UWorld Step 3

In tx-naive HIV-positive pts, antiretroviral therapy should decrease viral load to ...

*<50 copies/mL within 6 mos* - virologic failure = failure to achieve viral load <200 copies/mL within 24 wks (6 mos) of ART and may be due to drug resistance or noncompliance - following ART, VL should be measured appx q3-6 mos

The following data were reported for incidence of gout according to the fifth of Western dietary pattern scores: First (lowest) - Cases 297, Person-years 190,572 Second - Cases 363, Person-years 194,533 Third - Cases 373, Person-years 196,671 Fourth - Cases 354, Person-years 197,114 Fifth (highest) - Cases 348, Person-years 192,778 What is true about the magnitude of the risk of gout patients adopting a Western diet in the highest fifth as compared to patients adopting a Western diet in the lowest fifth?

*A Western diet in the highest fifth is associated with a 20% increase in the risk of gout when compared to a Western diet in the lowest fifth* RR = risk of disease in exposed group/risk of disease in unexposed group = how high or low the risk for disease is among exposed compared to unexposed group - can also be extended risk for disease at different levels of intervention or risk factor RR <1 = decreased risk in group in numerator RR = 1 = no difference in risk between groups RR >1 = increased risk in group in numerator Numerator = group of pts adopting a Western diet in highest fifth Denominator (reference group) = group of pts adopting a Western diet in lowest fifth RR = (348/192,778)/(287/190,572) = 0.0018/0.0015 = 1.2 RR = 1.2 = 120% = adopting western diet in highest fifth increases risk of gout by 20% 1.2 - 1 = 120% - 100%, when compared to adopting a Western diet in lowest fifth

Study examines association between benzos use and hip fracture in elderly patients >70 yo. Total of 180 pts admitted to 20 hospitals with hip fractures were included in analysis; 10 pts used benzos in week before admission. For comparison, investigators selected 200 pts who were admitted for different reason; 7 of them used benzos in week before admission. Best measure of association to be reported for this study?

*(10 x 193) / (7 x 170)* Case-control study - case group includes individuals with outcome of interest (hip fracture) - control group include ind.s without it - distribution of exposure (benzo use) retrospectively measured within each group Odds Ratio - measure of association commonly used in case-control studies - represents odds that case was exposed divided by odds that control was exposed Hip Fracture - Benzo use = 10 = a - No benzo use = 170 = c No hip fracture - Benzo use = 7 = b - No benzo use = 193 = d Odds = probability divided by (1 minus probability) = P / (1 - P) Pts with hip fracture - (10/180) probability that they used benzos - (170-180) probability they did not (170/180) = [1-(10/180)] Pts had odds of (10/180) / (170/180) = 10/170 of having used benzos Pts without hip fractures - had odds of (7/200) / (193/200) = 7/193 of having used benzos OR refers to ratio of these 2 measures = (a/c) / (b/d) = (10/170) / (7/193) = (ad) / (bc) = (10 x 193) / (7 x 170)

The following data were reported for the incidence of gout according to the fifths of DASH and Western dietary pattern scores: DASH diet First (lowest) - Cases 396, Person-years 192,891 Second - Cases 391, Person-years 195,970 Third - Cases 354, Person-years 196,510 Fourth - Cases 332, Person-years 192,697 Fifth (highest) - Cases 252, Person-years 193,455 If this pt decided to adopt a strict version of the DASH diet (corresponding to the highest fifth intake ranking) as compared to a less strict version of the DASH diet (corresponding to the third fifth intake ranking), what proportion of his reduction in risk of gout could be attributed to this intervention?

*0.28 [42%]* RRR frequently calculated by subtracting the relative risk (RR) from 1 RRR = 1 - RR - RR = risk of developing disease (gout) in exposed group (DASH diet in highest fifth) divided by risk of developing same disease in unexposed group (DASH in third fifth) RR = 0.0013/0.0018 = 0.72% --> RRR = 1-0.72 = 0.28 OR Exposed/intervention group is DASH diet in highest fifth, and unexposed/control group is DASH diet in third fifth --> risks reported in person-years (incidence densities) Risk of gout among subjects adopting DASH diet in third fifth (unexposed/control group) = 354/196,510 = 0.0018 or 1.8 per 1,000 person-years Risk of gout among subjects adopting DASH diet in highest fifth (exposed group) = 252/193,455 = 0.0013 or 1.3 per 1,000 person-years RRR = (1.8 - 1.3) / 1.8 = 0.5/1.8 = 0.28 (28%)

15 yo boy comes to office for f/u visit regarding acne. He first developed acne a year ago and has tried OTC acne washes with no improvement. His first visit for acne was 3 mos ago, at which time he was prescribed a topical retinoid and benzoyl peroxide for inflamed papules and pustules on his cheeks and forehead. Pt says, "I've been using these 2 ointments every day. Do you think I should keep using them? Sometimes my face gets red and stings a little. I don't think my skin looks much better than before." He takes no other meds and always uses oil-free, non-comedogenic sunscreen when outdoors. He has no allergies. Most app next step in management?

*Add topic erythromycin* Inflammatory acne vulgaris unresponsive to initial therapy (topic retinoids and benzoyl peroxide) - many pts with inflammatory acne require addition of topic abx (erythromycin, clindamycin) - by decreasing skin colonization with cutibacterium acnes, topical abx decrease inflammation in acne vulgaris

Pt was managed for peptic ulcer perforation and recovers well. 3 years later, he comes to ED with 1 day hx of nausea, vomiting, upper-abdominal pain, and distention. Abdominal radiograph reveals presence of multiple air-fluid levels in SI consistent with intestinal obstruction. Most likely mechanism of his intestinal obstruction?

*Adhesion formation in peritoneal cavity* SBO - complete obstruction of intestinal lumen --> dilation of stomach and proximal SI --> abdominal distention, nausea, vomiting, intermittent abdominal pain - postop adhesion formation = most common cause of SBO in pts with hx of prior abdominal or pelvic sx

34 yo woman, gravida 1 para 0, comes to office at 35 wks gestation for routine prenatal visit. Pt reports good fetal movement and has no contractions, vag bleeding, or leakage of fluid. She has T2DM that was managed with oral med prior to pregnancy. She was started on insulin regimen during first trimester due to poor glycemic control. Pregnancy has also been complicated by fetal growth restriction diagnosed at 28 wks gestation when fundal height measured 24 cm and US revealed an estimated fetal wt at 3rd percentile for gestational age. Since diagnosis, pt has been followed with weekly US's. She doesn't use tobacco, alcohol, or illicit drugs. BP is 130/80 mmHg and pulse is 92/min. BMI is 34. Fetal heart rate is 150/min by bedside Doppler. Fundal ht is 31 cm. US prior to pt's appt revealed fetus in vertex presentation with oligohydramnios. Doppler studies of umbilical artery showed new onset of reversed end diastolic flow. Nonstress test showed moderate variability; there are no accelerations. 2-hour postprandial blood glucose level is 155 mg/dL. Group B strep rectovaginal culture has not yet been collected. Best next step in management of this pt?

*Admit to hospital for induction of labor* Fetal growth restriction = US-estimated wt <10th percentile for gestational age - placental insufficiency that impedes normal fetal growth - placental pathology --> increased umbilical artery resistance that can be monitored via Dopple sono - growth-restricted fetuses screened with serial umbilical artery Doppler sono and biophysical profiles to evaluate for worsening placental insufficiency and dev't of fetal hypoxia - growth measurements performed q3-4 wks - *absent or reversed umbilical artery end-diastolic flow = placental insufficiency and impending fetal hypoxia, particularly with concomitant oligohydramnios = indication for delivery* - absence of acclerations on nonstress test also reflects fetal hypoxia

43 yo man comes to office with his wife for eval of his snoring. His wife reports he snores loudly most nights and keeps he awake, but she has not observed him choke, gasp, or stop breathing while asleep. Pt is unaware of his snoring and reports no morning headaches, memory loss, or poor concentration. He occasionally falls asleep after lunch while seated at his desk. He reports no fatigue, wt gain, or constipation. His med probz includes seasonal allergies and hypothyroidism. Pt's meds include intranasal fluticasone and levothyroxine. He drinks 12-24 ounces of beer daily, usually 1-2 hours before going to bed. He doesn't use tobacco or illicit drugs. Both his parents have HT. Temp is 98.2 F, BP is 125/75 mmHg, pulse is 65/min, and respirations are 16/min. BMI is 26 kg/m^2 and neck circumference is 39.4 cm (15.5 in). PE reveals alert, oriented, and cooperative man in no distress. Oropharyngeal exam normal. No nasal polyps or septal deviations seen, and the nares are normal in appearance. Cardiac exam reveals normal first and second heart sounds and no JVD. Lung fields clear bilaterally. No edema or rashes present. Lab results: Leukocytes 4,100/mm^3 Hemoglobin 14.4 g/dL Platelets 320,000/mm^3 Best next step in management?

*Advice elimination of alcohol intake before bedtime* Snoring - via resp-induced soft tissue vibrations in setting of relaxed upper airway during sleep This pt = habitual snoring in absence of OSA - habitual snoring and male sex - does not have other characteristics of OSA (observed apneas, elevated BP, BMI >35, age >50, neck circ >43 cm) STOP-Bang questionnaire - poor PPV - high NPV for OSA - score <3 --> unlikely to have OSA = no diagnostic testing - both smoking and alcohol consumption before bedtime (relaxation of pharyngeal muscles) are associated with increased snoring

57 yo woman comes to PCP for f/u visit after undergoing a screening colonoscopy. Colonoscopy revealed adenocarcinoma of ascending colon and 2 well-differentiated, sessile, adenomatous polyps of sigmoid colon. Pt has hx of mitral valve prolapse and fibromyalgia. She has also had prior hysterectomy. Her meds include HRT and ibuprofen. Pt eats high-fiber veggie diet and has consumed 3-4 alcoholic beverages per day for past 30 years. She smoked 1 pack of cigz a day for nearly 5 years, but quit 30 years ago. No fam hx of cancer. Pt is very concerned about being diagnosed with colon cancer. What was her most significant risk factor developing colon cancer?

*Alcohol intake* Risk factors for CRC - fam hx, polyposis syndromes (FAP), IBD, AA race - alcohol intake, cig smoking, obesity - *Even moderate alcohol intake (2-3 drinks/day) associated with increased CRC risk* --> interferes with folate absorption - cig smoking also associated with increased CRC risk but risk primarily seen in current long-term smokers (>30 yrs)

Previously healthy 4 yo boy brought to doc in July with fever, productive cough, and left-sided chest pain that began yesterday. He attends preschool where other children have had cough and runny nose. PMHx is negative for asthma or other resp illnesses. Child's immunizations are UTD and he takes no meds. He lives with his parents and has not traveled outside the country. His temp is 103.1 F, BP is 98/64 mmHg, pulse is 104/min, and respirations are 25/min. O2 sat by pulse ox is 97%. Exam shows cooperative boy with intermittent coughing. Left lower lung lobe has decreased breath sounds. A 2-view chest radiograph shows mild alveolar consolidation with air bronchograms in left lower lobe. Most app pharm for this pt's condition?

*Amoxicillin* Pneumonia - fever, tachypnea, cough, adventitious lung sounds - severe = hypoxia, resp distress - equivocal dx --> 2-view (PA and lateral) CXR = infiltrates Uncomplicated CAP - PE and x-ray = lobar process, most commonly via strep pneumo - tx in outpt setting = high-dose oral amoxicillin

50 yo obese man comes to ED with toe pain. He awoke this morn with sudden severe pain in his left great toe. He has never had this type of pain before and has had no trauma to the toe. Pt has hx of HT tx'ed with HCTZ. He also has OA in his right knee that was treated with intraarticular steroid injection 6 mos ago. He smokes pack of cigz and drinks 1 or 2 glasses of wine daily. His temp is 98.1 F, BP is 130/80 mmHg, pulse is 88/min, and respirations are 12/min. Pt's left great toe is inflamed, with swelling and erythema at metatarsophalangeal joint. There is pain with minimal ROM. No skin rashes. Remainder of exam wnl. Best next step in confirming diagnosis?

*Arthrocentesis* Acute monoarticular gout - via intraarticular deposition of monosodium urate crystals - even if it is highly suspected, gout should be confirmed with arthrocentesis

4 yo boy brought to ED by mom due to refusing to walk since this morning. Pt started having right groin pain 2 days after T-ball practice, and his mom noticed him "walking funny" yesterday. She says, "I had to carry him here because he says it hurts too much to walk." Mom has witnessed no recent falls or injuries, and the symptoms have not improved with acetaminophen. Pt has had upper resp symptoms for last 2 wks and was diagnosed with viral pharyngitis a week ago. He has hx of atopic dermatitis that is controlled with low-dose topical corticosteroids. Immunizations UTD. He takes no meds and has no known allergies. Temp is 101.5 F. Pt appears tired but nontoxic. Posterior pharynx clear and without exudates. Lungs area clear to auscultation. On exam of right hip, pt cries and resists passive movement. There is decreased range of motion of right hip. Dry, erythematous patches noted on bilateral forearms. Lab findings show WBC of 14,000/mm^3 and C-reactive protein of 4 mg/L (normal < 3 mg/L). Best next step in management of pt's condition?

*Aspiration of hip joint* Septic arthritis - most cases occur in health children - swelling + decreased ROM around joint - children often keep hip in flexed, abducted, and externally rotated position Kocher criteria - non-weight-bearing - fever > 101.3 F - ESR >40 mm/hr or CRP > 2 mg/dL - leukocytosis - ped pts with >/= 3 criteria = high likelihood (>93%) likelihood of septic arthritis --> immediate joint aspiration --> diagnosis parenteral abx + surgical drainage + debridement

60 yo man comes to ED due to fever, burning on urination, generalized body aches, and lower abdominal discomfort. Dysuria began 3 days ago, and remainder of symptoms developed within last 24 hours. Pt also has been unable to urinate for past 18 hours. He has hx of HT, hyperlipidemia, CAD, and BPH. Meds include aspirin, metoprolol, atorvastatin, lisinopril, and tamsulosin. He is not sexually active. Pt doesn't use tobacco, alcohol, or illicit drugs and has no med allergies. Temp is 100.9 F, BP is 130/75 mmHg, pulse is 105/min, and respirations are 16/min. Abdominal exam reveals mild lower abdominal tenderness with no costovertebral angle tenderness. Urinary bladder palpable in hypogastric area. Rectal exam reveals swollen, tender, and enlarged prostate with no palpable nodules. Genitals normal in apperance and nontender in palpation. Lab testing show leukocyte count of 12,500/mm^3 with 85% neutrophils and elevated serum Cr at 1.3 mg/dL (last known value: 0.9 mg/dL). Microscopic urinalysis results: Specific gravity 1.013 Blood moderate Leukocyte esterase positivee Nitrites positive Bacteria many WBCs 50+/hpf RBCs 20-30/hpf Best next step in management?

*Bladder decompression and empiric abx* Acute bacterial prostatitis - acute urinary retention via urethral impingement - bladder can can confirm diagnosis (>300 mL residual volume) - tx = urgent bladder decompression with suprapubic cath and empiric abx (TMP-SMX, cipro)

Pt with persistent chest pain and neuro symptoms with recent cocaine use. After 2 hours in ED, pt has weakness in right arm. Chest pain is somewhat better, but she still has pain in middle and upper part of sternum. She has been treated with lorazepam, morphine, and nitroglycerin infusion. BP is 133/80 mmHg and HR is 88/min and regular. Neuro exam shows mild muscle weakness affecting right upper and lower extremities. Speech normal. Repeat ECG shows normal sinus rhythm with no significant abnormalities. Lab results: Leukocytes 11,000/mm^3 Hemoglobin 12.2 g/dL Platelets 220,000/mm^3 Sodium 134 mEq/L Potassium 4.1 mEq/L Creatinine 0.8 mg/dL Troponin undetectable Immediate noncontrast CT scan of head = no evidence of bleeding. Best next step in management of this pt?

*CT angiography of chest* chest pain + new neuro findings --> acute dissection of ascending aorta - ascending (type A) --> sharp anterior chest pain - back pain more common in type B dissections - rapid diagnosis essential = CT angiography of chest

60 yo man with hx of COPD comes to office due to hemoptysis. For past several days, he has had increasing cough with greenish-yellow sputum. He also had 2 episodes of blood-streaked sputum, which prompted clinic visit. Pt has mild dyspnea but no fever or CP. His other med probz are peripheral vascular disease and OA. His current meds include aspirin, inhaled fluticasonne and salmeterol, and ipratropium. He continues to smoke 1/2 pack of cigz daily and drinks alcohol occasionally. Pt had screening CT scan 2 yrs ago that was negative for lung mass. His dad died of lung cancer. BP is 140/95 mmHg and HR is 100/min. Pt's pulse ox shows 95% on RA. Lung ausc reveals bilateral expiratory wheezing. Best initial step in management of this pt?

*CXR* worsening cough with sputum = acute bronchitis causing exacerbation of underlying COPD - airway inflammation --> erosion of superficial vessels --> hemoptysis = scant or small in volume - plan chest radiograph = initial test --> identifies site and cause of bleeding in over 1/3 of pts

83 yo Caucasian man comes to ED bc of sudden onset, transient visual loss in his right eye. He is currently symptom-free, and denies any other new symptoms. His other med probz include HT and peripheral vascular disease. His meds include aspirin, HCTZ, and enalapril. His temp is 98 F, BP is 160/90 mmHg, pulse is 80/min, an respirations are 12/min. What signs is most likely to be associated with his symptoms/condition?

*Carotid bruit* - pt has developed fugax, an acute ischemic event involving retinal artery - condition is sudden and usually reversible - marker of carotid artery atherosclerotic disease - carotid bruit on auscultation of neck is a very frequent finding --> significant carotid obstruction

15 yo boy with CKD being evaluated for kidney transplant. He has chronic glomerulonephritis for last 3 years. His current estimated GFR is 12 mL/min. He also has HT and mild intermittent asthma. His sis, who is 22 yo, is willing to donate her kidney. She has no med probz. Initial testing shows ABO antigen match and one human leukocyte antigen mismatch. Sis should prob be appropriately counseled about what long-term risks of kidney donation?

*Gestational complications* Complications of donor nephrectomy Immediate risks - DVT - hospital-acquired infections Increased risk of gestational complications in female donors of childbearing age - fetal loss - preeclampsia - gestational diabetes - gestational HT

23 yo AA female with T1DM comes to office bc of recurrent hypoglycemic episodes, which are distributed evenly throughout day. She has had diabetes for past 6 yrs, and has been on stable dose of insulin. She had 4 lb wt loss over period of 3 mos. She has marked loss of app, and feels fatigued. She denies any changes in her activity level. She also denies constipation, diarrhea, urinary complaints, cough, SOB, and fever. She didn't have menstrual period for past three mos. She is a college student who lives with female roommate, and is not sexually active. She denies smoking, drinking, or use of recreational drugs. She denies any sick contracts or foreign travel. Her fam hx is unremarkable. On PE, she is 5'5" tall and weighs 120 lbs. Her BP is 90/60 mmHg, and her HR is 100/min. No skin rashes. Pigmentation hard to discern. Other systems normal. Lab results: CBC - Hct 38% - Platelet count 280,000/cmm - Leukocyte count 5,500/cmm - Segmented neutrophils 47% - Eosinophils 7% - Lymphocytes 40% - Monocytes 6% Serum - Serum Na 135 mEq/L - Serum K 5.6 mEq/L - Cl 104 mEq/L - Bicarb 17 mEq/L - BUN 30 mg/dL - Serum Cr 1.2 mg/dL - Ca 9 mg/dL - Blood glucose 45 mg/dL - HBA1c 5.5% (normal 4-6%) - TSH 4 uU/mL EKG and urinalysis results unremarkable. Most appropriate course of action in management of this pt?

*Check cosyntropin stimulated cortisol levels* - pts with one autoimmune dz predisposed to get other autoimmune dzes - most likely reason for decreasing insulin requirement = adrenal failure, for which cosyntropin test is indicated - other clues to adrenal failure = wt loss, asthenia, eosinophilia, borderline sodium, hyperkalemia, mild anion gap acidosis, prerenal azotemia, low blood glucose - absence of menstruation for 3 mos could be due to wt loss and systemic illness --> functional hypothalamic amenorrhea - autoimmune ovarian failure should be ruled out by checking FSH and estradiol

43 yo man brought to the ED after suffering serious injuries during a fight at a local bar. Pt smells heavily of alcohol, slurs his words, and has difficulty standing and walking. It is unclear if her experienced a LOC. PE reveals numerous contusions and lacerations on his face that will require suturing. Pt has unilateral pupil dilation in right eye and appears sleepy. When he is told that a head CT scan is needed for further eval, he rouses and becomes belligerent. Pt begins to shout and curse, claiming that the staff is harassing him and that he will sue the hospital for violation of his civil rights. Most appropriate course of action?

*Chemically sedate pt and perform head CT scan* - In emergency situations, pts who lack decision-making capacity may be treated without formal consent under the doctrine of implied consent - implied consent allows physicians to provide such txs to an incapacitated pt that a "reasonable person" would be expected to accept under similar circumstances.

65 yo man brought to ED by his wife due to severe upper-abdominal pain. Pain began suddenly 4 hours ago while he was watching TV. Radiates to back and is exacerbated by any movement. Pt has had GERD for many years and has been taking OTC antacids for symptom control. He also has HT, which is controlled with thiazide. He walks 5 miles daily. Pt has been consuming large amounts of milk and other dairy products to relieve "burning" symptoms in his stomach. His temp is 100 F, BP is 110/62 mmHg, pulse is 110/min, and respirations are 22/min. He lies flat and motionless on the bed. His mucous membranes are dry. Abdominal exam shows marked tenderness on superficial palpation. Pt does not allow any further palpation of the abdomen. Electrocardiogram shows sinus tachycardia. Best initial test for this pt?

*Chest and abdominal x-rays* acute abdominal pain + significant tenderness + guarding = bowel perforation with peritonitis - most common etiology = perforated peptic ulcer, especially with hx of "burning" abdominal sensations - rupture of hollow organ allows air into abdomen (pneumoperitoneum) - air can often be detected by upright CXR - important to keep pt in upright position so air within peritoneal cavity can be visualized beneath diaphragm

24 yo woman comes to office accompanied by her caseworker. This is the first time that she has been seen in the office, and she appears mildly anxious. However, she quickly once the female physician enters room. The caseworker reports that the pt would like to discuss contraceptive options as she has become sexually active with her bf. Med hx is remarkable for moderate intellectual disability and surgical repair of a cardiac defect as an infant. The pt says, "I would like to go on birth control. I want a baby one day but not until I am married." The caseworker reports that the pt's mother, who was unable to attend the appt, is extremely concerned about the pt's plan. The mother wants the pt to have a tubal ligation as she does not think her daughter would ever be able to care for a child. The pt becomes tearful and says, "My mom doesn't know what's best for me. I know I can be a good mom." What is the most appropriate next step in assisting the pt with these decisions?

*Determine if the pt has a guardian who assists her with health care decisions* - priority at this time = determine whether she has designated guardian, as the guardian must be included in the decision-making process - appropriate and respectful to ask adult pt about guardianship status first - if pt doesn't know or appears confused, it is appropriate to ask the parent or caseworker - when children reach 18, their parents may pursue guardianship in order to continue to make decisions for those with intellectual disability, especially if adult child's disability is severe enough to impair global decision-making capacity or ability to communicate --> however, if parent does not pursue guardianship, pt becomes his or her own guardian

52 yo man comes to office accompanied by his wife to discuss results of a routine screening colonoscopy in which several polyps were removed. He has hx of knee pain for which he takes glucosamine and chondroitin and multiple food allergies managed with dietary modifications. He doesn't use tobacco, alcohol, or illicit drugs. Pt adheres to a vegetarian diet and exercises regularly. Fam hx is not significant and he takes no meds. PE is normal. His mood is good and he is looking forward to his eldest son's upcoming graduation from college. Doc informs pt that biopsy of polyp showed cancerous cells, and stage 1 colorectal cancer diagnosed. Surgical resection recommended, and physician explains that sx is considered curative for localized colon cancer. The pt prefers to tx his condition nonsurgically and says, "Positive energy from natural light and foods can cure me. I will be find." He shows the doc results of his internet research on natural fruit therapy and believes that "the fruit enzymes will eat the cancer cells." The pt's wife disagrees with his decision and is in favor of sx. Most appropriate course of action?

*Formally assess pt's decision-making capacity* Pt's with decision-making capacity have right to refuse tx based on ethical principal of autonomy - when risks of refusing tx are high, most appropriate approach is to assess pt's decision-making capacity to determine if pt demonstrates both consistent, logical reasoning and clear understanding of condition and risks of refusing tx

Study is conducted to assess role of different treatment regimens on CV outcomes. Two treatment arms are evaluated: high-dose HCTZ (100 mg/day) and low-dose HCTZ (25 mg/day). After a defined follow-up period, the mean systolic blood pressure in high-dose group is 139 mmHg, with a mean diastolic BP of 88 mmHg. In the low-dose, the mean value are 143 mmHg and 92 mmHg, respectively. A 2-sample t-test gives p-values of 0.03 for systolic BP and 0.04 for diastolic BP differences between the high-dose and low-dose groups. Relative risk of sudden cardiac death in low-dose as compared to the high-dose is 0.4 (95% CI 0.25 - 0.55). Another subset of pts from this sample was given a placebo, and the risk of sudden cardiac death was assessed. When compared to the low-dose HCTZ group, the placebo group's relative risk of sudden cardiac death was very close to 1.0. Mean systolic and diastolic BP is the placebo group were higher when compared to the low-dose HCTZ group. Best statement concerning risk of sudden cardiac death in the overall sample of pts?

*High-dose HCTZ increases the risk of sudden cardiac death by a factor of 2.5* - Relative risk of sudden cardiac death in placebo group compared to the low-dose HCTZ group if 1.0 --> pts taking low-dose HCTZ have risk of SCD that is appx equal to that of pts taking placebo RR of SCD in low-dose HCTZ group as compared to the placebo group = 1.0 RR of SCF in low-dose HCTZ as compared to high-dose HCTZ group = 0.4 RR is a ratio obtained by dividing 2 values, the numerator and the denominator can be inverted (x --> 1/x) to change the reference. Inverting the values in.. RR of SCD in high-dose HCTZ group as compared to the low-dose HCTZ group = 1.0/0.4 = 2.5 *If the relative risk of an outcome in group A as compared to group B is x, then RR in group B as compared to the group A is 1/x*

28 yo woman with given diagnosis of GM has recently decided to transition to hospice care following intracranial surgery and course of chemo. She has been informed by her oncologist that her prognosis is poor and that she will likely not live more than 6 mos. Doc overseeing hospice team visit pt's home for f/u. During visit, pt mentions she h as been having second thoughts about choosing hospice care and, after speaking with fam members and friends, feels that this would be "giving up." Her twin bro will be getting married in 8 mos and she wants to attend his wedding. She has counseled 2 other oncologists who are experts in the field of glioblastoma for second opinions; they recommend experimental life-prolonging chemo regimen. She says, "I feel like I have to give this a try." What response by the hospice physician would be most appropriate?

*I respect your decision; hospice will be available to you if you decide to return* Hospice - criteria = diagnosis of life-limiting illness with estimated prognosis < 6 mos - pts permitted to leave hospce to receive life-prolonging txs and are free to return as long as they continue to meet these criteria

3 yo girl brought to ED due to pain and fever. 2 days ago, she developed mild abdominal and back pain. Her fever began yesterday morning and reached max of 104.2 F last night. Over last 8 hours, she had 6 episodes of emesis but has since tolerate a few sips of water. Girl has hx of constipation since start of toilet training at age 2 and has "pellet-like" stools once a week. She has frequent urinary accidents during day and night. She takes no meds and has no other med probz. Immunizations are UTD. Temp is 104 F, BP is 90/60 mmHg, pulse is 110/min, and respirations are 20/min. PE shows tired-appearing girl with dry mucous membranes. She has right costovertebral tenderness. Abdomen is soft, nontender, and nondistended. Remainder of exam is unremarkable. Lab results are: CBC - Hgb 13 g/dL - Platelets 260,000/mm^3 - Leukocytes 16,500/mm^3 Urinalysis - Blood negative - Glucose negative - Ketones positive - Leukocyte esterase positive - Nitrites positive - WBCs 50/hpf - RBCs 9/hpf 20 mL/kg normal saline bolus administered. Pt has another episodes of emesis and additional void in ED. Appropriate management plan for this pt?

*IV abx due to pt's vomiting* Pyelonephritis - kidney infection + fever + n/v + flank/suprapubic pain - costovertebral angle tenderness (leukocyte esterase on dipstick analysis or >5 WBC/hpf on microscopy), and bacteriuria - risk factors = female, hx of bladder and bowel dysfunction (chronic constipation) - initial management of suspected UTIs, including pyelo = empiric abx (3rd-gen ceph) - IV abx for pts with hemodynamic instability, inability tolerate oral meds (persistent vomiting), or failure of improvement on oral abx - infants <2 mos at increased risk of sepsis = should be initially treated IV

Eval shows pneumoperitoneum on upright CXR. Pt's WBC is 11,300/uL, creatinine is 1.1 mg/dL, and lactic acid level is 2.1 mg/dL. Most appropriate next step in management of this pt?

*IV abx* - peptic ulcer perforation = potentially fatal complication of peptic ulcer disease --> if left untreated, pt can have rapid clinical deterioration, leading to death in 12-24 hours - emergency surgery (open or laparoscopic) indicated in all pts with perforated peptic ulcer - in prep for sx, pts with perforated viscus should receive fluid resuscitation and broad-spectrum IV abx with good coverage for gram-negative organisms - IV PPI therapy also suggested

27 yo woman brought to ED due to 4 hr hx of chest pain localized to middle of chest and upper sternal area. Describes it as "intense." Pt has never before experienced similar pain. She also describes some nausea and mild occipital headache. No vomiting, abdominal pain, or SOB. Friend who accompanies her to the ED says that they attended party and pt smoked crack cocaine shortly prior to her episode of chest pain. She did not consume alcohol. Pt has hx of IV drug use. She was treated with abx for upper extremity cellulitis 6 mos ago. No fam hx of premature CAD. Pt doesn't take any meds and has no known drug allergies. On initial eval, temp is 100 F, BP is 204/102 mmHg on right arm and 210/104 mmHg on left arm, pulse is 102/min and regular, and respirations are 18/min. O2 sat is 99% on room air. Pt appears thin, anxious, and agitated. Heart sounds normal and no murmurs heard. Lungs clear to auscultation bilaterally. Abdomen soft and nontender. LE pulses full and symmetric. No peripheral edema. ECG shows sinus tachycardia but otherwise unremarkable. Portable CXR reveals clear lung fields. Finger-stick blood glucose 98 mg/dL. Most appropriate next step in management of this pt?

*IV lorazepam* Cocaine-related chest pain (CRCP) - inhibition of presynaptic reuptake of NE in CNS --> overstimulation of adrenergic receptors (alpha-1, beta-1) --> tachycardia, increased myocardial contractility, arterial vasoconstriction, HT - benzos (lorazepam, diazepam) = preferred --> reduce sympathetic outflow to alleviate tachycardia and HT and improve myocardial ischemia + calm psychomotor agitation

Sulfonylurea (glyburide) causes increased insulin secretion, which can cause hypoglycemia. Persistence of hypoglycemia suggests large dose of med was taken. Initial tx with dextrose is appropriate. Dextrose admin can cause transient hyperglycemia that may elicit an even higher level of insulin secretion and subsequent rebound hypoglycemia. What should be considered in pts with large sulfonylurea overdose, particularly if the pt is unable to say how much med was ingested?

*Octreotide* - somatostatin analogue - decreases insulin secretion SO - dextrose = first-line tx of sulfonylurea poison --> then octreotide

63 yo man with HT comes to clinic for f/u. He was last seen a year ago and has been maintained on amlodipine for past 3 yrs. Pt has no symptoms and describes good exercise tolerance. He takes rosuvastatin for hyperlipidemia. Pt doesn't use tobacco, alcohol, or illicit drugs. During current visit, his BP is 132/78 mmHg, and pulse is 82/min and regular. O2 sat is 99%. Exam reveals 2/6 ejection-type systolic murmur at right second intercostal space. Pt's lungs are clear, and there is no peripheral edema. ECG shows normal sinus rhythm with nonspecific T wave abnormalities. He is referred for an echo, which reveals mild aortic sclerosis and left ventricular dilation with ejection fraction of 35%. No regional wall motion abnormalities. Best management for this pt?

*Initiate lisinopril* Stage B HF with asymptomatic LV systolic dysfunction (LVSD) All pt with asymptomatic LVSD (EF < 40%) --> ACEI (or angiotensin II receptor blocker) = initiated on low-dose therapy (lisinopril 5 mg daily) --> titrate up - once suitable ACEI achieved, beta blocker added - should eventually discontinue amlodipine

70 yo man brought to ED by his nephew due to redness and pain in his right leg. Pt lives alone and has no fam except for nephew, who occasionally checks on him. Other than hx of GI bleeding, little is known about pt's med hx. In ED, he is mildly febrile, but vital signs are otherwise normal. On PE, there is cellulitis of his lower right extremity and mildly tender hepatomegaly. Lab exams normal except for WBC of 12,400/mm^3, AST of 332 U/L, and ALT of 158 U/L. CXR and urinalysis normal. Pt admitted to hospital and IV abx started. At time of admission he appears calm and agrees to hospitalization. That nt, pt becomes irritable and restless. He is unable to sleep and becomes increasingly trumulous and diaphoretic, as well as argumentative with nurse, whom he slaps on hand as she tries to help him. Temp is 99 F, BP is 160/90 mmHg, pulse is 108/min, respirations are 18/min, and pulse ox is 93% on room air. Pt appears cognitively intact. Most appropriate pharmacotherapy for this pt?

*Lorazepam* restlessness + insomnia + agitation + diaphoresis + tremulousness + elevated pulse and BP on first night of hospitalization = alcohol withdrawal - occult alcohol use disorder should be suspected when symptoms emerge early during course of hospitalization - 2:1 ratio of AST:ALT = unhealthy alcohol use - tx with benzodiazepine - lorazepam = int-duration = preferred in hospital setting = safer in pts with possible liver dz and has no active metabolites

57 yo man comes to office for f/u visit 2 wks after ED visit during which sudden rise in his BP to 190/110 mmHg was noted. He has had essential HT for appx 12 years, optimally controlled by HCTZ and amlodipine, until this past month when his BP readings were consistently higher than before. He has been extremely compliant with his diet and meds. He doesn't have any other med probz. He has smoked one pack of cigz daily for 20 years. He denies any recent use of alcohol or illicit drugs. In the office, his BP is 160/94 mmHg in the right arm and 162/96 mmHg in the left arm. His BMI is 28 kg/m^2. CV exam reveals regular heart sounds and 1/6 systolic murmur at apex. There is faint right-sided carotid bruit. Left-sided popliteal and posterior tibialis pulses are barely palpable. His serum creatinine level is 1.1 mg/dL. Most helpful in establishing this pt's diagnosis?

*MR angiography of the renal arteries* Severe HT resistant to 2 meds and has acutely worsened from previously stable state = secondary cause of HT - age of onset before 30 years or malignant HT --> secondary hypertension Renovascular HT = most common secondary cause of HT - renovascular disease possible given likelihood of atherosclerotic disease in right carotid artery and left lower extremity vasculature based on PE - other clues = elevated Cr, unilateral renal atrophy, recurrent flash pulmonary edema, abdominal bruit on PE - moderate risk of renovascular HT --> imaging eval = MRA, CTA, Doppler US

9 mo old boy brought to office for well-child visit. Parents concerned that he has not been meeting milestones as quickly as his older bro. Pt has not started crawling and requires support from his parents to sit up. His mom states, "I think his lack of crawling is bc he cannot roll over from his back to stomach." Parents say he sleeps well through the nt and is a happy infant overall. Pt spits up occasionally after bottle feedings but less so than when he was a newborn. His diet is still primarily infant formula, bu the has been self-feeding solid foods since 6 mos with no gagging or coughing. Pt was born at 35 wks gestation via uncomplicated delivery. Due to gestational age, infant was observed in NICU; however, his stay was uneventfu, and he was discharged from hospital week after delivery. Fam hx is negative for dev'tal delays or metabolism disorders; his 3-year-old bro is healthy with no chronic med conditions. Ht, wt, head circ at 75th percentile. Infant alert and smiling and has no dysmorphic facial feautures. Anterior fontanelle open and flat, and gaze is conj with no nystagmus. Reaches for small toys and laughs when they rattle. MSK exam reveals increased tone in bilateral LEs. When infant is suspended by axillae, his legs maintain scissoring posture. Patellar reflexes are 3+. Sustained clonus noted in ankles bilaterally. Best next step in management?

*MRI of brain* CP - common comp of prematurity (<37 wks) - insult to CNS in nonprogressive motor dysfunction - spastic CP (as in this infant) = most common subtype - early signs = delayed disappearance of neonatal reflexes (tonic neck reflex), persistent or asymmetric fisting, early hand preference (before age 1) - may have initially normal or low tone at birth --> hypertonia/spasticity develops within few mos = can result in contractures and scissoring of legs - this infant with corrected gest age around 8 mos should be rolling and sitting without support --> by 9 mos, infants expected to pull up to stand and cruise - *when clinical presentation is consistent with CP, MRI of brain recommended --> periventricular leukomalacia, brain malformation, ischemia)* - comorbid epilepsy common

24 yo man brought to ED by his gf due to progressive weakness. They have been on cross-country road trip for past mo. While traveling through midwestern US 2 wks ago, pt developed diarrhea, nausea, and vomiting. He rested, drank fluids, and improved spontaneously after 2-3 days. However, pt had persistent fatigue, and 4 days ago they had to stop traveling as his legs became too weak to press down the brake pedal. He is now unable to get out of bed. Pt has also had tingling of hands and feet as well as SOB. He has had no fever, chills, abdominal pain, or recurrent diarrhea. Pt has no prior med probz and takes no meds. He doesn't use tobacco, alcohol, or illicit drugs. Temp is 99.8 F, BP is 120/70 mmHg, pulse is 90/min, and respirations are 20/min. Pulse ox shows 98% on ambient air. Pt is awake, alert, and speaking in full sentences but develops weak cough after taking sip of water. Lungs are clear to auscultation and heart sounds are normal. Abdomen soft and nontender. Neuro exam shows symmetric bilateral LE weakness. DTRs are absent at knees and ankles, and 1+ in biceps and triceps. CN exam and sensation are normal, and he has no neck rigidity. No skin rash or LAD. Best immediate step in management?

*Measure vital capacity at bedside* GI illness + severe symmetric muscle weakness + absent DTRs = GBS - high risk for rapid-onset resp failure - *frequent measurement of vital capacity and negative insp force required to monitor* - 30% of pts with GBS require mech ventilation

61 yo woman comes to doc due to mild exertional dyspnea. She has difficulty going up stairs and feels very tired by end of day. She has no chest pain, orthopnea, LE swelling, or syncope. Pt is being treated for locally advanced HER2-positive breast cancer. She underwent left-sided mastectomy and received adjuvant chemo with docetaxel and carboplatin in addition to trastuzumab 6 mos ago. Preop eval showed normal cardiac function. Currently, pt receives periodic trastuzumab infusions. Echo shows LV ejection fraction of 30%. Pt wonders if her symptoms are related to cancer therapy and wants to know her long-term prognosis. Best response to pt's concerns?

*Most pts completely recover heart function after discontinuing trastuzumab* Trastuzumab-associated cardiotoxicity - trastuzumab = monoclonal Ab that targets HER2 = used in addition to adjuvant chemo for tx of pts with HER2-positive tumors --> may cause decline in LVEF --> usually asymptomatic but may occasionally lead to overt clinical heart failure - incidence = 5% --> 25% when combined with anthracycline/doxorubicin and cyclophosphamide - in most pts, this is reversible

25 yo woman comes to office due to 4 days of burning with urination, increased urinary frequency, and blood in her urine. Pt has not had fever, chills, or abdominal vaginal discharge. She has tried to treat her symptoms with cranberry juice and increased fluid intake but has had no improvement. Pt has been in monogamous relationship for last 8 mos. She and her partner have intercourse 2 or 4 times a week; they use a progestin subdermal implant and condoms with spermicide for contraception. Pt voids immediately after intercourse but has had 3 UTIs in last 7 mos. She has no chronic med conditions but had a laparoscopic ovarian cystectomy for mature teratoma at age 20. Pt takes multivitamin daily. She drinks wine on special occasions but does not use tobacco or illicit drugs. Temp is 98F, BP is 110/60 mmHg, and pulse is 58/min. BMI is 22. Abdominal exam shows suprapubic tenderness but no costovertebral angle tenderness. Pelvic exam reveals small, nontender uterus with no adnexal mass. Speculum exam reveals normal cervix with no abdominal discharge. Urinalysis results: Blood moderate Glucose negative Ketones negative Leukocyte esterase positive Bacteria moderate 1-wk course of abx is prescribed. In addition to course of abx, what is the best next step in management of this pt?

*Prescribe postcoital abx prophylaxis* Recurrent UTIs = >/= 2 infections in 6 mos of >/= 3 infections in 1 yr - risk factors = hx of cystitis at <15 yo, spermicide use, recent new sexual partner, postmenopausal status - behavioral strategies = early postcoital voiding, adequate oral hydration, avoidance of spermicides - most effective tx for recurrent cystitis = abx prophylaxis = TMP/SMX, nitrofurantoin, cephalexin, ciprofloxacin

11 yo girl brought to clinic due to concerns about her posture. She does not fully extend her back and has difficulty with some of the positions in her ballet class. Pt is active in multiple sports as well as dance and typically practices 2 hours a day with various activities. She also has mid-thoracic back pain that feels like a "dull ache," and she occasionally wakes up at night to adjust her position due to discomfort. Pt takes no meds and has no allergies. She had no undergone menarche. No fam hx of scoliosis. Pt is at 50th percentile for ht and wt. Exam shows talkative girl with no dysmorphic features. Cardiopulm exam reveals normal heart tones and good air entry in all fields. Breasts and pubic hair are sexual maturity rating stage 3. Forward bend test reveals moderate scoliosis with right rib hump that doesn't correct by placing block under left leg. Gait normal. Two cafe-au-lait spots, each measuring 2 cm, are noted on right flank. What features of this pt's presentation is concerning for a pathologic cause of scoliosis?

*Presence of back pain* Scoliosis - most commonly idiopathic in asymptomatic adolescents Red flags - back pain - neuro symptoms - rapidly progressing curvature (>/= 10 degrees each year - vertebral anomalies on x-ray Pt's back pain that causes nocturnal awakening concerning for underlying spinal cord tumor --> can extend and disturb surrounding nerves = constant pain that is dull or gnawing

33 yo woman comes to office for eval of hypercalcemia. She was recently seen in ED for uncomplicated appendicitis and was found to have serum calcium level of 10.7 mg/dL. Pt underwent laparoscopic appendectomy and was released following day. Prior, she had not seen a doc in over 7 yrs. She now feels well and has no other med probz. Pt has had 2 uneventful pregnancies and her menstrual periods are normal. She is divorced and currently no sexually active. She does not use tobacco, alcohol, or illicit drugs. Her mom has had "high calcium level for a long time," but pt doesn't know if she received any specific tx. BP is 123/68 mmHg and pulse is 87/min with regular rhythm. BMI is 22 kg/m^2. PE normal with well-healing abdominal wounds. Lab results Serum chemistry - Sodium 140 mEq/L - Potassium 4 mEq/L - Chloride 104 mEq/L - Bicarbonate 24 mEq/L - BUN 9 mg/dL - Cr 0.8 mg/dL - Glucose 86 mg/dL - Calcium 10.9 mg/dL - Magnesium 2.8 mg/dL - Albumin 3.9 g/dL Urinary calcium 75 mg/24 hr Calcium:Cr clearance ratio <0.01 Serum PTH 55 pg/mL 25-hydroxyvitamin D 30 ng/mL (normal 30-50 ng/mL) 1,25-dihydroxyvitamin D 33 pg/mL (normal 25-65 pg/ml) Most appropriate next step?

*Reassurance and observation* Mild, asymptomatic hypercalcemia + high-normal PTH level + low urinary calcium excretion = familial hypocalciuric hypercalcemia (FHH) - AD - via mutation of calcium-sensing receptor (CaSR) --> decreased sensitivity to calcium - higher calcium concentrations required to suppress PTH release - defective CaSR --> increased reabsorption of calcium in renal tubules

2 yo girl brought to office for eval of persistent watery diarrhea. Five days ago, pt began having watery diarrhea and vomiting multiple times throughout the day. Vomiting resolved within 24 hours, but pt has since refused to eat her normal meals bc of nausea, preferring to drink apple and pear juice throughout the day. She has had large, watery stools 4 or 5 times a day with no visible blood and she passes gas frequently, but she has no diarrhea overnight. Pt takes no meds and has no allergies. Immunizations are UTD. Fam hx significant for celiac dz in her mom and maternal grandmother. Temp is 98 F, BP is 100/70 mmHg, and pulse is 120/min. Ht is 85 cm (33.5 in, 50th percentile) and wt is 10.8 kg (23.8 lb, 40th percentile), down 1 kg (2.2 lb from her well-child visit a month ago. Lips appear dry but oral mucosa is moist and has no oral lesions. Auscultation reveals hyperactive bowel sounds. Abdomen mildly tender to palpation in all quadrants, but there is no rebound or guarding. Skin exam shows perianal erythema and irritation but no jaundice or other abnormalities. Capillary refill is brisk. Best next step in management of this pt?

*Recommend discontinuing fruit juice consumption* emesis + watery diarrhea + abdominal tenderness + hyperactive bowel sounds = viral gastroenteritis - symptoms may be exacerbated by fruit juice - excessive consumption of juice high in fructose (apple juice) or sorbitol increases osmotic load --> fructose malabsorption in SI - fluid repletion = first-line tx for vital gasteroenteritis --> oral rehydration with hypo-osmolar solution containing electrolytes and small amounts of glucose

Health care worker's IGRA is positive. He is asymptomatic and feels well. CXR reveals no abnormalities. Next most appropriate step in management of pt?

*Recommend tx with isoniazid for 9 mos* no symptoms or x-ray abormalities = latent TB infection (LTBI) - considered noninfectious - at risk for conversion to active dz - health care providers with LTBI generally given tx with isoniazid daily for 9 mos

Subclinical hypothyroidism is an elevated serum TSH level with normal free thyroxine. Tx warranted for most pts with significant elevations in TSH, goiter, or convincing hypothyroid symptoms. For asymptomatic pts with mild elevations in TSH, what's the next step?

*anti-thyroid peroxidase antibody level* - elevated antithyroid peroxidase Ab titer increases likelihood of progression to overt hypothyroidism SCH - most common cause = chronic lymphocytic/Hashimoto thyroiditis

16 yo boy brought to ED via amb. School nurse who accompanied him informs doc that he had 2 days of headache and generalized body aches that didn't respond to acetaminophen. He felt well enough to attend school and to work his part-time job at local hardware store. However, this morn, his headache worsened and he was extremely drowsy. Paramedics administered IV normal saline; no other interventions required during transport. In ED, he becomes lethargic, has a seizure, and is immediately intubated by resident physician. Subsequent eval reveals that pt is suffering form acute meningococcal meningitis. In addition to pt's fam members, what contacts requires abx prophylaxis to prevent dev't of meningococcal meningitis?

*Resident who intubated him* N meningitidis = most common cause of acute bacterial meningitis in children and adolescents 2-18 yo - attaches to nasopharyngeal epithelium --> replicates asymptomatically or cause invasive dz --> mucosal invasion followed by bacteremia --> sepsis, meningitis, etc Abx chemoprophylaxis - those who live in same household or who have prolonged, close contact with pt and his or her secretions - health care workers who have had direct exposure to pt's resp secretions (during suctioning or intubation) - child care workers

19 yo woman brought to the ED by her mom due to suspected drug poisoning. Pt has severe depression treated with fluoxetine and lives with her mom and grandparents. Pt suddenly became ill at home earlier today and developed nausea and vomiting. Her mom suspects pt may have intentionally ingested a substance to harm herself as her grandparents' medicine cabinet door was open. On further questioning, pt states she swallowed a handful of one of the meds in the cabinet but does not specify further. Her grandparents' med condition include anxiety, seasonal allergies, coronary artery disease, and chronic back pain. The pt's mom doesn't know the specific names and dosages of the meds. Currently, pt reports nausea and dizziness and has vomited 3 times since arriving at the ED. She as smoked a pack of cigz daily for the past 5 years and drinks 1 or 2 beers occasionally. She has a hx of prior ectasy use but has no recent use of illicit drugs. Temp is 100.6 F, BP is 100/55 mmHg, pulse is 110/min, and respirations are 28/min. Pulse ox shows 99% sat on ambient air. Exam reveals awake, agitated young woman with dry mucous membranes. Pupils are 4 mm bilaterally and reactive to light. Heart sounds are normal and lungs are clear to auscultation. Abdomen is soft, nontender, and nondistended; bowel sounds are normoactive. Motor and sensory deficits are absent, and pt is fully oriented. A 12-lead ECG shows sinus tachycardia. CXR reveals clear lung fields and no cardiomegaly. Pt is given IV fluids and is placed on continuous ECG monitoring. Lab tests are ordered. Most likely cause of this pt's condition?

*Salicylate toxicity* - marked tachypnea, tachycardia, hyperthermia, dizziness, GI symptoms after ingestion of unknown substance Salicylate - crosses blood-brain barrier - directly stimulates medullary resp center (increasing resp rate and causing resp alkalosis) and chemoreceptor trigger zone (causing nausea and vomiting

7 mo old boy brought to office for routine visit. Parents's only concern is that their son's "private area looks abnormal," which his PCP has been monitoring. He breastfeeds on demand and recently started eating pureed fruits and veggies. Infant urinates frequently and stools once a day. He rolls in both directions, responds to his name, and transfers objects from one hand to the other. Pt was born c-section at 36 wks gestation for maternal preeclampsia. He was for gestational age but has gained weight appropriately since birth. Wt, length, and head circumference track along 30th percentile. PE shows interactive and alert infant. Abdomen soft, nontender, and nondistended. Genital exam reveals hypoplastic, hypopigmented, empty left scrotum. Small mobile mass palpated in left inguinal canal. Right testicle palpated in right hemiscrotum, which has normal cremasteric reflex and normal rugae. Penis is uncircumcised, and urethral meatus is at tip of glans. Most appropriate next step in management of this pt?

*Schedule pt for orchiopexy* hypoplastic, hypopigmented, poorly rugated, empty scrotum = undescended left testis/cryptorchidism - hx of being premature and small for gest age increases risk - diagnosis based on PE - tx = orchiopexy/surgical fixation of testis to scrotal wall --> referral for sx indicated by age 6 mos (corrected for gestation), as spontaneous test descent rarely occurs after this age - early orchiopexy before 1 yo optimizes fertility potential and test growth

29 yo woman, gravida 0 para 0, comes to office for preconceptual exercising. Pt has been taking OCPs for past 6 yrs and would like to become pregnant within next 6 mos. She has no chronic med conditions or previous surgeries. Her menses occur every 28 days and last for 4 days. Her menstrual flow is light and accompanied by mild cramping. Pt's Pap tests, last of which was 2 yrs ago, has been normal. In addition to OCPs, she takes multivitamin daily and uses acetaminophen occasionally. She has no known drug allergies and is UTD on all vaccinations. Pt drinks socially once a week but doesn't use cigz or illicit drugs. She is an aerobics instructor and teaches for 90 minutes 5 days a week. On days the pt doesn't teach, she exercises with light weights. In addition, she frequently goes scuba diving on weekends. BP is 100/60 mmHg and pulse is 62/min. BMI is 22. Pelvic exam reveals retroverted, normal-size uterus with no adnexal masses or tenderness, a closed cervix, and no vaginal discharge or bleeding. In addition to recommending prenatal vitamins, what is the best advice for this pt?

*Scuba diving should be avoided until after delivery* - recommended regimen during pregnancy 30 minutes of moderately intense aerobic exercise (pt should be able to converse while exercising) on most or all days of week - Exercises associated with high risk of falling and contact sports should be avoided - Swimming is safe, but scuba diving is not recommended due to risk of fetal decompression sickness from air embolus formation

76 yo man admitted to hospital with nausea, vomiting, generalized abdominal distention. He has long-standing hx of T2DM. His med f/u has been poor. PE and diagnostic workup are consistent with complicated SBO. He undergoes exploratory laparotomy with no operative complications and is extubated postop in SICU. Few hours after extubation, pt experiences sudden onset of chest discomfort, nausea, and marked diaphoresis. Temp is 97F, BP is 84/50 mmHg, pulse is 32/min, and respirations are 26/min. Exam shows minimal crackles at both bases. No murmurs on cardiac exam. Fingerstick glucose 150 mg/dL. ECG shows sinus bradycardia with 3 mm ST segment elevations in leads II, III, and aVF. Immediate CXR shows increased interstitial markings bilaterally. IV normal saline infusion started and IV atropine administered without sig improvement. Next step?

*Temporary cardiac pacing* - temporary transcutaneous, following transvenous, cardiac pacing tx of choice for pts with persistent symptomatic bradyarrhythmias not responsive to atropine - after = taken for urgent revascularization by PCI Cardiogenic shock via acute inferolateral wall ST elevatoin MI (STEMI) complicated by sinus bradycardia - sinus bradycardia and AV block commonly seen with acute inferior wall MI = explained by increase in vagal tone - in setting of acute inferior MI, bradyarrhythmias transient often but not always responsive to IV atropine

59 yo woman brought to ED by her son. He reports his mom sounded anxious and confused on the phone. When he arrived home, he found her shaking, sweating profusely, and unsteady on her feet. Pt's med probz include OA, seasonal allergies, depression, anxiety, and chronic insomnia. She has 25 pck year smoking hx but doesn't use alcohol or illicit drugs. Pt took 40 mg of fuoxetine for years with only partial improvement in her depression. However, this med was discontinued month ago. She was recently started on phenelzine. Her other meds include ibuprofen, diphenhydramine, and lorazepam. Temp is 101 F, BP is 160/90 mmhg, pulse is 116/min, and respirations are 24/min. On exam, pt is oriented to person and place but not time. She is agitated, diaphoretic, and tremulous. Oropharyngeal exam reveals no abnormalities; mucous membranes dry. Cardiopulmonary exam reveals tachycardia but is otherwise normal. Pt's abdomen is soft, nontender, and nondistended with increased bowel sounds. Deep tendon reflexes are increased. Muscular strength is preserved, but there is some muscular rigidity in LEs. Most likely diagnosis?

*Serotonin syndrome* - anxiety, confusion, tremulousness, diaphoresis, hyperreflexia - likely via drug interaction between monoamine oxidase inhibitor phenelzine and SSRI fluoxetine - recommended washout period for most antidepressants prior to beginning MAOI = 14 days - fluoxetine = long half-life --> recommended at least 5 weeks elapse between stopping fluoxetine and starting MAOI tx - this pt waited only 4 wks - classic triad = mental status change, autonomic dysregulation, neuromusc hyperactivity

27 yo woman comes to office for annual PE. She currently works as medical interpreter in regional hospital. Pt feels well and has no med probz. Her only med is daily OCP. She doesn't use tobacco, alcohol, or illicit drugs. Pt is UTD with recommended vaccines and has had no known contact with person infected with TB. Vitals wnl. Mucous membranes moist and without lesions. Lung fields clear to auscultation and heart sounds are normal. Abdomen soft and nontender with no organomegaly. No skin rash present. TB skin test performed and produces 12-mm induration at 48 hours. Chest radiograph normal, and urine pregnancy testing negative. Pt receives counseling and initiation on anti-TB therapy. Most appropriate employment-related recommendation for this pt?

*She is noninfectious and may work without restrictions* HCP - should receive annual TB with TB skin test or interferon-gamma release assay - TST with >10 mmg induration at 48 hours likely infected with M TB and should undergo CXR - no CXR abnormalities and no symptoms considered to have latent TB infection (LTBI) = noninfectious

29 to woman, gravida 1 para 0, at 11 wks gestation is brought to the ED by her husband who says she has been acting "bizarrely and out of control" for the past 8 days. Pt reported to her husband, "I am smartest graduate in America right now. This new company I am working on will rocket to the top." She has not slept in 4 days and spends most of the night writing plans for a company that will sell baby shoes. The pt quit her job suddenly yesterday and began shopping online for luxury baby clothes and furniture despite the couple's financial difficulties. Psychiatric hx is remarkable for 3 similar episodes that required hospitalization. The pt's husband says that she has been relatively stable since discharge from her hospitalization 2 years ago. She took lithium took 5 months ago, when she asked to discontinue it due to adverse effects of weight gain and hand tremors and to her desire to start a family. PE is normal. Mental status exam shows loud, pressured speech and rapid shifts in mood and affect. The pt starts to cry when discussing her grandmother's 6 mos ago and then bursts into laughter after making an inappropriate joke. She has no suicidal or homicidal ideation. She tells the doctor, "My baby is going to be a king and a prince of the weak, like Moses." What is the most appropriate treatment recommendation for this pt?

*Start haloperidol* - pts suffers from bipolar I disorder - currently experiencing acute manic episode First-line txs for mania = lithium, anticonvulsant mood stabilizers, and antipsychotic meds First-gen antipyschotic haloperidol = safe and effective treatment for pregnant pts with bipolar mania - due largely to its favorable reproductive safety profile, demonstrated over a long period of market - efficacy equal to that of second-gen antipsychotics for mood stabilizer in bipolar disorder

16 yo boy brought office by mom, who is worried he has been acting strange for past wk. She says, "He stays up late at night and is unable to sleep. He eats very little and is really irritable. He seem nervous and hyper and argues with the fam, which is not like him. I am a little worried bc his dad has bipolar disorder. I don't think he would use drugs, but I know that he has some friends who recently got in trouble for smoking marijuana." Med hx includes football injury and arthroscopic injury for anterior cruciate repair 3 mos ago. Pt has no other med issues. He takes no meds other than diphenhydramine, which his mom has given his over the past wk to help him sleep. Fam hx is significant for bipolar disorder and HT in his dad and ADHD in his younger brother, who is treated with med. When interviewed alone, pt states that he does not use alcohol, tobacco, or illicit drugs. He says, "I was nervous about final exams. After staying up late to study, it was hard to fall asleep." Temp is 98 F, BP is 130/90 mmHg, pulse is 102/min, and respirations are 20/min. Exam shows restless but otherwise healthy-looking boy. He is slightly diaphoretic and has trouble sitting still. Pupils are dilated and mouth is dry. Exam of ears and nose is normal. Lungs are clear to auscultation. Pt's heart is tachycardic with loud S2 heard on auscultation. Abdominal exam shows no abnormalities. No neuro deficits and no meningeal signs. Pt is talkative and his speech is mildly pressured. Most likely diagnosis?

*Stimulant toxicity* - new-onset insomnia, decreased appetite, irritability + dilated pupils, tachycardia, HT, diaphoresis - psychosis and seizures can also occur

30 yo Caucasian man with no significant PMHx presents to his PCP complaining of nausea, vomiting, diarrhea, abdominal cramping, and fever to 100.9 F. Symptoms started 12 hrs after man consumed beverage that contained pureed fruit, powered protein, and three raw eggs. PE of man is unremarkable. Salmonella enteritidis subsequently isolated from his stool culture. Best means of managing pt's care?

*Supportive therapy and observation* Symptomatic individuals infected with salmonella enteritidis --> replacement fluids and electrolytes - at risk for dehydration - gasteroenteritis usually self-limited - abx not shown to hasten resolution of symptoms or improve rate of clearance - *does not need to be treated with abx in immunocompetent ind's 12 mos of older*

testicular torsion is a surgical emergency that presents with acute-onset scrotal pain and swelling, classically presenting with...

*absent cremasteric reflex* - sign is nonspecific and may be absent in some children without torsion - acute scrotal pain and swelling often develop hours after vigorous physical activity - elevated, transverse testis - elevating scrotum does not tend to relieve pain - detorsion within first 6 hours typically allows for complete viability - after 24 hrs, testis is rarely salvageable

7 yo girl brought to office due to neck swelling. Her father states, "We noticed it a few mos ago and thought it would go away, but it has been getting larger over past few wks." Pt has had no preceding trauma, and there has been no redness, tenderness, or warmth of area. She has had no fevers, sore throat, difficulty swallowing, or change in phonation. Pt has hx of mild persistent asthma for which she takes inhaled budesonide daily and albuterol inhaler as needed. She takes no other meds and her immunizations are UTD. PE reveals well-appearing, well-nourished young girl reading a book on exam table. 3-cm round, slightly fluctuant, nontender mass palpated over midline neck. Mass moves upward with protrusion of pt's tongue. Most likely diagnosis?

*Thyroglossal duct cyst* - most common congenital neck mass - commonly presents in school-aged children or adolescents - asymptomatic, cystic, midline neck mass - if thyroglossal duct fails to atrophy normally, cyst develop from epithelial remnants within duct - mass moves superiorly with protrusion of tongue or swallowing - due to risk of infection, surgical excision = recommended

Randomized, double-blinded clinical trial was conducted to assess role of a multidrug chemotherapy regimen for tx of newly diagnosed stage III and IV stomach cancer. In study, 150 patients were enrolled in tx group and received the new multidrug tx, and 100 pts were enrolled in the control group and were treated with standard first-line therapy. All pts were followed for 24 mos. A total of 120 pts in tx group (80%) and 80 pts in control group (80%) died during f/u period. Despite these calculations, investigators concluded that the new multidrug regimen was more effective than standard therapy. What most likely accounts for the conclusion reached by the study investigators?

*Time-to-event data was analyzed* - time-to-event data collected when elapsed time before event occurs is of significant interest = accounts for total # of events in both groups and timing of events (can be important when assessing tx benefit) - commonly used in survival analysis where event of interest is death

13 yo boy brought to clinic by parents due to copious, purulent discharge from his right eye. Pt's eye was crusted shut this morn. Father was able to open eye by wiping it with damp washcloth. Pt went to school but was sent home by school nurse. He has not had ocular pain, visual changes, or fever. He lives at home with his parents and older sister, none of whom have similar symptoms. Pt has mild myopia and wears contact lenses. He takes loratadine daily for seasonal allergies. Vitals wnl. Exam shows conjunctival erythema and yellow exudate in right eye. Conjunctiva of left eye is also erythematous, but there are no secretions. Visual acuity testing with pt's contacts removed shows 20/80 vision in both eyes, consistent with well-child exam at 12. Most appropriate pharmacotherapy?

*Topical fluoroquinolone* - most common causes of bacterial conjunctivitis = staph aureus, strep pneumo, moraxella catarrhalis, h influenza - first-line = erythromycin ointment or polymyxin-trimethoprim drops - *incidence of p aeruginosa conj higher in contact lens wearers --> topical fluoroquinolones (cipro, ofloxacin)*

27 yo HIV positive man comes to ED with SOB, dry cough, and right-sided chest pain since yesterday. CP worse when he takes deep breath or coughs. He has had chills and night sweats for last week, which he has attributed to flu. Pt has been hospitalized for opioid overdose several times in past. 4 mos ago, he was admitted and treated for aspiration pna. Last year, he was hospitalized for cocaine overdose complicated by tonic-clonic seizures. His most recent CD4 lymphocyte count was 190/mm^3 2 mos ago. He has no drug allergies. In ED he appears mildly uncomfortable and has shallow breathing. Temp is 103 F, BP is 100/70 mmHg, pulse is 110/min and regular, and respirations are 22/min. BMI is 19. Pulse ox is 95% on RA. Multiple needle tracks and painful subcutaneous mass in right antecubital area. Neck veins are flat with pt in semi-recumbant position. There is a 2/6 systolic murmur heard at left sternal border. Liver palpated 1 cm below costal margin and is nontender. CXR reveals nodular opacities in both lung fields, including subpleural opacities on right. Serum potassium is 3.8 mg/dL and creatinine is 1.1 mg/dL. Blood cultures are obtained and IV fluids initiated. Most likely to establish diagnosis in this pt?

*Transthoracic echo* - transthoracic initially, followed by transesophageal if needed Acute right-sided infective endocarditis - IV drugs users at increased - HIV infection = further risk, especially with low CD4 - S aureus >50% in drug users = acute and high fever - pleuritic chest pain + cough via septic pulm emboli - emboli = CXR: multiple nodular opacities + cavitation possibly - cardiac murmur

34 yo Caucasian female presents to ED with 24 hr hx of headaches, myalgias, and low-grade fever. She grades intensity of her headaches as 6-7 on 10-grade scale, and states that she has never had such symptoms before. She doesn't know what could have brought these symptoms on. Nobody in her fam, or among her co-workers, has recently had similar symptoms. She has no hx of recent travel. Her past med hx is significant for episode of severe pyelonephritis one year ago. CT scan of head without contrast does not reveal any abnormality. LP performed, and CSF findings are... Xanthochromia Absent RBCs 75,000/mm^3 WBCs 100/mm^3 Protein 50 mg/dL Glucose 90 mg/dL CSF analysis on cryptococcal antigen, Lyme titer, bacterial stains, as well as bacterial cultures, are pending. Most consistent with CSF findings in this pt?

*Traumatic LP* - RBC count exceeding 6,000/mm^3 (or SA hemorrhage - rule out) - high RBC count without xanthochromia - WBC elevation via blood leak is appx one WBC is present per 750 - 1000 RBCs - protein elevated - glucose typically high

65 yo postmenopausal woman comes to office for eval of dyspareunia. Pt recently became sexually active after 7 yrs of abstinence after death of her husband. She has new partner and has pain with intercourse but has had no postcoital or postmenopausal bleeding. Pt was last seen in office 10 yrs ago when she underwent tx for biopsy-proven lichen sclerosus. Her symptoms improved after she was treated with high-dose topical corticosteroids. Pap test at time was normal. Pt has T2DM and HT, for which she takes metformin and ACEI. She had 3 vaginal deliveries when she was in her 20s. Pt tstopped smoking 5 yrs ago and doesn't use alcohol or illicit drugs. Fam hx is noncontributory. BP is 128/82 mmHg and pulse is 72/min. BMI is 28 kg/m^2. Pelvic exam shows raised, pigmented lesion over clitoral hood and extending to right labium majus. Multiple areas noted throughout vulva. No palpable inguinal LAD. Speculum exam reveals atrophic vagina and cervix with no visible lesions. Best next step in management of this pt?

*Vulvar biopsy* Raised, pigmented lesion suspicious for vulvar cancer - dyspareunia, vulvar pruritus, bleeding - 2 major causes = persistent HPV, chronic inflammation - common cause of chronic inflammation in postmenopausal women = lichen sclerosus Lichen sclerosus - routine exam + topic steroids --> no improvement --> vulvar biopsy

22 yo woman comes to office with right lower quadrant pain for past 3 wks. Pain is exacerbated with BMs, but there is no associated nausea, vomiting, diarrhea, constipation, or melena. She has no chronic med conditions and has never had surgery. Fam hx is noncontributory. Pt has regular menstrual periods every 28-30 days. She is sexually active and uses condoms for contraception. She doesn't use tobacco, alcohol, or illicit drugs. Temp is 99 F, BP is 110/70 mmHg, and pulse is 80/min. BMI is 24 kg/m^2. PE shows well-appearing woman in no apparent distress. Abdomen is soft with normal bowel sounds. There is tenderness to deep palpation in RLQ without rebound or guarding. Uterus is small, nontender, and anteverted. No cervical discharge or cervical motion tenderness. Right adnexa is enlarged and tender. Nondularity and tenderness on rectovaginal exam. Pt is at increased risk of...

*infertility* Pelvic pain exacerbated by BMs (dyschezia) and rectovaginal nodularity on pelvic exam = endometriosis - ovarian inv't = unilateral pelvic pain and tender adnexal mass (endometrioma) - tx = NSAIDs, OCPs, GnRH agonists, surgical resection

Tx options for initial C dif include...

*oral vanc* or oral fidaxomicin - fulminant disease (hypotension, ileus, toxic megacolon) --> IV metronidazole and high-dose oral vanc - vanc may be administered rectally if ileus present

Isotretinoin, used in tx of nodulocystic acne, is teratogenic. Female pts with childbearing potential must have what before initiating therapy?

- 2 negative pregnancy tests - commit to 2 forms of contraception

Recognize ECG of Wolff-Parkinson-White

- cardiac preexcitation via accessory pathway - short PR interval + delta wave + widened QRS (>0.12 sec) - some develop *tachyarrhythmias* - paroxysmal supraventricular tachycardia = most common arrhythmia = regular, narrow complex tachycardia - ingestion of alcohol = ppt of a fib - overall incidence of sudden cardiac death low but increased in pts with tachyarrhythmia episodes - tachy + a fib especially dangerous - cath ablation = recommended therapy in WPW syndrome

Pyelonephritis: IV meds indicated for pts who are...

- unable to tolerate oral meds - have failed oral meds - hemodynamically unstable

Spontaneous descent of undescended testes is rare after what age?

6 mos - orchiopexy

Adequate trial of fluoxetine

6 wks - GI symptoms = common --> improve with time

DOC for significant wound infections due to mammalian bites, including human bites.

Amoxicillin/clavulanate - or amp-sulbactam if parenteral therapy needed - provides coverage against oral aerobic or anaerobic flora, especially Eikenella corrodens

Pts with unexplained hematuria or other manifestations for RCC require...

CT scan of abdomen - to evaluate for renal mass

Important protective factors against suicide

Connection to *family*, pregnancy, responsibility for children

Occurs when extraneous variable (effect modifier) changes direction or strength of effect that the independent variable (exposure or tx) has on dependent variable (outcome)

Effect modification/interaction bias - ex. aspirin use associated with Reye syndrome in children but not adults --> age (effect modifier) modifies effect of aspirin (exposure) on Reye syndrome dev't (outcome) - stratification based on modifier can help detect effect modification

Primary diagnostic tool to evaluate pts with persistent or nonresolving pneumonia or pulmonary infiltrates

Flexible bronchoscopy - best diagnostic tool for endobronchial obstructive lesions is flexible bronch - if question asks for next best step in management --> CT

Should be used initially to treat thick psoriasis plaques on extensor surfaces.

High-potency agents: *fluocinonide*, augmented betamethasone dipropionate 0.05% - given twice daily application for up to 4 wks - lesions may be covered with occlusive barrier (plastic wrap or occlusive tape) after application to maximize tx

Preferred initial therapy for lowering HR and BP and reducing left ventricular contractility in pts with acute aortic dissection

IV beta blockers - sodium nitroprusside should only be used in addition to beta blockers if systolic BP remains >100-120 mmHg after adequate beta blockade - goal = lower systolic BP to 100-120 mmHg - esmolol = preferred in acute settings due to short half-life (9 minutes)

Used to screen TB in most pts with previous Calmette-Guerin vaccine as these pts may have a false-positive TB skin test

Interferon-gamma release assay - requires blood sample

Physiologic breathing pattern characterized by pauses of 5-10 seconds in breathing followed by rapid, shallow breaths. Without stimulation or intervention, a regular rhythm of breathing resumes after several cycles of period breathing.

Period breathing - benign - secondary to recurrent central apnea via immaturity of nervous system in infants up to age 6 mos - can be frightening for caregivers - anticipatory guidance and reassurance

Classically presents with Parinaud's syndrome, which is characterized by loss of pupillary reaction, vertical gaze paralysis, loss of optokinetic nystagmus, and ataxia.

Pineal tumor - headache = prominent feature, via obstructive hydrocephalus - some are germinomas --> secrete HCG --> precocious puberty in prepubertal males

Stent thrombosis is an uncommon but potentially fatal complication of coronary artery stenting, with most events (MI or death) occurring within 30 days of stent placement. What is the most important risk factor for stent thrombosis?

Premature cessation of dual antiplatelet therapy - with aspirin and platelet P2Y12 receptor blocker (clopidogrel, prasugrel, ticagrelor)

relative risk reduction (RRR)

RRR = (risk in unexposed - risk in exposed) / (risk in unexposed) - quantifies the proportion of risk reduction attributable to specific intervention of exposure as compared to a control - considers the risk for disease in the exposed/intervention group and unexposed/control group

Most common pathogen causing septic arthritis in all ages

S aureus, followed by S pneumo and S pyogenes - vancomycin!!!

Pt with injury to this nerve will complain of weakness affecting most of the lower leg musculature, including the hamstrings. Sensory loss involving lower leg. Knee jerk normal, but ankle jerk unobtainable.

Sciatic nerve

Synovial fluid WBC of >50,000/mm^3 with neutrophil predominance indicates septic joint. Empiric abx?

Vancomycin --> covers s aureus, steptococci

Severe c diff infection

WBC >15,000 and/or serum Cr >1.5 mg/dL = oral vanc or fidaxomicin

hiv-associated thrombocytopenia can occur at any stage of dz. mainstay of therapy is...

antiretroviral therapy

FHH can be distinguished from Primary Hyperparathyroidism by...

assessment of urinary calcium excretion - FHH = low urinary calcium levels (<100/24 hr) - PHPT = >300/24 hr Urine calcium excretion = urine calcium/creatinine clearance ratio (UCCR) = (Caurine/Caserum)/(Crurine/Crserum) - UCCR in FHH = <0.01 - UCCR in PHPT = >0.02 If UCCR is low, diagnosis of FHH is confirmed by testing for CaSR mutations

Bacterial conjunctivitis can progress to...

bacterial *keratitis* - most commonly occurs in pts who wear contact lenses improperly or have decreased immunity - inflammation of cornea - should be seen urgently by opthalmologist - dx via slit-lamp exam showing corneal ulceration --> epithelial injury via fluorescein - cultures of corneal scarping - can cause scarring or ulceration of cornea and blindness if not aggressively treated

Pain and numbness in the wrist and palmar surface of the first three fingers associated with repetitive movements of the wrist is typical for

carpal tunnel syndrome

Most significant risk factor for postpartum endometritis

cesarean delivery - especially when performed after labor commences or after rupture of membranes - postop course after c-section associated with necrosis of myometrium along with hysterotomy repair, presence of foreign bodies (sutures), and potential for incisional hematomas/seromas --> all amplify infection risk

Postpartum endometritis is a polymicrobial infection characterized by fever, uterine tenderness, and purulent vaginal discharge. First-line regimen...

clindamycin + gentamicin

Tx with vitamin B12 in pts with moderate to severe megaloblastic anemia can cause...

hypokalemia - can be severe and life-threatening - results following uptake of potassium by newly forming RBCs - serum K levels should be monitored during first 48 hours - some docs transfuse packed RBCs in pts with severe megaloblastic anemia before vit B12 supplementation to prevent hypokalemia

Supracondylar fractures usually occur after fall on outstretched hand and typically present with elbow pain and swelling as well as limited ROM. An occult, nondisplaced fracture may be presumed if there is fat-pad displacement on radiography and should be treated with ...

immobilization - ex. place splint for immobilization

Absent or reversed umbilical artery end-diastolic flow = sign of....

impending fetal hypoxia = indication for delivery

Subclinical hypothyroidism associated with what OBGyn probz?

increased risk for number of pregnancy complications - *recurrent miscarriages* - severe preeclampsia - preterm birth - low birth wt - placental abruption - anti-thyroid peroxidase (anti-TPO) Abs associated with increased risk for pregnancy loss

Common finding in up to 70% of male and female neonates. High levels of maternal estrogen cross placenta during third trimester but level in newborn's blood decreases after delivery --> stimulates neonatal pituitary gland to produce prolactin --> simulation causes...

neonatal breast hypertrophy - milk may be expressed when manipulated (galactorrhea) - usually resolve within 6 mos Other findings in newborn girl - labial swelling - leukorrhea - uterine withdrawal bleeding

Pt's CT scan of abdomen reveals enhancing mass of kidney with thickened, irregular septa, raising strong suspicion for RCC. Tx?

nephrectomy - 65% of pts with RCC have localized dz at diagnosis

Overlapping standard error of measurement suggest...

non-statistically significant difference - ex. similar effect of glycemic control

Guillain-Barre syndrome is treated with...

plasma exchange or IV immunoglobulin - to speed recovery and reduce risk of resp failure - pts who are nonambulatory should receive tx if symptoms have been present <4 wks

common finding in adolescents. on lateral radiographs, angle of spinal convexity is generally normal to slightly increased (20-40 degrees).

postural kyphosis/slouching - easily correctable by voluntary back extension - requires no tx

Tx of sunburn with intact epidermis

supportive - cool compresses - NSAIDs

Progression/timeframe of Guillain-Barre syndrome

tend to worsen over 2 wks --> plateau for 2-4 wks --> then spontaneously recover over mos - time to recovery shortened by use of plasma exchange or IVIG - after year: 85% of pts regain ability to walk & 60% have had full, spontaneous neurologic recovery

Acute bronchitis is the most common cause of hemoptysis. What is warranted in pts with increased dyspnea, increased sputum volume, or increased sputum purulence?

trial of abx

Method of birth delivery for woman with condyloma acuminata...

vaginal delivery, unless condyloma are large and obstruct birth canal - cesarean delivery does not prevent vertical transmission of HPV

Sodium-glucose cotransporter 2 inhibitors reduce glucose levels by promoting renal glucose excretion and are associated with...

vulvovaginal candidiasis UTIs polyuria SGLT2 - promotes glucose reabsorption at level of proximal renal tubule