < 9 = abnormal Erectile dysfunction is strong predictor for CAD. If have other RF, get ABI, cardiac stress test prior to starting therapy for sexual dysfunction

UTI abx in pregnancy

Get: - Nitrofurantoin (not 1st trimester 2/2 hemolytic anemia) - Amoxicillin - Amoxicillin-clavulanate - Cephalexin - Fosfamycin Contraindicated - Tetracyclines - Fluoroquinolones (cartilage) - TMP-SMX (NTD, cleft palate, kernicterus) - Aminoglycoside (gentamycin - deafness) Repeat urine cx as bacturia increases risk pyelonephritis and respiratory distress

Dx associated with polymyalgia rheumatica

Giant cell temporal arteritis

Herbal meds: Ginkgo biloba (memory booster) - Most common SE - Other SE Ginseng (mental performance) Aconite (heart failure) SE Pyrrolizidine alkaloid SE

Ginkgo biloba - bleeding and platelet dysfunction, potentiating anticoagulant effects - Seizures, HA, irritable, restless, n/v/d Ginseng: bleed risk Aconite: arrhythmias Pyrrolizidine alkaloids: hepatotoxic

Rheumatic fever - Who - Presentation - Late sequelae - Prevention

Girls age 5-15 J oints (migratory arthritis) O (carditis) N odules (subQ) E rythema marginatum S ydenham chorea (emotional lability, irregular jerking movement) Minor: fever, arthralgia, elevated ESR and CRP, prolonged PR MR/MS Penicillin for group A strep pyogenes pharyngitis

Rett syndrome

Girls appear normal at birth then develop microcephaly, epilepsy, hand movements`

Admit pts w/ severe DKA (pH <7.1, bicarb <5, AMS) to ICU - Increased risk of cerebral edema

Give IVF 1 hr then start insulin drip - NS bolus decreases cerebral edema risk

tPA - When can you give - BP recommendations - ASA okay? BP if don't get tPA?

Give tPA w/in 4.5 hr of sx Keep BP <185/105 - IV labetaolol, nicardipine, nitroprusside - NO ASA w/in 24 hr after tPA If no tPA, BP <220/120

Jehovah's Witness child who's parent says no transfusion but emergently bleeding out and hypotensive

Give the dang blood Act to preserve the life of the child even if contradicts parent's wishes

Celiac dx - Tx - Deficiencies - Extra stuff they have to get

Gluten-free diet Iron, calcium, vit D, folic acid - DXA 2/2 increased risk osteopenia/porosis - Pneumococcal vaccine 2/2 associated hypersplenism

Goal for hyperthyroid treatment in pregnancy? Why?

Goal is mild hyperthyroid state - Overtreatment leads to fetal hypothyroidism and goiter

Going to conference - what can you take from pharmaceutical company? - Just going - Presenting

Going - can't take subsidies Lecturers - honoraria and/or reimbursement for travel expenses - Must disclose - CANNOT USE THEIR SLIDES

Hashimoto's thyroiditis presentation

Goiter Sign/sx hypothyroidism (may have initially hyperthyroid phase) TSH high

Graves disease - Labs - Presentation

Goiter, opthalmopathy, other hyperthyroid signs Low TSH, high free T3/T4 High RAIU in diffuse pattern

Copious exudate and eyelid swelling at 2-5 days old - What - Tx - Prevention

Gonoccocal conjunctivitis - Tx: IM ceftriaxone 1 dose - Prevent: erythromycin ointment w/in 1 hr of birth

Prognostic factors in schizophrenia - Good - Poor

Good - Late onset, female, precipitant factor, positive sx, no family hx, short duration of active sx Poor - Onset as kid/teen, male, gradual onset w/o precipitant, negative sx, family hx, long duration of untreated psychosis

Antipsychotic -> tardive dyskinesia - What - Tx

Gradual onset after prolonged use >6 months Dyskinesia of mouth, face, trunk, extremities NO TX, clozapine may help

Antipsychotic -> parkinsonism - What - Tx

Gradual-onset tremor, rigidity, bradykinesia Benztropine Amantadine

Vibrio vulnificus - Where from? Who gets it? - Presentation - Dx - Tx

Gram (-) lives in MARINE saltwater - oysters or in wound - inc. risk severe reaction w/ liver dx Rapidly progressive septic shock & cellulitis with hemorrhagic bullae & necrotizing fasciitis Blood/wound cx Empiric abx w/ IV CTX and doxy - highly fatal

Subclinical hyperthyroid + diffusely increased thyroid uptake of radioactive iodine. - Dx? - Ab associated with this?

Graves dx Thyrotropin receptor ab - don't have to get if already have iodine scan

Syphilis effects on baby during pregnancy

Growth restriction Intrauterine fetal demise Congenital syphilis - Hepatomegaly - Jaundice - Rash - Skeletal abnormalities TREAT WITH PENICILLIN NO MATTER IF ALLERGIC, JUST DESENSITIZE AND GIVE IT

GI illness -> ascending, symmetric muscle weakness, dysautonomia, and absent DTRs - What - Check this - Tx - Prognosis

Guillain-Barre syndrome Vital capacity - Increased risk rapid respiratory failure Plasma exchange or IVIG if... - Nonambulatory - W/in 4 weeks sx onset If ambulatory or recovering, no tx Resolve spontaneously but tx shortens recovery rate

Postconcussive syndrome

HA, confusion, amnesia, difficulty concentrating/multitasking, vertigo, hypersensitivity to sound/light, mood alteration, sleep disturbance, anxiety - Resolve w/in a few weeks w/ symptomatic tx (may last 6 mo or longer)

Vaccines in people with HIV

HAV - chronic liver dx, MSM, IVDU HBV - if no immunity to HBV (anti-HBs antibody) HPV - everyone 11-26 Influenza - everyone, inactivated Meningococcus - 11-18, large groups in close proximity, aspen or complement deficiency Pneumococcus - PCV13 once, PPSV23 8 weeks later, 5 yr later, and at age 65 Tdap - once (repeat w/ pregnancy), Td every 10 yr NOT Haemophilus B - get non-typable strains

Anti-HTN that causes photosensitivity - Tx

HCTZ - Sulfonamides can cause photosensitivity or generalized dermatitis Stop HCTZ, sunscreen, avoid sun

Isoniazid tx for latent TB - SE

HEPATOTOXICITY - In first 2 months of tx - Usually asx and self-limited - Stop med if LFTs >5x normal or sx plus LFTs 3x Ataxia, peripheral neuropathy - competes w/ vit B6 pyridoxine

DOE, weight gain, orthopnea, HTN, dry cough worse at night, obese, LE edema, normal BNP CXR: linear densities at margins of lung fields Echo: LA enlargement, LVH, normal EF - What

HFpEF - Kerley B lines on CXR - BNP artificially lowered in obese patients

Low grade fever, persistent RUQ pain, leukocytosis, normal bili and RUQ US shows gallstones w/o edema or sonographic Murphy's and CBD not enlarged - Next step

HIDA scan - Acute cholecystitis - Will need lap chole w/in 72 hr but confirm dx before the surgery Biliary colic pain is more transient (<6 hr) and no leukocytosis or fever - tx w/ PRN pain meds and elective chole

Plaque psoriasis tx

HIGH POTENCY TOPICAL STEROIDS - fluocinonide, augmented betamethasone dipropionate - BID up to 4 weeks Methotrexate and phototherapy for severe dx Low potency steroids on face

AIDS -> cryptococcal meningitis - Main CSF finding - Tx

HIGH opening pressure Induction - amphotericin B and flucytosine 2 weeks (until sx gone) Consolidation - high dose oral fluconazole 8 weeks Maintenance - low-dose oral fluconazole 1+ yr Delay starting HAART for 2-10 weeks to avoid immune reconstitution syndrome

Young person with fever, LAD, weight loss, sore throat, myalgias, diarrhea, HA - Look for what?

HIV - Think about it in young person with new weight loss and other nonspecific sx - Ask about IVDU and sex hx

Kaposi sarcoma

HIV and human herpes virus 8 Deep red/purple macule on trunk, extremities, face

HIV screening tests and timeline

HIV antigen p24 AND HIV-1/2 antibodies Will be negative during window period of first 4 weeks so test after that

Primary CNS lymphoma

HIV positive person who's CD4 count is <50 - Related to EBV - Starting HAART improves prognosis, as it increases CD4 count and decreases HIV viral load

IVDU, HA, blurry vision, papilledema, CSF non diagnostic but high opening pressure, molluscum contagious appearing skin lesions

HIV pt with cryptococcal meningoencephalitis - CD4 <100 - Papular lesion sight central umbilication - HIGH opening pressure - Low leukocyte count w/ lymphocytic predominance - High protein, low glucose - Positive India ink prep Tx: 2 weeks AMPHOTERICIN B and FLUCYTOSINE - Serial LPs to reduce ICP

HIV -> loss of subQ fat from extremities, face, butt; increased fat in buffalo hump, abd fat pad - What - Associated with - Tx

HIV-associated lipodystrophy INSULIN RESISTANCE Dyslipidemia Cardiovascular dx Differentiate from adrenal hyperplasia and Cushings b/c no proximal weakness, focal plethora, easy bruising, purple abd striae Statin

Garlic used to treat...

HLD

Condylomata acuminata - Bug - Dx - Tx

HPV Shave bx Topical imiquimod - immunomodulatory

Cervical cancer - Cause - Dx - Worry about what if HIV+

HPV 16 or 18 Cervical bx Invasive cervical cancer and HIV+ is AIDS defining illness

Most important modifiable RF for ischemic stroke? Others? Non-modifiable RF?

HTN!!!! DM, smoking, HLD Family hx, old age

Subarachnoid hemorrhage - RF - Presentation - Dx

HTN, smoking, fam hx, sympathomimetic drugs MCC: ruptured saccular berry aneurysm - Sudden, worst HA of my life - N/V, brief LOC, FND, meningismus Noncontrast CT + in 2-6 hr LP required to definitively r/o if CT negative - Xanthochromia 6+ hr after onset w/ stable # RBC in each tube

Graves dx - What - Tx - Complciations

HYPERthyroid Autoimmune - TSH receptor stimulating antibodies activate receptor -> high T3/T4, low TSH Methimazole +/- radioactive iodine Arrhythmia (a fib), dilated cardiomyopathy Osteoporosis MVP and MR

New bipolar 1 disorder in pregnancy - tx?

Haloperidol Not... - Lithium - Ebstein's anomaly - Carbamazepine or valproate - NTD - Lamotrigine - used for maintenance, not acute - ECT - reserved until meds don't work or if imminent risk to themselves or the fetus

Fever, malaise, poor PO intake Painful vesicles/ulcers on anterior oral mucosa, mac/pap/vesicles on palms, soles, buttock - What - Tx

Hand-foot-mouth dx - Coxsackievirus - Direct contact w/ secretions or fecal-oral - Infants/young kids - Summer time Supportive tx (Herpangina has vesicles on posterior oropharynx)

HOCM murmur - What - Inc vs dec

Harsh crescendo-decrescendo murmur Increases w/ valsava and standing

VSD murmur

Harsh holosystolic murmur with over 3rd-4th intercostal spaces w/ palpable thrill

Diffuse thyroid goiter, depression, ovulatory dysfunction, postive anti-TPO ab - What - Tx

Hashimoto chronic lymphocytic thyroiditis Levothyroxine

Antithyroid antibodies

Hashimoto's thyroiditis - hypothyroidism

Stress ulcer with head trauma or shock - Mechanisms - Where - Prophylaxis and SE

Head trauma -> increased gastrin -> parietal cell activation -> increased stomach acid Shock -> mucosal ischemia -> ulceration Usually within first 72 hours - proximal stomach Later - duodenum PPRI (or H2 antagonist) - increased risk C diff and PNA

Left sided headache, left miosis, left ptosisHTN, CT negative - Next step - Dx, RF, Tx

Head/neck CT angio Carotid artery dissection until proven otherwise - RF: trauma, HTN, smoking, connective tissue dx - Thrombolysis (if <4.5 of sx) - ASA + anticoagulate

Clinical microsystems

Health care settings where patients, families, and health care teams interface - ICU, cancer center, ED, etc.

Osteomyelitis in kids - bug and tx - Healthy - Sickle cell

Healthy - Staph aureus - If low risk for MRSA - nafcillin/oxacillin OR cefazolin - If high risk for MRSA - clindamycin OR vancomycin Sickle cell - SALMONELLA, staph aureus - Tx as above but add ceftriaxone

Recent immigrant with chronic diarrhea, weight loss, blood loss w/ iron deficiency, and eosinophilia - What

Helminthic infection - Good prognosis if tx - High risk reinfection if other family is infected

Albendazole used to tx...

Helmnithic infections - Ascaris lumbricoides - Enterovius vermicularis

Primary hyperparathyroidism - Presentation - Labs - Tx

Often asx but may have hypercalcemia sx High calcium High/inappropriately normal PTH High 24-hr urinary calcium Parathyroidectomy if... - <50 YO - Symptomatic hypercalcemia - Complications like osteoporosis or fx, nephrolitiasis, CKD - High risk of complications (HIGH calcium or urinary excretion)

Malignant otitis externa - RF - Bug - Findings - Concern - Tx

Old age, DM, HIV or immunosuppressed PSEUDOMONAS >95% Other bacteria/fungi (Aspergillus) Intense pain, erythema/edema of external canal, purulent discharge, granulation tissue at floor of canal Can involve skull bones or CN IV abx for pseudomonas - ciprofloxacin (first line), zosyn, ceftazidime (3rd gen ceph) - Follow CRP, ESR and change to oral when normal

Actinomyces - Who - Presentation

Old people with DM Oral cavity - slow-growing, nontender mass, sinus tracts, granular purulent discharge - SULFER GRANULES

Lumbar spine stenosis presentation and workup

Old person with back pain on extension but improved when sits or bends forward (grocery cart) MRI spine

Recurrent pneumonia -> lung cancer - What kinds - Next best test vs best diagnostic test

Old, smoker - bronchogenic carcinoma Young, nonsmoker - carcinoid tumor Next best test: CT Best diagnostic test: Flexible bronchoscopy and bx

Nonclassic congenital adrenal hyperplasia

Oligomeorrhea Acne Hirsutism Cliteromegaly

H pylori - Tx - Confirm eradication

Omeprazole, clarithromycin, amoxicillin Urea breath test or fecal antigen test 4 weeks after completing therapy (urea more accurate) - Serology positive after eradicated so don't use for confirmation

Naloxone

Opioid OVERDOSE - Miosis, respiratory depression, lethargy

Secondary hypogonadism (low FSH/LH), ED, sparse body hair, hepatomegaly, DM, dark complexion - What - Tx

Hemochromatosis Therapeutic phlebotomy

Perforated gastric ulcer

Hemodynamic instability, acute-onset severe abdominal pain Free air on upright CXR

Type 2 HIT - Clinical signs - Dx - Tx

Hep 5-14 days and any of: - Plt less than 50% baseline - Art or DVT - Necrotic skin lesion at inj site - Anaphylactoid rxn after hep Serotonin release assay Stop ALL heparin Start argatroban or fondaparinux Can start warfarin after plts >150,000

Naloxone vs naltrexone

Opioid antagonists Naloxone - IV or intranasal - RAPIDLY reverse opioid overdose Naltrexone - oral or IM - MAINTENANCE tx to prevent opioid use relapse, also for EtOH

Yawning baby suggests what (besides being tired)

Opioid withdrawal - Also irritability, sleep disturbance, tremor, poor feeding, diarrhea

Copper removal in Wilson's dx

Oral D-penicillamine

ICS for asthma -> oral white plaques on mucosa that can be scraped off, leaving hyperemic spots - What - Tx

Oral candidiasis - Nystatin suspension or clotrimazole troches - Rinse mouth after using inhaler - Can use spacer if needed

Topical acyclovir used for...

Oral or genital herpes simplex NOT zoster

On farm -> poisoning - What - Sx - Tx

Organophosphate - Inhibit acetylcholinesterase -> CHOLINERGIC TOXICITY Diarrhea, vomiting, tearing, mitosis, bradycardia, muscle weakness, respiratory failure O2, IVF, intubate Activated charcoal if <1 hr ATROPINE and pralidoxime

Cholinergic toxicity - How - Presentation - Tx

Organophosphate exposure - pesticides Diarrhea, urination, mitosis, bradycardia, emesis, lacrimation, salivation (DUMBELS) Atropine

types of dysphagia

Oropharyngeal - difficulty initiating swallow, associated with drooling, coughing, aspiration Esophageal - delayed sensation of food sticking in upper or lower chest

Isolated proteinuria in teen - What - Next step - Tx

Orthostatic proteinuria Split 24 hr urine collection b/w day (high) and night (normal) Reassurance - self-resolves

Tibial tuberosity apophysitis

Osgood-Schlatter dx

Osteoblastic cancers Osteolytic cancers Cancer that can be either

OsteoBLASTIC - Prostate - Small cell lung - Hodgkin lymphoma OsteoLYTIC - Melanoma - Non-small cell lung - Non-Hodgkin lymphoma EITHER - Breast cancer

Glucosamine and chondroitin used to treat

Osteoarthritis

OCPs -> 3 cm, well-demarcated lesion in the liver with peripheral enhancement on CT w/ contrast

Hepatic adenoma - Benign epithelial liver tumor Often asx, sometimes episodic abdominal pain, LFTs usually normal Tx - Asx and <5 cm - STOP OCP - Sx or >5cm - surgical resection Rupture and hemorrhage Malignant transformation (10%) - Serial imaging, AFP levels

Methotrexate SE and prevention

Hepatotoxicity, stomatitis, bone marrow suppression GIVE FOLIC ACID

C1 esterase inhibitor

Hereditary angioedema - Throat, tongue, lips - Abd pain 2/2 angioedema of intestinal mucosa

Syphilis in newborn - Presentation - Workup

Osteocondritis and periostitis, desquamating rash of palms and soles, snuffles (mucopurulent rhinitis) Initial: VDRL screen Specific: IgM-FTA-ABS

Polyarticular arthopathy, hepatomegaly, DM - What - Inheritance pattern - Findings - Dx - Tx - Complication down the line

Heriditary hemochromatosis - Autosomal recessive CPPD on joint aspiration Hyperpigmentation, arthopathy, high LFTs, hypogonadism, hypothyroid, restrictive/dilated CMO Genetic testing for HFE mutations Serial phlebotomies Hepatocellular carcinoma Infxn risk w/ listeria, vibrio vulnificus, yersinia enterocolitica

Tzanck smear positive

Herpes zoster

Car accident -> unilateral, burning, vesicular rash - What - Tx

Herpes zoster (shingles) - Reactivation increases with age and after recent trauma Oral valacyclovir for 7 days If present >72 hr after onset, just give analgesia and topical zinc oxide cream

Ramsay Hunt syndrome

Herpes zoster optics - Reactivated varicella - Ear pain, external auditory vesicles, ipsilateral facial paralysis

Neonatal polycythemia - What - Next step - Causes - Tx

Hgb >65% in term infant - Usually first level taken on foot stick, repeat test from peripheral - Increased erythropoiesis from intrauterine hypoxia: DM, HTN, smoking, IUGR - Erythrocyte transfusion: delayed cord clamping, twin-twin transfusion - Genetic/metabolic: thyroid, trisomy IVF, glucose Partial exchange transfusion - take blood, give NS - helps w/ hyperviscosity

Dx of sickle cell dx Management - Maintenance - Acute pain crisis

Hgb electrophoresis - mostly HbS and absent HbA Maintenance - Pneumococcal vaccine - Penicillin (until age 5) - Folic acid - Hydroxyurea Acute pain crisis - IVF - Pain meds (opioids) +/- Transfusion

Initial solitary painful inflamed nodule in intertriginous area -> abscess with drainage -> multiple recurrent nodules w/ sinus tracts, comedones, and scaring - What - Tx

Hidradenitis suppurativa All: weight loss, smoking cessation, clean skin daily Mild - topical clinda Moderate - oral tetracycline Severe - TNF-alpha inhibitor, oral retinoid, sometimes excision

Preeclampsia - Who is high vs moderate risk - Do what for prevention

High - prior preeclampsia, CKD, HTN, DM, multiple gestation, autoimmune dx Moderate - obesity, advanced maternal age, nulliparity Daily ASA at 12+ weeks if high risk

HIV post-exposure ppx - High risk - Low risk - Timing - Tx

High - vagina, rectum, mucus membrane w/ blood/semen blood/breast milk - GET PPX Low - urine, nasal secretion, saliva - NO PPX Start w/in 72 hr and tx 28 days Triple drug therapy: 2 NNRTI plus integrase, protease or reverse transcriptase inhibitor - Tenofovir, emtricitabine, or lamivudine PLUS raltegravinr, rittonavir, or rilpivirine

Labs in hemolysis

High LDH and indirect bilirubin Low haptoglobin

List of sensitivities and specificities - Which to pick for highest PPV

High PPV w/ high specificity due to low false positive rate

Secondary hyperthyroidism labs and next step

High TSH, high free T3 and T4 MRI pituitary

Subclinical hypothyroidism - Labs - Next steps

High TSH, normal T4 TSH >10 - levothyroxine TSH <10 - check anti-TPO ab - Yes = levothyroxine (likely to progress to overt) - No - goiter, sx, pregnant, HLD, irregular menses? - Yes = levothyroxine - No = routine monitoring

Viral meningitis CSF

High WBC 100-1000 Normal glucose 40-70 Normal-high protein <100

Complications during removal of pheochromocytoma

High chatecholamine - HTN crisis (IV nitroprussise, nicardipine) - Tachyarrhythmia (IV esmolol or lidocaine) Low chatecholamine -Hypotension (NS bolus, pressors if unresponsive) - Hypoglycemia (chatecholamines suppress insulin - IV dextrose)

Management of pt with... - High imminent suicide risk (ideation, intent and plan) - High non-imminent risk (ideation, intent, NO plan)

High imminent - Hospitalize (involuntarily if needed) - Remove personal belongings or objects from room that can be used for self harm - Constant observation High non-imminent - Ensure close follow up - Treat modifiable RF (depression, psychosis, substance abuse, pain) - Recruit friend/family support - Reduce access to potential means (firearms, meds)

CML - Dx - Tx

High neutrophils, low LAP (would be high in reactive leukocytosis) Philadelphia chromosome by PCR or BCR/ABL by FISH Initial: Imatinib Cure: bone marrow transplant

Who gets hep B vaccine

High risk = 1+ of... - Multiple sexual parters or hx STD - MSM - IVDU - Chronic kidney dx, HCV, HIV - Household contacts of patients with chronic HBV All pregnant women, healthcare workers, and inmates who are unvaccinated get the vaccine

Antibiotic endocarditis ppx ONLY recommended if high risk CV condition: - ACTIVE GI or GU infection - Dental procedure involving mucosa - Respiratory tract procedure involving mucosa - Surgical placement of prosthetic cardiac material

High risk CV conditions: - Prosthetic heart valve - Previous infectious endocarditis - Structural valve abnormality in transplanted heart - Unrepaired cyanotic congenital heart dx - Repaired congenital heart dx w/ residual defect

Revised cardiac risk index for pre-operative evaluation - RF - Interpretation

High risk surgery, hx ischemic HD, CHF, hx stroke, IDDM, Cr >2 0-1 low risk 2 mod risk 3+ high risk Inability to climb 2 flights of stairs (<4 metabolic equivalents) AND 2+ RF = do exercise stress test - If not BOTH, no further testing

Olsetamivir can be started put to 48 hr after sx start - After 48 hr, just Tylenol and sx tx HOWEVER, if at high risk, require hospitalization, or have severe illness, treat with antiviral regardless of sx duration

High risk: - >65 YO - Pregnant or 2 weeks postpartum - Underlying chronic medical dx - Immunosuppressed - Morbidly obese - Native American - Nursing home patient

What to look for in a screening test

High sensitivity - rule SNout - low false negatives - increases the negative predictive value

Celiac dx

High stool osmotic gap Microcytic anemia - iron deficiency Villous atrophy, lymphocytic infiltrate, crypt hyperplasia

Concern for epidural spinal cord compression - Next steps

High-dose steroids - give right away MRI spine

Polymyositis -> interstitial lung disease - Dx

High-resolution CT: ground-glass opacities, reticular changes, honeycombing, patchy consolidation PFTs: low FVC, TLC, and DLCO

Things that cause high/low maternal serum AFP

High: - Neural tube defect - Vental wall defect (omphalocele, gastroschisis) - Multiple gestation Low: - Aneuploidies (trisomy 18, 21)

Solitary pulm nodule - what suggests high, intermediate and low risk of malignancy? Next step?

High: >2 cm, >60 YO, smokes or quit <5 yr ago, corona radiata or spiculated margin, ground glass appearance Int.: 0.8-2 cm, 40-60 YO, smokes or quit 5-15 yr ago, scalloped margin Low: <0.8 cm, <40, non-smoker or quit >15 yr ago, smooth margins

Solitary pulm nodule - next step if high, int., or low risk

High: surgical excision - bronch if central, VATS if peripheral Int/low: >0.8 cm - PET/bx 5-7 - serial CT 4 or less - low = no f/u, int = serial CT

Bee sting - when to use what med

Hives and itching localized to the site of bee sting - benadryl Generalized cutaneous, respiratory, GI, and CV sx - IM epinephrine Allergist referral for venom immunotherapy

Anorexia - When to hospitalize - Tx

Hospitalize for: - Hemodynamic instability - Syncope - Electrolyte abnormalities - Hypothermia - Refeeding syndrome - <70% expected weight, BMI <15 - Acute food refusal - SI/psychosis Psychotherapy and nutritional rehab

Tx for hot vs cold thyroid nodule on iodine scintigraphy

Hot - hyperfunctional - tx with methimazole to achieve chemical euthyroidism then definitive tx w/ radioactive iodine ablation or surgery (preferred if large) Cold - hypofunctional - FNA

Who gets ppx when pt has Neisseria meningitis What do they get

Household members Roommates or inmates Child care workers If directly exposed to respiratory or oral secretions (kissing, CPR, intubate) Sit next to person for >8 hr (plane) NOT coworkers, classmates, teachers, health workers with no direct secretion contact Rifampin - q12h, 4 doses Ceftriaxone - IM, if preggo Cipro - 1 dose, not in kids

Allergic bronchopulmonary aspergillosis - Hx - What - Imaging - Dx - Tx

Hx asthma or CF, fever, lethargy, cough w/ brown mucus plugs, asthma exacerbations Exaggerated IgE and IgG response to Aspergillus fungus w/ pre-existing asthma CXR - infiltrates CT - central bronchiectasis Skin test + for Aspergillus Eosinophilia >500/uL IgE >417 IU/mL Specific IgG and IgE for aspergillus Steroids and itraconazole

Gross hematuria workup

Hx trauma or suspect stone? - Yes -> ultrasound/CT - No -> UA and culture

Genstation contianing hypertroph and hydropic throphoblastic vili - What - How - Tx - Check what level - May develop what

Hydatidiform mole Empty ovum fertilized by 2 sperm or 1 who's genome duplicates Suction curetage Beta-hCG (>100,000) - check weekly until undetectable -> monthly for 6 mo -> can get preggo again Gestational trophoblastic neoplasia (choriocarcinoma)

Drug induced lupus - Drugs - Presentation - Labs

Hydralazine, procainamide, minocycline, anti-TNF alphas (etanercept, infliximab) Fatigue, night sweats, arthralgia, pleural effusion/pleuritis ANA+, anti-histone antibodies

Toxoplasmosis - Presentation - Workup

Hydrocephalus, generalized intracranial calcifications, choriorerinitis Toxo IgM

Lupus treatment

Hydroxychloroquine + prednisone - Antimalarial improves arthralgias, serositis, cutaneous sx, and prevents future renal and CNS damage - Short course of steroids - high dose if significant renal/CNS dx Cyclophosphamide and methotrexate are only used with significant nephritis, CNS dx, vasculitis

Drug that reduces frequency of vase-occlusive episodes in patients

Hydroxyurea - Takes time to work, not used in acute episode

Ehlers-Danlos - Skin - MSK - Cardiac - Other - Genetics

Hyerextensible, easy bruising, velvety skin w/ atrophy & scarring Joint hyper mobility, pectus excavatum, scoliosis, arched palate MVP, may lead to chordeae tendineae rupture and acute MR Hernias, uterine prolapse Autosomal dominant COL5A1-2 mutation

Major surgery or extensive transfusion -> Hyperactive DTR -> Hypoactive DTR

Hyper - hypocalcemia Hypo - hypomagnesemia

Rapid onset cause of elevated Ca w/ associated renal dysfxn

Hypercalcemia of malignancy

Multiple myeloma -> HA, blurry vision, confusion, nasal/oral bleeding, potentially heart failure - What - Tx

Hyperviscosity syndrome Plasmapheresis More common in Waldenstrom's macrogammaglobulinemia

Amiodarone and the thyroid - High or low - Why - Tx

Hypo (more common) - Large iodine load suppresses synthesis, no tx - Amio inhibits T4 conversion to T3, tx levothyroxine Hyper - Increased synthesis if nodal thyroid dx - Latent Graves dx (AIT type 1), tx antithyroid dx - Destructive thyroiditis w/ release of preformed hormone (AIT type 2), tx steroids Check TSH q3-4 months

Hypoglycemia eval - What's Whipples triad - Next steps

Hypoglyc sx, low glucose, sx resolved w/ glucose 1. Labs: insulin, C-peptide, and proinsulin - All elevated: endogenous insulin 2. Oral hypoglycemic medication levels - Could be taking meds to lower it 3. CT or US for insulinoma Mixed meal challenge test only used to eval hypoglycemic sx occurring only after eating

SIADH - Labs - Tx - Causes

Hyponatremia HYPOTONIC serum osmolality <275 HIGH urine osmolality >100 HIGH urine sodium >40 Clinically euvolemic Fluid restrict +/- salt tabs Hypertonic saline if SEVERE PNA, psych meds (SSRIs, carbamazepine, valproate)

Signs of primary adrenal insufficiency

Hyponatremia Hyperpigmentation Weight loss Hypotension Hyperkalemia

Oxycarbazepine SE

Hyponatremia 2/2 inappropriate ADH release

Looks like old person has dementia. Test for what?

Hypothyroidism B12 deficiency Depression

Hemodynamic measurements in shock: - Hypovolemic - Cardiogenic - Septic

Hypovolemic - High SVR (after load) - Low everything else Cardiogenic (impair contraction) - LOW cardiac index - High everything else Septic shock - High cardiac index - Low/normal RA pressure, PCWP - Low SVR

Perianal abscess - next step?

I & D - Give abx as well if have DM, immunosuppression, extensive cellulitis, or valvular heart dx - Increased risk of fistula formation

Illness anxiety disorder vs somatic sx disorder

IAD - mild or no sx SSD - physical sx persist over time and pt is preoccupied w/ them (vs panic dx where sx episodic)

5-aminosalicylates treat what?

IBD - Crohns or UC

HCOM -> syncopal episode - Next step?

ICD placement

Restrictive lung dx - Examples - PFTs

ILD, obesity hypoventilation syndrome FEV1 and FVC equally decreased so FEV1/FVC normal!

Gonorrhea NAAT positive, chlamydia negative - Tx - Sexual parters?

IM ceftriaxone (1 dose) AND Azithromycin (1 dose) - reduces cephalosporin resistance - Give in clinic to ensure compliance All partners need to be evaluated, regardless of sx Can use 7 days of doxy instead of azithro if allergic to penicillin

PCP pneumonia - Presentation - Dx - Use steroids? - Tx

INDOLENT! - CD4 <200 - Fever, dry cough, dyspnea, weight loss, hypoxia, CXR: diffuse reticular interstitial infiltrate Induced sputum sample usually positive but may be negative! - Get BAL TMP-SMX Steroids if A-a gradient >35 OR PaO2 <70 on room air - Commonly have respiratory decompensation after tx started

1st line contraception in adolescent

IUD or implant - 99% - can be removed early - Copper IUD lasts 10 yr - Progestin IUD 5 yr - Subdermal implant 3 yr Patch and OCP only 91% and often miss doses Depot medroxyprogesterone shot 94%, serial injections lowers likelihood of continuation - Spermicides 80% on own, use w/ diaphragm or cervical cap - increase STD risk

Oligohydramnios - Pregnancy complications and effects on baby

IUGR, preeclampsia, pulmonary hypoplasia, flattened facies, limb deformity

Mono -> spontaneous splenic rupture -> intraabdominal bleed -> hypovolemic shock -> next step?

IV FLUIDS!!!!!!!!! Then US or CT abdomen Supportive care w/ non-operative tx preferred but may need ex lap for splenectomy

Reduce risk of contrast-induced nephropathy with contrast CT

IV NS or sodium bicarb before and after contrast

Septic abortion - fever, tachycardia, hypotension, lower abd pain, mucopurulent cervical discharge - Next steps

IV abx AND suction curettage

Someone has pneumoperitoneum. Next step?

IV antibiotics Start IVF, broad-spectrum IV abx, and IV PPI. Needs emergency surgery

Preserve organs of braindead patient how?

IV fluids and desmopressin to maintain euvolemia - develop central diabetes insidious Inotropic/pressure support to maintain BP - lose sympathetic tone Warm air blankets to prevent hypothermia - Don't need anticoagulation

Jehovah's Witness says no transfusion but bleeding out and hypotensive

IV fluids and pressors

Acute limb ischemia tx - Viable limb - Threatened limb (inaudible arterial doppler for pulse) - Nonviable limb (inaudible arterial AND venous doppler)

IV heparin plus... Viable - catheter-based or surgical revascularization Threatened - emergency surgical revascularization Nonviable - amputation

Severe HTN -> flash pulmonary edema -> tx?

IV nitroglycerin - Used because it's rapid improvement is better than with IV lasix

Acute decompensated heart failure -> inadequate response to IV lasix -> ???

IV nitroglycerin - venous dilator that decreases cardiac preload -> decreased intracardiac filling pressure and less pulmonary edema

Concern for vatical hemorrhage -> stabilized -> what?

IV octreotide - decreases splanchnic blood flow, lowing portal venous pressure Start while waiting for endoscopy

Autoimmune pancreatitis tx

IV steroids

MS - Exacerbation tx? What if pregnant? - Long term tx? - Spasticity tx? - Fatigue tx? - Urge incontinence?

IV steroids if optic neuritis - PO or IV if no optic neuritis - Plasmapheresis if refractory Still use steroids if pregnant - MS pt has increased risk of c-section or assisted delivery Beta-interferon - decrease frequency and reduce development of brain lesions Spasticity - stretch, baclofen Fatigue - amantadine, sleep hygiene Urge incontinence - oxybutynin, timed voiding, volume restriction

Hyperosmolar hyperglycemic state, hyperkalemia, and new onset a fib. Next step?

IVF - Volume down - HyperK 2/2 low insulin and hyperosmolality - whole body K is actually low - A fib likely convert when HHS tx

DKA and HHS management - IVF - Insulin - K - Bicarb - Phosphate

IVF: start NS, add D5 when glucose <200 Insulin: drip, overlap subQ and IV by 1-2 hr, start SQ basal bolus when: eating, glucose <200, AG <12, HCO3 >15 Potassium: IV K if serum <5.2, hold insulin if K <3.3 Bicarb: consider if pH <6.9 Phosphate: consider if pos <1, cardiac dysfunction, respiratory depression - monitor serum Ca

Legg-Calve-Perthes dx

Idiopathic avascular necrosis of hip Kids 3-12 w/ insidious hip pain and limp Deformity of femoral head on imaging

Pseudotumor cerebri - Other name - Who - Exam - Causes

Idiopathic intracranial HTN Obese premenopausal women Sometimes 2/2 endocrine dx or meds (retinoids, -cyclines, steroids, lithium, nitrofurantoin, etc.) Papilledema, venous engorgement, hard exudates -> progressive optic atrophy and blindness

Restless leg syndrome - Causes - Test - Tx

Idiopathic, iron deficiency anemia, uremia, DM, MS, Parkinsons, pregnant, drugs Ferritin Pramipexole (dopamine ag) - 2nd line is gabapentin

Constrictive pericarditis - Cause - Presentation - Dx - Tx

Idiopathic, viral, cardiac surgery, radiation, TB Fatigue, DOE, peripheral edema ascites, JVD (R heart failure) Pericardial knock (mid-diastolic) Pulsus paradoxus Kussmaul sign (increase JVP on inspiration) ECG - a fib, low voltage, non-specific XR - pericardial thickening and calcification JVP - prominent x and y descents Supportive tx (NSAIDs)

ADPKD screening?

If >18 and family hx -> counseling THEN screening renal ultrasound

Cervical screening guidelines

If have HIV: at onset of sex, at dx, annually until 3+ normal results then routine testing Immunosuppressed: onset of sex, annual Pap/HPV cotesting <21: no screening 21-29: cytology q3y 30-65: cytology q3y OR cotesting q5y >65: no screen if previously neg. Hysterectomy: no screen if previously negative and low risk

Ureteral stone -> CT scan - Next steps

If in urosepsis, ARF, complete construction -> urology consult <10 mm - medical management - fluids, pain control, alpha blocker, discharge home - <5 mm usually pass spontaneously - Pain uncontrolled or no passage in 4-6 weeks -> urology consult >10 mm - urology consult

GERD sx -> next steps?

If no RF for malignancy (>55 YO, weight loss, gross bleeding, anemia) -> H2 blocker or PPI trial - If don't improve, especially if from area of high prevalence (Mexico), do H pylori stool antigen or breath test No improvement and high CA risk -> EGD probably

Who gets washed RBCs for transfusions?

IgA deficiency Complement-dependet autoimmune hemolytic anemia Continued allergic reactions with RBCs despite antihistamines

HSP - Etiology - Presentation - Labs - Tx

IgA-mediated leukocytoclastic vasculitis - May have prior URI sx LE palpable purpura, arthralgia, abdominal pain/intussusception, renal dx like IgA nephropathy Hematuria +/- RBC casts +/- proteinuria Normal platelets, coags Normal to high Cr Hydration and NSAIDs Hospitalize and oral steroids if severe

Type I immune reaction

IgE-mediated - Anaphylaxis

N/V, soft distended abdomen, decreased bowel sounds, gaseous distention in large/small bowel on XR

Ileus - Gas in colon/rectum and no air fluid levels points against SBO - Check potassium because hypoK can cause paralytic ileum

Acute prostatitis

Ill w/ high fever, dysuria, pelvic/perineal pain, cloudy urine Warm, edematous, very tender prostate Urine cx - gram negative E coli or Proteus

Gastroesophageal reflux in baby - Pathogenesis - Presentation - Tx - Difference in GER vs GERD

Immature lower esophageal sphincter Spit-up, normal weight, no pain/back arching, "happy spitters" Upright positioning after feeds Burping during feeds Frequent, small volume feeds Resolves by 12-18 months GERD causes weight loss, feeding refusal, aspiration, pain with back-arching and irritability during feeds

Complications of kidney DONOR

Immediate - DVT, hospital acquired infection Long term - females have increased risk of fetal loss, preeclampsia, GDM, gestational HTN NO increased risk ESRD 2/2 compensatory hypertrophy

Nurse with needle stick -> pt refused HIV test -> next step?

Immediately start HIV post-exposure prophylaxis - 2-3 antiretroviral meds - Can d/c if pt has negative test

Needle stick, source HBsAg positive - Next step

Immune already? - Nothing Not immune - HB immune globulin AND vaccinate If source patient negative and worker is not immune, just vaccine

Type III immune reaction

Immune complex mediated - Serum sickness

HIV -> start HAART -> worsening infectious sx weeks later - What - Next step

Immune reconstitution inflammatory syndrome - Common if tx for TB at same time Continue current therapy - Self-limited

Viral infection -> petechiae, mucous membrane bleeding w/ isolated thrombocytopenia - What - Tx

Immune thrombocytopenia - Antibodies to platelets - No systemic sx - Negative antiglobulin test No bleed/mild (petechiae, purpura) - observe Mod/severe bleed (gingival, epistaxis, hematochezia, ICH) or if high risk (platelet <30,000) - IVIG Only splenectomy if refractory

Previously healthy -> petechiae -> thrombocytopenia and otherwise normal labs, platelets still low after transfusion - What - Tx

Immune thrombocytopenia - Antibodies to platelets (GPIIb/IIIa) Kids - Skin manifestations: observe - Bleeding: IVIg or steroids Adults - Plt >30 w/o bleed - observe - <30 OR bleeding - IVIg or steroids Rituximab if failed, then splenectomy

Perinatal hepatitis B - Labs/presentation if present - Prevention

Immune tolerant (normal or mildly elevated liver enzymes, no sx) - High risk for chronic infection - High viral load and HBeAg + If concerned.... - Newborn hep B vaccination and immunoglobulin with 12 HOURS - IG not much help after the 12 hr - LFTs not helpful 2/2 immune tolerant phase - Normal HBV vaccines (0, 2, 6 mo) - Serology 3 months after 3rd vaccine

CMV - Who - Sx

Immunocompromised - HIV Fever, malaise, lymphadenopathy Retinitis and encephalitis in immunocompromised

Celiac dx workup

Immunoglobulin A anti-tissue transglutaminase (TTG) Small bowel bx - villous atrophy, loss of normal villus architecture, intraepithelial lymphocytic infiltrate, crypt hyperplasia

When to change form oral to IV bisphosphonated

Impaired absorption

Adolescent female with cyclic pelvic pain, primary amenorrhea, constipation, and blue intralabial mass - What - Tx

Imperforate hymen - Dx as newborn w/ vaginal dc accumulated behind hymen (mucocolpos) or as teen w/ blood/vag dc (hematocolpos) Cyclic abd pain, primary amenorrhea, uterine enlargement -> bulk sx (anorexia, constipation) BLUE INTRALABIAL MASS Tx is hymenectomy

Superficial wound -> nonpruritic painful, HONEY CRUSTED lesions - What - Bugs - Tx - Complications

Impetigo (nonbullous) Staph aureus Group A strep pyogenes Topical abx (mupirocin) - Oral cephalexin if extensive Poststreptococcal glomerulonephritis

COPD exacerbation -> supplemental O2 -> improves - Mechanism

Improved oxygenation of low V/Q ratio lung unit - COPD limits airflow 2/2 loss of elastic tissue and small bronchiolar collapse - In exacerbation, mucus plug and bronchospasm further limit airflow - Poor ventilation -> hypoxic vasoconstriction -Supp. O2 reaches alveoli, lessens vasoconstriction, and improves gas exchange

Necrotizing fasciitis - Bugs - Presentation - Tx

Otherwise healthy: GAS pyogenes PVD, DM - polymicrobial - Staph aureus, clostridium perfringes (makes gas -> crepitus) Often a minor trauma -> erythema, swelling edema, pain out of proportion to exam, fever, hypotension - Common on extremities, parineal Surgical debridement Broad-spectrum abx - Zosyn or carbapenem - GAS and anaerobes - Vancomycin - MRSA - Clinda - inhibit toxin formation by strep/staph

Primary nocturnal enuresis

Inability to achieve night time dryness at age 5 or older First step in management is in enuresis alarm

Absolute contraindications to being a living kidney donor

Inability to consent (<18, untreated psych dx, intellectual disability) DM HTN w/ end-organ dysfunction BMI >35 Malignancy

Meds that effect warfarin - Inc INR - Dec INR - INR-independent

Inc INR - Flagyl, quinolone - alter microbiome - Amiodarone, -azoles - CYP inhib. - Tylenol - decrease K recycling Dec INR - Rifampin, phenytoin, SJW - induce CYP - OCPs - increase coag factors - Green leafy veggies - increase vit K ingestion INR independent - NSAIDs, plavix - inhibit platelets - Ginkgo biloba - increase bleeding

Vasovagal syncope - Presentation - Dx - Tx

Inciting event (stress, standing); prodrome (pallor, n, diaphoresis); regain consciousness rapidly Clinical dx but can to tilt-table Avoid triggers, counterpressure techniques -Note pallor, nausea can persist after which is helpful for dx

Meds that increase and decrease thyroid binding globulin concentration

Increase TBG - Estrogen, tamoxifen, raloxifenem heroin, methadone Decrease TBG - Androgens, glucocorticoids, anabolic steroids

Meds that impact thyroid levels

Increase TBG: estrogen, tamoxifen, raloxifine, methadone, heroin Decrease TBG: androgens, danazol, anabolic steroids, glucocorticoids Check TSH after 12 weeks

Kussmaul sign

Increase in JVP during inspiration - Constrictive pericarditis or restrictive CMO

Lithium is excreted by the kidney - Meds that impact levels

Increase level - Thiazide, NSAID (not ASA), ACEi/ARB, tetracyclines, flagyl Inc or dec - Lasix, verapamil Decrease - Spironolactone, theophylline Treat BP with amlodipine

Worsening HA, n/v, blurry vision, papilledema - What - Next step

Increased ICP - Mass, increased CSF, decreased CSF outflow (venous sinus thrombosis), pseudotumor cerebri MRI w/ contrast (If it were sudden worst HA of my life, CT w/o contrast for SAH)

Late neurosyphilis = tabes dorsalis - Who - What - Presentation

Increased incidence of syphilis in MSM and HIV Treponema pallidum spirochetes damage dorsal sensory roots Secondary degeneration of dorsal columns Sensory ataxia Impaired vibration/proprioception Lancinating pains Neurogenic urinary incontinence ARGYLL ROBERSTON PUPILS - constricts with accommodation but not with light

Community acquired pneumonia treatment - Outpatient - Inpatient non-ICU - Inpatient ICU

Outpatient - Healthy: doxy OR macrolide - Comorbid: resp fluoroquinolone OR beta-lactam PLUS macrolide Non-ICU - IV fluoroquinolone - Beta-lactam PLUS macrolide ICU - Beta-lactam PLUS macrolide OR fluoroquinolone

Depressed, suicidal thoughts but no plan or intent - Next step

Outpatient tx with med and/or therapy Only hospitalized w/ active suicidal ideation and intent and/or plan

Litium toxicity >1.5 = toxicity >2.5 = need emergency management - Etiology - Presentation acute vs chronic - Management

Overdose, volume depletion, low GFR, drugs (THIAZIDES, NSAIDs not ASA, ACEi) Acute: n/v/d, neuro sx much later Chronic: ataxia, confusion, agitation, tremor Lithium level q2-4h IV fluids Bowel irrigation for asx acute overdose HD if... - Level >4 - >2.5 w/ sx or renal failure - Increasing level despite IVF

MCC obesity in kids

Overeating

Idiopathic intracranial HTN - aka pseudotumor cerebri Who? Sx?

Overweight women of childbearing age HA is primary sx Visual disturbances, nausea - Do ophthalmoscopic exam for papilledema

Thyrotoxicosis in elderly sx

*Apathatic thyrotoxicosis* - Neuro: Lethargy, confusion, depression - Often confused w/ dementia - A fib, tachy (may be masked by beta blocker) - Proximal muscle weakness/wasting - Proptosis, lid lag, thyromegaly (often absent) - Anorexia - Constipation

Gastroparesis -> labile glucose control in diabetics - Dx - Tx

*Assess motility w/ nuclear gastric-emptying study* Exclude obstruction w/ upper GI endoscopy Exclude external compression w/ CT (if suspected) Small frequent meals w/ low fat and soluble fiber Promotility drugs: erythromycin, metoclopramide Gastric electrical stim or jejunal feeding tube if refractory

What increases risk of colon cancer and how do we screen

- 1st degree relative <60 w/ CC or adenomatous polyps - 2+ first degree relatives w/ CC or ad. polyps at any age C-scope at 40 or 10 yr before cancer onset in relative - REPEAT EVERY 3-5 YEARS

Indications for ppx anti-D IG for Rh(D)-negative patients

- 28-32 weeks - <72 hr postpartum, Rh(D) + baby - <72 hr spontaneous abortion - Ectopic pregnancy - Threatened abortion - Hydatidiform mole - CVS, amniocentesis - Abdominal trauma - 2nd/3rd tri bleeding - External cephalic version

Contraindications to kidney donation

- <18 YO - Can't make informed decision - Uncontrolled HTN, HIV, DM - Active/partially tx cancer - Acute infection - High suspicion of donor coercion or illegal payment - Uncontrolled psych dx - Active substance abuse

Giant cell arteritis - Criteria - Associated with - Tx

- >50 (greatest RF) - New onset localized HA, jaw pain w/ fever, visual disturbance - ESR >50 - Tenderness or decreased pulse of temporal artery - Temporal artery bx showing necrotizing arteritis w/ mononuclear cells Polymyalgia rheumatic - exam unremarkable, stiff aROM, normal pROM of shoulders/thighs High dose steroids - start right away

Delayed puberty in boys - Presentation - Workup

- Absent testicular enlargement (>4ml) by age 14 - Delayed growth spurt - FSH, LH, testosterone, TSH, prolactin - Bone age radiograph - No family history of constitutional delay? Have to do workup!

Mitral stenosis murmur

- Accentuated S1 - Opening snap after S2 - Low-pitched diastolic murmur at apex

Suggestions of secondary HTN

- Acute rise in BP - Hasn't hit puberty - <30 in non-obese, non-black pt w/o family hx - Malignant HTN - Severe/resistant HTN

Polymyalgia rheumatic

- Age >50 - Systemic signs/sx - Stiffness > pain in shoulders, hip girdle, neck - Associated with giant cell temporal arteritis - Elevated ESR, CRP - Improves with steroids - Stiffness more so than weakness

Subclinical hypothyroidism means mildly high TSH (5-10) and normal free T4 - When to treat?

- Antithyroid (TPO) antibodies - Abnormal lipid profile - Sx of hypothyroidism - Ovulatory or menstrual dysfunction Increased chance of progression to overt hypothyroidism

Best predictors for severity of acute alcoholic pancreatitis

- BUN >20 on admission - Hematocrit >44% - third spacing - Elevated CRP - Older age - BMI >30 - SIRS - APACHE II score (Not lipase or triglycerides)

Cardiac tamponade - Presentation - Dx - Suggests need for urgent invasive management

- Becks triad: hypotension, tachycardia, JVD - Pulsus paradoxus - SBP dropps >10 w/ inspiration - EKG: low voltage, electrical alternans - CXR: enlarged cardiac silhouette, clear lungs - Echo: RA/RV collapse, plethora of IVC Early diastolic collapse of RA/RV - Catheter pericardiocentesis or pericardial window

Hyperthyroidism treatment

- Beta blocker if symptomatic - Start methimazole as well (PTU preferred during first trimester but is hepatotoxic) - RAI for mod to severe dx or if preferred to meds by patient - Thyroidectomy for larg goiter, obstructing sx, suspect cancer, severe dx Check total T3 and free T4 after 4-6 weeks of meds

NF1 - Inheritance - Findings

- Cafe-au-lait macules - Inguinal/axillary freckling - Neurofibromas (peripheral nerve sheath tumors) - Lisch nodules (iris hamartomas - don't affect vision) - OPTIC GLIOMA - bilateral is pathognomonic - progressive vision loss NF2 doesn't have CALMs & has sensorineural hearing loss 2/2 vestibular schwannomas

Post-op complications of breast implants

- Capsular contracture causing pain - Distortion of shape - Implant deflation or rupture May need surgical removal

Tuberous sclerosis

- Congenital hypopigmented maculae (ash leaf spots) - Glial proliferation - Organ hamartomas/cysts

Things that suggest lactose intolerance

- Diarrhea after eating lactose - High stool osmotic gap - Low stool pH - Positive lactose hydrogen breath test Not usually associated with weight loss

Medical contraindications to pregnancy

- EF <40% - NYHA class III-IV HF - Prior permpartum cardiomyopathy - Severe obstructive cardiac lesions - Severe pulm HTN (Eisenmenger) - Unstable aortic dilation >40 mm

Thiamine deficiency

- Encephalopathy - Oculomotor dysfunction - Ataxia Alcoholics

Common malformations with Down's syndrome

- Endocardial cushion defect (most common congenital heart dx in Down's - dx w/ echo) - Duodenal atresia - Hirschsprung dx - Atlanto-axial instability - Hypothyroidism Increased risk of acute leukemia, Alzheimer-like dementia, autism, ADHD, depression, seizure

Thin membrane disease

- Episodic hematuria - Benign course w/o progression of renal dx - Unrelated to URI, unlike IgA nephropathy

Histrionic personality disorder

- Excessive emotionality, attention seeking since early adulthood - Seductive or provocative - Impressionistic, vague speech - Suggestible - Considers relationships more intimate than they really are

RF for colorectal cancer Protective factors

- Family hx, polyposis syndromes (familial adenomatous polyposis), IBD, African-American Modifiable - Alcohol - Obesity - Smoking - long term >30 yr Protective - High-fiber diet w/ fruit/veggies - NSAIDs - Hormone replacement therapy - Exercise

Systemic sclerosis - Presentation - Labs - Complications

- Fatigue, weakness - Telangiectasias, sclerodactyly (thickened puffy digits) - Arthralgias, contractures - Esophageal dysmotility, dysphagia, dyspepsia -Raynaud phenomenon ANA, anti-topoisomerase I (Scl-70), anti-centromere (CREST) ILD, pHTN - get PFTs HTN, sclerodermal renal crisis Myocardial fibrosis, pericarditis, pericardial effusion

Dengue fever

- Flu-like febrile illness - Myalgias and joint pains - Retro-orbital pain - Rash - Misquito in tropics If dengue hemorrhagic fever... - Increased vascular permeability - Thrombocytopenia - Spontaneous bleed -> shock - Positive tourniquet test (petechiae) Tx is supportive

Cystoscopy indications

- Gross hematuria w/o glomerular dx or infection - Microscopic hematuria w/o "" but increased CA risk - Recurrent UTIs - Obstructive sx w/ suspicion for stone/stricture - Irritative sx w/o UTI - Abnormal bladder imaging or urine cytology

Suspect renovascular dx causing secondary HTN if... - How to check?

- Hx atherosclerotic dx (carotid bruit, PVD) - Elevated Cr - Unilateral renal atrophy - Recurrent flash pulm edema - Abdominal bruit MRA, CTA, doppler US

Schizoaffective disorder - Definition - Differentiate from bipolar or major depression w/ psychotic features

- Hx of delusions/hallucinations for 2+ weeks IN ABSENCE OF DEPRESSIVE OR MANIC EPISODES - Depressive or manic episode concurrent with schizophrenia - Mood sx present majority of illness MD or bipolar w/ psych features - Psych sx EXCLUSIVELY DURING mood sx Schizophrenia - Mood sx for relatively brief periods

Serum sickness - What - Presentation - Tx

- Immune complex-mediated hypersensitivity reaction (type III) - Abx (beta-lactam, sulfa) - Acute hep B - serum sickness-like syndrome as prodrome then resolves when jaundice begins Sx 1-2 weeks after expusre Fever, rash, polyarthralgia Remove/avoid tigger Supportive care Steroids/plasmapheresis if severe

21-hydroxylase deficiency - Hormone levels - Labs and presentation - Tx

- LOW cortisol and aldosterone - HIGH testosterone - HIGH 17-hydroxyprogesterone Autosomal recessive Girls: ambiguous genitalia Boys: precocious puberty Salt wasting - vomiting, low Na, high K, HYPOTENSION Hypoglycemia (low steroid) Cortisol

11 beta-hydroxylate deficiency - Hormone levels - Labs and presentation

- LOW cortisol and aldosterone - HIGH testosterone - High 11-deoxycorticosterone (weak mineralocorticoid) and 11-deoxycortisol Girls: ambiguous genitalia Fluid and salt RETENTION, hypertension

Hyperpigmentation of face during pregnancy Generalized hyper pigmentation, fatigue, and pain, hypotension Bronze discoloration, lethargy, arthralgia, high LFTs, DM

- Melasma - Adrenal insufficiency - Hemochromatosis

Cluster HA - who - Presentation - Acute tx - Prevention

- Men - Last <3 hours, 1-8 times per day over at least weeks - UNILATERAL (can be orbital, supraorbital, or temporal) - SEVERE pain - Restless agitation - IPSILATERAL AUTONOMIC SX ptosis, mitosis, lacrimation, conjunctival injection, rhinorrhea Tx: 100% oxygen (sumatriptan is second line) Prevent: verapamil (steroids are second line)

Subclinical hypothyroidism - Labs, specific lab to get - Tx - Increases risk of...

- Mild high TSH, normal T4 +/- mild sx - Check anti-thyroid peroxidase (TPO) for Hashimoto's - if high, increase chance becomes overt dx - Inc. risk miscarriages, preeclampsia, low birth weight, placental abruption

Painless thyroiditis - Presentation - Dx

- Mild, brief hyperthyroid phase - Small, NONTENDER goiter - Spontaneous recovery - High TOP - Low radioactive iodine uptake

Tourette disorder - Dx - Tx - Associated with

- Motor AND vocal tics >1 year - Dx <18 YO (usually <11) Antipsychotic, alpha-2 receptor agonist, behavioral therapy OCD, ADHD

Amiodarone -> interstitial pneumonitis

- Nonproductive cough - Fever - Pleuritic CP - Weight loss - DOE - Focal or diffuse INTERSTITAL OPACITY on CXR - After months to years of tx - Cumulative dose effect Tx: stop amiodarone - Sometimes steroids if real bad - Stopping drug stabilizes or improves condition

Congenital hypothyroidism - Presentation - Tx - Prognosis

- Normal at birth - mom's T4 crosses placenta - <1 mo - jaundice, poor feeding, hypothermia - 1-4 mo - failure to thrive, constipation Confirm high TSH, low T4 Levothyroxine immediately US thyroid Endocrinology referral Good prognosis w/ tx - Permanent neuro deficits (intellectual disability) if no tx by 2 weeks

Duchenne muscular dystrophy - Presentation - Dx - Tx - Prognosis

- Onset age 2-3 - Proximal muscle weakness w/ Gowers sign, calf pseudohypertrophy - Dilated cardiomyopathy - Scoliosis - Achilles hyporeflexia - Waddling gait High CK Dystrophin gene deletion on X ch. Muscle bx - fibrosis, fat, muscle degeneration Tx: steroids Wheelchair-dependent by adolescence Death at 20-30 from heart/lung failure

Hypocalcemia signs

- Perioral numbness - Muscle cramps - Carpopedal spasm - + Chvostek sign - + Trousseau's sign (rapid carpopedal spasm on occlusion of blood supply to UE) - Usually bilaterally symmetrical

Posterior urethral valve

- Prenatal US: b/l hydronephrosis, dilated and thickened bladder, oligohydramnios - Palpable bladder on exam - Boy and bladder distention are keys Dx w/ voiding cystourethrogram - Dilated proximal urethra once catheter removed Place catheter temporarily until ablation of valve

Spina bifida - RF - Clinical features and comorbidities - Tx

- Prenatal maternal folate deficiency - See elevated AFP - Motor/sensory dysfunction - Neurogenic bladder/bowel - Hydrocephalus - Scoliosis - Surgical closure, may lead to hydrocephalus and need VP shunt - Intermittent clean cath - Scheduled laxatives/enemas

MS - Common presenting sx - RF - Dx

- Sensory/motor change, bowel/bladder dysfunction - Optic neuritis (pain w/ movement), INO (impaired adduction) - Lhermitte sign - Uhthoff phenom. - sx w/ heat Female, white, USA/Europe, cold, low vit D, smoking Episode sx Hyperintense lesion on T2 MRI, ovoid periventricular white matter lesions Oligoclonal bands, high IgG index in CSF

Suspect secondary HTN if...

- Severe HTN resistant to meds and acutely worsened - Onset before 30 YO - Malignant HTN

Angle-closure glaucoma

- Severe eye pain - Mid-dilated pupil - HA - N/V - Blurry vision - Conjunctival erythema

Cauda equina sx

- Severe low back pain - Urinary/bowel incontinence - Motor weakness or sensory loss in b/l legs - Saddle anesthesia

Paget's dx - Sign/sx - Labs - Dx - Tx

- Skull deformity w/ enlargement, hearing loss, dizziness - Bone pain, spinal stenosis - Bowing long bones, osteosarcoma, giant cell tumor High ALP - boney turnover Normal Ca and phos XR - osteolytic or mixed lesions, inhomogeneous bone XR findings plus high ALP Radionuclide bone scan to ID other sites Bisposphonates, calcitonin - slow progression, don't reverse sx

Prevent skin damage from sun

- Sunscreen - Clothing - Hydration NOT sea foods, steroids, avoiding EtOH, or vit E

TTP presenation

- Thrombocytopenia (purpura) - MAHA - Acute renal insufficiency - Neuro abnormalities - Fever

Graves dx

- Thyrotropic receptor antibodies - Stimulate iodine uptake and hormone synthesis - Diffuse RAIU uptake - Nontender goiter - Radioiodine ablation definitive tx

Group B strep = strep agalactiae - Found in urine at 14 weeks pregnant. What are all the things you do?

- Treat with ampicillin - Check UA 1 week after abx finish - Penicillin intrapartum - don't have to do the rectovaginal cx at 35-37 weeks like normal, just give abx

NF1

- Unilateral acoustic neuroma - Cutaneous neurofibromas - Axillary freckling

Electroconvulsive therapy - When to use

- Unipolar & bipolar depression - Catatonia - BIPOLAR mania Indicated for... - Treatment resistance - Psychotic features - Emergency conditions (refusal to eat, imminent suicide risk) - Pharmacotherapy contraindicated - Pregnancy when meds undesirable or ineffective - Hx of ECT response NO absolute contraindications

Signs of adrenal insufficiency

- Weight loss - Asthenia - Eosinophilia - Borderline sodium level - Hyperkalemia - AG acidosis - Prerenal azotemia - Low glucose - May have decreased insulin requirement - Other autoimmune dx - Check cosyntropin stim test

T1DM

- Young people, whites - Rapid onset with osmotic sx - DKA more common - Low C-peptide - Pancreatic autoantibodies (to glutamic acid decarboxylase) - Insulin deficiency - Tx with basal-bolus insulin - Metformin doesn't work since don't have insulin in the first place

Fibromyalgia

- Young-middle aged women - Chronic widespread pain - Fatigue, impaired concentration - Tenderness at mid-trap, costochondral junction - >3 mo. of sx - Normal labs

sexual abuse behaviors kids

- anogenital injury, recurrent UTIs, stimulating actual sexual acts (showing one doll kissing another's genitals; shouldn't know details of sexual acts) - normal: asking to other another kid's genitals, taking clothes off in public, genital self-stimulation in public

Opioid withdrawal - Sx - Tx

- n/v/d, cramping, hyperactive BS - Tachycardia, HTN, diaphoresis - Insomnia, YAWNING, dysphoric - Myalgia, LACRIMATION, RHINORRHEA, piloerection, mydrasis Methadone (or buprenorphine) Clonidine - preferred if kicked out of methadone clinic - Adjunct benzos, antiemetics

IRB objective, modifications

- protect rights and welfare of human sujects - any modifications to an approved study -> resubmission of entire protocol to IRB for review and approval before implementing changes

Indications for ICD placement

-Prior history of cardiac arrest or sustained spontaneous VT -Family history sudden death -Recurrent exertional syncope -Nonsustained VT -Hypertension with exercise -Extreme LVH

old person with hba1c <7-8

-can decrease tx regiment, esp if limited life expectancy, sig comorbidity, or high risk hypoglycemia (old ppl may not be able to tell when having sxs)

neonatal lupus

-devo from transplacental passage of mom's anti-SSA (ro) and anti-SSB (la) ab; a/w risk of congenital complete heart block -women with SLE should avoid preg until dz quiescent for 6mo and those taking hydroxychloroquine should continue meds; also ASA starting at 12weeks to prevent preeclampsia

CHADS2-VASc scoring

0 - no anticoagulation 1 - +/- anticoagulation 2+ - oral anticoagulation

Give what to prevent neural tube defects? Risk factors for high risk? Give how much then?

0.4 mg folic acid at least 1 mo before pregnancy and during 1st trimester 4 mg if high risk - Methotrexate, antiepileptics, DM, prior NTD

What percent of distribution in 1, 2, and 3 standard deviations

1 - 68% 2- 95% 3 - 99.7%

Skin ulcer stages and tx

1 - Nonblanchable erythema - Dressing 2 - Partial thickness loss of epidermis, dermis, or both - Dressing 3 - Full thickness loss w/ damage to subQ tissues into but not through underlying fascia - Debridement and dressing 4 - Full thickness loss w/ damage of adjacent muscle, bone, or supporting structures - Debridement and dressing

MEN 1 vs 2A vs 2B

1 - diamond - hyperparathyroid, pancreatic tumor, pituitary 2A - square - MTC, pheo, parathyroid hyperplasia 2B - triangle - MTC, pheo, intestinal neuroma, marphanoid habitus

MEN 1 and 2A

1 - primary hyperparathyroidism, pituitary tumor (visual field defect), neuroendocrine tumor 2A - primary hyperparathyroidism, medullary thyroid cancer (palpable mass), pheochromocytoma

Mobitz type 1 vs 2 AV block

1 - progressive elongation of PR and eventually a nonconducted P - Benign 2 - intermittent nonconductor P - Permanent pacemaker 2/2 risk of progression to 3rd degree

Trichomoniasis and breastfeeding

1 dose metronidazole - For 24 hr, express milk but don't feed to baby. Can resume after 24 hr.

Length of tx for depression - Single episode - Multiple episodes, chronic, strong fam hx, severe episodes - Highly recurrent (3+ in lifetime), very severe chronic

1 episode - 6 months following acute response, keep same dose 2 episodes - 1-3 yr 3+ - indefinite

Cocaine -> STEMI - ECG - Tx

1+ mm ST elevation in 2+ contiguous leads IV benzos reduce sympathetic outflow & reduce HTN, HR, coronary vasoconstriction Nitro - lower HR and LV wall stress ASA PCI if persistent ST-elevation despite medical tx NO BETA BLOCKERS - unopposed alpha

Febrile non hemolytic transfusion reaction

1-6 hrs of transfusion RBCs and plasma separated but small residual plasma/leuk debris remains in RBC concentrate. Leuks release cytokines causing transient fevers, chills, and malaise Stop transfusion, give med for fever, used leukoreduced in future

Statin guideliens for 1. Clinically significant ASCVD (give example too) 2. High LDL (give number too) 3. Age 40-75 w/ DM 4. 10 yr ASCVD risk >7.5%

1. ACS, stable angina, CABG, stroke, TIA, PAD - <75, high intensity statin - >75, moderate intensity 2. LDL >190 = high intensity 3. 10 yr risk >7.5, high; <7.5, mod 4. Moderate to high

Symptomatic peripheral artery disease tx

1. ASA and statin (regardless of lipid panel), lifestyle mods (stop smoking, BP/DM control, supervised exercise) 2. Cilostazol is a vasodilator but only recommended after lifestyle modifications fail 3. Angioplasty +/- stent, bypass graft

Allergic rhinitis tx

1. Avoid allergen 2. Intranasal steroids (SE: epistaxis) 3. Intranasal cromolyn sodium or 2nd gen antihistamine (cetirizine)

Root cause analysis

1. Collect data 2. Create causal factor flow chart 3. Identify root causes 4. Generate recommandations and implement changes 5. Measure success of changes

Unresponsive and large volume active hematemesis - Next step

1. Endotracheal intubation - aspiration risk 2. Large bore IVs 3. Blood type and crossmatch 4. Once stabilized, upper endoscopy

MCC viral CNS infection in kids

1. Enteroviruses - Coxsackie and Echo 2. Herpes and arbo viruses

HIV management during pregnancy 1. Antepartum 2. Intrapartum 3. Postpartum

1. HIV RNA viral load consistently - CD4 every 3-6 mo - Resistance testing (if not done before) - Start ART right away - NO amniocentesis until viral load <1000 2. NO artificial ROM, fetal scalp electrode, operative vag delivery - <1000 : ART + vag delivery - >1000 : ART + zidovudine + c-sect 3. Mom: continue ART - Baby (mom <1000): zidovudine - Baby (mom >1000): ART

Management of... 1. Gallstones on image w/o sx 2. Gallstones w/ typical sx 3. Gallstones w/ atypical sx 4. Typical sx but no gallstones

1. No tx 2. Elective lap chole, possible UDCA in poor surgical candidates 3. Empiric UDCA followed by chole if sx improve 4. Cholecystokinin-stim cholescintography to eval for functional gallbladder disorder - Chole if low gallbladder ejection - Look for something else if normal

Hypercalcemia eval for person with mild asx hypercalcemia, normal renal function, and father with high calcium

1. PTH will be high-normal 2. Urinary calcium - high in familial hypocalciuric hypercalcemia FHH has no clinical findings and needs no treatment

Hyperkalemia and EKGs

1. Peaked T wave 2. Prolonged PR and QRS 3. Disappearance of P wave 4. Sine wave Give IV calcium gluconate to stabilize cardiac membrane potential

Syphilis tx for... 1. Primary/secondary/early latent (<12 mo) 2. Late latent (>12 mo), ?duration, gummatous/CV syphilis 3. Neurosyphilis 4. Congenital syphilis

1. Primary/secondary/early latent (<12 mo) - 2.4 million units benzathine penicillin G IM 1 dose 2. Late latent (>12 mo), ?duration, gummatous/CV syphilis - 2.4 million units benzathine penicillin G IM weekly for 3 weeks 3. Neurosyphilis - 3-4 million units aqueous penicillin G IV q4h for 10-14 days 4. Congenital syphilis - 50,000 u/kg/dose aqueous penicillin G IV q8-12h for 10 days

Decrease opioid misuse 1. 2. 3.

1. Random UDS 2. Check prescription drug-monitoring program at visits 3. F/U at least every 3 months

Suspect heat stroke - Next steps

1. Remove from hot environment 2. ABCs 3. Rapid cooling - naked patient sprayed with tepid water or covered with wet sheet and fans circulate air 4. Ice packs, ice water lavage, or cold IVF as adjuncts

Pregnant, suspect nephro/ureterolithiasis - Algorithm

1. Renal/pelvic US 2. Transvaginal US 3. Tx empirically and observe OR MR urogram OR low-dose CT urogram (2nd/3rd trimester only) Increased Ca in urine, urinary stasis, and decreased bladder capacity increase risk in 2/3 tri If no hydronephrosis or pyelonephritis, tx is pain control

Hyponatremia eval algorithm

1. Serum osms >290 = advanced renal failure or hyperglycemia 2. Urine osms <100 = 1 polydipsia, beer drinker's potomania 3. Urine Na <25 = volume down, CHF, cirrhosis No = SIADH, adrenal insufficiency, or hypothyroid

Normal anion gap Causes of anion gap metabolic acidosis

10-14 Methanol Uremia Diabetic ketoacidosis Propylene glycol/paraldehyde Isoniazid/iron Lactic acidosis Ethylene glycol (antifreeze) Salicylates (ASA)

H pylori tx

10-14 days of: PPI + clarithromycin + amoxicillin PPI + bismuth + flagyl + tetracycline if restant or FAILURE after 1 course of abx

Infertility - Time - Eval

12+ months Women age 35+ get eval after 6+ months First step: semen analysis

Testicular cancer - Presentation - Dx - Tx

15-35 YO w/ fam hx or hx of cryptorchidism Unilateral, painless testicular mass Dull lower abdominal ache Metasatic sx (SOB, neck mass, low back pain) Exam Tumor markers (AFP, b-HCG) Scrotal US CT Radical orchiectomy + chemo 95% cure rate

Pneumococcus vaccine schedule

19-64 - PPSV23: chronic heart/lung/liver dx; DM, smokers, EtOH - PCV13 and PPSV23: CSF leak, cochlear implant, sickle cell, asplenia, immunocomp., CKD 65+: PCV13 then give PPSV23 after 6-12 mo

Maternal hyperglycemia - 1st trimester effects - 2nd/3rd

1st - Congenital heart dx - NTD - Small left colon syndrome - Spontaneous abortion 2nd/3rd - Fetal hyperglycemia and hyperinsulemia

PCOS tx

1st line: weight loss OCPs for menstrual regulation Clomiphene citrate to induce ovulation Spironolactone for hirsutism, PCOS Normal hysterosalpingogram shows bilateral spillage from fallopian tubes

Recurrent C diff treatment

1st recurrence: metronidazole (vanco if severe) 2nd recurrence: pulsed tapering oral vanco 6-7 weeks Subsequent: fidaxomicin, consider fecal transplant

Active phase protraction in labor - What - Tx

1st stage has 2 phases: latent (0-6 cm dilation) and active (6-10 cm) Active phase protraction - contractions LESS than q2-3min, no cervical change over 2 hr Oxytocin and amniotomy (artificial rupture of membranes)

Hyperthyroid meds during pregnancy

1st trimester: PTU - Methimazole causes aplasia cutis 2nd/3rd: methimazole - PTU hepatotoxic

Herpes in newborn - Presentation - Workup

1st week: PNA 2nd week: skin vesicles, keratoconjunctivitis 3rd/4th week: meningioencephalitis Initial test: Txanck smear/culture (neg doesn't exclude) Specific: HSV PCR

Examples of 1st gen antipsychotic and SE Second gen

1st: fluphenazine, pimozide, haldol - EPS, QTc prolonged w/ pimozide 2nd - risperidone, aripiprazole

TB meningitis tx - Meds - What else can help

2 mo. of RIPE - rifampin, isoniazid, pyrazinamide, & fluoroquinolone or aminoglycoside THEN 9-12 mo rifampin plus isoniazid 8 weeks adjuvant STEROIDS - less M&M by decreasing inflammation

Pregnant woman with active TB tx

2 months of 3 drug therapy - Isoniazid (w/ pyridoxine) - Rifampin - Ethambutol THEN 7 months of isoniazid and rifampin (Pyrazinamide not given to pregnant pts 2/2 teratogenicity)

Diagnose acute pancreatitis

2 or more of: - Acute epigastric pain radiating to the back - Elevated amylase or lipase - Imaging suggesting it DO ONLY EXAM & LABS FIRST, NOT THE ULTRASOUND/CT/MRI

Implantation bleeding

2 weeks after fertilization and 4 weeks after LMP Scant and painless

Recurrent UTI - Definition - RF - Eval - Tx

2+ in 6 mo or 3+ in 1 yr Hx cystitis at <15 yr, spermicide use, new sexual partner, postmenopausal UA and cx Behavior modification Postcoital ppx if after sex or daily abx ppx

TB meningitis - Sx - Eye exam - Imaging - CSF - Tx

2-3 week prodrome (HA, low fever, lethargy) Progressive meningeal signs (nuchal rigidity, vomiting, AMS) Choroidal tubercles - yellow-white nodules near optic disc CT - basilar mening. enhancement High protein >250 VERY LOW glucose <10 High lymphocytes 5-1000 High ADA + Acid-fast bacilli on smear/culture 2 mo. of RIPE then 9-12 mo RI

Lupus causes premature CAD

2/2 HTN and HLD plus chronic inflammation and steroid use Can lead to premature death from MI and ventricular arrhythmia

Post-op urinary retention - Why - RF - Dx - Tx

2/2 anestesia plus larve volume IVF during surgery - Suprapubic tenderness and abdominal distention RF: >50 YO, surgery >2h long, previous pelvic surgery Place foley to dx and tx - Voiding trial w/in a week Expect hemodynamic instability if post-op hemorrhage

Pubertal gynecomastia

2/2 imbalance of estrogens and androgens in mid-puberty Small <4 cm, firm, uni- or bilateral subareolar mass, may be tender - No discharge, axillary LAD, or systemic illness Reassure - resolves w/in 1 yr (Pseudogynecomastia = overweight, no palpable mass)

Erosive esophagitis

2/2 medications like bisphosphonates and tetracyclines Burning CP

Methemoglobinemia - Cause - Presentation

2/2 oxidation of iron molecules in hemoglobin which prevents O2 binding - Meds: dapsone, benzocaine - Toxins: aniline dyes HA, nausea, lethargy, cyanosis

Diabetic with orthopnea, b/l crackles, S3 on exam, CXR w/ inc interstitial markings w/ Kerley B lines and b/l pleural effusions - What - Why - Tx

2/2 thiazolidinedione med like pioglitazone (PPAR-g agonist) Med increases Na reabsorption -> fluid retention -> worsening of underlying heart failure Spironolactone - pioglitazone acts on same channels as aldosterone Metformin (lactic acidosis) and glyburide (hypoglycemia) don't cause this

Variable decelerations in fetal HR - What - Tx

2/2 umbilical cord compression Amnioinfusion to relieve compression

PID - What - Sx

2/2 untreated G or C -> polymicrobial infxn upper reproductive tract Fever, dyspareunia, abd/pelvic pain, mucopurulent cervical discharge, cervical motion tenderness (chandelier sign)

Gestational diabetes algorithm

24-28 weeks 1. 50g oral glucose, check 1 hr - <140 = no more testing - >140 = on to step 2 (or 2hr >120) 2. 100g oral glucose, check in 3 hr - GDM if 2+ values elevated - Fasting >95 - 1 hr >180 - 2 hr >155 - 4 hr >140 Can use insulin, metformin, or glyburide if lifestyle mods fail

Fat embolism - Timing - Symptoms - Prevention

24-72 hours after trauma - femur or multiple fractures Triad: respiratory insufficiency, neuro impairment, petechial rash on trunk - Fever, tachycardia, AMS Early immobilization and operative fixation

Stool osmotic gap - Calculate - What it means

290 - 2 (stool Na + K) <50 secretory diarrhea 50-125 ??? >125 Osmotic diarrhea

Chronic urticaria treatment

2nd gen H1 blocker - loratadine or cetirizine NOT TOPICAL STEROIDS If not better: increases dose, add 1st gen H1 blocker (hydroxyzine) or H2 blocker (ranitidine), add leukotriene receptor antagonist (montelukast), brief course oral steroids - Still nothing: hydroxychloroquine, tacrolimus, omalizumab

22 YO AAM w/ peripheral edema, dyspnea, HTN

2ndary HTN 2/2 renal parenchymal dx - Focal segmental glomerulosclerosis - dx w/ BMP and confirm w/ bx

Alcohol healthy limits

3 and 7 for women 4 and 14 for men

Suspect acute uncomplicated cystitis over the phone

3 days TMP-SMX or 5 days nitrofurantoin - Don't need additional testing or eval

After how long a course do steroids need to be tapered?

3 weeks Suppression of hypothalamic-pituitary-adrenal axis

When to consider tympanostomy tubes and prophylactic abx for recurrent ear infections

3+ episodes in 6 months 4+ episodes in 12 months High risk for speech/hearing impairment - craniofacial abnormalities and neurodevelopment disorders

Chronic prostatitis - Presentation - Bugs - RF - Tx

3+ months urinary sx, pelvic pain, urine leukocytes, bacturia especially after prostate massage E coli (MCC), Enterococcus, Klebsiella, Proteus, Pseudomonas DM, smoking, urinary tract hardware/manipulation 6 weeks of copra or TMP-SMX

- When to suspect chromosomal abnormality as cause of infertility - MCC

3+ spontaneous abortions or if abnormal semen analysis Klinefelter syndrome (47 XXY) is MCC - Cryptorchidism, gynecomastia, space body hair, intellectual disability

Nutrition recommendation for enteral feeding

30 kcal/kg/day with 1g/kg protein Lower amount in severe preexisting malnutrion to prevent refeeding syndrome

Exercise during pregnancy - Goal - Why it's good - Good types - Bad types

30 min moderate exercise most days Lower gest DM, preeclampsia, and C section risks, shorter postpartum recovery Walking/running, cycling, yoga, swimming, light weight training BAD: scuba diving, contact sports, high fall risk sports, sky diving

Meds to give in preterm labor - 34 - 36 6/7 weeks - 32 - 33 6/7 - <32

34 - 36 6/7 weeks +/- Betamethasone (decreases RDS, necrotizing enterocolitis, intraventricular hemorrhage, mortality) - Penicillin if GBS +/? 32 - 33 6/7 - Betamethasone, tocolytic (nifedipine), penicillin if GBS +/? <32 - Betamethasone, tocolytic, penicillin if GBS +/?, mag sulfate (decrease cerebral palsy)

GBS testing - When - Who gets PPx - Tx/PPx

35-37 weeks - rectovaginal cx - Prior delivery complicated by neonatal GBS infection - GBS bacturia/UTI during current pregnancy - Positive cx - Unknown GBS status plus... <37 weeks OR intrapartum fever OR ROM >18 hr Penicillin 4+ hr prior to delivery

Needle stick of known HIV patient but he is on HAART, undetectable viral load, and no hx viral hepatitis - Do what

4 weeks combo antiretroviral tx - Repeat HIV testing in 6 weeks and 4 months EVERYONE WITH PERCUTANEOUS OR MUCOUS MEMBRANE EXPOSURE GETS 4 WEEKS OF COMBO TX

HIV viral load after starting ART. Check every 3-6 months. - 4 weeks - 8-16 weeks - 16-24 weeks - Virologic failure?

4 weeks: <5,000 copies 8-16 weeks: <500 16-24 weeks: <50 Expect viral load <50 per mL within 6 months! If >200, in virologic failure and likely 2/2 drug resistance or noncompliance.

Asymptomatic LV systolic dysfunction - EF cutoff - Do what

40% or less Start ACEi, titrate to max tolerated dose then add beta blocker (Spironolactone beneficial in sx LVSD, non in asx LVSD w/o prior MI)

Dx Turner syndrome - Karyotype - Presentation - Tests needed

45,XO Short stature, hypogonadism Echo - coarctation of aorta, bicuspid aortic valve, MVP Renal US - horseshoe kidney Visual/hearing screen TSH - hypothyroidism Eventually need hormone replacement but not until 14 so growth plates don't close early

Primary nocturnal enuresis tx

5+ YO 1. UA to r/o secondary causes 2. Lifestyle changes 3. Enuresis alarm (best long term outcome and low relapse risk) 4. Desmopressin (good in short term)

Croup - Presentation - Dx - Tx

6 mo - 3 YO in fall/early winter - parainfluenza virus - Inspiratory stridor - Barking cough - Hoarseness CLINICAL DX - don't have to get XR (steeple sign) Mild (no stridor at rest) - humidified air +/- steroids (1 dose) Mod/severe (stridor at rest) - IM steroids AND nebulized epinephrine

Intussusception - When - How - Presentation - Dx - Tx

6 mo - 3 yr Preceding virus -> lymphoid hyperplasia/Peter patches (or have Meckel's, etc) -> telescoping of proximal intestine into distal Sudden, intermittent and pain, currant jelly stools, sausage shaped mass, lethargy/AMS, knees pulled up, nonbilious emesis Dx and tx with air or water soluble enema - US to see target sign if unclear - NOT barium enema 2/2 risk for peritonitis if perforates - Surgery if doesn't work

Carotid endarterectomy indicated when?

70-99% high grade lesions with sx (stroke, TIA) and 5+ yr life expectancy - Risks outweigh benefits if poor surgical candidates, ipsilateral stroke w/ persistent disabling neuro deficits, and 100% occlusion If <70%, ASA, statin, control of HTN, DM, smoking

When to give platelet transfusion

<10,000 <50,000 plus active bleed OR planned major surgery

Causes of secondary HTN - <20 - 21-39 - 40-64 - >65

<20 - Renal parenchymal dx (FSGS) - Coarctation of aorta 21-39 - High/low thyroid - Fibromuscular dysplasia - Renal parenchymal dx 40-64 - Hyperaldosteronism - Thyroid - OSA >65 - Atherosclerotic RAS - CKD

Spontaneous abortion - When - RF - MCC

<20 weeks Advanced maternal age Previous spontaneous abortion Substance abuse Fetal chromosome abnormality

Pediatric sepsis - bug and abx if - <28 days - >28 days

<28 days - E coli (UTI) and GBS - Ampicilin PLUS cefotaxime (or gentamicin - more resistance, less CSF penetration)) >28 days - Strep pneumo and N meningitidis - Ceftriaxone or cefotaxime - Add vancomycin if meningitis Ceftriaxone replaces albumin-bound bili in neonates -> kernicterus

Palpable breast mass algorithm

<30 -> US +/- mammogram - Simple cyst -> needle aspiration - Complex cyst/mast -> core bx >30 -> mammogram +/- US - Suspicious for CA? Core bx

Palpable breast mass next step

<30 = ultrasound 30+ = mammogram

Fibroadenoma - Presentation - Management

<30 YO female with single, unilateral, mobile, well-circumscribed breast mass - Increases in pain/size prior to menses 2/2 hormonal fluctuation Teen - observe and reassure - improves after menses Older/persistent - ultrasound shows solid, avascular mass

Acute epididymitis - Cause - Sx - Dx - Tx

<35: STD (G or C) >35: bladder outlet obstruction (coliform bacteria) Unilateral testicle pain, epididymal edema, dysuria, frequency UA/Cx; NAAT for G&C Ceftriaxone/doxy if STI Levofloxacin if coliform bacteria

When to give vitamin K for elevated INR from warfarin

<5 - just hold/decrease warfarin 1-2 days 5-9 - hold warfarin OR give low dose (1-2.5) oral vit K if high bleed risk >9 - hold warfarin, high dose (2.5-5) oral vit K ANY INR with serious bleed - hold warfarin, give vit K 10 mg IV, FFP, recombinant factor VIIa, or prothrombin complex concentrate

Frequent GERD sx >2x/week plus no alarm sx -> PPI trial 8 weeks What are alarm sx?

<55 YO Dysphagia Odynophagia Anorexia Weight loss GI bleed If mild/infrequent GERD sx, just try lifestyle changes and PRN H2 blocker first

Estrogen/progesterone for menopause - What age does risk/benefit change? - Increases risk of... - Decreases risk of...

> 60: increases stroke, CAD, breast cancer, DVT All ages, has minor increase of stroke < 60: decreases menopause sx, boney fx, colon cancer, DM2, all cause mortality - Safe to use for 3-5 yr

Botulism - Who - Where from - Mechanism - Sx - Tx

>1 YO Honey, canned food, farms Inhibits presynaptic ACh release Constipation, oculobulbar weakness, descending flaccid paralysis IV Botulism immune globulin

PTSD - Duration - Tx

>1 month CBT SSRI Prazosin for nightmares

Chronic prostatitis - Presentation - Types and how to tell

>3 months of dysuria, GU pain, pain during ejaculation Prostate exam often normal Often think it's a UTI, get short abx course, feel better then worse Dx requires UA and urine cx before and after prostate massage >20 leuks/hpf after prostate massage Chronic prostatitis/chronic pelvic pain syndrome - urine cx aseptic - Most common - Cause unclear, tx w/ meds for prostate enlargement (alpha blockers), abx, anti-inflammatories, psych therapy Chronic bacterial prostatitis - urine cx bacturia (>10x increase after prostate massage)

TB skin test positive if...

>5 mm - HIV infection or immunocomp. - Recent TB contact - Fibrotic changes on CXR suggesting prior TB - Organ transplant >10 - Recent immigrant - IVDU - Prison, shelter, healthcare - Kid <4 YO >15 - No known risk factor BCG causes false positive but rarely >15 mm and decreases 15 yrs after received

Suspect polymyalgia rhematica - Presentation - Exam - Labs - Tx

>50 YO, b/l pain and morning STIFFNESS - Neck/torso - Shoulders/proximal arms - Proximal hip/thigh Decreased active ROM in shoulders, neck, hips - No joint inflammation - Pain more in soft tissues ESR >40, high CRP Normocytic anemia (ACD) Steroids - Don't need to check ANA or RF, just tx

Normal language development at 2 YO

>50 wood vocal and use 2 word phrases All kids with language delay need audiology eval for hearing impairment

Postpartum hemorrhage - Define - RF - Causes - Tx

>500 ml after vaginal or >1000 after c-section Prolonged/induced labor, chorioamnionitis, multiple gestation, polyhydramnios, grand multiparty, operative delivery Uterine atony (most common - soft big uterus above umbilicus) Retained placenta, laceration, uterine rupture, coagulopathy Bimanual uterine massage + oxytocin; IVF and O2 = Uterotonics, intrauterine balloon tamponade, uterine artery embolization, hysterectomy

Dyspepsia = abdominal fullness or pain w/o significant heartburn. Next step if... >55 or alarm sx? Neither?

>55 or alarm sx - EGD Neither - H pylori testing

Think multiple myeloma when you see...

>65 YO Monoclonal protein in serum/urine >10% clonal plasma cells in BM or soft tissue/bone plasmacytoma Calcium elevation Renal insufficiency Anemia - normocytic Bone pain - lytic lesions Do a skeletal survey at dx

Indications for CT after minor head trauma

>65 YO, coagulopathy (hemophilia), intoxication, high risk injury mechanism Retrograde amnesia, vomiting 2x, seizure, severe HA GCS 14 or less, depressed skull fx, AMS, LOC, neuro deficit, sign of basilar skull fracture (mastoid/orbital ecchymoses, CSF rhinorrhea/otorrhea, hemotympanum)

Parts of Medicare

A - inpatient B - Outpatient, hospital observation C - Medicare Advantage, private health insurance provide Medicare D - Prescription drugs

Bacterial prostatitis - Presentation of acute vs chronic - Tx

A: fever, chills, cloudy urine, +/- voiding sx C: >3 mo of urinary sx and/or perineum pain TMP-SMX 6 wk

Status epilepticus is 5+ minutes generalized convulsive seizure of 2+ generalized convulsive seizures w/o interval recovery of consciousness - Tx algorithm?

ABCs, eval for cause, IV access 1. lorazepam 2. fosphenytoin, phenytoin or valproic acid 3. EEG, continuous infusion of midazolam, pentobarbital, or propofol

Priapism - persist >4h painful erection 2/2 impaired outflow from corpora cavernosa - Dx - Tx

ABG of corporeal aspirate - Confirms ischemic priapism - If high now (nonischemic), tx w/ angiographic embolization 1. Urination, cold compress 2. Aspiration of corpora caveronosa then irrigate w/ cold saline 3. Intracavernosal injection of alpha agonist (phenylephrine)

Knee injury with pop, rapid hemarthrosis swelling, and pain

ACL - MCL doesn't have hemarthrosis - Meniscus may have locking/catching but not hemarthrosis and edema is SLOW - Baker's cyst rupture is posterior and no effusion or hemarthrosis

Depressed -> partial response to monotherapy with SSRI -> next step?

ADD second medication - Buproprion good because it doesn't have the weight gain or sexual side effects If didn't respond at all, stop the med and try another SSRI (try at least 2) or choose a different category

Factorial study

AKA fully crossed design - 2+ interventions and all combinations of the interventions are tested

CMV encephalitis

AMS, focal neuro deficits, polymorphonuclear pleucytosis

Acute opioid intoxication - Exam - Workup - Tx - Increased risk in who

AMS, miosis, decreased RR (crackles from basal atelectasis) +/- decreased bowel sounds ABG (resp acidosis), glucose, UDS, EKG (prolonged QTc w/ methadone) Naloxone Liver or renal dx - break down/excrete morphine Post-op increases risk too

Antibodies in lupus

ANA almost always + dsDNA - most sensitive - correlates with disease activity - associated with lupus nephritis Smith - most specific for lupus

What type of statistical test to use to analyze the MEAN of continuous variables in SEVERAL groups

ANOVA - Gives the F statistic

Attributable risk percentage is the excess risk 2/2 exposure - Formula Population attributable risk percent - Formula

ARP = (risk in exposed / risk in unexposed) / risk in exposed PARP = (risk in pop - risk in unexposed) / risk in pop

Analgesic nephropathy

ASA and tylenol with phenacetin or NSAIDs Constriction of vasa recta -> ischemic renal papilla -> sloughing of papilla -> hematuria and renal colic (if chronic, see calcification) Sloughed papilla may cause temporary obstruction leading to dilation but no stone seen Elevated BUN/Cr UA - hematuria, proteinuria, pyuria with WBC casts, culture negative

Ingested medication -> n/v, tachypnea, resp alkalosis, lactic acidosis, hyperthermia, AMS - What and other sx - Tx

ASA toxicity - Tinnitus - Arrhythmia - Hepatitis IV sodium bicarb for mixed acid-base disorder - Resp alk - activate medullary resp center (high pH, low PaCO2) - AG acidosis - inhibit cell metabolism - Bicarb alkalinizes urine/plasma - inhibits protonation of ASA - can't pass through BBB or renal tubules Glucose prevent neuroglycopenia Activated charcoal if <2 hr after ingestion Dialysis if pulm edema or V overload, renal failure, severe acidosis

When to do HPV co-testing after Pap

ASCUS (atypical squamous cells of undetermined significance) AND LSIL (low grade squamous intraepithelial lesion)

Mid-systolic murmur at left upper sternal border with RA and RV dilation

ASD with L to R shunt Wide-fixed splitting S2 Mid-systolic ejection murmur from increased flow across P valve Mid-diastolic rumble from increased flow across tricuspid

HSP triad

Abd pain, skin rash, joint inflammation - Seen in kids

Strep pharyngitis - Presentation/exam - Tx - Complications

Abrupt onset sore throat Fever NO COUGH Abd pain/vomiting Palatal petechiae Tonsillar ERYTHEMA/EXUDATE Tender ANTERIOR CERVICAL LAD Penicillin or amoxicillin - 10 days to prevent rheumatic fever

Environmental risk factors for recurrent ear infections

Absence of breast feeding Going to daycare Using pacifier Secondhand smoke - mom should quit all together, smoking outside still brings in particles on clothing

Black section in armpits - What - Associated with?

Acanthosis nigricans - GI malignancy - DM

Pyridostigmine

Acetylcholinesterase inhibitor - Treat myasthenia gravis

Dementia-related cognitive impairment treatment

Acetylcholinesterase inhibitors - Donepizil, rivastigmine, galantamine 2nd line: NMDA receptor antagonist memantine - No evidence of disease modification

PCOS - Presentation - Labs - Associated conditions - Tx

Acne, bald, hirsutism (androgens) Menstrual irregularities Obesity Polycystic ovaries High testosterone and estrogen LH/FSH imbalance Metabolic syndrome (HTN, DM) OSA, NASH ENDOMETRIAL CANCER Weight loss, OCPs PROGESTIN - endometrial cancer Clomiphene citrate to induce ovulation

Scaly hyperkeratotic lesion on the ear that disappeared and returned - What - Next step - Tx

Actinic keratosis Biopsy - may evolve into squamous cell carcinoma Tx w/ 5-FU, imiquimod, cryodestruction w/ liquid nitrogen

Contraindications to tPA

Active internal bleed Platelets <100,000 Hypodensity in >33% arterial territory on CT Incracranial surgery w/in 3 mo BP 185/110+

Herpes zoster definition and pain control - Acute herpetic neuralgia - Subacute herpetic neuralgia - Postherpetic neuralgia

Acute - Persists <30 days from onset - NSAIDs, analgesics Subacute - Persists >30 days but resolves w/in 4 months - NSAIDs, analgesics Postherpetic - Persists >4 months from onset - TCAs (amitriptyline 1st line), gabapentin (1st line in elderly), pregabalin

ACL/PCL injury characteristics

Acute "pop" Deceleration or pivot RAPID LARGE EFFUSION or HEMARTHROSIS

Acute poststreptococcal glomerulonephritis vs IgA nephropathy

Acute PSGN - 10+ DAYS after throat/skin infxn - Gross hematuria uncommon - HTN - RBCs and RBC casts - Low complement level IgA nephropathy - GROSS hematuria soon after URI - Flank pain - Dysmorphic RBCs in urine - No definitive therapy - Usually benign course

Burn -> antibiotic ointment -> gesticulation, faith erythema - What - Next step

Acute allergic contact dermatitis 2/2 ointment Stop the ointment (can consider low potency topical steroids) Only partial or full thickness burns get topical abx, not superficial

Cholecystectomy years ago -> fever, jaundice, RUQ pain - What - Labs - Tx

Acute cholangitis +/- hypotension, AMS - High D bili and alk phos - Mildly high LFTs - Biliary dilation on imaging Abx ERCP w/in 24-48 hr for biliary drainage Drug induced liver injury subacute and not have fever/abd pain

Ogilvie's syndrome

Acute colonic pseudo-obstruction - Dilation of cecum and right colon in absence of mechanical obstruction to the flow of intestinal contents

Common perineal nerve injury

Acute foot drop Weakness w/ dorsiflexion and eversion Sensory loss over foot dorm and lateral shin (superficial peroneal n) Injury at lateral fibular head

Fever, chills, flank pain, hemoglobinuria w/in 1 hour of transfusion - What - Test

Acute hemolytic reaction Can progress to renal failure and DIC Positive direct antiglobulin test (Coombs)

Sudden onset severe periumbilical pain and n/v w/o guarding or rebound. Labs show leukocytosis, high amylase, high lactate - What/how - Dx - Progress to - Tx

Acute mesenteric ischemia - Arterial occlusion of SMA (a fib emboli?), hypoperfusion to splanchnic circulation Metab. acidosis 2/2 high lactate Leukocytosis Hemoconcentration (high Hct) CT abd or CT angio - focal or segmental bowel wall thickening, mesenteric stranding, porto-mesenteric thrombosis Can progress to SB ischemia or infarct and distended abd, pneumatosis, absent BS, peritoneal signs IVF, abx, NG tube, surgery cons.

Recent MI -> acute n/v, severe abd pain OOP to exam, metabolic acidosis - What - RF - Labs - Dx

Acute mesenteric ischemia - Hematochezia is late complication - Chronic presents w/ cramping after eating Atherosclerosis, embolic source, hypercoagulable Leukocytosis, elevated amylase and phosphate, metabolic acidosis from elevated lactate CTA or MRA

Herpes simplex encephalitis

Acute onset <1 week, fever, headache, seizure, AMS, focal neuro deficits like hemiparesis and cranial nerve deficits

Leser-Trélat sign

Acute onset of multiple seborrheic keratoses Associated with GI ADENOCARCINOMAS

Sickle cell vaso-occlusive pain episode - Features - Management

Acute pain Pain at 1 or more sites (dactylitis) +/- low grade fever May be triggered (stress, illness, temp change, dehydration) NSAIDs/opioids Heat Hydration +/- RBC transfusion Hydroxyurea prevents episodes over long term

Extensive retinal hemorrhage on fundoscopy

Acute retinal vein thrombosis

Anti-streptolysin

Acute rheumatic fever - Migratory polyarthritis - High ESR

Pregnant w/ sickle cell disease -> nausea and vomiting -> abdominal pain

Acute sickle hepatic crisis -> triggered by dehydration Repeat sickling -> intra-extravascular hemolysis Hepatic sinusoid vase-occlusion -> ischemia/infarct (RUQ pain, high LFTs) and systemic inflammation (fever) More common in pregnancy - may cause IUGR, preterm birth, preeclampsia, placental abruption

Meniscus injury characteristics

Acute/subacute sx SMALL EFFUSION LOCKING sensation on extension Inability to fully extend Joint line tenderness Positive McMurray test

Camping trip and drank contaminated water and now has giardiasis - Presentation acute vs chronic - Tx, who gets treated

Acute: loose, foul smelling, fatty stools; abd cramps; flatulence; weight loss; typically seek care after weeks (cysts need time to mature) Chronic: malabsorption (lactose intolerance), weight loss, vitamin deficiencies Metronidazole - only sx or high-risk patients Sx/tx pt avoid recreational water Wash with soap and water treat water with iodine

High normal lithium level but still manic - Next step

Add antipsychotic

Esophageal cancer types

Adenocarcinoma - lower 2/3, GERD, Barrett's Squamous cell carcinoma - upper 1/3, chronic tobacco and alcohol Incidence of SCC has decreased and AC has increased

Decreased PASSIVE AND ACTIVE shoulder ROM w/ more stiffness than pain

Adhesive capsulitis - Frozen shoulder - Worse at night then progresses - Tx w/ PT (sometimes steroid shot)

Mono -> airway obstruction imminent. Next step?

Admit, IV steroids Also consider steroids if immunocompromised or other serious conditions

Functional abd pain - Presentation - Tx

Adolescent Chronic 2+ months Non-localized/periumbilical pain No v/d/weight loss Normal exam Negative stool guaiac Sx diary

Disseminated Mycobacterium avid complex

Advanced AIDS Fever, night sweats, abd pain, weight loss, diarrhea - Rarely have skin lesions and if present are nodular and ulcerating

Cryptococcal meningitis - Who - Test

Advanced HIV - Can rarely have subacute meningitis in normal people India ink prep of CSF

When to get genetic counseling for miscarriages

After 3 or more miscarriages, not including ectopics

Second stage of labor - Define - When is arrest? Why? Next step?

After completely dilated (10 cm) and ends w/ fetal delivery Arrest = no fetal descent in nulliparous pt after 3+ hr w/o epidural or 4+ w/ epidural - 2/2 cephalopelvic disproportion - Do a c-section

Most important RF for osteoporosis and related fracture

Age

Crohn dx

Age 15-40 Abd pain and bloody diarrhea Colonoscopy: pathos ulcers, cobblestoning, ski lesions - Rectum often spared

2 most important prognosis predictors in COPD

Age and FEV1

presbycusis

Age related hearing loss - gradual, sensorineural May lead to social withdrawal To with whisper test or audiometry

Presbycusis - What - Test

Age related sensorineural hearing impairment - High frequency Difficulty discriminating speech with background noise

Antipsychotic med -> restless, urge to move - What - Tx

Akathisia - 1st (MC) or 2nd gen antipsychotics 1. Reduce dose 2. Propranolol - Benztropine and benzos also used

AMS, ketonuria, mildly elevated glucose - What - Other labs - Tx

Alcoholic ketoacidosis High AG, high osmolal gap, ketonemia/ketonuria, variable levels of blood glucose Thiamine and IVF (dextrose b/c inc insulin->metabolism of ketones) Expect glucose >250 if DKA

Why give sodium bicarb in ASA toxicity

Alkylinizes the urine -> increased excretion

Decompensated cirrhosis -> ascites -> right sided transudative pleural effusion 2/2 passage of ascites through diaphragm - Tx

All three of: - Sodium restriction - Lasix - Spironolactone TIPS only if refractory

Tretinoin used to tx...

All-trans-retinoic acid used to treat... - Photoaging - Actinic keratoses - Fine wrinkles - Mottled hyperpigmentation - Roughness of facial skin - Appearance of brown spots regardless of etiology

Pre-existing asthma or CF -> recurrent episodes of fever, malaise, cough w/ brownish sputum, wheezing - What - Imaging - Dx - Tx

Allergic bronchopulmonary aspergillosis CXR: recurrent fleeting infiltrates Bronchiectasis on CT Eosinophilia Positive skin test for Aspergillus Positive Aspergillus IgG High Aspergillus and total IgE Oral STEROIDS ITRACONAZOLE or voriconazole

Excoriated, lichenified plaques at beltline - What - Tx

Allergic contact dermatitis - Avoid allergen - Topical high-potency steroid (betamethasone, flucinonide) - Topical tacolimus if steroid contraindicated (face)

Tx of primary myelofibrosis

Allogenic hematopoietic cell transplant

Discrete, smooth circular hair loss Scaling and inflammation of scalp in area of hair loss

Alopecia areata - Autoimmune - High recurrence rate - Tx: topical/intralesional steroids but may grow hair even w/o tx Tinea capitis - Tx:

Types of meds that cause urinary incontinence

Alpha agonists - urethral relaxation Anticholinergics, opiates, CCB - retention -> overflow Diuretics - increased volume

BPH tx and SE

Alpha antagonist - Tamsulosin, terazosin - Relax smooth muscle - Orthostatic hypotension 5-alpha-reductase inhibitor - Finasteride - Inhibit conversion of testosterone to dihydro-T - Decreased libido, ED Antimuscarinic - Tolterodine

Increased risk of bacterial vaginosis in women who have sex with women - Spread via vaginal secretions

Also increased risk of... - Cardiovascular dx - T2DM - Obesity - Cervical cancer - less HPV vaccinations and screening rates - Breast cancer - Ovarian cancer - Depression, anxiety - Intimate partner violence - Bacterial vaginosis

Hemosiderin laden macrophages

Alveolar hemorrhage - Wegner's - Goodpasture's

Sudden blindness in one eye - Condition - Physical exam

Amaurosis fugax - retinal artery occlusion, usually reversible Carotid bruit 2/2 carotid artery atherosclerosis - do a carotid doppler

Primary ovarian insufficiency - Presentation - Cause - Tx

Amenorrhea and <40 YO Hypoestrogenic sx (hot flashes) High FSH Low estrogen Cancer tx, Turner syndrome, fragile X, autoimmune oophoritis, pelvic radiation, galactosemia Estrogen therapy - With progestin if uterus intact - Continue until normal menopause age (~50)

A fib and systolic heart failure - Failed rate control so what antiarhythmic?

Amiodarone or dofetilide

Polyhadramnios - Define - Causes - Complications

Amniotic fluid index 24+ Esophageal/duodenal atresia Anencephaly Multiple gestation Congenital infection Diabetes mellitus Fetal malposition Umbilical cord prolapse Preterm labor Preterm premature ROM

Oligohydramnios - Define - Causes - Complications

Amniotic fluid index <5 Preeclampsia Abruptio placentae Uteroplacental insufficiency Renal anomaly NSAIDs Meconium aspiration Preterm delivery Umbilical cord compression

GBS ppx - what and when Indications for GBS ppx

Ampicillin, penicillin, cefazolin 4 or more hours before delivery - Maternal GBS bacturia - Positive rectovaginal culture for GBS at 35-37 weeks - Previous infant w/ invasive GBS Positive rectovaginal culture in previous pregnancy is NOT indication for future pregnancy

MC site ectopic pregnancy

Ampulla of fallopian tube

Anaphylactic vs urticarial/allergic transfusion reaction

Anaphylactic - Rapid onset shock, angioedema, urticaria, resp distress w/in seconds to minutes - Recipient is IgA deficient - 2/2 recipient anti-IgA antibodies Urticarial/allergic - W/in 2-3 hr - 2/2 recipient IgE antibodies and mast cell activation

Contraindication to DTaP vaccine

Anaphylaxis immediately after Encephalopathy w/in 7 days - 2/2 pertussis, can still get Td Immunosuppression, minor illness, or local site reactions are NOT contraindications

Contraindications to MMR vaccine

Anaphylaxis to prior MMR, neomycin, or gelatin Immunodeficiency Pregnancy NOT FEVER - GIVING TYLENOL BEFORE SHOT DOESN'T PREVENT FEVER AND MAY DECREASE IMMUNOGENICITY Okay to give with URI or AOM

Rh sensitization causes what in baby?

Anemia -> heart failure Extramedullary hematopoiesis -> HSmegaly, portal HTN, ascites, hydrous fettles Hyperbilirubinemia -> kernicterus

ACEi skin SE; kidney SE

Angioedema and urticaria; Can sometimes aggravate psoriatic rash increase serum Cr (30% expected) d/t dec GFR within first several weeks of tx; shouldn't prompt stopping

Tinea corporis - Appearance and tx

Annular plaques with peripheral scaling and central clearing

Young person with sudden cardiac death during exercise with normal echo - What - Presentation

Anomalous aortic origin of coronary arteries - Sharp curvature of anomalous artery -> less amenable to high volume flow - Passes b/w aorta and pulmonary arteries -> compression during exercise Premonitory sx of exertion angina, lightheadedness, syncope - ECG and echo may not dx

SE of SSRI/SNRI

Anorgasmia, decreased libido

Doxorubicin and danorubicin - Type of chemo - Major SE - Check this when on it

Anthracycline chemo Cardiotoxicity - Related to cumulative dose - Increased w/ pre-existing low EF Radionuclide ventriculography - MUGA - more accurate vs echo - Each chemo dose depends on MUGA result from that time

Benztropine

Anticholinergic Treat drug-induced dystonia - 2/2 dopamine antagonists like antipsychotics & metoclopramide

Subchorionic hematoma - separates chorion (outer amniotic membrane) from uterine wall - RF - Tx - Increases risk of...

Anticoaulants, infertility tx, uterine septum, leiomyoma, hx recurrent pregnancy loss Often found incidentally and are crescent shaped, hypo echoic lesions Expectant management Spontaneous abortion, abrupt placentae, PPROM, preterm birth

Buproprion mechanism

Antidepressant that inhibits reuptake of norepinephrine and dopamine

Bradyarrhythmias (sinus brady or pauses) increase risk of tornadoes in pt w/ drug-induced acquired long-QT syndrome - Meds that causes long QT?

Antipsychotics Antidepressants Macrolides Fluoroquinolones Antifungals Diuretics

Tourette syndrome tx

Antipsychotics - 1st gen FDA approved but prefer 2nd gen risperidone, aripiprazole 2/2 less SE Alpha-2 adrenergic receptor agonists - clonidine, guafacine Tetrabenazine Cognitive behavior therapy - Habit reversal therapy

HIV can cause asymptomatic thrombocytopenia and splenomegaly - Next step

Antiretroviral therapy Rare but can have active bleeding from HIV-TP so can transiently use steroids or IVIg

Epileptic woman now pregnant even thought taking OCPs. - Why?

Antiseizure meds can decrease efficacy of OCPs by inducing cytochrome P450 metabolism Phenytoin, carbamazepine, ethosuximide, phenobarbital, topiramate - Valproate and gabapentin don't - Doesn't have the same effect on IUDs or implants

New Hep C diagnosis - Tx - Check for what

Antivirals - sofosbuvir-velpatasvir Immunity to HAV and HBV - Immunize if not already - May have rapid hepatic decompensation and liver failure if they get one of them - Avoid alcohol

Who gets stress ulcer prophylaxis

Any 1 of: - Coagulopathy (low platelet, high INR or PTT) - Mechanical ventilation >48 hr - GI bleed or ulcer in last 12 mo - Head trauma, SCI, major burn 2+ of: - Steroid therapy - >1 week in ICU - Occult bleed >6 days - Sepsis

Molluscum contageosum - Where - Spread how - Think about what - Tx

Anywhere but palms and soles Skin-to-skin contact HIV test if widespread or on face Conservative tx, mostly watch

Murmur with ejection click followed by crescendo-decrescendo systolic murmur

Aortic or pulmonic stenosis - Increases with increased venous return MR is constant

Wide pulse pressure

Aortic regurgitation - Related to stroke volume

Main cause of M&M in Marfan's

Aortic root dx - Aneurysmal dilation - Aortic regurgitation - Aortic dissection Get echo prior to sport participation

Car accident -> steering wheel injury

Aortic rupture - Rapid deceleration -> shearing force along aortic arch

Bicuspid aortic valve increases risk of...

Aortic, dilation, aneurysm, or dissection - Get further imaging 1st degree relatives also get echo F/U echo every 1-2 yr

Sickle cell -> aplastic crisis vs splenic sequestration crisis

Aplastic crisis - Low reticulocyte count - Transient arrest of erythropoiesis - 2/2 infection like PARVO B19 attacking erythroid precursor cells Splenic sequestration crisis - High reticulocyte count - Splenic vaso-occlusion -> rapidly enlarging spleen - Kids prior to autosplenectomy

Brain death dx - CNS catastrophe -> neuro exam w/o reflexes -> next step?

Apnea test - No response in 8-10 minutes - PaCO2 >60 or >20 from baseline - pH <7.28

Epiglottitis - Presentation - Do what?

Appears TOXIC w/ high fever, drooling, leaning forward, severe respiratory distress, fever, stridor - NO COUGH -Hib Intubate

Pregnant with fever, right-sided abdominal pain, and leukocytosis - What - Next step - Risk of what

Appendicitis - appendix moved by baby - sometimes have normal anorexia, periumbilical pain Graded compression abdominal ultrasound -> MRI if inconclusive - CT in non pregnant is first-line If perforates, risk of spont abortion, preterm labor, pylephlebitis

Sunscreen

Apply 15=30 minutes prior to sun exposure Apply every 2 hr or after water SPF 30+ for outdoor work or recreation

3-4 mm warty projections on posterior wall of vagina, scant vaginal discharge - Test - What - Tx

Apply acetic acid - lesions turn white - Small lesions often found incidentally on PE Condylomata acuminata 2/2 HPV (STD) Trichloroacetic acid - just like you treat regular warts with acetic acid - Alternative: interferon immunotherapy - Podophyllin works but can't use internally or in pregnancy

TCA side-effect

Arrhythmia

Psoriatic arthritis - Presentation

Arthritis - DIP, asymmetric oligo, symmetric poly, mutilans (deforming), spondylarthritides Enthesitis, NAIL PITTING, dactylics, swelling of hands/feet Arthritis precedes skin lesions 15%

Mesothelioma

Asbestos exposure DOE, CP Nodular thickening of pleura and/or obscuring diaphragm

Acute cholangitis - Etiology - Presentation - Dx - Tx

Ascending infection 2/2 biliary obstruction Fever, jaundice, RUQ pain +/- hypotension, AMS High D bili, alk phos Mildly high LFTs Biliary dilation on US or CT Abx for enterics (zosyn, cipro + flagyl) ERCP w/in 24-48 hr for biliary drainage - Lap chole in future

Lactose intolerance - Presentation - Dx - Tx

Asian or AA - GI distress after dairy, periumbilical pain, flatulence/bloating, watery diarrhea No sx after dairy-free diet, lactose breath hydrogen test Don't eat the darn dairy - Cheese and yogurt have less dairy and cause less sx than milk or ice cream

Perform suicide risk assessment on all patients in ED with psych symptoms or erratic behavior - EtOH's disinhibition effect increases suicide risk

Ask about ideation, intent (desire to act) and if there's specific plan

ED but gets normal nocturnal erections - Next step?

Ask about psych stuff

Guy doesn't want to be tested for HIV. - Next step? - Gets tested. Is positive. Doesn't want to tell partner. Next step?

Ask why - Don't just accept - Must report HIV to Dept Public Health - Requirement to tell partners is state dependent, but do encourage pt to tell them

Old person with new-onset cognitive impairment - Next step - Increased risk of...

Assess for depression leading to pseudodementia - Impairment often resolves w/ tx - NOT MMSE Increased risk of actual dementia later in life (vascular, Alzheimer, etc.)

Fisher's exact test

Association b/w 2 categorical variables when number of observations is small

Parvovirus

Asx in adults usually - Can cause arthritis/arthralgia, fever, reticulated or lace-like rash

Chronic diarrhea - How long - Causes

At least 4 weeks IBS, IBD, chronic infxn, malabsorption (celiac, lactose intolerance)

Posterior inferior cerebellar artery aneurysm - sx?

Ataxia and bulbar dysfunction

Post-op day 2-5 w/ increased WOB or hypoxemia and CXR w/ linear pacification's at lung bases - What - ABG - Tx

Atelectasis Increased A-a gradient 2/2 intrapulmonary shunting Mild - CPAP Severe or more secretions - chest physiotherapy and suctioning

Itchy rash on abdomen and cheeks sometimes with crusted lesions that's worse in summer and after bathing - What - Tx

Atopic dermatitis (eczema) RF: low humidity, family hx Topical emollients +/- topical steroids

AML - smear and tx

Auer rods Idarubicin and cytosine arabinoside

Primary biliary cholangitis - What - Sign/sx - Dx - Tx - Associated with

Autoimmune - fibrosis of intrahepatic biliary ducts Fatigue and pruritus Inflammatory arthritis, hyper pigmented skin, RUQ pain, xanthelasmata, xanthomata HIGH alk phos, antimitochondrial antibody (liver bx if negative) Ursodeoxycholic acid - Liver transplant is cure Osteopenia/porosis

Pemphigoid gestionis

Autoimmune dx in 2nd/3rd tri Abdominal pruritus -> truncal rash - Periumbilical urticarial papules or plaques that develop into vesicles and bullae and spread over entire body (not MM) Dx with skin bx Tx w/ topical steroids - Antihistamines for pruritus

Guillain-Barre syndrome

Autoimmune, demyelinating polyradicuoneuropathy - Preceding respiratory/GI illness (C. jejune) - Ascending weakness and mild sensory symptoms with later bulbar/diaphragmatic involvement

HOCM - Inheritance - Murmur - Tx

Autosomal dominant SEM at left sternal border Increases w/ decreased preload Decreases w/ increased preload Negative inotropic medications - Beta-blockers for mono therapy - Add verapamil or disopyramide - Alcohol ablation on if fail meds

Marfan syndrome - Etiology and inheritance - Signs/sx - Concerned about what developing

Autosomal dominant defect in fibrillar-1 gene High arm:height ratio, low upper:lower body ratio, arachnodactyly, joint hyper mobility, pectus excavatum/carinotum Ectopia lentis - lens dislocation Aortic dissection 2/2 aortic root dilation - echo at dx/annually and give beta-blocker

Tuberous sclerosis - Pathophys - Features - Eval

Autosomal dominant or de novo mutation of TSC1 or 2 gene Derm - Hypopigmented "ash-leaf spots" - Angiofibromas of malar region - Shagreen patches Neuro - CNS lesion - glial hamartomas - Epilepsy - Cognitive disability, autism CV - rhabdomyosarcoma Renal - angiomyolipoma Skin exam, fundoscopy, brain MRI, EEG, abdominal imaging-kidney

Homocysteinuria

Autosomal recessive Marfanoid habitus, myyopia, ectopie lentis (downward vs upward in Marfan syndrome)

Kartagener syndrome

Autosomal recessive Situs inversus Chronic sinusitis Airway dx -> bronchiectasis

Colon cancer screening - Who is average risk? Screen rec? - Who is high risk? Screen rec?

Average - gen pop, one 1st degree relative >6o w/ colon CA or adenomatous polyps - Screen at 50 - c-scope q10, flexible sigmoidoscopy q5 - Annual FOBT or FIT High - 1st degree <60 w/ CA or adenomatous polyps; >2 1st degree w/ colon CA any age - C-scope at 40 OR 10 years before age of CA dx - Repeat q3-5y

Hawthorne effect

Aware being observed, changing behavior Leads to overestimation of effect which threatens internal validity

Syphilis tx if allergic to penicillin - Non-pregnant - Pregnant

Azithromycin or erythromycin IF PREGNANT, DESENSITIZE THEN GIVE PENICILLIN!!!!!!!! - Repeat titers in 3rd trimester and at delivery

Enlarged neck lymph node associated with cancer

B cell lymphoma associated with Sjogren's syndrome if no EtOH/smoking Metastatic squamous cell carcinoma if smoke/drink

Cancer associated with Sjogren's

B-cell non-hodgkin's lymphoma Sjogren's causes polyclonal B cell activation and infiltration of salivary glands

Essential tremor - Presentation - Tx

B/l hands Worsens with fine motor activity Often the only neuro finding Propranolol, primidone

B12 vs folate deficiency anemia

B12 - neuro symptoms Folate - NO neuro symptoms

Progressive memory impairment, impaired vibration sense, positive Romberg sign, spastic paresis, hyperreflexia

B12 deficiency -> subacute combined degeneration - Dementia - Dorsal spinal column: vibration, Rhomberg - Lateral corticospinal: spastic paresis, hyperreflexia Sx reversible w/ B12 supplements

What increases risk of male breast cancer?

BRCA mutation - autosomal dominant - BRCA2 is biggest RF Klinefelter syndrome - extra X chromosome - not inherited so family hx doesn't mater Hepatic dysfunction, marijuana, obesity - increase estrogen-to-androgen ratio

Treatment of the vaginal infections

BV - clinda or metronidazole (cover anaerobes) Trich - metronidazole and treat partner (STD) Candida - fluconazole

- Red flags with scoliosis - Concern for what? - Test

Back pain, neuro sx, rapidly progressive (>10 degrees/yr), vertebral anomalies on XR Spinal cord tumor - dull, gnawing MRI spine

Conjuctivitis treatment - Bacterial - Viral - Allergic

Bacterial - Erythromycin, polymyxin-trimethoprim, or azithro drops - Wear CONTACTS? FLUROQUINOLONE drops for pseudomonas Viral - Warm/cold compress +/- antihistamine drops Allergic - OCT antihistamine/decongestant drops - Mast cell stabilizer/antihistamine drops for frequent episodes

CSF in bacterial meningitis vs TB

Bacterial - VERY HIGH WBC >1000 - Low glucose <40 - HIGH protein >250 TB - High WBC 5-1000 - VERY LOW glucose <10 - HIGH protein >250

Child with fever, cramps abdominal pain, bloody diarrhea

Bacterial enteritis Tx - oral volume replacement - Avoid abx until organism identified as it can prolong Salmonella or worsen E coli O157:H7 into HUS

Most common complication in hospitalized patient for acute vatical bleed

Bacterial infection - SBP, UTI, URI, aspiration PNA, primary bacteremia - Give ppx cipro 7-10 days

Endopthalmitis

Bacterial infection of deep eye (vitreous) 2/2 direct inoculation (surgery/trauma) or hematogenous spread

Thin malodorous vaginal discharge with stippled epithelial cells - What - Test - Tx - Increased risk of what if preggo?

Bacterial vaginosis - overgrowth of anaerobic vaginal flora Positive KOH whiff test Clue cells Oral or vaginal metronidazole or clindamycin PPROM, preterm labor, chorioamnionitis, postpartum endometriosis

Cat scratch dx - Bug - Presentation

Bartonella henselae Suppuration of lymph nodes - Also neuroretinitis, fever, encephalopathy, HSmegaly

Cat scratch dx - What - Presentation - Dx - Tx

Bartonella henselae - Via cat scratch or bite Papule at site, regional LAD +/- fever unknown origin Dx usually clinical, +/- serology Mild cases self-resolve in 1-4 months Azithromycin shortens length and symptoms Add clindamycin (staph/strep) in unclear cases of lymphadenitis

Vascular dementia presentation

Behavioral changes and cognitive deficits - RAPID ONSET and progresses in STEP-WISE fashion Clinical or radiographic evidence of stroke

Lung nodule - What calcification pattern suggests benign? Malignant?

Benign: popcorn, concentric, laminated, central, or diffuse homogenous Malignant: eccentric, reticular, punctate

Cocaine-induced chest pain tx - Increases risk of ACS, aortic dissection

Benzos - Also nitro, ASA, and O2 Get CTA chest if new weakness, pain not improved - suspect aortic dissection NO BETA BLOCKERS

Lifestyle medications and HTN - Best - Others

Best - weight loss DASH diet, exercise, low sodium diet, mild EtOH intake

Rapid a fib -> first line tx

Beta blocker (metoprolol, atenolol) OR Nondydropyridine CCB (diltiazem, verapamil) Careful if hypotensive, decompensated CFH, bradyarrhthmias

Hospitalized pt for CAP - Abx?

Beta-lactam (ceftriaxone) AND Macrolide (azithromycin) OR Rest fluoroquinolone (levofloxacin) Covers S. pneumo + atypicals (Legionella) Don't have to cover for Pseudomonas unless HAP, recent abx, or has structural lung dx

Anterior shoulder pain Pain w/ lifting/carrying/overhead reaching

Biceps tendinopathy

Cholecystectomy -> watery diarrhea - Why - Tx

Bile salts converted to 1 bile acids in liver then to 2 bile acids by bacteria in gut -> excess amount after chole leads to diarrhea Also seen after ill resection (short bowel syndrome) Tx with cholestyramine, a bile salt-binding resin

Dx sarcoidosis

Biopsy easiest access lesion - Lymph node - Skin lesion Fiberoptic bronchoscopy only if other lesions not present

Herbal meds that cause hepatotoxicity

Black cohosh - postmenopausal sx Kava - anxiety, insomnia

Tx of acute bacterial prostatitis

Bladder decompression with suprapubic cath if retaining Empiric abx - bacterium, cipro DON'T DO PROSTATE MASSAGE AND FLUID ANALYSIS - Only done with chronic bacterial prostatitis - Increases bacteremia risk

SGLT2 inhibitors can causes what SE?

Blocks glucose reabsorption in proximal renal tubule -> glucosuria Leads to vulvovaginal candidiasis, polyuria, increased UTIs

Who gets irradiated RBCs for transfusions?

Bone marrow transplant recipient Acquired/congenital cellular immunodeficiency Blood components donated by 1st or 2nd degree relative

Paget's dx - When to tx - Tx

Bone pain, involvement of weight bearing bones, neuro compromise, hyperCa, hypercalciuria, CHF Alendronate

Lyme dx - Bug - Early sx - Tx

Borrelia burgdorferi from Ixodes scapularis W/in 1 mo - Viral-like sx - Erythema migrans - slow spreading, erythematous rash which starts as confluent macule Start oral doxy 14 days - Early disease dx clinically as serologic test often false negative - Late dx? Test first w/ ELISA and confirm w/ Western blot then tx

Brugada syndrome Long QT syndrome

Both can cause sudden cardiac death but not usually exertional Brugada - RBBB, ST elevation V1-V3 Long QT - >450 in men, >470 in women

Blepharospasm - Involuntary eye closure provoked by external stimuli (lights, smoke) - A focal dystonia Tx?

Botulinum toxin injections

Bulbar weakness, impaired pupillary response, preserved sensory function after eating home-canned food

Botulism - Toxin acts at peripheral nerve endings to inhibit Each release - leads to NMJ failure - Descending limb and bulbar weakness - Absent reflexes - Autonomic dysfunction (blurry vision 2/2 accommodation failure) - Normal sensation

Ulcerative colitis flare -> severe abd pain, bloody BM, fever, tachycardia - Tympany to percussion suggests what? Do what?

Bowel dilation - Abdominal X-ray w/ air fluid levels, dilated transverse colon 6+ cm -> toxic megacolon - Try nonsurgical management with NG tube, bowel rest, admit to ICU, IVF, steroids to decrease inflammation 2/2 UC (don't use if infectious origin)

Kawasaki dx - Presentation - Sequela - Look out for, check this - Tx

Boy age 5 or less w/ - Fever 5 days - Cervical LAD - Swelling/erythema palms/soles - Mucositis (strawberry tongue) - Conjunctivitis w/o exudate - Rash (inguinal folds, perineum, trunk) - peeling - High CRP, ESR MI and coronary artery aneurysm - Usually after 10th day - Echo - f/u studies at 2 & 6 weeks - low risk in future if baseline normal IVIg and ASA - No live vaccines for 11 months after IVIg

Precocious puberty

Boys <9 and girls <8 Central precocious puberty 2/2 early maturation of HPA axis - Causes normal sequence with breast or testicular development first

Fragile X syndrome

Boys with long, narrow faces, large ears, large testicles Increased frequency of autism spectrum disorders

Mixed osteolytic/osteoblastic lesions - Cancer - Next step

Breast cancer Usually seen on radionuclide but may need PET

Raloxifene

Breast cancer treatment - Used in post-menopausal women - Estrogenic effects on bones - Anti-estrogenic effects on breast and uterus - May increase risk of hot flashes and DVT

What hormone therapy - Increases breast cancer - Increases endometrial cancer

Breast cancer: combined estrogen/progesterone Endometrial cancer: unopposed estrogen

Diffuse, b/l breast tenderness 1. What 2. Tx

Breast engorgement Cold compress and NSAID

Breastfeeding (failure) jaundice vs Breast milk jaundice

Breastfeeding failure - 1st week - Lactation failure -> decrease bile elimination - Poor feeding, sx of dehydration Breast milk - 3-5 days, peaks at 2 weeks - High b-glucuronidase in milk deconjugates intestinal bilirubin - Ok feeding, normal exam - Continue breastfeeding exclusively, resolves by 3 months

Shoulder dystocia - anterior fetal shoulder doesn't deliver w/ usual maneuver - gentile downward traction - Tx

Breath, don't push Elevate legs, flex hips (thighs against abdomen) - McRoberts maneuver is 1st line Apply suprapubic pressure Episiotomy 2nd line maneuvers - Deliver posterior arm - Rotate posterior shoulder - Adduct posterior shoulder - Mother on hands and knees - Replace fetal head into pelvis for c-section

Periodic breathing

Breathing pause of 5-10 seconds then rapid, shallow breaths then back to normal without stimulation or intervention - No signs of respiratory distress Recurrent central apnea 2/2 immaturity of nervous system up to age 6 months

Recurrent pneumonia, foul smelling sputum, hemoptysis What's going on?

Bronchiectasis Damage to bronchial walls from infection and inflammation predisposes to repeat infections. Chronic airway edema and inflammation leads to rupture of superficial vessels and hemoptysis.

Exercise-induced asthma - Dx - Tx

Bronchoprovocation testing -Exercise -Inhalation of dry, cold air -Positive test is fall in FEV1 greater than 10% Treatment: SABA prior to exercise - Sometimes mast cell stabilizers (cromolyn)

Bullous pemphigoid vs Pemphigus vulgaris

Bullous pemphigoid - TENSE bullae - Itching - Erythema, urticaria Pemphigus vulgaris - FLACID bullae - Sloughing of skin - Oral lesions

Antidepressant that doesn't cause weight gain

Buproprion

Buproprion vs Varenicline (Chantix)

Buproprion - Less post-cessation weight gain - Tx unipolar depression - Contraindicated w/ seizure or eating disorder Varenicline - More effective - Increased risk cardiovascular outcomes

Tx of opthalmopathy with Graves

Prednisone prior to RAI or thyroidectomy

Acne treatment in women - Use if may become pregnant - Avoid in pregnancy - Absolutely contraindicated in pregnancy

Prefer topical erythromycin, clindamycin (inflammatory), or azelaic acid (comedonal) Avoid tretinoin and benzoyl peroxide (class C) Never tazarotene or isotretinoin (class X)

HELLP Syndrome - Presentation - Lab - Tx - Complications

Pregnant w/ n/v, RUQ pain, HA, vision changes, HTN - >20 weeks or postpartum - Variant of preeclampsia MAHA - anemia, high bili Elevated LFTs Thrombocytopenia +/- Proteinuria Delivery, give mag sulfate for seizure ppx, hydrazine if BP >160 Abruptio placentae, sub capsular liver hematoma, ARF, pulmonary edema, DIC

Cerebral venous sinus thrombosis - Presentation - Tx

Pregnant, OCPs, cancer, infection, head trauma - Increased ICP -> HA - Venous congestion -> focal deficits (hemiparesis), seizures, AMS Dx w/ MRI Tx - LMWH even if see hemorrhagic foci or infarct

Inferior MI (II, III, aVF) -> hypotensive shock?

Preload dependent - probably got nitrates, diuretics, or opioids Give IVF - Dopamine if not working (inotrope)

Biggest risk factor for coronary stent thrombosis

Premature discontinuation of DAPT

Iron deficiency in kids >1 YO <1 YO Dx Tx

Prematurity, lead exposure <1 - delayed introduction of solids (after 6 mo), cow soy or goats milk >1 - >24 oz cow milk a day, <3 servings per day iron rich food Screening hgb at 1 YO - <11 Empiric trial of iron

Cryptochridism - RF - Presentation - Tx - Complicaitons

Prematurity, small for gestionational age, low birth weight, genetic d/o Empty, hypo plastic, poorly rugated hemiscrotum +/- inguinal fullness Surgery referral by 6 months (rare to descend spontaneously after that) - Orchiopexy BEFORE age 1 yr Inguinal hernia, testicular torsion, sub fertility, testicular cancer

Prolactinoma - Sx - Testing - Tx

Premenopausal: galactorrhea, oligo/amenorrhea, hot flashes, osteoporosis Postmenopausal: HA, bitemporal hemianopsia (mass effect) Men: infertility, decreased libido, impotence, gynecomastia High prolactin, check for AKI (Cr) and hypothyroidism (TSH, T4) MRI brain/pit Cabergoline (dopamine agonist - inhibits prolactin secretion) Trans-sphenoidal surgery

ADHD tx - Preschool kids - Older kids

Preschool - behavior therapy first - Parent-child behavioral therapy Older >6 - pharmacotherapy first

Antibiotic choice for PNA in... - Preschool age OR focal lung findings - Older child OR well-appearing w/ bilateral lung findings

Preschool age OR focal lung findings - AMOXICILLIN for strep pneumo Older child OR well-appearing w/ bilateral lung findings - AZITHROMYCIN for mycoplasma pneumoniae - Doxy contraindicated in kids <8 2/2 teeth staining

Tamoxifen - Used for - SE

Prevent BC in high risk patients Adjuvant tx of BC - Endometrial hyperplasia and cancer - don't have to screen unless sx develop - Hot flashes - DVT

Solitary pulm nodule on CXR. Next steps?

Previous CXR - If stable, no further tests No previous - CT chest - Benign features - serial CT - ?/intermediate - bx or PET - Suspicious for CA - surgical excision

Risk factors for ectopic pregnancy

Previous ectopic Previous pelvic/tubal surgery Pelvic inflammatory dx Smoking

Strongest RF for suicide

Previous suicide attempt

Anti-mitochondrial antibodies

Primary biliary cirrhosis

Causes of primary and secondary hypogonadism in boys

Primary: Klinefelter syndrome Secondary - Constitutional, chronic illness, malnutrition - Hypothyroid, hyperprolactinemia - Kallmann syndrome - Craniopharyngioma

FSH and LH levels in primary vs secondary hypogonadism Why get prolactin and TSH levels?

Primary: elevated FSH/LH Secondary: low to normal FSH/LH Increased prolactin or TSH interferes with GnRH secretion

Prevention... - Primordial - Primary - Secondary - Tertiary - Quaternary

Primordial - Prevent risk factors Primary - Prevent event before it happens Secondary - Halt progression at initial stage before irreversible changes Tertiary - Dx past initial stages, now taking all actions to limit impairment and disability Quaternary - Limit consequences of unnecessary/excessive intervention

Pt with egg allergy. Flu shot?

Prior reaction to egg was urticarial, give shot and no observation required Poor reaction was more severe, GIVE shot, observed for a bit. ONLY CONTRAINDICATION TO FLU SHOT IS ALLERGIC REACTION TO VACCINE ITSELF

Uterine rupture - RF - Presentation - Management

Prior uterine surgery, induction/prolonged labor, congenital uterine anomalies, fetal macrosomia Vaginal bleed, intra-abd bleed (high HR, low BP), fetal heart late decelerations , loss of fetal station, palpable fetal parts on abd exam, loss of intrauterine pressure Laparotomy

NPV

Prob dx absent given negative test TN / (TN + FN)

PPV

Prob dx is present given positive test TP / (TP + PF)

Sensitivity

Prob dx person testing postive TP / (TP + NF)

Specificity

Prob non-dx person testing negative TN / (TN + FP)

Likelihood ratio

Probability of a given result occurring in pt with a dx compared to same result in pt without a dx - DO NOT CHANGE WITH DISEASE PREVALENCE (like sensitivity and specificity) +LR = sensitivity / (1 - specificity) - LR = (1 - sensitivity) / specificity

Osteomyelitis - Initial screen - Officially dx with... - How to decide on abx

Probe-to-bone testing MRI - sensitive, high NPV Bone bx w/ culture - NOT wound cultures (polymicrobial), blood cultures are a little better

Suspect bullies pemphigoid - Presentation - Dx - Tx

Prodromal itching and urticaria Erythematous rash, tense bullae Confirm dx with skin bx of margin of lesion - Sometimes with serum assay for basement membrane antibodies Mild: topical high-potency steroids (clobetasol, betamethasone) Mod-severe: oral prednisone, azathioprine, methotrexate, doxy

Rabies - Features - Posteexposure ppx - Prognosis

Prodrome of fever, malaise then.... Encephalitis - hydrophobia -> pharyngeal spasm, aerophobia, agitation, spastic paralysis Paralytic - ascending flaccid paralysis Rabies immune globulin and vaccine - only effective if no sx yet Coma, respiratory failure, death within weeks

Contraceptive to use in PCOS

Progestin IUD - Protects against endometrial hyperplasia and cancer

- Most effective contraceptive? - Mechanism - SE

Progestin subnormal implant >99% - less failure vs IUD & sterilization - Progesterone thickens cervical mucus, decreases tubal motility - Decreases FSH and LH secretion which suppresses ovulation Unscheduled bleeding (most common), weight gain, HA

Choledocholithiasis - Sx - Dx and next step

Prolonged biliary colic and high LFTs, bili, and alk phos Dx with RUQ US then do ERCP to remove the stone if... 1. Visualized choledocholithiasis on US 2. High risk features (dilated CBD, elevated bili) 3. Acute cholangitis (fever, RUQ pain, jaundice, hypotension, confusion) - also get IV abx Non-emergent lap chole after ERCP

Case fatality rate

Proportion of people WITH condition who die from it Contrast with mortality rate which is the probability of dying from a dx in the general population

Attack rate

Proportion of people in whom dx occurs out of total population at risk for dx

Relative risk reduction (RRR)

Proportion of risk reduction 2/2 specific intervention/exposure vs. control (risk unexposed - exposed) / (risk unexposed) OR 1 - RR and RR = (risk unexposed / risk exposed)

Migraine HA prevention

Propranolol

Misoprostol - What - Why

Prostaglandin E1 analog Cervical ripening and labor induction (stimulate contractions prior to spontaneous labor) NOT for labor augmentation

Cancers that met to spinal column

Prostate, breast, NHL, RCC

Osteoblastic cancer lesion - What cancers - Next steps

Prostate, small cell lung, Hodgkin lymphoma Radionuclide bone scan - If +, MRI if neuro involved

Intracranial bleed on warfarin - give what for reversal?

Prothrombin complex concentrate - Vit K dependent clotting factors - Normalized INR in <10 min Also give IV vit K but takes 12-24 hours for full effect FFP is 2nd line due to large volume and required blood compatibility testing

Chagas dx - What - Signs/sx

Protozoan Trypanosoma cruz - Mexico and C/S America DILATED CARDIOMYOPATHY Biventricular heart failure w/ cardiomegaly Ventricular apical aneurysm Mural thrombosis w/ emboli Fibrosis -> arrhythmia, AV block Progressive dilation of esophagus and colon

Myasthenia graves sx

Proximal muscle fatigability rather than weakness Facial/oculobulbar sx Normal muscle enzymes

Dermatomyositis - Presentation - Labs - Tx

Proximal, symmetric UE and LE muscle weak Gottron's papules, heliotrop rash ILD, dysphagia, myocarditis High CPK, aldolase, LDH Anti-RNP, -Jo1, -Mi2 If still ?, EMG or bx High dose steroids PLUS steroid sparing agent Associated with cancers and sx may resolve if cancer tx

Atopic dermatitis - Clinical findings - Labs - Tx

Pruritic Infants: red crusted lesions of extensor surfaces and face Kids/adults: flexural eczema and lichenification High IgE, eosinophilia, high leukocyte phosphodiesterase 1. Avoid dry environment/harsh soap, oral antihistamine, lotion 2. Topical steroid

Scabies - Presentation - Tx

Pruritic rash in webbed spaces of hands/feet, axillary folds, and genitalia Oral ivermectin

Dermatitis herpetiformis - Presentation - Associated with - Dx

Pruritic vesicles and papule on elbows, knees, low back, butt Celiac dx Skin biopsy

Groin accessed cardiac cath, now has pulsatile tender mass with systolic bruit - What - Next step - What if bruit was continuous

Pseudoaneurysm Ultrasound Continuous murmur = AV fistula

B/l cataracts, basal ganglia calcification, low calcium, high phosphorus, high PTH

Pseudohypoparathyroidism -> chronic hypocalcemia 2/2 end-organ resistance to PTH -> Calcium released from bone and increased vit D to stimulate intestinal calcium absorption Seizures, muscle cramping, hyperreflexia, BG calcificaiotns, cataracts

Pain in RLQ with passive ipsilateral hip extension

Psoas sign of retrocecal appendicitis

MVC -> chest discomfort and tenderness -> rales in LUL -> CXR w/ irregular opacification of LUL - What?

Pulmonary contusion - Blunt trauma - Irregular localized opacification - Onset of respiratory sx may be delayed 24 hr - Tx is supportive

Factitious disorder

Purposefully falsify sx to assume sick role

Gonococcal urethritis - Urethral fluid characteristic - Urethral gram stain - Tx

Purulent Intracellular gram-negative diplococci Ceftriaxone plus azithro

Maternal macrolide use during pregnancy increases risk of...

Pyloric stenosis - Age 1 month non bilious projectile vomiting - Olive shaped abdominal mass - Target sign on US

Give what with isoniazid? Why?

Pyridoxine (B6) to prevent neuropathy

Recurrent PNA, sinusitis, episode of bloody diarrhea. Fibrosis on CXR. - Next step

Quantitative measurement of serum Ig levels for deficiency - IgG3 - adult females, recurrent sinopulmomary and GI infxns - IgA - Common variable immunodef. - suppressed cell immunity and increased cancer risk

Quantitative vs qualitative variable

Quantitative: measured numerically Qualitative: groups or categories (male or female)

RBBB EKG

R prime in V1 Wide S in V6

TNF-alpha receptor inhibitors treat what?

RA

TURP -> complication

RETROGRADE EJACULATION - UTI and urethral strictures less common - Urinary incontinence and ED even less common

Auricular hematoma

RF - contact sports Tender, fluctuant blood collection on anterior pinna Tx: immediate I&D to prevent permanent deformity - Pressure dressing - Sometimes ppx abx - F/U daily 3-5 days Complications: - Cauliflower ear (fibrocartilage overgrowth), bacterial superinfection, reoccurence

Epithelial ovarian cancer - RF - Protective factors - Lab - US finding - Tx

RF: fam hx, BRCA1/2, >50 YO, hormone replacement, endometriosis, infertility, early menarche, late menopause PF: OCPs, multiparty, breastfeeding CA-125, unreliable if pregnant Solid, complex mass w/ separations, ascites Surgery +/- chemo - If pregnant, surgery in 2nd tri

Hip developmental dysplasia - Abnormal acetabular devleopment -> shallow hip socket - Hip dislocates -> hip "clunk," asymmetric leg creases on exam - If missed when little, see leg-length discrepancy, toe walking on affected side, Trendelenburg gait - Early OA and activity-related hip and groin pain RF, maneuvers, mgmt

RF: females, breech position, fhx, excessively tight swaddling maneuvers: barlow (attempt to dislocate an unstable hip) and ortolani (attempt to reduce it); galeazzi test (see apparently leg length discrepancy; affected leg is shorter; kid lies supine with knees flexed) mgmt: referral to ortho; if <6mo Pavlik harness for 3 mo (hip is flexed and abducted) (inc risk for avasc necrosis, femoral nerve palsy); if tx early in infancy - no long term sequlae

Mallory-weiss

RF: hiatal hernia, alcoholism -d/t vomiting -> mucosal tear -> see longitudinal lac on endoscopy -tx: resuscitation; PPi; most heal spontaneously, endoscopic tx for persistent bleeding

Peripartum cardiomyopathy - RF - Clinical features - Management - Recurrence risk

RF: mom >30 YO, multiple gestation, pre/eclampsia LVEF <45%, starts between 36 wks and 5 mo postpartum, no other cause Deliver based on maternal hemodynamic stability Start standard heart failure meds (1st loops for vol overload; then dec both preload and afterload to lessen demand on LV with combo hydralazine (direct arterial dilator) and long acting nitrate (venous dilation); when acute decomp of HF is adequately treated, BB can be started; if persistent sxs can use cardiac glycoside) Thromboembolism pix Increased recurrence if EF <20% at dx, persistent LV systolic dysfxn ACE and ARBs a/w fetal renal tox, PDA, neonatal death; spironolactone may cause feminization of male fetus and other endocrine problems

Onychomycosis - RF - Exam - Dx - Tx and potential SE

RF: older age, tine pedis, DM, PVD Thick, brittle, discolored nails KOH, periodic acid-Schiff stain, if negative do culture ORAL TERBINAFINE or itraconazole - 6 wk fingernail, 12 wk toenail - Second line is griseofulvin, fluconazole, or ciclopirox - SE: hepatoxicity, reoccurrence

Woman with right sided pelvic pain and tender adnexal mass - What - RF - Imaging - Tx

RF: ovarian mass, reproductive age, infertility tx Adnexal mass w/ absent Doppler flow to ovary Laparoscopy w/ detorsion Ovarian cystectomy Oophrectomy if necrosis or malignancy

Active TB tx

RIPE for 2 months THEN RI for 4 months Only need to do sputum or gastric lavage AFB testing and cx for active pulm TB, not latent

When to use RR vs OR

RR - observational or experimental follow-up studies OR - case-control or cross-sectional studies

Relative risk (RR)

RR = risk exposed / risk unexposed

Acetaminophen overdose - Labs - Tx

RUQ pain Markedly elevated LFTs >3000 Elevated T bili N-acetylcystein

Tetralogy of Fallot

RV outflow obstruction Overriding aorta RV hypertrophy VSD

Radiation-induced cardiotoxicity

Radiation -> fibrosis - Narrowing of postal part of coronary vessels -> MI - Restrictive cardiomyopathy w/ diastolic dysfxn - Constrictive pericarditis - Mitral and aortic stenosis or regurg - Conduction defects (sick sinus syndrome, heart block)

Turner syndrome inheritance

Random - result of nondisjunction so girl is 45,XO (monosomy X) No increased risk for next pregnancy

ACL tear - Mechanism - Sx - Exam - Dx - Tx

Rapid deceleration or direction change - pivot w/ foot planted RAPID pain onset, may be severe POPPING sensation Rapid swelling/HEMARTHROSIS Joint instability - awkward walking Anterior drawer and Lachman MRI RICE +/- surgery

Post-op tachycardia, tachypnea, persistent hypoxemia even after supplemental O2 - Do what?

Rapid-sequence intubation - Use rapidly acting sedative (succinylcholine, etomidate, propofol) and a paralytic (succinylcholine, rocuronim)

Negative likelihood ratio

Ratio of likelihood of having dx given negative result LR- = (1 - Sensitivity) / specificity <1 = decreased likelihood dx present 1 = no change >1 = increased likelihood dx present

Positive likelihood ratio

Ratio of likelihood of having dx given positive test LR+ = Sensitivity / (1 - Specificity) <1 = decreased likelihood dx present 1 = no change >1 = increased likelihood dx present

Congenital toxoplasmosis - How to get it - Presentation - Dx - Tx

Raw meat, contaminated soil on unwashed produce, cat poop - Macrocephaly - DIFFUSE intracranial calcifications - Hearing impairment - Hydrocephalus - Chorioretinitis - Jaundice, IUGR, HSmegaly, blueberry muffin spots Serology Pyrimethamine, sulfadiazine, folate

Vulvodynia - Presentation - Dx - Tx

Raw, burning vulvar pain 3+ mo. Pain with labial separation Idiopathic Sharp pain with light contact of Q-tip Behavior modification Pelvic floor physiotherapy Cognitive behavioral therapy

Recent chlamydia => asymmetric oligoarthritis w/ high WBC but negative culture

Reactive arthritis - 1-4 weeks after infection - Repeat chlamydia test even if asx - May see after gastroenteritis - Also see urethritis, uveitis, circinate balanitis (painless, shallow ulcers on penis, may last months), keratoderma blennorrhagicum - Tx w/ abx for chlamydia, NSAIDs

Increased C diff risk with...

Recent antibiotics Gastric acid suppression - PPIs alter colonic microbiome Hospitalization Advanced age

Long-term complication of IVC filter

Recurrent DVTs - Prevents PEs, not DVTs

Acute intermittent porphyria

Recurrent episodes of abd pain worsened by meds (phenytoin), menstruation, illness, surgery Peripheral neuropathy, tachycardia, hyponatremia Presents early, usually after puberty

Acute decompensated heart failure initial symptomatic management goal

Reduce cardiac preload - Diuretics and/or vasodilators Increased preload leads to back up of fluid and increased pulm cap wedge pressure and fluid accumulates in the lung

Vertebrobasilar insufficiency - What - Presentation - RF

Reduced blood flow in the base of the brain 2/2 secondary emboli, thrombi, or arterial dissection Labyrinth and brainstem -> vertigo, dizziness, dysarthria, diplopia, numbness - Vertigo often resolves on its own RF: DM, HTN, HLD, arrhythmia, CAD, smoking

Do CABG in...

Refractory angina despite max medical therapy Left main dx Multivessel CAD (especially proximal LAD or if have DM) and LV systolic dysfunction

Clozapine - Use - SE

Refractory schizophrenia or schizoaffective Neutropenia/agranulocytosis - Monitor absolute neutrophil count weekly during first 6 months then every other week for 6 months then every 4 weeks forever - Fever, weakness, lethargy, sore throat

Non-gonococcal urethritis with sx after azithromycin tx - Why - Next steps

Reinfection, med non-compliance, organism resistant to azithro (Mycoplasma genitalium) Repeat urethral swab and NAAT for the common urethritis bugs

Lupus -> proteinuria, hematuria, RBC casts, LE edema, elevated creatinine - Next step?

Renal biopsy - DO BEFORE TREATMENT - Class 1, II = no tx - Class III, IV = steroids and cyclophosphamide or mycophenolate mofetil - Class V (membranous) = immunosuppression if proliferative lesions or nephrotic sydrome - Class VI = advanced dx, immunosuppression not recommended

Abd CT: enhancing mass of kidney w/ thickened, irregular septa - What - Tx

Renal cell carcinoma Nephrectomy usually curative

Smoking hx with erythrocytosis and hematuria - Concern for what - Risk factors - Exam - Workup - Tx

Renal cell carcinoma RF: smoking, obesity, HTN Flank pain, hematuria, palpable abdominal mass Erythrocytosis on CBC CT abdomen

High Ca, next step? Then what?

Repeat Ca and get PTH - If high PTH, check PTHrP, 25- and 1,25 vit D

Polycythemia - Next steps and interpretation

Repeat H&H and if still high then check erythropoietin level Low EPO - polycythemia vera - Check JAK2 High EPO - chronic hypoxia, RCC - Check carboxyhemoglobin - carbon monoxide toxicity - Nocturnal oximetry for obesity hypoventilation or OSA

Pituitary incidentaloma with normal labs. Next step?

Repeat MRI 6-12 months

Sensitivity analysis

Repeat primary analysis calculations after modifications of criteria to see if modifications change results

Find out other doctor had sexual relationship with patient. Do what?

Report it to the state medical board yourself

TRALI

Resp distress and noncardiogenic pulm edema w/in 6 hr 2/2 donor anti-leukocyte antibodies

ADHD pts may outgrow the hyperactive sx but continue to have attention deficits ->

Resume tx with CBT if >6 YO, stimulant medication otherwise is 1st line No increased risk of substance abuse unless pt already has hx of substance use disorder (more than just occasional use)

Normocytic normochromic anemia - Check what? What does it mean if high or low?

Reticulocyte count High - hemolytic - check bili, haptoglobin, LDH, look for splenomegaly, Coombs' test, electrophoresis Low - hypoproliferatie - renal dx, hypothyroid, aplastic anemia

Vision loss w/ increased floaters and flashing lights (photopsias)

Retinal detachment - Fundus w/ vitreous hemorrhage and retinal elevation - Need surgery

Angular cheilosis and stomatitis

Riboflavin B2 deficiency

Neisseria meningitides post-exposure ppx - General recommendation - If on OCPs

Rifampin 600 BID for 2 days Not rifampin if on OCPs because it increases hepatic clearance - Cipro 500 once - Ceftriaxone 250 once

T wave inversion in II, III, aVF

Right heart strain

Aspiration pneumonia - Where you see it on CXR - Bug - Tx - Test to consider after stable

Right middle or lower lobe Anaerobes or polymicrobial Clinda VFSS

Abdominal surgery, swinging fever, leukocytosis, cough, shoulder-tip pain - What - Test

Right subphrenic abscess Abd ultrasound

HIV, IVDU w/ high fever, pleuritic chest pain, no murmur - What/where

Right-sided infective endocarditis - Tricuspid valve - Often don't have murmur or peripheral signs (splinter hemorrhages, Janeway lesions) - Septic pulmonary emboli -> nodular opacities on CXR

Moderate exercise during pregnancy decreases gestational DM, preeclampsia, and c-sections - However, contraindicated if...

Risk of preterm delivery - Cervical insufficiency (even w/ cerclage) - Preterm labor or PPROM Risk of antepartum bleeding - Placenta previa - Persistent 2nd/3rd tri bleeding Underlying condition worsened by exercise - Severe anemia, preeclampsia, restrictive lung dx, bad heart dx

Short-term travel diarrhea - Rotavirus/norovirus - E coli - Salmonella - Shigella - Campylobacter - Giardia

Rotavirus/norovirus - Brief, vomiting, nonbloody diarrhea, fever Norovirus: rapid onset, resolves within days, emesis Rotavirus: MCC diarrhea kids <2; sxs in 1-2 days (fever, emesis, abd pain, watery diarrhea) E coli - Contaminated food/water - ETEC MCC travelers diarrhea (copious, watery) - days to 1 week Salmonella - Fever Shigella - Dysentery: fever, BLOODY mucoid diarrhea, abd pain Campylobacter -days to 1 week - Abd pain, bloody diarrhea, PSEUDOAPPENDICITIS Giardia - excess flatulence and foul smelling stool

Meckel's diverticulum

Rule of 2s - 2% prevalence - 2:1 male:female - 2% sx at age 2 - W/in 2 feet of ileocecal valve Dx w/ technetium 99m nuclear scan Surgical resection Risk of intussesception

MSK pain, fatigue, point tenderness. Normal CBC and ESR. Considering fibromyalgia but what is next step?

Rule out common things first - CBC for anemia - Inflammatory markers for anemia (normal in fibromyalgia) - Thyroid function test Fibromyalgia is a dx of exclusion

New psychosis, positive for drugs

Rule out substance induced first - Wait until off substances to and evaluate

Connective tissue dx -> acute onset pulmonary edema, hypotension, hyperdynamic precordium w/ holosystolic decrescendo murmur at apex - What - Why - Tx

Ruptured cord tendineae -> acute mitral regurgitation -> sudden onset hypotension and cardiogenic shock Papillary muscle rupture 3-5 days after MI can also -> acute MR

Tinea capitis - Presentation - Tx

SCALY ERYTHEMATOUS PRURITIC patch w/ hair loss on scalp +/- black dots +/- tender LAD ORAL griseofulvin or terbinafine

As about ____ if has depression symptoms

SI

Lasix skin SE

SJS type reaction or urticarial rash

Reactive arthritis - Presentation - Labs -

SPONDYLOARTHOPATHY - After GU (chlamydia) or GI infxn - Asymmetric oligoarthritis - Uveitis - Urethritis - Enthesitis "Can't read, can't see, can't climb a tree" - High WBC, negative blood cx - Increased likelihood they are POSITIVE HLA-B27

Pt with all the sx of depression including insomnia - Next step?

SSRI - Will treat depression and associated insomnia - NOT sleep hygiene alone, SSRI most important here

PMS or premenstrual dysphoric disorder (anger and irritability) - Tx - What if it fails

SSRI - fluoxetine Another SSRI - If fails and don't want to be pregnant, combined OCPs

% Hb A vs Hb S - Sickle cell trait - Sickle cell-beta thalassemia

SSt - A:S is 60:40 SSB(0)T is 100% S SSB(+)T is up to 25 A:75 S

Start fluoxetine -> hypomanic sx - Next step

STOP FLUOXETINE NOW - Can give mood stabilizer or second-gen antipsychotic if sx persist

Synchronized cardioversion

SVT (a fib w/ RVR) with a pulse

Testing cutoffs for diabetes

SYMPTOMS plus any of: A1c 6.5+ Fasting glucose 126+ Random glucose 200+ w/ sx 2hr glucose tolerance test: 200+ Asx pt w/ abnormal testing requires repeat measurement of same test

Plantar wart treatment

Salicylic Acid - soak in water, apply acid, cover with tape, keep dry for 48-72 hours, remove and scrape with file May take 2-3 weeks before response, continue 2-3 weeks after wart gone to eradicate virus Duct tape alone doesn't have studies showing it works Can use liquid nitrogen but burns and may cause hypopigmentation

Mycobacterium marinum

Salt and fresh water Lesions are papular and ulcerative, occur over days Unlike vibrio vulnificus that causes acute sepsis and hemorrhagic bullies lesions

Selection bias

Sample is not representative of target population

Hepatomegaly with high alk pos and GGT with normal-ish LFTs, hypercalcemia, b/l hilar fullness on CXR - What - Best next step for dx - Tx

Sarcoidosis - Noncaseating granulomas seen on imaging Biopsy to r/o TB or metastatic malignancy Systemic steroids

Young adult w/ exertion dyspnea, cough, hyperCa, b/l hilarious LAD - What - Other labs - Dx - Tx - Prognosis

Sarcoidosis - young, AA May also have skin lesions, uveitis, or B sx (fatigue, weight loss) Hypercalcemia, hypercalcuria High ACE level Bx - noncaseating granuloma stains negative for fungi and AFB Oral steroids Resolves over time

Medical error categories

Save - recognized early and never reaches the patient Near miss - reaches patient but no apparent harm Preventable adverse event - causes harm 2/2 not following evidence-based best practice Non-preventable adverse event - appropriate choice made for approved indication but still harm Negligent adverse event - preventable adverse event 2/2 gross negligence from provider

FOOSH -> swelling in dorm of right hand, preserved ROM, right hand grip reduced, ttp radial aspect of wrist

Scaphoid fracture - May not show up on XR right away - Splint and XR in a week (or MRI/CT now) - Risk of nonunion and avascular necrosis (Hamate fx after FOOSH w/ pain at hypothenar eminence and ulnar aspect or wrist)

Injuries with fall on outstretched hand

Scaphoid fx Distal radius fx - Colles' Ulnar styloid fx Acute carpal tunnel syndrome

Immigrant from Africa with dysuria, urinary frequency, terminal hematuria, eosinophilia - What - Dx - Tx

Schistosomiasis Urine sediment microscopy - see parasite eggs Praziquantel

NF1 -> neurofibromas of what cell type?

Schwann cells - Myelinize peripheral nervous system axons including cranial nerves

Raynaud phenomenon and GERD now with new HTN, papilledema, blurry vision, nausea, and elevated Cr - What - Tx

Scleroderma renal crisis - HTN plus renal vasculature thick walls and narrow lumen -> ischemia -> activate RAAS -> crisis ACEi - reverse angiotensin-induced vasoconstriction - Captopril has short onset time - Acute bump in Cr okay, monitor ADD IV nitroprusside if malignant HTN with CNS manifestations - Lower slowly to avoid ATN - Usually only need 1 dose before captopril starts working CCB 2nd line adjunct w/ captopril

Scoliosis vs kyphosis vs lordosis

Scoliosis = LATERAL S-shaped Kyphosis = hunchback - Posterior thoracic = Easily correctible "slouching" = postural, no tx - Structural w/ progressive back pain, tx w/ exercises to strengthen and straiten the back - Back brace or surgery only if chronic pain or severe Lordosis = swayback - Anterior lumbar

Vibrio parahaemolyticus

Seafood-associated diarrhea - Watery or bloody diarrhea, abd cramps, n/v, fever

New onset pruritic erythematous greasy plaques on scalp, central face, ears, chest, upper back, and inguinal area - What - Tx - Check for

Seborrheic dermatitis Topical anti fungal, topical steroids, calcineurin inhibitor (pimecrolimus cream) HIV - severe or widespread SD may be presenting sx OR Parkinson dx

Erythematous, scaly rash on scalp, face, ears, chest - What - Tx

Seborrheic dermatitis 2/2 Malassezia - Looks like loose, greasy scales Topical anti fungal like ketoconazole or selenium sulfide - Consider topical steroids, salicylic acid, coal tar shampoo, or tacrolimus (calcineurin inhibitor) May need weekly retreatment to prevent recurrence

All the sudden have a bunch of "stuck on" brown lesions - What are they - What's the sign - Associated with what - Tx

Seborrheic keratosis Leser-Trelat sign Lung and GI malignancy No tx of lesions needed

Methylnatrexone

Selectively blocks mu opioid receptors in the gut - Tx opioid induced constipation - Don't block opioid analgesic effect

Incidental diagnosis with short cervix on US - tx

Serial US measurements and vaginal progesterone

Serotonin syndrome - How - Presentation - Tx

Serotonergic meds plus MAOI or linezolid, or overdose or MDMA AMS, diaphoresis, tachycardia, HTN, hyperthermia, vomiting, diarrhea, tremor, myoclonus, hyperreflexia D/C serotonergic meds, bentos, cyproheptadine (antagonist) if supportive tx fails

Recent otitis media now with asymptomatic, retract tympanic membrane with yellow fluid and decreased mobility - What - Tx

Serous otitis media Watchful waiting - May persist up to 3 months - If sx, b/l, or >3 mo, consider tx

Breastfeeding and starting anti-depressant. - First line?

Sertraline and paroxetine Can continue other antidepressant if on before ECT is safe but used if meds don't work

Suspect meningovascular syphilis - Test - Tx

Serum RPR and CSF VDRL IV penicillin

SAAG

Serum-ascites albumin gradient <1.1 = NO portal HTN - Peritoneal carcinomatosis (from malignancy) or TB, nephrotic syndrome, pancreatitis, serositis 1.1+ = portal HTN - CHF, cirrhosis, alcoholic hepatitis

Indications for aortic valve replacement w/ aortic stenosis

Severe = jet velocity 4+ m/s or mean gradient 40+ mmHg on echo Replace if severe and 1+ of: - Sx develop (angina, syncope) - EF <50% - Having CABG or other cardiac surgery

Who doesn't get low-molecular-weight heparin?

Severe renal insufficiency

Neuraxial analgesia (epidural) - Most effective pain relief, low risk - What are contraindications?

Severe thrombocytopenia (<70) Rapidly dropping platelets (preeclampsia w/ severe features) - Increases risk of spinal epidural hematoma

Primary HIV presentation

Sexually active Unexplained fever, fatigue, weight loss, lymphadenopathy, diarrhea, rash NO exudative pharyngitis

Cherry angioma

Sharply circumscribed area w/ congested capillaries and post-cap venues in papillary dermis - Lesions are small, bright red, dome shaped - Usually multiple - Benign, increase w/ age - Do not regress spontaneously but no tx

Postpartum pituitary necrosis - Name of syndrome - Cause - Sign/sx

Sheehan syndrome Severe obstetric hemorrhage and hypotension -> pituitary necrosis Present with lactation failure CENTAL hypothyroidism (low TSH and T4)

Old person with burning pain on left flank with itchy rash that turned into grouped vesicles - What - Why - Tx

Shingles - herpes zoster Reactivation of varicella from dorsal root ganglia of sensory nerve - waning VZV cell-mediated immunity, malignancy, liver, kidney dx, immunocompromise increase risk Oral valacyclovir if sx <72 hr - Reduce transmission, new lesions, & postherpetic neuralgia

WPW EKG

Short PR Delta wave - slurred QRS upstroke Wide QRS Often develop AV reentrant tachycardia (AVRT) - narrow, regular QRS

Painful arc test

Shoulder pain when arm abducted b/w 60-120 degrees Rotator cuff impingement

Xerostomia and keratoconjuctivitis sicca in elderly - What - Initial workup

Sicca syndrome Schirmer test for secretory deficiency Autoantibody screen with ANA, Ro- and La-, RF Salivary gland bx is gold standard to dx Sjogren's but not first test

Signs of severe aortic stenosis

Single, soft S2 - Delayed closure of AV - Sometimes have paradoxical splitting where A2 after P2 Delayed, diminished carotid pulse - Parvus et tardus Loud, late-peaking systolic murmur

Dry eyes and mouth sx - What is it - What mouth stuff

Sjogren Dental caries, candidiasis, esophagitis

Anti-Ro/SSA antibodies

Sjogren's syndrome Sometimes SLE - Associated with butterfly rash, ILD, congenital heart block

Gritty burning sensation and conjunctival irritation plus dental caries, mobile contender submandibular mass - What - Test - Associated with

Sjogren's syndrome - keratoconjunctivitis sicca and xerostomia Anti-Ro/SSA and anti-La/SSB antibodies Associated with B-cell NHL

Central line bloodstream infections - Bugs - Decrease risk

Skin organisms - coag-neg staph, Staph aureus, Candida, aerobic gram negatives Clean site w/ chlorhexidine, sterile drapes, masks, remove when not needed (increased risk after 6 days)

Scabies dx and tx

Skin scrapings under microscope - Mites, ova, feces Permethrin cream applied to whole body excluding head - Oral ivermectin in nursing homes or other facilities

Fat young boy with hip pain - What - RF - Presentation - Dx - Tx - Complications

Slipped capital femoral epiphysis Obesity, adolescent Dull hip pain, referred knee pain, altered gait, limited hip internal rotation Posteriorly displaced femoral head on XR Surgical pinning, non-weight-bearing Avascular necrosis, osteoarthritis

Lung cancer with SIADH

Small cell carcinoma - Low sodium - normovolemic - Mild then neuro sx, seizures, and coma if Na low enough Perihilar mass and increased hilarious opacity

Interval for colonoscopy after polyp removed - Small rectal hyperplastic polyp - 1-2 small <1 cm tubular adenoma - 3-10 adenomas, adenoma >1cm, OR adenoma w/ high-grade dysplasia or villous features - >10 adenomas - Large >2 cm sessile polyp - Polyp w/ adenocarcinoma

Small rectal hyperplastic polyp - 10 yr 1-2 small <1 cm tubular adenoma - 5 yr 3-10 adenomas, adenoma >1 cm, OR adenoma w/ high-grade dysplasia or villous features - 3 yr >10 adenomas - <3 yr, consider familial syndrome Large >2 cm sessile polyp - 2-6 mo Polyp w/ adenocarcinoma - 2-3 mo

Goal TSH level for papillary or follicular thyroid cancer - Small, low risk - Intermediate risk - Large, aggressive

Small, low risk - TSH 0.1-0.5 for 6-12 mo then low-normal range Intermediate risk - TSH 0.1-0.5 Large, aggressive - TSH <0.1 Up levothyroxine to lower TSH

Carbon monoxide poisoning - How - Presentation - Dx - Tx

Smoke inhalation, car in garage Mild/mod - HA, confusion, malaise, dizziness, nausea Severe - Seizure, syncope, coma - Myocardial ischemia, arrhythmia ABG - carboxyhemoglobin level ECG (and cardiac enzymes if ischemia or CAD) High flow 100% O2 - Intubate/hyperbaric O2 if severe - PULSE OX CAN'T SEE OXY vs CARBOXYHEMOGLOBIN

RF for AAA

Smoking Male White Advanced age HTN

Isolated snoring?

Smoking and EtOH consumption before bedtime increase snoring - Snoring isn't an indication for OSA diagnostic testing

Varenicline - Used for - SE

Smoking cessation - Partial nicotinic ACh receptor agonist Psych SE - Don't use if current unstable psych status or recent SI

AAA - RF - Screening - Tx - F/U

Smoking, male, old, white, fam hx, atherosclerotic dx Abd US if 65-75 and ever smoked SMOKING CESSATION ASA and statin Elective repair if... - >5.5 CM, rapidly enlarging (>0.5 cm in 6 mo), peripheral artery dx or aneurysm 4-5.4 cm - US every 6-12 MO <4 cm - US every 2-3 yr

OSA risk factors

Snoring Daytime tiredness Observed apnea or choking HTN BMI >35 Age >50 Neck size >17 in (16 women) Male 3-4 intermediate risk 5+ high risk

Antipsychotics don't treat the negative sx of schizophrenia very well. What to do?

Social skills training

Protective factors against suicide

Social support & family connectedness Pregnancy Parenthood Religion

When to use _____ for diarrhea - Somatostatin - Cholestyramine - Pancreatic enzyme supplements

Somatostatin for neuroendocrine tumor (VIPoma) and AIDs diarrhea Cholestyramine for bile salt induced diarrhea after chole or short bowel syndrome Pancreatic enzymes for chronic pancreatitis steatorrhea

Acute bronchitis - presentation - treatment

Sore throat, nasal congestion, cough then only cough for five days to three weeks, no fever, crackles clear with cough +/- yellow/green sputum Symptomatic treatment - No antibiotics!

Jarisch-Herxheimer reaction - History/presentation - Why - Prevention/tx

Spirochetal infection (syphilis, leptospirosis, tick-borne spirochete) -> treatment -> within 24 hours develop fever, HA, myalgias, tachycardia, malaise Rapid lysis of spirochete. -> release bacterial proteins -> innate immune response NO PREVENTION Self-limited and resolves in 48 hr - can give tylenol

Kid w/ chronic cough (>4 weeks) w/o hx/exam findings. Next step?

Spirometry - Simple PFT to detect asthma CXR also recommended to r/o mediastinal widening (chronic infection, neoplasm), hyperinflation (foreign body aspiration) or cardiac defects

Pancreatitis and see gastric fundal varices - Why/what

Splenic vein thrombosis - Redirection of blood flow to collateral gastroepiploic system and short gastric (no esophageal varices) Can develop left-sided portal HTN, ascites, and congestive splenomegaly w/ hypersplenism (anemia, thrombocytopenia)

Nipple discharge - Pathologic if? 2/2? - Next step?

Spontaneous, unilateral, persistent - May be sanguineous or serous Papillary tumor - Typically benign but cab be associated w/ cancer Bilateral - pregnancy test, galactorrhea evaluation Unilateral < 30 - ultrasound +/- mammogram >30 - ultrasound AND mammogram

Order of default power of attorney if not assigned

Spouse, adult children, parent, adult sibling, nearest living relative, close friend Designated power of attorney overrules all these

Actinic keratosis - Lead to what - Tx

Squamous cell carcinoma Excision or destruction w/ cryotherapy If numerous or small, field therapy with 5-FU cream (or imiquimod cream, topical diclofenac, and photodynamic therapy)

PE -> lovenox bridge to warfarin -> hypotension -> GI bleed - Next step?

Stabilize patient Stop lovenox and warfarin, place IVC FILTER

Renal cell carcinoma tx

Stage I - confined w/in renal capsule - partial nephrectomy Stage II - extends through renal capsule but not beyond Gerota's fascia - radical nephrectomy

Mom (Rh-) and dad (RH+) - How does anti-D immune globulin dosing work - What if there's a fetomaternal hemorrhage

Standard dose at 28 weeks and at <72 hr postpartum Use rosette test to see if hemorrhage occurred. Use Kleihauer-Betke test or flow cytometry to see how much hemorrhage - INCREASE DOSE based on % fetal RBCs in maternal circulation

Corneal foreign body. What bacteria grows?

Staph aureus (coagulase negative) - Strep, Haemophilus, Pseudomonas If wear CONTACTS, pseudomonas

Fluctuant, tender, erythematous nodule w/ pus collection in dermis or subQ +/- surrounding cellulitis and fever - What bug - Tx

Staph aureus abscess I&D Abx if >2 cm or cellulitis present - cover for MRSA

Otitis externa = swimmer's ear - Bugs - Presentation - Tx

Staph aureus or Pseudomonas Pain w/ tragal pressure or pulling on auricle Clear cerumen Mild - topical acidifier (acetic acid) Moderate - topical abx (cipro, neomycin/polymyxin) Severe - malignant otitis externa - seen w/ DM or immunosuppression - broad spectrum ORAL abx (cipro)

Sudden-onset pleuritic CP, loud P2, pleural friction rub, hypoxemia, pleural effusion -> contrast allergy -> V/Q scan low probability for PE - Next step?

Start anticoagulant for PE - Pt has high pretest probability of PE - Low- or moderate-probability V/Q scan is indeterminate and doesn't r/o PE

How soon after HIT can start warfarin? Why? What to do in meantime?

Start warfarin when platelet count >150,000. Low protein C causes prothrombotic state. Direct thrombin inhibitor (argatroban, bilvalirudin) or fondaparinux

ALS - Neurons involved - Presentation - Preserved? - Tx

Starts w/ upper OR lower and progresses to BOTH Lower motor neurons: Anterior horn cells of SC and brainstem neurons for bulbar muscles Upper or corticospinal motor neurons - Insidious asymmetrical weakness, distal limb first. Cramping with movement in early morning. - Progressive wasting, muscle atrophy, twitching/fasciculations. - Bulbar involvement -> difficulty chewing/swallowing with tongue fasciculations Preserved: ocular motility, sensory, bowel, bladder, cognition Riluzole - glutamate inhibitor - slows, doesn't cure

Pancoast tumor often has spinal mets that causes cord compression - Tx

Steroids, surgery, radiation

Resistant HTN - Define - Next step

Still HTN after 3+ meds Renal duplex Doppler US (or CTA or MRA) - looking for RAS

Presentation of diabetic neuropathy - Classic - Other things

Stocking-glove pattern Absent cremasteric reflex Erectile dysfunction Decreased testicular sensation, bladder dysfxn, inability to masterbate

Acute diarrhea (<14 days) w/ visible blood or mucus (dysentery) - Labs - Causes - Tx

Stol culture, immunoassay for Shiga toxin, fecal leukocyte count E. coli (O157:H7), Shigella, Campylobacter, Salmonella, IBD, ischemic colitis - Rehydration (ORAL) - Empiric ORAL abx (unless EHEC suspected - increases HUS risk) - CT if think ischemic colitis - Endoscopy if think IBD

Licorice - Tx - SE

Stomach ulcers, bronchitis Inhibits conversion of cortisol to cortisone -> increased mineralocorticoid receptor activation - HTN w/ low renin and aldo - Hypokalemia

Menopausal hormone therapy -> DVT -> next step?

Stop hormone therapy Start SSRI or SNRI

Acute otitis media - Bugs - MCC AOM AND purulent conjunctivitis - Tx

Strep PNEUMO, NONTYPEABLE H influenzae, Moraxella catarrhalis Nontypeable H influenzae causes AOM + bacterial conjunctivitis 1st: amoxicillin 2nd: amoxicillin-claviculinate (use if repeat infection)

MC bug causing pneumonia in HIV?

Strep pneumo - Encapsulated - Lobar infiltrate - Outpatient tx if single lobe and normal resp status

Erysipelas

Strep pyogenes - Often after abrasion or insect bite - Superficial dermis - Raised, sharply demarcated borders - Rapid onset and spread - Often fever, chills - Tx: ampicillin, amoxicillin Vs cellulitis which has ill-defined flat borders and indolent progression

Concern for angina and already have negative EKG, trop. - Next step

Stress test - exercise ECG preferred IF PATIENT CAN'T WALK DO A PHARM STRESS TEST - Adenosine myocardial perfusion study or dobutamine echo

Unexplained heart failure 2/2 LV systolic dysfunction - Next step?

Stress test or coronary angiography - CAD MCC secondary dilated cardiomyopathy

Acute onset left-sided weakness

Stroke in right MCA distribution

Healthy worker effect

Study population is healthier than the general population - mortality data inaccurate since there aren't as many sick people in workforce vs real world

Facial port-wine stain

Sturge-Weber syndrome - Also see leptomeningeal angiomatosis

Mycoplasma pneumonia

Subacute - fever, HA, sore throat, cough, dyspnea Patchy interstitial infiltrates

Central retinal vein occlusion

Subacute timeline w/ asymptomatic to severe vision loss Fundus w/ retinal hemorrhages and optic disc edema - "Blood and thunder"

Sudden onset, worse headache of life HA and >50 YO

Subarachnoid hemorrhage Mass lesion, giant cell arteritis

Cerebral vasospasm

Subarachnoid hemorrhage Vasculitis

Sudden onset HA, nausea, nuchal rigidity with ptosis and anisocoria - What and what artery and what nerve

Subarachnoid hemorrhage - Posterior communicating artery - CN III = ptosis, anisocoria

Infective endocarditis with headache, lethargy, and neck stiffness

Subarachnoid hemorrhage secondary to rupture of mycotic aneurysm (septic embolization and localized wall destruction) - Dx with CTA - Tx with IV abx and surgery

Antipsychotic -> akathisia - What - Tx

Subjective restlessness Beta blocker (propranolol) Benzo (lorazepam)

Hawthorne effect

Subjects change behavior as a result of being studied

Cephalohematoma

Subperiosteal bleed in newborn that doesn't cross suture lines; firm, well-demarcated area of swelling - Can lead to hyperbilirubinemia 2/2 RBC breakdown - Takes several weeks to resolve - May calcify or ossify -> skull deformation vs caput succedaneum: serosang fluid collection located beneath scalp that crosses suture lines; swelling located at site of presentation (vertex) and resolves within few days

Depressed patients who do worse after initially doing better on med. -> Check for what?

Substance abuse

B12 deficiency in the elderly

Subtle - Increased MCV - High indirect bilirubin 2/2 ineffective erythropoiesis - Pancytopenia - NEURO SYMPTOMS - ataxia, dementia, delirium Folic acid deficiency doesn't cause neuro symptoms

Childhood absence epilepsy - Presentation - Dx - Associated dx - Tx

Sudden "staring spells" Preserved muscle tone Unresponsive to stimulation Short <20 sec Simple automatics Provoked by hyperventilation Many episodes per day EEG: 3 Hz spike and wave discharges ADHD, anxiety, depression Ethosuximide - check granulocyte count perioridcally Often resolves by puberty

Cataplexy

Sudden onset muscle weakness after emotional episodes - Narcolepsy - Tx w/ SSRI/SNRI/TCA

Hungry bone syndrome

Sudden withdrawal of parathyroid hormone -> increased influx of Ca from circulation to bone -> hypocalcemia

RF for pediatric dental caries

Sugary drinks/food NIGHTTIME FEEDING Low fluoride intake - oral supplement if water is low Fam hx or low SES Get a dentist by age 1 and f/u every 6 months - Plaque, white spots or enamel defects, brown discoloration

HTN after renal transplant with normal baseline renal function but Cr increases after given ACEi

Suggests underlying renal artery stenosis (usually bilateral in normal folks and unilateral if solitary kidney or transplant) Calcineurin inhibitor (cyclosporine, tacrolimus) toxicity can increase endothelia, inhibit nitric oxide, and increase sympathetic outflow -> HTN

Adolescent who cuts to cope with distress. Next step?

Suicidal eval and comprehensive psych eval If not suicidal and only cutting to cope, can D/C and have outpatient psych eval

DM med that causes - Hypoglycemia - UTI, hypotension - Weight gain, heart failure, fluid retention, bone fx

Sulfonylurea - glimepiride Meglitinitde - repaglinide, nateglinide - These increase insulin secretion even when glucose is normal SGLT-2 inhibitor -florin Thiazolidinediones - pioglitazone

Dyspareunia - What dx causes? Tx? - Superficial - Deep

Superficial - vaginismus - Pelvic floor PT - Sometimes progressive vaginal dilation Deep - endometriosis - NSAIDs +/- OCPs - Laparoscopy

Erysipelas

Superficial skin infection - Well-demarcated - Bright red erythema - Classically on cheeks

Dyspnea, persistent cough, facial fullness, neck pain -> hoarseness, dysphagia, chest pain Edema and erythema of neck, dilated veins of arms and neck

Superior vena cava syndrome Usually 2/2 bronchogenic carcinoma obstructing SVC - Sometimes met nodes or thrombus CT scan neck and chest with contrast

N/V/D with abd cramping and fever -> stool cx grow Salmonella enteritidis - tx?

Supportive Can do abx if <1 yr or immunocompromised

Management and prognosis of febrile seizure

Supportive unless >5 minutes long then abortive therapy Benign, may recur, slight increase risk of epilepsy

Kid with fever, crankiness, ear pain -> purulent drainage from ear -> tympanic membrane obscured by otorrhea, no tenderness

Suppurative otitis media with TYMPANIC MEMBRANE PERFORATION - A.k.a. acute or bacterial OM - Untreated AOM -> rupture of TM -> releases pain - Group A strep

Pregnant and suspect ovarian cancer. What makes you want to do surgery now?

Surgery in 2nd trimester if... - Complex, septations - Large >10 cm, increases risk of torsion, rupture, labor obstruction

TRALI (form of ARDS) - Increased risk with critical illness - AHRF w/in 6 hr of getting blood - Tx is supportive - High mortality rate Residual effects?

Survivors often have - Impaired memory & concentration for 1+ yr - Impaired strength and lung fx - Psych illness

RA -> methotrexate +/- steroids -> not effective after 6 mo -> do what?

Switch to or add anti-cytokine drug like infliximab or etanercept - Have to check for TB with PPD first though 2/2 increased opportunistic infxns Can consider triple therapy with methotrexate, hydroxychloroquine, and sulfasalazine or switching to cyclosporine

Low back pain diagnostic algorithm

Sx cord comp? MRI >50, worse at night, hx ca, IVDU, >1 mo? XR and ESR Others get PT and NSAIDs

Primary hyperparathyroidism and MEN1 - When to do parathyroidectomy

Sx hypercalcemia, ends-organ complications (CKD< osteoporosis), increased complication risk (urine Ca >400 mg/day) <50 -

Acute inferior MI often leads to AV block or sinus bradycardia - Next steps

Sx patients get IV atropine If still sx, temporary cardiac pacing After pacing started, urgent PCI

Hyperthyroidism heart symptom and tx

Sx tacky or afib/aflutter -> beta blocker then thyroid med

Girl with emotional lability, irregular jerking movements of arms, hands, face - What - Tx

Sydenham chorea form JONES criteria of rheumatic heart dx Penicillin - continued until adulthood to prevent recurrent rheumatic fever

Fetal growth restriction (<10th %) - Symmetric vs asymmetric

Symmetric - 1st trimester - Chromosomal abnormalities, congenital infection - GLOBAL Asymmetric - 2nd/3rd tri - Utero-placental insufficiency, maternal malnutrition - HEAD SPARING Weekpy BPP, serial umbilical artery US, serial growth US

Viral encephalitis tx

Symptomatic Except give acyclovir for HSV

Catatonia - 2/2 what - Presentation - Tx

Syndrome seen in severe psych illnesses (schizo) POSTURING (limbs stay where you put them), immobility, mutism, stupor, catalepsy (limbs remained in fixed posture for long periods), echolalia, echopraxia Tx w/ BENZOs or ECT

Bone density scores - T vs Z - Classification - Tx

T = 30 YO Z = Age matched Osteopenia, T -1 to -2.5 Osteoporosis T -2.5 or lower Bisphosphonate (alendronate) if... - Low bone mass & hx fragility fx - Osteoporosis - 10yr prob major fx >20% or hip fx >3% Hormones ONLY if intolerable menopause sx Repeat DXA every 3-5 yr if postmenopausal and osteopenia

Type IV immune reaction

T-cell mediated - Contact dermatitis

Squamous cell carcinoma of the glottis treatment

T1 Localized to one vocal cord - Radiation or laser excision (or partial vocal cordectomy if involves anterior commissure) T3 (larynx + vocal cord) - induction chemo then radiation

Candida vaginitis (Candida albicans) - Exam - Labs - Tx

THICK, COTTAGE CHEESE discharge, +vaginal inflammation NORMAL pH (3.8-4.5), pseudohypahae Fluconazole - can continue breastfeeding

Management of UA/NSTEMI - Do risk assessment

TIMI - >65 YO - 3+ RF for CAD - Known CAD w/ >50% stenosis - ASA use in last 7 days - 2+ anginal episodes in last 24 hr - Elevated biomarkers (troponin) - ST deviation >0.5 mm Tx depends on number - 0-2 = stress test - 3-7 = cath lab w/in 24 hr - Hemodynamic instability, HF or new MR, recurrent CP, ventricular arrhythmia = immediate cath

Specificity Sensitivity

TN / (TN + FP) TP / (TP + FN)

Sensitivity Specificity

TP / (TP + FN) TN / (TN + FP)

Holosystolic murmur at lower sternum that increases with inspiration

TR

Flail chest - Presentation - Management

Tachypnea, tachycardia, rapid shallow breathing, peripheral cyanosis, anterior chest bruising - Don't always see paradoxical movement of free segment during inspiration Uncomplicated - O2, non-inv PPV, pain meds Complicated - mechanical vent and surgery

Diabetic retinopathy - Timeline - What do you see on exam - How does it cause blindness - Tx

Takes YEARS to develop - Acute blurry vision 2/2 swelling of optical lens due osmotic changes Microaneurysms, hard/soft exudates, dot/blot hemorrhages - leads to vitreous hemorrhage - leads to retinal detachment Laser photocoagulation - If acute blurry, tight glycemic control is answer

Parent and teen at visit. Parent concerned about teen. Next step?

Talk to teen alone

Meds used for breast cancer prevention in high risk women? - Other uses for the meds? - Mechanism - SE

Tamoxifen and raloxifene Competitive inhibitor of estrogen binding; mixed agonist/antagonist action Prevent BC in high risk pts Tamoxifen - adjuvant BC tx Raloxifene - postmenopausal osteoporosis Hot flashes, DVT Tamoxifen only: endometrial hyperplasia/CA

Tetanus vaccine schedule

Td every 10 yr with one sub of Tdap

myelofibrosis - smear - mutation

Teardrop cells JAK2

Iron deficiency in ESRD +/- HD

Technically transferrin sat <20% or ferritin <100 BUT INFLAMMATION INCREASES FERRITIN so it isn't accurate measure of iron - use other labs Functional iron def - normal iron stores but can't mobilize with epo IV IRON if ESRD and on dialysis and transferrin sat <30 or ferritin <500 (oral iron if no dialysis)

Test for eradication of H pylori when? What test? When?

Test if... - Persistent sx - H pylori ulcer on endoscopy - H pylori malignancy (MALTOMA) Urea breath or fecal antigen test 4+ weeks after completion of tx

Paired T test

Test the difference between 2 paired means - Mean BP before and after tx in same subject

Leydig cell tumor

Testicular asymmetry or palpable testicular mass Peripheral precocious puberty

Absent cremasteric reflex and scrotal pain

Testicular torsion

Infant with severe microcytic and hpyochromic anemia. Same dx killed uncle. HSmegaly and subicteric discoloration of sclerae. - What - Tx and it's SE

Thalassemia major - congenital hemolytic anemia leading to early death from anemia and expansion of erythroid precursors Hypertransfusion - Lead to iron overload and organ damage

Microcytic, hypochromic anemia with high RBC count, high ferritin

Thalassemia trait - Ferritin high in thalassemia (high turnover) but low in iron deficiency (ID) - RDW normal (low in ID) - RBCs normal/high (low in ID) - Target cells - Hemoglobin electrophoresis (normal in alpha, high A2 in beta) - If mom has trait, do testing on dad too for kids' risk - Asian people

Wernicke encephalopathy - What/why - Presentation - Tx - Look out for

Thiamine deficiency 2/2 alcoholism or malnutrition Encephalopathy Oculomotor dysfxn - lateral rectus palsy Gait ataxia - wide-based gait No specific test but 2:1 AST:ALT or low albumin/high INR suggests dx IV thiamine - Eye sx improve right away, confusion/gait ataxia take longer and may not fully resolve - DON"T GIVE DEXTROSE PRIOR Korsakoff syndrome - mammillary body atrophy - retro/anterograde amnesia - rarely improve

Candida vaginitis

Thick, cottage cheese discharge Vaginal inflammation PSEUDOHYPHAE pH 3.8 - 4.5 (normal) Fluconazole

Lichen simplex chronics (neurodermatitis)

Thickened excoriated plaques 2/2 persistent scratching and rubbing - Associated with anxiety - Occurs in easy to reach places like arms, leg, neck

Trichomoniasis (Trichomonas vaginalis) - Exam - Labs - Tx

Thin, YELLOW-GREEN, malodorous, frothy discharge; +vaginal inflammation with dyspareunia, punctate hemorrhages on vagina/cervix pH >4.5, motile trichomonads Flagyl (1 dose) - express breast milk but don't give it to baby for 24 hr - TREAT SEXUAL PARTNER

Bacterial vaginosis

Thin, off-white discharge Fishy odor No inflammation CLUE CELLS +KOH whiff test pH >4.5 Metronidazole or clindamycin

Bacterial vaginosis (Gardnerella vaginalis) - Exam - Labs - Tx

Thin, off-white discharge, no inflammation, FISHY ODOR pH >4.5, CLUE CELLS, + whiff test w/ KOH Flagyl or clinda

Trichimoniasis

Thin, yellow-green, malodorous, frothy discharge Vaginal inflammation MOTILE TRICHOMONADS pH >4.5 Metronidazole - TREAT PARTNER

Treatment of UTI/ pyelonephritis in kid? When IV vs oral?

Third generation cephalosporins IV if hemodynamically unstable, vomiting, don't improve on oral, or if <2 months (increased sepsis risk) Otherwise use orals Renal ultrasound AFTER antibiotic course if was febrile or has recurrent UTIs

HELLP syndrome

Third trimester pregnant lady with N/V, mid-epigastric pain HTN, proteinuria, platelet count <100,000

SE of valproic acid

Thrombocytopenia - dose related Hepatotoxicity and pancreatitis Neural tube defects

Budd-Chiari syndrome

Thrombosis of hepatic vein or intra/suprahepatic IVC Acute RUQ pain, hepatomegaly, jaundice, ascites If chronic, ascites, cirrhosis, portal HTN w/ varices, splenomegaly

Hemolytic anemia w/ schistocytes, thrombocytopenia w/ increased bleed time and normal PT/PTT - What - Other things you may see - Tx

Thrombotic thrombocytopenia purpura - Antibody -> low ADAMTS13 (metaloprotease) -> uncleared vWF -> platelet trapping/activation - May be acquired or hereditary May see renal failure, neuro sx, or fever PLASMA EXCHANGE - remove autoantibody against ADAMTS13 and gives new ADAMTS13 from donor serum Steroids Rituximab

Thyroglobulin level in exogenous thyrotoxicosis vs postpartum thyroiditis or Graves dx

Thyroglobulin co-secreted with thyroid hormone LOW in exogenous thyrotoxicosis HIGH in postpartum thyroiditis (follicle destruction) or Graves dx (increased activity)

Midline neck mass that rises w/ tongue protrusion - Who - Dx - Tx

Thyroglossal duct cyst - presents in kids/adolescents Clinical dx but do US to confirm dx and make sure thyroid normal Surgical excision 2/2 increased infection risk

Hx mild thyroid goiter -> rapid size increase -> difficulty swallowing, high TSH, low T4, positive antithyroid peroxidase s/o Hashimoto's -> rapid enlargement - What

Thyroid lymphoma - Rapid enlargement of thyroid goiter in pt with Hashimoto's thyroiditis Positive Pemberton's sign - facial plethora/neck vein distention when arms raised, indicated enlarged thyroid causing difficulty swallowing

Ehrlichiosis

Tick-borne bacteria Fever, B-sx, n/v, cough Low WBC, low platelet, high LFTs

Pink annular plaques with scaly border and central clearing

Tinea corporis

Light skin patch worsens in summer - What - Dx - Tx

Tinea versicolor - Malassezia furfur inhibits pigment transfer to keratinocytes and makes skin paler - More obvious in summer KOH prep shows yeast and hyphae Topical anti-fungal

Centor criteria - What - Interpret

Tonsillar exudate, tender anterior cervical LAD, fever, NO COUGH Score 3+ -> rapid strep test BEFORE treatment for group A strep pharyngitis (most cases viral) - 1st line: 10 days oral penicillin V or amoxicillin - Penicillin allergy: 10 days cephalexin, 5 days azithromycin

Group A strep

Tonsillar exudates Fever Anterior cervical adenopathy Sore throat NO COUGH

Mono

Tonsillar exudates Fever Diffuse cervical lymphadenopathy +/- HSmegaly

Nodular (cystic) acne tx

Topical retinoid, benzoyl peroxide, and topical abx Add oral abx Still unresponsive, oral isotretinoin

Inflammatory acne tx

Topical retinoids + benzoyl peroxide Add TOPICAL antibiotic (erythromycin, clinda) Add oral antibiotic

Nasal packing -> nausea, diarrhea, fever chills, myalgias, rash (diffuse, red, macular, palms and soles), thrombocytopenia, neutrophilia - What - How - Tx

Toxic shock syndrome - Staph aureus releases TSS toxin-1 which activates T cells (acts as superantigen) -> cytokine release Lots of IVF Abx - vancomycin (oxacillin or nafcillin if susceptible)

New onset psychosis. Next best test?

Toxicology screen - Rule out substance-induced psychosis before considering primary psych dx

Multiple ring-enhancing lesions on brain MRI and encephalitis

Toxoplasmosis in immunocompromised pt

Acute hepatitis B - Labs - Presentation - Management

Transaminitis + Hep B surface antigen + Hep B e antigen (high infectivity) + Hep B DNA Usually asx but may have n/v/jaundice/RUQ pain Supportive care, outpatient f/u - Only admit if super sick - Monitor regularly for hepatic decompensation or progression to chronic hep B (>6 mo and still hep B surface antigen +)

Choriocarcinoma - What - Check what level - Further eval if present - Tx

Transformed from hydatidiform mole Beta-HCG Pelvic US for mass/uterine enlargement; CXR for mets Methotrexate

de Quervain (subacute granulomatous) thyroiditis - What - Labs - Presentation

Transient hyperthyroidism 2/2 follicular injury and release of preformed hormone Low TSH, high T4, high thyroglobulin, low RAIU TENDER thyroid gland RECENT VIRAL INFECTION

Acute decompensated HF of ? etiology -> next step?

Transthoracic ECHO

Light criteria

Transudative if... - Fluid protein <0.5 serum - Fluid LDH <0.6 serum - Fluid LDH <2/3 upper limit of normal in serum

URI -> rapidly progressive weakness in b/l LE with sensory loss and urinary retention - What - Other PE findings

Transverse myelitis Muscle flaccidity and hyporeflexia with subsequent spasticity and hyperreflexia

Hyporeflexia, acute flaccid paralysis with sensory level or bowel/bladder dysfunction with recent URI

Transverse myelitis - MRI immediately - Steroids Sensory level and bladder/bowel dysfunction after URI differentiate from Guillian-Barré

LP - traumatic tap vs subarachnoid hemorrhage

Traumatic - High RBC, no xanthrochromia Subarachnoid - High RBC, + xanthrochromia

Pulm sx - dry cough dyspnea Then GI sx - n/v/abd pain/diarrhea, +FOBT Dx on stool ova/parastite testing w/ intestinal helminth infection - What's the history - Lab - Tx

Travel to poor country EOSINOPHILIA Abendazole

Saw palmetto - Used for - Side effect

Treat BPH (doesn't work) Increased bleeding risk

Publication bias

Trials with significant positive results are published but not ones with negative/null results

Tinea capitis

Trichophyton or microsporum - Kids Erythema, scaling, "black dot" ALOPECIA, pustules, bogey plaques, posterior cervical or auricular LAD

Apnea of prematurity

True apnea and pauses lasting >20 seconds Resolves by corrected gestational age of 37 weeks - If born at 35 weeks, resolved by 2 weeks after birth

PID -> fever, leukocytosis, pelvic pain and adnexal mass

Tubo-ovarian abscess

Screen for diabetic neuropathy Tx

Tuning fork test - check vibratory sensation Most important: glycemic control First line med options: - SNRIs (duloxetine) - Pregabalin - TCAs Can do gabapentin, lamotrigine, or carbamazepine NOT: steroids, opioids, NSAIDs, SSRIs

Congenital condition associated with aortic coarctation

Turner syndrome

Chronic pancreatitis -> destruction of alpha (make glucagon) and beta (make insulin) cells -> diabetes

Tx with metformin or insulin

HIT - Type 1 - Type 2

Type 1 - Heparin-induced platelet clumping - Within 2 days of starting heparin - Resolves w/o intervention Type 2 - Platelets drop >30-50% - 5-10 days after starting heparin OR <1 day w/ recent prior heparin exposure, thrombosis or skin necrosis - STOP HEPARIN, start direct thrombin inhibitor or fondaparinux - Transition to warfarin when platelets >150,000 - No heparin again EVER

Type I error Type II error

Type I - prob of rejecting null hypothesis when it's true Type II - prob of not rejecting null hypothesis when it is not true

Unstable angina vs NSTEMI

UA - normal biomarkers (Example: anginal CP at rest, T wave inversions, normal trops) NSTEMI - elevated troponin

Strongly suspect exercise-induced hematuria. Next step?

UA now will have RBCs Repeat UA in 1 week to make sure it resolved

Rapid onset UPPER AND LOWER facial weakness Rapid onset LOWER ONLY facial weakness

UPPER AND LOWER - Bell's palsy - idiopathic - CN 7 - Start steroids, artificial tears, and eye patching - Recovers w/in 1-6 months LOWER - Forehead muscle sparing suggests intracranial lesion -> CT or MRI for ischemia/tumor No Lyme dx workup unless b/l, in Lyme-endemic area,

How to dx pneumothorax in acute setting

Ultrasound - Inability to detect 2 pleural layers sliding against each other - Do upright PA CXR in non-acute setting If urgent tension pneumo highly suspected, just needle decompress or put in chest tube

Papillary or follicular thyroid cancer diagnosed - Next step - Management

Ultrasound neck and cervical lymph nodes for staging <1 cm and no lymph = lobectomy >1 cm +/- lymph/mets = total thyroidectomy

Sentinel event

Unanticipated event in healthcare setting that results in death or serious physical/psych injury In-hospital suicide, abduction, d/c infant to wrong family, surgery on wrong site or person

Tx of ..... in non pregnant patients - Uncomplicated cystitis - Complicated cystitis - Pyelonephritis

Uncomplicated cystitis - Nitrofurantoin 5 days (not if pyelo or low Cr clear) - Bactrim 3 days - Fosfomycin 1 dose - Fluoroquinolone next - Urine cx needed if tx fails Complicated cystitis - Fluoroquinolone 5-14 days - Always get urine cx Pyelo - Outpatient: fluoroquinolone - Inpatient: IV fluoroquinolone or aminoglycoside +/- ampicillin

Diffuse esophageal spasm - What - Sx - Dx - Tx

Uncoordinated, simultaneous contraction - stuff gets "stuck" Intermittent chest pain Solid AND liquid dysphagia Manometry: intermittent peristalsis, multiple simultaneous contractions Esophagram: corkscrew pattern CCB - Alternatively nitrates or TCAs

Chlamydia in pregnancy - Screening - Obstetric complications - Fetal complications - Tx

Universal screen first prenatal visit High risk repeat screen at 3rd tri. PPROM, preterm labor, postpartum endometritis Neonatal conjunctivitis or PNA Azithromycin

Eisenmenger syndrome

Unrepaired VSD -> pulm HTN -> R to L shunting -> cyanosis -> heart failure May be exacerbated by decreased SVR, like in pregnancy - High mortality rate, especially postpartum, recommend termination of pregnancy - Recommend tubal ligation or subdermal progestin implant (not estrogen 2/2 thromboembolism risk)

Hematochezia - Next steps?

Unstable or suspect UGIB? - Resuscitate, surgery/IR consult, EGD No source? - Still unstable: angiography - Stable: colonoscopy Stable - COLONOSCOPY - No source? EGD If still no source, capsule endoscopy

Baby weight loss starting breastfeeding

Up to 10% in first week - Colostrum increases by day 5 - F/U in 2-3 days

Gross hematuria = eval upper and lower urinary tracts - How?

Upper: CT urogram (US if CKD) Lower: cystoscopy (urine cytology if low risk)

Dysuria, post-void dribbling, dyspareunia, anterior tender vaginal mass that expresses bloody, purulent fluid on manipulation - What/why - Other sx - Dx - Tx

Urethral diverticulum 2/2 repeated infxn, inflammation, and urethra trauma from pelvic trauma (babies) Hematuria, recurrent UTI, stress incontinence MRI or transvaginal US Manual decompression, needle aspiration, surgery

BPH -> acute urinary retention 2/2 BOO -> next step?

Urethral or suprapubic cath

Abdominal gunshot wound algorithm

Urgent ex lap if... - Hemodynamically unstable, peritoneal signs, evisceration of abd contents CT/FAST/abd plain films if not. Peritoneal penetration or significant injury? - Yes - laparotomy - No - close observation

Primary nocturnal enuresis - Define - Mangement

Urinary incontinence age 5+ UA even if no dysuria to r/o secondary causes Lifestyle changes - No fluids before bed - Avoid sugary/caffeinated drinks - Void before bed - Reward system (gold star chart) Enuresis alarm Desmopressin therapy UA checks for glycosuria and diabetes insipidus and occult infxn - Less invasive than finger stick glucose

Porphyria cutanea tarda

Uroporphyrinogen decarboxylase deficiency Painless blisters, increased skin fragility, facial hypertrichosis, hyper pigmentation Triggered by alcohol or estrogen Confirm dx w/ high urine uroporphyrins Tx: phlebotomy or hydroxychloroquine - Interferon alpha if have hep C

Fluoxetine and eating disorders

Use for bulimia (and depression) NOT for anorexia

Lyme disease - Timeline for transmission - How exactly do you get the dx from the tick? - Timeline for erythema migrans

Usually after 36-48 hours of attachment Can only get if the tick is feeding - if timeline unclear, go off if tick is ENGORGED Erythema migrans takes >3 days and usually 7-14

Acute hep C - Presentation - Labs

Usually asx but may have malaise, RUQ pain, transaminitis Initially Hep C RNA + and may take up to 12 weeks before anti-hep C antibody +

Biventricular pacing decides if in sinus rhythm and have all of: - EF <35% - NYHA class II or higher (basically if they have sx) - LBBB w/ QRS >150 msec

Usually get defibrillator too: Primary prevention - Prior MI and EF <30%; - NYHA II or III & EF <35% Secondary prevention - Prior VF or unstable VT - Prior sustained VT w/ underlying cardiomyopathy

Neuroleptic malignant syndrome

Usually involves dopamine antagonists Bradykinesia, lead pipe rigidity Unlike serotonin syndrome, NO tremor, hyperreflexia, or clonus

Recurrent pregnancy loss (3+ consecutive) w/ normal menses and smooth, normal sized uterus hysterosalpingogram showing filling defect - What

Uterine septum - MC uterine cause RPL - Low blood supply - Hysteroscopic resection decreases risk of RPL Other causes: intracavitary leiomyoma, adhesions (Asherman syndrome, bicornate uterus)

Shockable rhythm

VF and pulseless VT NOT SHOCKABLE: PEA/asystole

Harsh holosystolic murmur over left third/fourth intercostal space and palpable thrill

VSD

Harsh 4/6 holosystolic murmur at 4th left intercostal space w/ thrill

VSD - Small VSD = loud murmur due to larger pressure difference

Step up in O2 sat from RA to RV

VSD w/ left -> right shunt Holosystolic murmur with maximal intensity over left 3rd/4th intercostal spaces +/- palpable thrill

Narrow complex supraventricular tachycardia - Next steps - What can go wrong - What type of error is this

Vagal maneuver - if doesn't work, IV adenosine If underlying WPW (short PR, wide QRS, delta wave), adenosine can lead to A Fib w/ RVR via accessory pathway and ultimately V Fib Non-preventable adverse effect - Appropriate med was used for approved indication

Threatened abortion

Vaginal bleeding Closed cervix Intrauterine pregnancy with normal fetal cardiac activity

Keep things to ask postmenopausal women about

Vaginal dryness, dyspareunia

HD via tunneled cath increases bloodstream infections - Tx - Remove catheter?

Vancomycin plus cefepime (or gentamicin) - MRSA and GN bacilli Remove with... - Severe sepsis - Hemodynamic instability - Pus from cath site - Metastatic infection (endocarditis) - Sx remain 72 hr after abx started If cath doesn't have to be removed, change over guide wire once afebrile and stable OR antibiotic lock therapy after HD

Prodrome in vasovagal syncope? Cardiogenic?

Vasovagal - tunnel vision, diaphoresis, nausea, pallor - can last after event too Not usually in cardiogenic - high number of episodes in short time span points to serious causes like arrhythmia

Delivery mode of positions of diamniotic twins

Vertex x2 - vaginal Vertex, breech - vaginal or c-section Breech, vertex or breech x2 - c-section

Herpes gingivostomatitis

Vesicles and ulcers on ANTERIOR oral mucosa and around mouth FEVER

Dyshidrotic dermatitis

Vesicular rash on palms, soles with pruritus, redness, scaling Sometimes on sides of digits

Hep C - How to get it - Presentation - Testing - Labs

Via blood - usually IVDU Usually initial infxn asx HCV antibody - if + can be acute/chronic or resolved Further test w/ HCV RNA via NAT - if +, antiviral therapy Chronic HCV may have normal LFTs and basic labs/sx usually can't tell chronic vs cleared

Dementia with Lewy bodies

Visual hallucinations Spontaneous parkinsonism Fluctuating cognition

Primary hypothyroidism now megaloblastic anemia. - What - Why - Presentation - Look out for this after tx

Vit B12 deficiency 2/2 pernicious anemia w/ antibodies to parietal cells so less intrinsic factor made Autoimmune primary hypothyroid increases risk of other autoimmune dx Subacute combined degeneration - Posterior columns: proprioception - Lateral column: brisk reflexes - Peripheral nerves: hyporeflexia Hypokalemia - increased uptake of K by new RBCs

Hypocalcemia - levels of phosphorus and PTH in... - Vit D def - Hypoparathyroidism - Pseudohypoparathyroidism - Hyperphosphatemia

Vit D - LOW PHOS, high PTH Hypoparathyroid - high phos, LOW PTH Pseudohypoparathyroid - both high Hyperphos - both high

Back pain, low phos, high alk pos, hx bariatric surgery

Vit D deficiency w/ osteomalacia and secondary hyperparathyroidism - Check 25-hydroxyvitamin D - Need 2-3,000u cholecalciferol Gastic bypass pts get lifelong B1, B12, folic acid, vit D, iron, calcium supplementation

Old person has delirium. First step?

Vitals then labs to r/o reversible causes (infxn, UTI, lytes, hypoglycemia, etc.)

Sever C diff - Define - Tx

WBC 15,00)+ Cr >1.5x baseline Serum albumin <3 g/dL Oral vancomycin - If really bad consider subtotal colectomy vs diverting loop ileostomy

When to do external cephalic version

Wait until 37 weeks - Gives time for spontaneous version to cephalic External cephalic version can cause non reassuring fetal heart rate abnormalities 2/2 abruption placentae requiring c-section - If ECV contraindicated (active herpes, placenta prevue, multiple gestation, IUGR), do c-section

Mechanical aortic/mitral valve - Anticoagulation - INR goals

Warfarin AND aspirin Aortic w/o RF: 2-3 Any mitral, aortic w/ RF: 2.5-3.5 Weak rec: INR goal 2.5-3.5 first 3 mo after any aortic replacement RF: a fib, LV dysfunction (EF <30), prior DVT or hypercoagulable

CHF -> decreases perfusion to kidneys -> increased ADH release -> RAAS and norepinephrine increase water reabsorption -> dilutional hyponatremia - Tx

Water restriction - Only tx w/ vasopressin antagonist (tolvaptan) if severe

SIADH - Why hyponatremic - Tx - Rate of correction

Water retention and loss of Na and K - If chronic, loss of Na more significant than amount of water retained Water restriction - If give Na tabs or hypertonic NS, give loop diuretic 0.5 mEq/hr - Monitor for volume depletion as may become Na deficient

Trendelenberg gait

Weak hip abductor -> OPPOSITE hip drops when standing on affected leg

Obturator nerve injury

Weakness of leg ADDuction Sensory loss over medial thigh

Sciatic nerve injury

Weakness of lower leg and hamstring Sensory loss of lower leg Ankle jerk absent

Femoral nerve injury

Weakness of quad muscle (knee extension) w/ sparing of adduction (obturator n) Lose sensation of anterior and very medial thigh down the medial shin to the foot arch (saphenous n) Decreased knee jerk reflex

Propensity scoring

Weighs different variables in both groups to ensure variables are balanced

Addison's dx = Chronic adrenal insufficiency - Physical exam - Electrolytes - Workup

Weight loss, abd pain, weak, amenorrhea, fatigue, anorexia, muscle tenderness, less axillary/pubic hair (low androgens), hyperpigmentation (co-secretion ACTH and MSH) Low Na, high K, mild high Cl met. acidosis Morning cortisol & ACTH or ACTH stim test: cortisol low and ACTH high = 1 adrenal insufficiency; both low = 2 or 3 insufficiency

Multiple myeloma

Weight loss, anemia, hypercalcemia, increased serum protein (low-normal albumin) Punched-out skeletal lesions Rapidly progressive generalized bone loss -> primary osteoporosis and fractures Get serum and urine protein electrophoresis

Glucagonoma - Sx - Think about this

Weight loss, necrolytic migratory erythema, hyperglycemia MEN1 - pituitary, parathyroid, pancreas

Alopecia areata

Well-demarcated, round, non-scarred patches of complete hair loss - Often associated w/ nail pitting - No scaling or erythema Autoimmune! Self-limiting but may relapse - Meds can cause hair loss but usually diffuse rather than discrete patches - Usually irregularly shaped areas in trichotillomania

During summer/early fall, pt has fever, HA, vomiting, nuchal rigidity, AMS, hyperreflexia, insect bites - What

West Nile from mosquitos

Wet Beriberi - Sx - Deficiency Wernicke-Korsakoff syndrome - What - Deficiency

Wet Beriberi - dilated cardiomyopathy, polyneuropathy WK - neurocognitive impairment, oculomotor dysfunction, ataxia, encephalopathy, amnesia Thiamine B1 deficiency for BOTH

Verification bias

When study uses gold standard testing selectively to confirm results of preliminary testing - Leads to over/underestimates of sensitivity/specificity Prevent by using gold standard on a random sample

Acute gout - Dx - Tx

While PE can be very suggestive, should confirm with arthrocentesis NSAID if no contraindication - Colchicine if no liver/renal dx - 1 joint - steroid injection - 2 joints - IV, IM, oral steroids

ASD murmur

Wide-fixed split S2 May also have - Mid-systolic EM 2/2 increased pulmonic valve flow - Mid-diastolic rumble 2/2 increased tricuspid valve flow

Penicillamine used for...

Wilson disease to increase copper excretion

Lyme-endemic areas

Wisconsin, Minnesota NE

Bulky, foul-smelling stool - With abd pain - Without abd pain

With - pancreatitis Without - Celiac

NPH - Presentation - Imaging - Dx - Tx

Wobbly, wet, wacky - Abnormal gait, urinary incontinence, impaired cognition Ventriculomegaly LP drainage of CSF -> improve sx VP shunt

HPV vaccine age recommendations HPV 6, 11 - genital warts HPV 16, 18 - cancer

Women 11-26 YO Men 11-21 and up to 26 for MSM Immunocompromised 11-26 YO NOT indicated in pregnant women

Amputated body part transport

Wrap in sterile gauze, moisten with saline, place in sealed, sterile plastic bag and transport in container with saline and ice

Hemophilia A genetics

X-linked recessive - Daughters born to affected father and normal mother will be a CARRIER - Son born to affected mother has 50% chance of having the dx

G6PD deficiency in babies - Who/inheritance - Presentation - Labs

X-linked, NON-WHITES Unconjugated hyperbili DAY 2-3 Acute hemolytic episode - Sulfa, fava beans - Jaundice, pallor, dark urine, back pain Hemolytic anemia BITE CELLS w/ Heinz bodies Low G6PD assay - may be normal during attack NEWBORNS DON"T HAVE TO HAVE STRESSOR LIKE ADULTS

Ankylosing spondylitis - LBP/stiffness 3+ months that improves w/ exercise - Limited lumbar spine motion - Decreased chest expansion - Seronegative (no ANA, RF) First test to order F/U Associated with what condition Exercise?

XR sacroiliac joints Spine/SI joint XR and ESR q3mo Uveitis, aortic regurgitation, IgA nephropathy, apical pulmonary fibrosis and restrictive lung dx - Limited costovertebral joint motion, apical pulmonary fibrosis - STOP SMOKING Aerobic exercise improves functional status No change in life expectancy

Multiple sclerosis - Presentation - Acute episode tx

Young female with 2+ DISTINCT EPISODES of CNS dysfunction - Sensory, visual, or bladder/bowel dysfunction Steroids

Abusive head trauma a.k.a. shaken baby syndrome

Young fussy kid, unstable home environment Irritability and vomiting are signs of increased intracranial pressure Retinal hemorrhages on fundoscopy Subdural hemorrhage (bridging veins) and diffuse brain injury

Antipsychotic -> acute dystonia - Who - What - Tx

Young male using high-potency 1st gen like haloperidol Torticollis - sudden, sustained contraction of neck, mouth, tongue Oculogyric crisis - forced, sustained elevation of eyes upward Benztropine or diphenhydramine - Anticholinergic effect - IV or IM

Narcolepsy - What - Dx - Tx

Young person w/ daytime sleepiness, hypnagogic hallucinations, cataplexy Recurrent lapses into sleep multiple times w/in same day at least 3x/wk for 3 months. AND 1+: - Cataplexy - Hypocretin-1 deficiency on CSF - REM sleep latency <15 minutes Dx w/ polysomnography - Spontaneous awakenings, reduced sleep efficiency, latency of REM sleep - Also r/o other things Modafinil - stimulant w/ less SE SSRI/SNRI for cataplexy Sodium oxybate good but abused

Androgen insensitivity syndrome

Young teenage girl with primary amenorrhea - 46 XY - Normal MALE testosterone level - Breast development 2/2 testosterone conversion to estrogen - No pubic or axillary hair - Cryptorchid testes

Positive likelihood ratio formula

[a / (a+c)] / [b / (b+d)]

whooping cough

bordetella pertussis longer prodrome (10-14 days) of rhinoorhea and cough, +/- fever (croupe has short prodrome) no stridor

psychotic depression tx

combo antidep + antipsych ECT (preferred if pt severely dep, psychotic, SI, refusing to eat or drink); no absolute CI

postop pleural effusion

common in pts undergoing cardiac surg, esp CABG; likely 2/2 pericardial inflammation -usu small and L sided, not a/w symptoms -if small (<25% hemithorax) and sxs: no intervention needed, usu resolve spontaneously

ODD vs conduct

conduct: repetitive and persistent pattern of behav violating basics rights of others or major societal norms or rules; see cruelty toward others, stealing, lying, destruction of property

Alpha = probability of type I error Beta = probability of type II error

increase in statistical power (small size) decreases probability for type II error

common causes vertigo meniere BPPV vestibular neuritis (labrynthitis)

meniere: inc P and vol of endolymph; see recurrent vertigo, ear fullness/pain, unilateral hearing loss and tinnitus BPPV: otholiths in semicirc canal; have brief episodes brought on by head movement, no auditory sxs VN: inflamm of vestibular nerve (viral or postviral); have single episode of severe vertigo that can last for days; =labrynthitis when a/w u/l hearing loss

colorectal screening limits

not rec for axs pts with no personal or fhx and who are >75 or have life expectancy < 10 years

psychogenic polydipsia

seen in pts with schizophrenia leads to hypoNa (lethargy, delirium, seizures) -don't routinely check antipsych levels unless clozapine

Glucose-6-phosphate dehydrogenase deficiency - Epidemiology - Presentation - Labs - Tx

x-linked - MC in non-whites - Neonatal unconj. hyperbilirubin. w/ jaundice and anemia day 2-3 - Acute intra- and extravascular hemolysis after oxidative stress (fava beans, sulfa) - pallor, jaundice, dark urine, abd/back pain - Hemolytic anemia (normocytic and normochromic) w/ low haptoglobin and high LDH - Schistocytes and bite cells with Heinz bodies - denatured Hgb - Low G6PD assay - normal during attack so check weeks later Self-resolves in 1-2 weeks Avoid triggers