General Internal Medicine Board Review

What are the borders of the anterior triangle of the neck?

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What are the borders of the posterior triangle of the neck?

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What are the management options of peripheral artery disease?

- Stop smoking - Regular exercise - Aspirin + other antiplatelet therapy - Cholesterol therapy - BP control - Blood sugar control - Foot care, esp diabetics - Surgery if severe: endovascular (balloon +/- stent), open surgical revascularisation (bypass)

What are the options for securing a ruptured SAH?

- Surgical: clipping - Endovascular: coiling, stenting

Polymyalgia Rheumatica

- Dx: ESR CRP - treat with low dose prednisone 15mg - neck, shoulders - hips, thighs - awakens from sleep, interferes with ADL - weight loss - painful ROM of shoulders but no motor defects - Normal CK

Interstitial Nephritis

- Dx: Sterile pyuria and leukocyte casts are hallmarks of interstitial nephritis, which can present acutely or may progress indolently and present as chronic kidney disease of unclear duration. Mild protienuria evident as well BACTRIM - within one week presents with WBC casts, maculopapular rash, Cr increase

Systemic sclerosis

- Dx: anti-Scl-70 - parenchymal lung disease - can cause Digital tuft resorption which is due to decreased blood flow and skin tightening where micro lesions on finger tips can lead to osteomyelitis and finger tip bone damage - can cause malabsorption due to bacterial overgrowth causing weight loss, abdominal cramping, and loose stools - due to altered peristalsis caused by fibrosis associated with systemic sclerosis - Microvascular cardiomyopathy is the most common symptomatic manifestation of heart involvement, resulting in CHF with reduced EF - Dx: glucose hydrogen breath test or barium swallow

primary Hyperparathyroidism

low vitamin D3 can stimulate PTH release Ergocalciferol more available in 50kIU carcinoma if Ca >14 and PTH > 250 50% elevated urine Calcium # low if concomitant Vit D deficiency Surgical indications: Ca > 1mg/dL CrCl < 60 T score -2.5 or worst Age 50 yo or younger cannot surveil (Sestamibi, High Def USG and intraoperative PTH) treat Vit D def to 30 ng/dL adequate hydration

RF for thyroid cancer in nodule

male extremes of age (< 20 or > 60) rapid growth hoarseness

DM and CKD/ESRD

measure postprandial glucose

MPI

measures ischemia LV function Myocardial viability

Herniation syndromes

medial temporal lobe (uncus) hernias down to the midbrain (compression on posterior cerebral artery and CN III)

Fixed and dilated

medullary lesion anoxia barbiturates anticholinergics

Atrophic gastritis

metaplastic atrophic gastritis - environmental v. autoimmune -- enviromental carcinogens or Hpi changes in antrum --AMAG- AD more common in women prone to pernicious anemia; increase in gastric carcinoid tumors - high gastrin levels from achlorhydria

Subclinical Hypothyroidism

mild high TSH and normal FT4 - FH of hypothyroidism; positive TPO - treat if TSH is > 10; positive TPO ab, large goiter

Asthma

moderate persistent = everyday symptoms no treatment of asymptomatic GERD 20% worse FEV1 with Methacholine/cold air/exercise 12%/200ml better with bronchodilator

lytic lesions

more than 30% of trabecular bone most be lost to show up on plain radiograph hence MRI for diagnosing bone mets

Migraine ppx

more than 4 a month no estrogen OCPs

post obstructive diuresis

most clinicians replace body volume at < 50% of UOP

Clarithromycin

most potent P450 inhibitor known to man!

melanonychia

nail matrix biopsy

AVNRT

neck pulsations caused by simaltaneous contractions of atria and ventricles 2/3 of SVT

ACS the other ACS

new infilatrates involving at least 1 complete lung segment with alveolar consolidation CP Fever 38.5 or greater Wheezing Cough Rule out PNA PE bone marrow embolism

CLABSI/CRBSI

no ABX for positive tip culture, phlebitis with signs of infection and positive blood cultures

Primary Amenorrhea

no menses by 16 POI (before 40 yo two sets of high FSH) 50% chromosomal abnormality - Turner, Fragile X Rx E2 with cyclic progestin

Pioglitazone

no one at risk for HF or with HF dilutional anemia

STICH trial

no relationship between myocardial viability testing and effectiveness from CABG

RA

nodules cavitary lesions Diffuse ILD 3: Males 1/3 patients Green effusion with low glucose NOT MTX

CAC scoring

non contrast low radiation dose calcium > 100 increase events < 0 high NPV > 400 = extensive plaque (odds 10:1 over 10 years of MACE)

Topiramate

non gapped metabolic acidosis (everybody) - why they feel funky - avg drop in bicarb is 4 - carbonic anhydrase inhibitor - raise uric acid as well

Hemineglect

nondominant parietal lobe

61. What antimicrobial would you prescribe for a periapical abscess in a patient with severe pain?

What antimicrobial would you prescribe for a periapical abscess in a patient with severe pain? None, this requires a root canal.

46. What antimicrobial would you prescribe for a periapical abscess prior to the patient going for a root canal?

What antimicrobial would you prescribe for a periapical abscess prior to the patient going for a root canal? None is needed as the endodontal surgeon will clean the area out during the procedure. Of course that assumes that there is quick access to the dentist for this very painful syndrome.

30. What are some drug-induced causes of hearing loss?

What are some drug-induced causes of hearing loss? Aminoglycoside, aspirin, NSAIDs, antimalarials, and loop diuretics

7. What are the 3 risk factors for bacterial vaginosis?

What are the 3 risk factors for bacterial vaginosis? a.Douching b.Lack of condom use c.Multiple or new sexual partners although BV can be diagnosed in women who are not sexually active

8. What are the 4 criteria for bacterial vaginosis?

What are the 4 criteria for bacterial vaginosis? a.Homogenous thin white discharge b.Vaginal pH greater than 4.5 c.Fishy odor before or after the addition of potassium hydroxide to vaginal secretions d.The presence of clue cells on saline microscopy

26. What are the 4 criteria for bariatric surgery according to the NIH Consensus Development Conference Statement?

What are the 4 criteria for bariatric surgery according to the NIH Consensus Development Conference Statement? a.The patient needs to be well informed, motivated, and able to participate in long term follow-up and accept operative risk. b.The patient should have a BMI greater than 40. c.For patients with BMIs between 35 and 39.9, they should have obesity related co-morbidities such as severe sleep apnea, diabetes, joint disease, etc. (some will do 30-35 also with uncontrolled DM or metabolic syndrome but data are lacking). d.The patient should be evaluated by a multidisciplinary team with medical, surgical, psychiatric and nutritional expertise. Of course bariatric surgery should not be considered until patients have failed diet, exercise or medication type treatments.

ITP

large platelet cause immature NOT ALL patients require therapy Rule out splenomegaly and thyroid disease, HIV, and Hep C Specific therapy if < 30k or bleeding Dex 40mg slow taper 25% response IVIG Rhogam only effective in Rh positive patients Rituximab Splenomegaly or TPO mimetic

Incidentaloma Surgical indications

larger than 4 cm, worrisome radiographic findings Pheo unilateral aldosteronomas subclinical CS with recent DM, HTN, obesity or low bone mass

Anal Fissure

lateral or anterior location suggests IBD rectal bleeding over 50 yo obviously C-scope

Locked in Syndrome

lesion of base of pons spares RAS below 3rd CN

SVT

local swelling & erythema 3.3% develop VTE increased risk with saphenous vein extremity swelling more pronounced Progressive symptoms USG Nonextensive = Less than 5cm & not near Deep Venous system analgesics and warm compression Fondaparinux

Nystagmus

look right but beat left that's a left beating nystagmus look left but beat right that's a right beating nystagmus

PT in the ICU

low dose vasopressors are NOT a contraindication

Drug Holiday

low risk osteoporosis on therapy 3-5 yeras stable BMD re-asses after 5 years of oral or 3 years IV Bisphosphonates

Pure Red Cell Aplasia

low to zero retics idiopathic mostly 2/2 drugs, thymoma or Parvo B19

What are the red flags for the ear?

- Swelling behind the ear = mastoiditis - Haematomas of the pinna = drainage - Otitis externa in immunocompromised patients = malignant OE - Unilateral effusion in adult = nasopharyngeal mass - Sudden hearing loss = urgent review - Sudden vertigo in elderly = cerebellar CVA

Candida

- Tx: Nystatin oral or skin -Fluconazole good for vaginal candidiasis CANDIDEMIA - blood infection best treated with echinocandins such as caspoFUNGIN, anidulaFUNGIN, or micaFUNGIN - Fluconazole not the best Candiduria - if assymptomatic, just remove foley - if symptomatic, treat with oral fluconazole

Helicobacter Pylori

- Tx: OClAm triple therapy - alternatives include Bismuth quadruple therapy 14 days (bismuth + Metro +tetracycline + PPI) or OLAm (OmeprazoleLevawuinAmoxicillin) - 1st line clarithromycin, amoxicillin, PPI - 2nd lines if resistant: (1) bismuth subsalicylate, metronidazole, tetracycline, PPI (2) levofloxacin, amoxicillin, PPI - follow up Urea breath test to reassess for eradication

Aspergillus

- Tx: Voriconazole - can cause acute sinusitis in immunocompromised, tissue biopsy shows septate hyphae

Acromegaly

- Tx: transsphenoidal pituitary surgery for removal of adenoma - might not completely remove tumor but surgery can effectively debulk the tumor and preserve vision in addition to significantly decreasing GH secretion as measured by IGF-1 levels - radiation therapy afterward may continue to work on the tumor if symptoms don't improve with surgery

What are the eligibility criteria for a pancreas transplant?

- Type 1 DM (C Peptide negative) - GFR <30ml/min - Absence of significant cardiac disease, or adequately treated cardiac disease - Patent iliac vessels bilaterally - BMI <35 - Age ideally <50years (unless medically fit)

Endometrial Cancer

- UNOPPOSED ESTROGEN increases the risk so only use this in post menopausal women WITH HYSTERECTOMY

What are the red flags for the nose?

- Unilateral discharge = FB - Battery = emergency - Unilateral clear fluid = CSF - Always image before biopsy in nose - Unilateral mass + bleeding in young male = JNA - never biopsy - Beware unilateral nasal mass

Nonocclusive mesenteric ischemia

- caused by decreased mesenteric perfusion in low-flow states such as heart failure, sepsis, profound hypotension, or hypovolemia - jejunal wall thickening and dilation, ongoing hypotension, fever, abdominal pain, diarrhea - vasoactive medications like vasopressors can cause as well

Tinea capitis

- causes scaling, inflammation, pustules, and pruritus, none of which are present in alopecia areata (listed previously)

Poison Ivy

- erythema and vesicular out break - wash cloths - Tx: 2 weeks of steroids if needed for severe outbreak....typical 5 day tapers actually create a rebound effect and are not optimal

meningioma

- extra-axial = not in brain parenchyma - homogeneous enhancement - dural tail - areas of calcification - light bulb sign

Pyoderma gangrenosum

- extraintestinal cutaneous manifestation of Crohn's - painful pustules that rapidly ulcerate and expand, with edematous, rolled, or undermined borders that may have a violaceous hue - Tx: glucocorticoids (oral, topical, intralesional) are first-line therapy

Carotid Artery Disease

- greater than 60% and symptomatic = surgery - greater than 60% and PERIOPERATIVE = surgery (to reduce event risk) - greater than 60% and ASYMPTOMATIC do not need surgery, rather starting a statin or in some cases RESTARTING statin to reduce stroke risk

Factor 13 deficiency

- last stage of clotting chain, activates fibrinogen crossing so deficiency = late stage bleed - ALL COAGULATION STUDIES ARE NORMAL - clot solubility in urea assay to screen - Iran patients (met Eiman at age 13)

Adrenal Tumor

- leads to SUPER INCREASE in DHEA resulting in inc test and inc estrogen due to peripheral conversion - follow up with CT and consider surgery

Burkitt lymphoma

- life-threatening metabolic and structural abnormalities - Tx for CD20-positive Burkitt lymphoma: hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (R-hyper-CVAD).

Cryoglobulinemic vasculitis

- like other vasculitis diseases, patients have palpable purpura, glomerulonephritis, mononeuritis, skin infarctions - however, presence of ear infarctions is most consistent with a diagnosis of cryoglobulinemia - RF is positive - C4 is low, the C3 is relatively preserved - associated with Hep C - Dx: check cryoglobulin levels in the context of all of the above

IgG4-related disease

- lymphoplasmacytic infiltration and enlargement of various structures, including the pancreas, lymph nodes, salivary glands, periaortic region leading to retroperitoneal fibrosis, kidneys, and skin - abnormal mass, Dx: biopsy - lymphadenopathy and gland involvement - Tx: steroids

HPV

- major culprit of squamous cell carcinomas of the head and neck, above even smoking and alcohol - Dx: p16 immunohistochemistry testing

Relapsing Polychondritis

- nonerosive seronegative inflammatory polyarthritis - bilateral auricular chondritis - nasal chondritis - ocular inflammation - respiratory tract chondritis - audiovestivular damage

Schatzki Ring

- nonpainful, nonprogressive dysphagia with solids but no liquids - "steakhouse dysphagia" bc predominantly meats

What is an anal fissure?

A split in the anoderm Typically located in the posterior midline May be precipitated by a hard stool, a bout of diarrhoea or after childbirth Usually no underlying cause but can occur in patients with Crohns or anal infection

What does the pattern of fevers tell you about the likely source of infection?

A temperature that rises and falls several degrees between readings suggests a collection of pus and intermittent pyaemia While a persistent high-grade fever is more in keeping with a generalised infection.

Dopamine agonists

dizziness, nausea, headache orthostatis and lightheadedness

ACC

do NOT biopsy cannot tell difference betwen benign and adrenocortical carcinoma

Zocor

do not put any new patients on 80 mg of Simvastatin It's crap Grapfruit juice Warfarin Amiodarone Fibrates Clarithromycin Azoles

Hpi Serology

doesn't tell of active infection poor PPV - low pretest probability - Urea Breath Test or Fecal antigen testing

MS cognitive dysfunction

domains: short term memory, processing speed and executive function neuropsych testing, counseling CBT

HPV DNA

don't test in under 30 pap Q3years 30-65 year old Q5 year dual testing

glimepiride & Glyburide

don't use it in the elderly don't use in CKD

SUNCT

dozens to hundreds a day 1 sec - 10 min Lamotrigine V1 distribution

LTOT

eval in all with FEV1 less than 35% clinical signs or symptoms of Cor Pulmonale or resp failure Chronic Resp failure pAO2 less than 55 mmHg SpO2 less than 88% PH, Polycythemia or peripheral edema suggesting Right HF paO2 less than 59 mmHg SpO2 less than or equal to 89%

Prolactinomas

even with invasion better to treat with carbergoline - normalize in 90% of pts - shrinks tumors - check prolactin level 1 month after starting - MRI every 3 months for macroadenomas - taper treatment after 2 years of normal prolactin level and no visible tumor on MRI even in mild visual impairment - OCP in women with symptomatic microadenomas

Hemoptysis

exclude GI or nose Massive > 500ml in 24hr vasculitis/CT disease AVM, Malignancies blood thinners PE Bronchoscopy Arteriography Surgery (CTS)

atrial septal defect

fixed S2 split R Ventricular heave pulmonary midsystolic flow murmur tricuspid diastolic flow rumble

Parvovirus for adults

flu like 5-10 acute symmetrical arthralgias that can resemble RA

Natalizumab

for Crohn's and MS JC virus PML inhibits leukocyte migration

Dalfampridine

for mobility voltage gated K channel antagonist amplifies APs AE: Seizures

Whole Brain radiation

for multiple mets CNS lymphoma ppx in small cell

glucagon kit

give to every patient with a meds associated with hypoglycemia

Hyperthyroidism in Pregnancy

hard clincal diagnosis: physio changes mean increased HR, fatigue and heat intolerance - Beta-HCG shares alpha subunit of TSH TSH 0.03-2.5 in 1st trimester ULN rises to 3 in 2nd and 3rd if cannot tolerate thionamides surgery

Physical exam features

hard, fixed and nonmobile on swallong LAD = cancer

Mitral stenosis

high PCWP high PAP

lichen sclerosus

high potency steroid clobetasol pruritic

CTA

high radiation dose iodinated contrast HR less than 60 BPM hold breath for 15 seconds

HF ascites

high total protein ( cirrhotics don't make it and nephrotics lose it)

stress testing

hold CCB or BB cannot achieve 85% MHR positive vasodilator better than dobutamine for LBBB or paced rhythms (cause artifact)

Calcium supplementation

if on PPI Should be on Calcium Citrate

CEA

in 1-2 weeks post stroke - 4-6 weeks in large strokes with edema

Osteoporosis in Men

in young men: Hypogonadism ETOH 1% is MM iatrogenic (glucocorticoid)

Primary Hyperparathyroidism

inappropriately normal/elevated PTH > 60s mostly women MC adenoma; MEN Carcinoma of Calcium > 14 or PTH > 250 24hr UCa, Vit D, Phos 50% elevated Urine Calcium Surgical indications: 1) Calcium > 1 mg/dL ULN 2) CrCl < 60 3) T score - 2.5 or worse 4) < 50 5) medical surveillance not possible or desired Sestamibi scan to identify offending gland or high def USG medical management - poor surgical candidiates refuse surgery IV bisphosphonate - 3 point DEXA every 1-2 years - keep Vitamin D level > 30 to minimize stimulation of PTH release

Long acting NSAIDs

increased risk of CHF in a patient with heart disease

VSD

indication for repair: significant shunt (Qp:Qs ratio is 2.0 or greater) and evidence of volume overload history of endocarditis Do not close: right to left shunt reversal

Length Time Bias

indolent disease detected

Effusive Constrictive Pericarditis

inflammation leads to effusion under pressure form inelastic pericardium low CO, systemic congestion and elevated JVP Y descent and JVP less prominent Tb - suspect if residual signs & symptoms after pericardiocentesis

Amlodipine

interacts with clarithromycin

Surgery in RA

intractable pain severe functional disability impending tendon rupture

Flow-Volume loop

intrathoracic is on exhalation 2/2 compression of airway from increased intrathoracic pressure extrathoracic (vocal cord paralysis)

DOSS

is colace

Paget Disease

isolated elevated Alk Phos Bone scan Pelvis (70%), Femur (55%), Lspine (53), Skull 42% Pain, HA, SN hearing loss, bowing of dem bones treatment: 1) pain 2) planned surgery at site of disease 3) hypercalcemia due to multiple affected sites Bisphosphonate NSAIDS, Gabapentin Lyrica

Time Zone Shift

jet lag westward travel causes less disruption than eastward

Chronic Pancreatitis

steatorrhea and malnutrition 90k Units of lipase per meal

Sacroilitis

stepping off a curb leg length discrepancies RF: altered pelvic mechanics, scoliosis, lumbar fixation, Posterior hip pain Positive FABER Gentle pressure applied downward to knee

Lacunar

sudden subcortical HTN, smoker, DM HLD

Ticagrelor

superior to Plavix in UA and NSTEMI no hepatic metabolism more potent faster onset of action

Type B Aortic Dissection

surgery for complicated disease refractory pain or hypertension, rapid aneurysmal expansion, rupture, or malperfusion syndrome.

Solitary Brain MET

surgically resect then XRT LP is rarely diagnostic in METs

unexplained hypoK and Met ALk

surreptitious vomiting or diuretic use

Cystic Fibrosis

sweat Chloride > 60 mmol inhaled DNAse

travel ABX

take when > 4 BMs

Multi-infarct Dementia

the accumulation of brain damage resulting from chronic ischemia (lack of blood supply) Chronic micro-angiopathic White matter lesions microscopic strokes Aricept and Nemenda

Refractory Vitamin D deficiency

think Celiac disease high dose treatment should prompt considering malabsorption - low Vitamin will prompt high PTH level; this is appropriate

Morton Neuroma

third and fourth toes clicking sensation (Mulder sign)

Decorticate Posturing

towards cord = above midbrain

Permissive HTN

treat only if greater 220/120

unilateral, fixed dilated

uncal herniation temporal lobe aneurysm affecting CN III

Disequilibrium

unsteadiness with walking or standing frail elderly multiple sensory deficits PT decides gait aid not you

Cardiac PET

useful for viability

MTAP

valve closer

arterial ulcer

well demarcated punched out painful toes cold. pulses low dry shiny skin worse pain with elevation of leg ABI BTI USG

MPI

with doing SPECT you need vasodilatory meds because exercise shows septal artifact

Nodules & Hyperthyroidism

you need RAIU might have a cold nodule which needs FNA TMN = surgical

Serum Sickness

- Due to Equine Antithymocyte Globulin which is a treatment for Aplastic Anemia

HIV

- Tx: First do resistance testing, then Ten, Emtri, and any integrase inhibitor OR Ten, Emtri, and any AVIR OR LamiAbaDo! - can cause Group 1 Pulm HTN - Continue regimen in PREGNANT patients and Zidovudine in baby after birth Eosinophilic pustular folliculitis - intensely pruritic papules (and rarely pustules) clustered on the chest and face, generally in areas with a high concentration of sebaceous glands - common rash in those with CD4 count < 300 - biopsy shows eosinophils - responds to antiretroviral therapy, although high-potency glucocorticoids and systemic antihistamines may be used for symptomatic treatment. Immune reconstitution inflammatory syndrome - when immune response improved with starting antiretrovirals within the last month - typically infection was present before, but as you treat HIV, immune response exposes or unmasks symptoms from the infection and on top of that, patient developes immune reconstitution inflammatory syndrome which presents with ****lymphadenopathy, hepatosplenomegaly, anemia, leukopenia, and elevated alkaline phosphatase level**** - Continue ART Disseminated Mycobacterium avium complex - concerned with CD4 count below 50 - fever, chills, sweats, fatigue, weight loss, abdominal pain - Dx: culture of the blood or other normally sterile site, such as bone marrow, lymph node, or liver - Tx: macrolide-based multidrug regimen, usually clarithromycin and ethambutol - Cobicistat med used to increase effect of elvitegravir but can cause AKI - change to abacavir-lamivudine regimen if AKI Post Exposure Prophylaxis - after sexual contact: three-drug regimen of tenofovir-emtricitabine and raltegravir (integrase inhibitor). No need to wait for results before treating - same with needle stick, Tenofovir and Emtricitabine plus integrase inhibitor, check levels in 4-6 weeks Vaccines - PCV13 (conjugate) )first THEN PPV23 (polysaccharide) - Hep A vaccine only if has symptoms but HIV alone is NOT a reason for Hep A vaccine - Patients with acute severe flare of PSORIATIC ARTHRITIS should be checked for HIV - Ring enhancing lesions due to Toxo but can also develop brain lesions due to LYMPHOMAS which are high risk in HIV patients - high dose steroids to reduce swelling and ICP if suspecting this dx Increased risk for Progressive Multifocal Leukoencephalopathy - PML due to JC virus - demyelination to parieto-occipital areas on MRI can be diagnostic but biopsy can confirm - decreased vision - Tx: upon resolution of immunodeficiency - Normal CD4 count RULES OUT CMX retinopathy - If patient is ASSYMPTOMATIC, no vision changes but noted to have COTTON WOOL SPOTS without hemorrhage or sx, diagnosis = HIV retinopathy Histoplasma Pneumonia - opportunistic infection with those with CD4 count below 50 - presents like PCP but the differentiating factor is diffuse lymphadenopathy, hepatosplenomegaly - PCP is strictly respiratory sx Mycobacterium Avium Intracellulare - CD4 count below 50 - disseminated disease can cause fever, diarrhea/abdominal pain, weight loss, night sweats, lymphadenopathy, hepatomegaly - AFB blood cultures - If CMV retinitis suspected, go ahead and treat empirically with Gangcyclovir PCP - differentiate from TB bc NO LYMPHADENOPATHY OR HEPATOMEGALY - if below 200, at risk - Tx: Bactrim and if hypoxic then give steroids too Tuberculosis - in immunocompromised patient (CD4 less than 50) we always think pnuemonia is PCP. However, TB has LN and hepatomegaly - night sweats - confusing bc TB in immunocompromised can be spread throughout the lung and disseminated - usually slow onset like 2 weeks - Step pneumo is also common but likely faster onset, days

Narcolepsy

- Tx: Modafinil

Spasticity

damage to corticospinal tract in MS - increased tone - painful cramps - spasms

Nephritis

***RBC CASTS*** is diagnostic. RBCs alone is not enough Infection Related Glomerulonephritis - Elevated Creatinine, urine erythrocytes and casts - low C3 complement, the absence of cryoglobulins, and the lack of clinical findings suggestive of other causes Alport syndrome - painless hematuria, COMPLEMENTS NORMAL - FAMILY HISTORY OF SIMILAR IgA Nephropathy - painless hematuria, COMPLEMENTS NORMAL - No family history - typically presents post illness even 24 HOURS AFTER but can occur spontaneously - in contrast to post strep which would be weeks - Dx: Kidney Biopsy Membranoproliferative Glomerulonephritis - low complement levels, associated with HCV

Ascites

**Serum-Ascites-Albumin-Gradient** Ratio > 1.1 - Ascites protein > 2.5 = cardiac ascites, early budd-chiari, veno-occlusive disease - Ascites protein < 2.5 = late budd-chiari, liver cirrhosis Ratio < 1.1 - Ascites protein > 2.5 = Malignancy, tuberculosis - Ascites protein < 2.5 = other

DVT ppx

- 15% DVT in 30 days -- Peak incidence from 2-7 days -- RF hemiparesis, a fib, immobility & advanced age - PE 25% of deaths - hemorrhagic stroke IPC within 72hrs -- consider lovenox in 1-4 days following repeat imaging

Acne

- 1st line is topical retinoid - 2nd abx - 3rd isotretinoin (for CYSTIC acne) NON INFLAMMATORY ACNE - open and closed comedones - Tx: topical retinoid is the best INFLAMMATORY ACNE - papules, pustules, nodules, cysts Pregnant patients should be off for ONE MONTH before conceiving

Atypical pneumonias

- 2 best meds are Macrolide and Quinolones - Clarithromycin or Azithromycin - Levaquin - Clarithromycin interacts with statins and fibrates, that why most of our patients we use Levaquin

What is the risk of rebleed following SAH?

- 2-4% aneurysmal SAH haemorrhage again within 24 hours - Approximately 15-20 % bleed a second time within the first two weeks. - Considering risk of rebleeding it is important to secure the ruptured aneurysm as soon as possible

What genes are implicated in the formation of cavernomas?

- 20% of cavernomas are familial - 3 genes: CCM1, CCM2 and CCM3 are strongly implicated in familial cavernoma formation - CCM1 & 2 are involved in signalling processes for normal blood vessel structure - CCM3 is involved in apoptosis

What is a nodular melanoma?

- 30% of all melanomas - Atypical melanocytes that initially grow vertically with little lateral spread - Uniformly ulcerated, blue-black, and sharply delineated plaque or nodule - Rapidly fatal - May be pink or have no colour at all, this is called an amelanotic melanoma - "EFG" Elevated, Firm, Growing

Plavix

- 300 mg load on STEMI given tPA - no evidence for prasugrel or ticagrelor yet - Prasugrel - not in stroke or TIA patients

HIT

- 5 to 10 days after exposure to heparin, with a decrease in platelet counts of 50% or more and, in a subset of patients, paradoxical arterial or venous thrombotic even despite the presence of thrombocytopenia - Cardiac and Ortho surgery patients have higher incidence - 4T score: Timing of platelet count decrease, Thrombosis, Thrombocytopenia, and no other cause of the Thrombocytopenia - Dx: serotonin release assay (SRA) and the heparin-induced platelet aggregation (HIPA) assay. SRA is considered the GOLD STANDARD study for HIT - switch from Heparin to lepirudin, argatroban, or danaparoid

What is an acrolentiginous melanoma?

- 5% of all melanomas - Ill-defined dark brown, blue-black macule - Palmar, plantar, subungual skin - Melanomas on mucous membranes have poor prognosis

Heparin Induced Thrombocytopenia (HIT)

- 5-10 days following heparin - paradoxical thrombocytopenia WITH INCREASED CLOTTING - 4 Ts: Thrombocytopenia, Thrombosis, Timing and other causes or Thrombocytopenia

A flutter

- 50% recurrence at 6 mo - Radio frequency ablation is preferred - isthmus between IVC and tricuspid annulus - hard to control with pharmacologic agents - Flecainide IC

Where do oesophageal cysts tend to occur?

- 60% lower oesophagus: dysphagia common - 20% mid oesophagus: cause retrosternal chest pain or dysphagia - 20% upper oesophagus: respiratory sx through compression of the tracheobronchial tree

What does the timing of fevers in relation to the surgrey tell you about the likely source of infection?

- <24 hours: common and may reflect little more than the body's metabolic response to injury. Atelectasis is common during this time and may produce a self-limiting low-grade fever. - 5 and 7 days: usually due to infection. While pulmonary infections tend to occur in the first few days after surgery, fever at this later stage is more likely to reflect infection of the wound, operative site or urinary tract. Cannula problems and deep vein thrombo- sis (DVT) should also be considered. - >7 days: may be due to abscess formation.

What is the typical presentation of oesophageal cancer?

- >50 years of age, M>F - Dysphagia is the most common symptom, and is rapid in onset, progressing from difficulty in swallowing solid food and later to liquid within a matter of weeks. Usually not felt until the tumour is advanced. - The site of the 'hold-up' sensation has only a modest correspondence to the location of the tumour - Regurgitation, loss of weight, and substernal pain or discomfort are common. - Hoarseness signifies recurrent laryngeal nerve palsy from direct tumour infiltration or from lymphatic spread and is thus a poor prognostic sign. - Coughing or choking on eating may be due to aspiration, predisposed by the presence of vocal cord palsy if present, or the development of an oesophageal-respiratory fistula. - Patients with dysphagia and also evidence of gastrointestinal bleeding are more likely to have adenocarcinomas of the gastro- oesophageal junction

What is the management of burns?

- ABCDE - Fluid replacement - Debridement initially to viable tissue - Daily or regular dressings - Prevent or treat infection. Consider silver based dressings - Dressings keep wound moist for adequate healing - If wound will take longer than 2-3weeks then skin grafting should be considered

Rheumatic fever

- ABO positive: TREAT with PENICILLIN! - 3 weeks after, patient gets 2-3 of the following: fever, arthralgias, chorea, subcutaneous nodules, erythema marginatum, ESR/CRP, valvular disease - Tx: Penicillin - any patient with joint pains, fevers, rash, think of rheumatic fever HIGH RISK for Mitral Valve STENOSIS years later - diastolic murmur/rumble best heard at apex - note that in CENTRAL AMERICA patients, MV stenosis appears earlier for some reason, evidence of LA enlargment, high risk of A fib as a result

Congestive Heart Failure

- ACE, BB, Spirinolactone, Dig - 35% or below and NYHA stage 2-3 need ICD - 35% or below and NYHA stage 2-3 who have significant conduction disease (LBBB with QRS duration greater than or equal to 150 ms) need biventricular pacemaker aka CRT (cardiac resynchronization therapy) - hence, CRT-D (combination of both in one) - Dobutamine is reserved for patients with end-stage heart failure, either as a bridge to transplantation or for palliative care - Digoxin contraindicated in diastolic dysfunction bc the goal is to RELAX and not increase contractility - in those with reduced EF reduced CO and volume overload (on cath, increased pulmonary capillary wedge pressure, usually ≥18 mm Hg) who are still short of breath, consider NITROPRUSSIDE addition to the medication regimen - NYHA stage 3-4 and black, add hydralazine and isosorbide mononitrate to the regimen - Workup new diagnosis (evidence on presentation and echo) with either stress test or straight to cardiac catheterization to help determine etiology - Anthracyclines, such as doxorubicin, can cause cardiotoxicity and lead to chem induced cardiomyopathy. Discontinue the med - LARGE V WAVES - "canon" A waves due to AV dissociation DM - do NOT use glitazones Hyponatremia - Decreased CO leads to activation of renin angio aldos system and ADH is also activavted due to decreased functional volume, as a result, increasing water resorption and can actually lead to HYPOnatremia - Lasix diuresis bring Na equally with water, so no direct effect on sodium level, but THIAZIDES actually can cause hyponatremia

Dermatomyositis

- AWESOME REVIEW rash on PIP and MIP but also eyelids, can extend to neck and chest - weakness, fatigue, elevated ESR, LFTs sometimes - increased standardized incidence ratio of solid malignancies such as adenocarcinomas of the lung, cervix, ovaries, pancreas, colorectal, stomach, and bladder as well as non-Hodgkin lymphoma. Risk of ovarian cancer may be especially increased in women - if ascites, get transvaginal US - if resp symptoms, get CT of the chest - if GI symptoms, consider endoscopic evaluation vs. CT abdomen - Dx: Biopsy with infiltration, hypercellular, necrotic cells

Prophylaxis

- Abx only needed for previous prosthetic valves or previous endocarditis, transplant patients with valvulopathy or unrepaired congenital disease where patient is cyanotic - Otherwise, no prophylaxis needed NO PROPHYLAXIS for GI or GU procedures HIV exposure - Tenofovir and Emtricitabine plus integrase inhibitor, check levels in 4-6 weeks

What is an acquired naevus?

- Acquired or naevo-cellular naevi are common. - An Australian survey demonstrated 15 such lesions per person in an adult white Caucasian population. Most common in sun-exposed areas. - Formed by melanocytes that have been transferred from their usual dendritic single-cell position among the basal layers of keratinocytes to form aggregates along the dermo-epithelial junction. This aggregation of cells forms a junctional naevus.

What are the risk factors for a hernia?

- Activities which increase intra-abdominal pressure:obesity, chronic cough, pregnancy, constipation, straining on urination or defecation, ascites, heavy lifting - Congenital abnormality (e.g. patent processus vaginalis) - Previous hernia repair

Multiple Sclerosis

- Acute flares: methylprednisolone IV - Longterm treatment with disease modifying agents (interferon beta-1a) and VITAMIN D SUPPLEMENTATION - Check Vit D level bc if it is not replenished, patient is more prone to acute flare ups Optic Neuritis - pain with eye movement, central scotoma, and an afferent pupillary defect - can occur on its own but often associated with MS; always do MRI for patients with optic neuritis to rule out MS - still give all routine vaccinations including influenza vaccine (which is INACTIVATED) - patients can sometimes have cognitive deficits like short term memory, performance at work...CBT usually helps - interferon beta-1a is long term therapy. Need to check LFTs every 6 months for autoimmune hepatitis that can occur - treat fatigue with MS patients with Modafinil - anticholinergic agents (oxybutynin) reduce the intensity and frequency of bladder spasms and thus may reduce symptoms of urgency, frequency, and incontinence with MS patients

Seizures

- Acute new onset: Benzos and initiation of 1st line phenytoin/fosphenytoin or valproic acid - Keppra and all those other drugs are additive therapies afterwards but do not use Keppra if the patient has PTSD because it can exacerbate anxiety and irritability. - Before treating, if pattern of seizures changes, consider video EEG inpatient monitoring to further classify and specify diagnosis so they can be on appropriate medication - patients with altered mental status after convulsive status epilepticus should have continuous electroencephalographic monitoring for at least 24 hours to detect nonconvulsive seizures - Aura with tonic clonic movements are typical "partial" epilepsy and treated with narrow agents like phenytoin - Unprovoked episodes with no warning are "unspecified" epilepsy episodes and treated with BROAD spectrum Topiramate; adverse effect includes kidney stones bc Topiramate can act as a carbonic anhydrase inhibitor which can also result in a non gap metabolic acidosis - Distinguishing between FOCAL and GENERALIZED epilepsy syndromes may not be possible if a patient has convulsions only. - Auras typically resonate with FOCAL as do early onset to early adult - 30s-40s are more GENERALIZED epilepsy Neurocysticercosis - CNS infection with Taenia solium CYSTS on CT - commonly presents as new onset seizures - Tx: Albendazole and sometimes GCs for mass effect TEMPORAL lobe epilepsy - aura is epigastric; rollercoaster sensation, dry mouth - anxiety episodes like panic attack, some confusion and fidgeting - Oxcarbazepine is associated with hyponatremia INTERACTIONS - Carbamazepine metabolized by liver enzymes - Phenobarbital induces enzymes so will decrease concentration of Carbemazepine - Valproate inhibits enzymes so increases concentration of Carbamazepine - Lamotriginen no effect - Levetiracetam renally metabolized so no effect NEUROSURGERY - MRI evidence mesial temporal sclerosis can contribute to refractory partial temp love epilepsy. These patients have refractory tonic clonic but also lip smacking absence type seizures. A risk factor for this type of disorder is febrile seizures as a kid - multiple AEDs typically not effective - MRI evidence of temporal sclerosis, consider neurosurgery bc partial resection can improve sx and dec dependence of AEDs ADVERSE - Phenytoin can cause psuedolymphoma with LN and mild LFT elevation - Valproate can cause aplastic anemia

What are the risk factors for a hiatus hernia?

- Age - Increased intra-abdominal pressure (eg obesity, pregnancy, coughing) - Smoking

What factors can affect wound healing?

- Age of patient - Nutrition - Radiation - Smoking - Systemic disease - Ischaemia - Infection - Necrosis

What are the red flags for the throat?

- Airway - open, maintain, protect - Airway FB until proven otherwise - Oral swelling / infection = airway threat - Unilateral Sore throat with asymmetrical tonsils = peritonsillar abscess - Sick kid+ sore throat +drooling = epiglottitis = airway emergency - Smoking + hoarseness = laryngeal cancer

What is healing by secondary intention?

- Allowing wounds to heal by themselves (with dressings) - Usually for smaller wounds that will not take too long to heal - It is the proliferative phase of wound healing where the new capillaries endow the new stroma with its granular appearance (granulation tissue) - The epithelium grows from the edges and the wound contracts to decrease the surface area - Heals better if the wound is free of infection and kept moist

Thalassemias

- Alpha and Beta thalassemias can present with microcytic anemias and show hypochromia, target cells on the peripheral blood smear...differentiate from iron deficiency anemia with: - **RDW** is often elevated in iron deficiency but normal in thalassemia - trait, assymptomatic and normal hemoglobin electrophoresis require no treatment - targer cells with BOTH conditions, thalassemias AND iron def anema ALPHA - No elevation in Hemoglobin A2 - one allele affected = silent - two alleles affected = mild microcytic hypochromic anemia - three alleles affected = Hb H disease... hemoglobin Barts (γ chains) and hemoglobin H (β chains). Both of these unstable hemoglobins have a higher affinity for oxygen than normal hemoglobin. Target cells and heinz bodies, hepatosplenomegaly - four alleles affected = major, hydrops fatalis - Alpha Thal TRAIT - remain microcytic even if Hb normal and even with iron supplements, often misdiagnosed as iron def! But even sometimes iron studies normal but remains microcytic with normal Hb, electrophoresis normal....trait trait trait! **Sickle cell trait and other "minors" have abnormal electrophoresis whereas alpha trait is normal** BETA - slightly increased Hemoglobin A2 and some residual hemoglobin F

Asherman Syndrome

- Amenorrhea and pelvic pain with normal lab values, following any instrumentation - caused by lack of basal endometrium proliferation and formation of adhesions, causing blockage of menstruation - occurs in an inflammatory setting such as endometritis or septic abortion, IUD, D&C - US shows thin endometrial stripe and may reveal small pockets of fluid where menstrual flow has been trapped by neighboring adhesions - Dx: hysterosalpingogram or saline sonohysterogram - Tx: hysteroscopic resection of lesions

What are the sites of significant arterial atherosclerotic deposition in PVD?

- Aortic bifurcation - Adductor canal Superficial Femoral Artery - Diabetics: tibial vessels (often with sparing of proximal arteries)

Which types of drugs are associated with microscopic haematuria?

- Aspirin - Anticoagulants - Penicillins - Sulphur containing drugs - Cyclophosphamide

What are the symptoms of varicose veins?

- Asymptomatic - Heaviness - Tension - Aching - Itching

Waldenström macroglobulinemia

- B cell lyphoma, neoplastic infiltrate consisting of clonal lymphocytes, plasmacytoid lymphocytes, plasma cells, and immunoblasts comprising 10% or more of the bone marrow cellularity with disease-related manifestations, including night sweats, weight loss, anemia, lymphadenopathy, and splenomegaly - hyperviscosity syndrome due to increased IgM level and can lead to visual changes, headache, dizziness - Tx: Plasmapharesis, anti-CD20 monoclonal antibody, rituximab along with chemptherapy - B CELL LYMPHOMAS have HIGH 1,25-dihydroxyvitamin D which leads to hypercalcemia seen in lymphoma

Immunology

- B cells present immunoglobulins - T cells on the other hand have NO IMMUNOGLOBULINS, but present T cell receptors that search out recognizable antigens

Follicular Lymphoma

- B-cell markers (CD10, 19, 20, and 22) - non Hodgkin lymphoma - Dx: biopsy showing translocation [t(14:18)] that causes overexpression of the BCL2 oncogene - Tx: not curable, so if assymptomatic and no evidence of bulky disease, observation is fine. If symptomatic, Lenalidomide, used in combination with rituximab

Peripheral Neuropathy

- B12 and folate deficiency - Often due to diabetes, even with the smaller fibers during the earlier stages - Patients with normal A1C and fasting BG levels cannot be ruled out. Those with smaller nerve neuropathies can show evidence of GLUCOSE INTOLERANCE in glucose intolerance test if precious studies unremarkable

Pernicious Anemia

- B12 deficiency - These patients can present without anemia but still have neurological symptoms of B12 deficiency, elevated MMA and HC levels

What tests are used to diagnose achalasia?

- Barium swallow "birds beak" - Endoscopy - Manometry

What is the clinical presentation of a BCC?

- Basal cell carcinoma presents in a wide variety of forms, but the most common is as a waxy translucent nodule with a thin overlying epithelium and a fine network of vessels traversing the margins - Central regression may lead to depressions in the centre of the lesion, which may progress to ulceration to show the classical 'rodent ulcer' appearance. - The tumours may be multi- focal and as they grow tend to become infiltrative and may involve deeper tissues. - They may thus become locally aggressive but they do not metastasise except in very rare instances.

Dysplastic nevi

- Benign melanocytic lesions most commonly found on the trunk and extremities that have atypical clinical and histologic features that may make them difficult to distinguish from malignant melanoma - monthly self-examinations and referral to a dermatologist for close clinical monitoring

Aortic Stenosis

- Bernoulli equation takes velocity of flow on echo to calculate systolic gradient - Systolic Gradient = 4v^2 where v is velocity determined via echo

What is a cavernoma?

- Berry like vascular malformation in the brain - Vary greatly in size - Microscopically: dilated vascular channels with thin capillary walls and simple endothelial lining, no elastic fibres or smooth mm - Adjacent brain tissue shows gliosis and haemosiderin deposition

Aortic coarctation

- Bicuspid valve present in 50% and have early sclerosis/stenosis, murmur

What is the surgical management of lower GI bleeding?

- Bleeding from a source distal to the ligament of Treitz - Often presents with bright red blood per rectum unless proximal to transverse colon, may occasionally present with melena Initial management with colonoscopy to detect and potentially stop source of bleeding - Angiography, RBC scan to determine source as indicated

What is the surgical management of upper GI bleeding?

- Bleeding from a source proximal to the ligament of Treitz - Often presents with hematemesis and melena unless very brisk (then can present with hematochezia, hypotension, tachycardia) Initial management with endoscopy; if fails, then consider surgery

What are the indications for platelet transfusion?

- Bone marrow failure + PLT count <10 - Invasive procedures + PLT count <50 - Haemorrhage + PLT count <50 - Diffuse microvascular bleeding + PLT <100

PCWP

dampened LA pressure increasese with L sided processes 15-20 dyspnea on exertion 25-35 dyspnea at rest >35 Pulmonary edema

Migraines

- Both amitriptyline and propranolol are effective agents for prevention - for migraines WITHOUT aura, NSAIDs, triptans, and dihydroergotamine are effective - WITH aura have higher risk of stroke, so avoid OCPs (which in itself increases risk of thrombosis) - Migraines can present global but also focal like unilateral and worse behind the eye. Don't be fooled into Cluster; if THROBBING and aura, think Migraine - White matter signal abnormalities are typically seen on MRIs but not clinically relevant neurologically, not true strokes - Tx: TRIPTANS! (if NSAIDS not working)

Allergic Bronchopulmonary Aspergillosis (ABPA)

- Bronchiactasis patients - Asthma patients - eosinophils - CXR: Segmental atelectasis or scattered infiltrates - Tx: Steroids and ITRACONAZOLE (2018)

When should referral to a specialist burns unit be considered?

- Burns >10% of TBSA - Burns of face, hands, feet, genitalia, perineum, major joints - Full thickness burns >5% of TBSA - Electrical burns - Chemical burns - Burns with an associated inhalation injury - Circumferential burns of the limbs or chest - Burns in the very young or very old

Mycobacterium Avium Intracellulare

- CD4 count below 50 - disseminated disease can cause fever, diarrhea/abdominal pain, weight loss, night sweats, lymphadenopathy, hepatomegaly - AFB blood cultures

Bell's Palsy

- CN7 palsy, clinical diagnosis, requiring simply clinical observation - such asif no improvement in 3 months, consider other forms of neuropathy including diabetes mellitus, Lyme disease, vasculitis, HIV infection, sarcoidosis, paraproteinemia, Sjögren syndrome and an MRI of the brain to rule out structural causes. If nothing, then consider persistent Bell's Palsy and clinical observation

Neurocysticercosis

- CNS infection with Taenia solium CYSTS on CT - commonly presents as new onset seizures - Tx: Albendazole and sometimes GCs for mass effect

Calcium Pyrophosphate Deposition Disease

- CPPD crystals on fluid analysis - chondracalcinosis - osteophytes at MCP joints - positive birefreingent - associated with HEMOCHROMATOSIS and HYPERPARATHYROIDISM

What investigations should you consider in a suspected hiatus hernia?

- CXR, barium swallow, endoscopy, or oesophageal manometry (technique for measuring LES pressure) - 24-h oesophageal pH monitoring to quantify reflux - Gastroscopy with biopsy to document type and extent of tissue damage and rule out oesophagitis, Barrett's esophagus and cancer

What investigations should you consider in a suspected oesophageal perforation?

- CXR: pneumothorax, pneumomediastinum, pleural effusion, subdiaphragmatic air - CT chest: widened mediastinum, pneumomediastinum - Contrast swallow (water-soluble then thin barium): contrast extravasation

What are the two layers of the superficial fascia?

- Campers fascia (fatty) - Scarpa's fascia (membranous)

Hepatocellular adenoma

- Can be caused by OCP (but OCP does not interact with cyp450 or coumadin!) - If less than 5cm, stopping may be sufficient and monitor every 6-12 months (unless β-catenin activation mutation present) - β-catenin activation mutation has prognosis of high risk transformation to Hepatocellular carcinoma - RESECTION indicated if evidence of hemorrhage, or are positive for β-catenin activation/glutamine synthetase antibody

Acute MI

- Can be complicated with Ventricular Septal Defect. - VSD manifests as hemodynamic compromise in the setting of a new holosystolic murmur AT LEFT STERNAL BORDER 3 to 7 days after an initial myocardial infarction. Patient has symptoms of CARDIOGENIC SHOCK, SYNCOPE and CHF, echo showing left to right blood flow. Emergency condition requiring EMERGENT SURGERY - if chest pain and new LBBB or 3rd degree block, go straight to cath - if over 50 and typical angina presentation, then GREATER THAN 90% chance of CAD - can be complicated with papillary muscle rupture and acute mitral regurg requiring EMERGENT SURGERY - no syncope reported and murmur usually at apex, though it can also be left sternal too -___- - Patient's who we start on medical therapy can have adverse effects, for example BB can lead to heart block so monitor and titrate dose - as we await cath, start antiplatelet therapy and heparin - please note, Bivalirudin is an anticoagulant that can be in place of Heparin :-< - please note, in NSTEMI, Ticagrelor is preferred over Plavix for DAPT - please note, in NSTEMI, Prasugrel can ONLY be used if initiated AT THE TIME of PCI - If stable then sudden chest pain, think RV infarct with acute right HF. Patient cannot perfuse left heart and ultimately rest of the body...these patients are PRELOAD dependent in order to keep cardiac output up. PCWP is LOW, but PA and RA is high - Biventricular failure you get low CO but high PCWP high RA. INOTROPIC dependence - Fibrin specific tPA preferred over streptokinase if available and PCI is not able to be performed - MENSES is NOT a contraindication for tpA - New LBBB can mask ST elevation so if evidence of LBBB go for PCI or tPA if unable - no tPA if CVA within 3 months NTEMI - Ticagrelor is preferred over Plavix for DAPT - urgent PCI within 24 hours if new ST depression with increased trops - PCI in 72 hours if other risk factors - obviously if chest pain, go now CARDIOGENIC SHOCK - PCWP high TA high and RA high - dopamine is dose dependent, start at 2-5mics/kg/min and titrate up to 10mics if needed THROMBUS - post MI patient presents with metabolic acidosis and evidence of peripheral ischemia like abdominal pain, exremities with lack of perfusion - hemodynamically BP is ok so no cardiogenic shock or rupture suspected - likely developed apical aneurysm due to acute MI and developed thrombus which is now causing embolic disease. Check echo! PRINZMETAL'S ANGINA (Variant angina) - chest pain that with ST elevations that are short lived when given nitrates; ST elevation quickly resolves as does chest pain - Tx: Nitrates and Ca Channel blockers

Pelvic Inflammatory Disease

- Ceftriaxone as a single-dose intramuscular injection plus a 14-day course of oral doxycycline can be used to treat PID in patients who do not have an indication for hospitalization - hospitalized patient consists of cefoxitin or cefotetan plus doxycycline Fitz Hugh Curtis syndrome - perihepatitis - PID ascends to fallopian tubes and seeds liver capsule causing RUQ pain

Histoplasmosis

- Central US, Mississippi to Ohio area, Central America - inhalation of spores from soil contaminated with bird or bat droppings - immunodeficient patients more likely - sx non specific, decreased lab abnormalities non specific - can have only small skin lesions like blasto, but typically blasto is more pronounced nodules and pustular, draning - CXR can show scattered nodular densities or a diffuse reticular pattern. Dx made with Ag in body fluids, blood smear, yeast in neutrophils - Dx: Clinical. Usually SELF LIMITING so just supportive care and reassurance - Tx: supportive most the time - Tx: for MILD disease, (sx>4weeks) Itraconazole - Tx: for SEVERE disseminated disease, liposomal amphotericin B with long-term suppressive therapy following short-term treatment

What is the clinical course of an untreated epidermal cyst?

- Central punctum may rupture (foul, cheesy odour, creamy colour) and produce inflammatory reaction - Increase in size and number over time, especially in pregnancy

What are the anatomical divisions of the oesophagus?

- Cervical oesophagus extends from the cricopharyngeus muscle at C6 level to the thoracic inlet (approximately 18 cm from the upper incisor teeth). - Upper third of the intrathoracic oesophagus extends from the thoracic inlet to the tracheal bifurcation (24 cm) - Middle third includes the proximal half of the oesophagus between the tracheal bifurcation to the diaphragmatic hiatus (32cm) - Lower third being the distal half of this segment, and a short segment of abdominal oesophagus remains. (40cm)

Cholangitis

- Charcot triad: fever, jaundice and pain in the right upper quadrant - cholelithiasis, elevated aminotransferase levels, and hyperbilirubinemia - empiric antibiotics - if signs of biliary colic with dilation, skip MRCP and go straight to ERCP - Dx: ERCP to remove gallstone....no MRI needed - if duct decompression with ERCP is not possible, percutaneous cholangiography with biliary tube placement can be performed

STDs

- Chlamydia treated with Azithro (Doxy 2nd line) - Gonn treated with Ceftriaxone but also Azithro bc high likelihood of dual infection with N. Gonn

What types of procedures can be performed using an endoscope?

- Dilatation of strictures - Biospy and diathermy ablation of polyps - Injection of adrenaline around bleeding gastric and duodenal ulcers - Cholangio-pancreatography - Removal of common bile duct calculi - Injection of haemorrhoids - Tumour phototherapy

What investigations should you consider in venous ulcers?

- Doppler/venous duplex: superficial vs deep incompetency, will show venous anatomy incompetent or obstructed - Plethysmography

Transplant patients

- Class 1 HLA is on ALL NUCLEATED CELLS in the body and are used during patient assessment for transplant compatibility - Bactrim for PCP prophylaxis in those who have acute rejection episode and who need increased immunosuppression therapy. Bactrim to remain onboard until acute increase in immunosuppression therapy is titrated - CMV occurs often with transplant patients due to immunosuppression - nonspecific febrile syndrome - Colitis - hepatitis, gastritis, and small bowel enteritis may also occur, although less often - Tx: Valgancyclovir, Gangcyclovir - if suspected especially in HIV patient, go ahead and treat empirically Posttransplant lymphoproliferative disease - related to B-cell proliferation induced by infection with EBV in the setting of chronic immunosuppression and resulting decreased T-cells - first few months to 1 year after transplantation - systemic symptoms with lymphadenopathy often recognized on CT EBV - can cause a mononucleosis syndrome, leukopenia and thrombocytopenia, and hepatitis or pneumonitis - confirmed by biopsy and histopathologic evaluation of the swollen lymph nodes or extranodal mass. - Tx: reduction in immunosuppression, if possible, and may require chemotherapy, which often includes rituximab

What is involved in triple testing for breast cancer?

- Clinical assessment - Breast imaging (US +/- mammogram +/- MRI) - Non-excisional breast biopsy (FNA or Core) Not all women with breast symptoms will require all elements of triple assessment

Osteosarcoma

- Codman triangle due to periosteal elevation - adolescents, early adult - biopsy with ORTHO for specialized approach and NOT INTERVENTIONAL RADIOLOGY - staging with CT of chest then CT abdomen - CT brain typically not needed if nothing on chest

What are the branches of the Coeliac trunk?

- Common hepatic artery: divides into hepatic proper, right gastric, gastroduodenal - Left gastric artery - Splenic artery

What is the epidemiology of bladder cancer?

- Common in age >60 - Male to female ratio - TCC-3:1, SCC-2:1 - 2446 new cases in 2012 in Australia - Worldwide incidence: 275,000, - Mortality rate: 108,000 - High HDI countries: TCC, Third world: SCC.

What are the treatment options for an inguinal hernia?

- Conservative: pts not fit for surgery or who have uncomplicated hernias with minimal symptoms - Truss or abdo binder: for large uncomplicated hernias in elderly or those not for surgrery - Reducing raised intra-abdominal pressure - Surgical management: indicated for all other patients because of symptoms and risk of complications. Can be open or laparoscopic, and may use mesh for tension-free closure

Ischemic Colitis

- Crampy abdominal pain with blood - differentiate from diverticular bleeds which are painless - MAROON STOOL can present, but need to do ABDOMINAL CT w CONTRAST rather than EGD if patient has abdominal pain associated - Tx: supportive care BUT if patient has evidence of circumfrential hemorrhage on colonscopy, then abx like Metronidazole is indicated - Tx: surgical indications only if hemodynamically UNSTABLE with no evidence of active bleeding, isolated right sided ischemia, pancolonic ischemia or evidence of gangrene/necrosis

What is the prognosis for a patient with critical limb ischaemia?

- Critical limb ischaemia is an absolute indication for intervention - Rest pain leads to limb loss in 50% at 6 months - Tissue loss leads to limb loss in 90% at 6 months - 2 year mortality is 33% (mainly from cardiac events)

What are the risk factors for testicular cancer?

- Cryptochidism: 5% risk for intra-abdominal and 1% risk for inguinal canal - Prior testicular cancer: up to 2% of testicular cancer patients will develop tumor in contralateral testes - Klinefelters syndrome (47XXY), Down's. - Family history.

PCOS

- DHEAS only MILDLY elevated in 80% of patients (3-4 µg/mL). ***If DHEAS is markedly more elevated, consider androgen releasing adrenal adenoma and assess with CT rather than US*** - high ESTROGEN too! - irregular periods ensure bc increased estrogens lead to LOW FSH -> ovulatory failure -> HIGH LH - major key: LOW FSH, HIGH LH, HIGH ESTROGEN with irregular periods

Eczema

- DO NOT give SMALLPOX vaccine to ashy

Vaccinations

- DO NOT give SMALLPOX vaccine to patients with ECZEMA

Small Pox

- DO NOT give vaccine if patient has hx of ECZEMA

Meningococcemia

- DROPlet precautions - high risk in complement deficient patient's so if diagnosed, check CH50 or CH100 for deficiency in complement pathway

Psoriasis

- Dactylitis poor prognostic factor, means severe disease

Bariatric Surgery

- Decreased Ca absorption in the gut so increased oxalate levels in serum and urine, leading to increased calcium oxalate stones - CITRATE helps dissolve stones in urine so supplement with CITRATE to reduce risk of stones post operatively

Normal pressure hydrocephalus

- Dementia symptoms, Parkinson's symptoms of "magnetic gait" along with URINARY INCONTINENCE - Large-volume lumbar puncture should be performed to see any potential benefit before placement of a ventriculoperitoneal shunt in patients

Henoch-Schönlein purpura

- Deposition of IgA, small vessels - can affect the kidneys, nerves, and skin as well as cause abdominal pain. - fatigue, joint pain, abdominal pain, petechial/purpural skin lesions, and glomerulonephritis following an upper respiratory tract infection - Dx: biopsy but tetrad of palpable purpura, arthralgia, abdominal pain, and glomerulonephritis can be presumptive clinical diagnosis until further studies result - active urine sediment is common, complements (C4) are typically low, and IgA levels may be elevated - Tx: prednisoline, methylprednisolone

Large B-cell Lymphoma

- Diffuse Large B-cell lymphoma - Risk factors include EBV and chronic T cell immunosuppression - B symptoms plus lymph nod enlargement - Dx: flow cytometry shows all CD markers, translocation (14, 18) - Tx: rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) LARGE B = CHOPPED, 90!!!!!! - revised International Prognostic Index (r-IPI) score has the greatest influence on the prognosis follwing CHOP therapy - B CELL LYMPHOMAS have HIGH 1,25-dihydroxyvitamin D which leads to hypercalcemia seen in lymphoma

Cardiotoxic CTX

- Doxyrubicin < 400 mg/m2 <1% > 550mg = 26% HF also high grade heart block SVT and VT - 5-FU CP & ECG changes 70% in 1st 72 hours 2-8 death - Dexrazoxane EDTA chelator reduces risk of chronic cardiotoxicity with Anthracycline

Herpes

- Dx: can be clinical but swab lesion for direct-fluorescent antibody testing and/or PCR. This is the gold standard as it is less than 24 hours - serological testing is usually positive and cannot differentiate active infection or not GENITAL HERPES - virus always shedding, even without lesions the other non-infected person still at risk of picking it up. In fact, up to 70% of transmission is without visible lesions - constant Valacyclovir daily in the infected partner can reduce transmission to a non-infected partner HERPES ZOSTER - due to reactivation of VARICELLA virus - Tx: Valacyclovir can actually decrease the length of post herpetic neuralgia - Ramsay Hunt: zoster of the face, acute facial nerve paralysis with pain in the ear, loss of front 2/3 tongue, vesicular rash to the ear canal, dry mouth and eyes

What are dysplastic naevi?

- Dysplastic naevi (BK-moles) occur as large (greater than 5 mm in diameter) flat macules or slightly raised plaques that are present in large numbers all over the body surface but with a particular concentration on the trunk. - Frequent in non-sun-exposed areas. - Commonly have an irregular contour and variable colour, particularly being darker in the centre than on the periphery. - Replacement of the normal basal cell layer of the epidermis by naevus cells at the dermo-epithelial junction with elongation of rete ridges

Lyme's Disease

- ERYTHEMA MIGRANS is characteristic of Lyme's when differentiating tick bites - can cause AV heart blocks, acutely requiring temporary pacing as we treat with antibiotics - can have Bell's Palsy, but with Lyme's patients can also develop bilateral nerve palsy - Borrelia - typically NORTHEAST - if patient has prodrome phase months prior then suddenly develops HEART BLOCK, consider Lyme - knee is most commonly affected, although other large joints can also be involved. - Serologic testing for Borrelia burgdorferi is the diagnostic test of choice - Enzyme immunoassay (ELISA) > if positive, confirm with Western Blot - 28-day course of doxycycline or amoxicillin if IgG positive on Western Blot - PREGNANT patient's should get macrolide instead (Erythromycin, Azithro) - if persistent with neuro sx and no response to oral, then IV CEFTRIAXONE - If chronic symptoms and IgM is present but NO IgG, consider FALSE POSITIVE - Arthritis pain can linger for months on end, even if no active infection. Doesn't need antibiotics if no active infection. However, if acute infection and no response to Doxy or Amoxicillin, consider IV CEFTRIAXONE EHRLICHIOSIS (aka Anaplasma according to Awesome Review) - Arkansas, Missouri (MidWest) ***MISSOURI, PANCYTOPENIA, TICK BITE*** - severe headache and systemic sx ***maculopapular or petechial rash, no ulcers*** - destruction of monocytes so usually monocytes absent ANAPLASMA - Arkansas, Missouri (MidWest) - severe headache and systemic sx - destruction of PMNs so usually PMNs absent - LFTs elevated and low platelets

Blastomycosis

- East coast, budding - comes from soil - Commonly as skin lesions! Bigger nodules than histo, and characteristic pustules, draining - disseminated disease include CNS sx with abscess or meningitis, bones, joints, and the male genitourinary tract - also check CXR for unexplained nodules or interstitial disease! - Tx: Itraconazole - Amphotericin reserved for immunodeficient patients

What are the potential hazards associated with diathermy?

- Electrocution - Inadvertent burn to the patient at a remote site and to the surgeon - Fire associated with pooled alcohol-based antiseptics, explosion of flammable anaesthetic gases - Interference with the function of cardiac pacemakers.

Pericarditis

- Elevated ST diffusely - Constrictive pericarditis can lead to significant hepatic congestion, fluid overload. Perform echo; if echo in determinant, need to do cath. Be careful with overdiuresis bc you could reduce stroke volume and create orthostatic hypotension. Needs to be treated in a timely manner with surgical pericardiectomy. - those without red flag symptoms (fever, leukocytosis, acute trauma, abnormal cardiac biomarkers, immunocompromise, oral anticoagulant use, large pericardial effusions, or evidence of cardiac tamponade) can be observed clinically - Tamponade physiology = pericardiocentesis TAMPONADE - PCWP, RA and diastolic PA are the SAME - PULSUS PARADOXUS where BP drops by >10 on inspiration CONSTRICTIVE - Kussmaul sign for constrictive pericarditis where inspiration elicits JVD - RAPID X-Y DECENT - Low voltage, LV usually normal size - Tx: NSAIDS...however, if associated with recent MI, only can use HIGH DOSE ASA

What will investigations typically show in ischaemic gut?

- Elevated WCC - Elevated amylase - Acidosis on BG - Lactate elevated None are specific

Vaginal Infection

- Empiric coverage for chlamydia or gonnorrhea with single intramuscular dose of ceftriaxone, 250 mg, and a single oral dose of azithromycin, 1 g. Oral cefixime can be substituted if needed - Vaginitis refers to inflammation of the vagina and is caused by infections such as candidiasis and trichomoniasis or by noninfectious conditions such as atrophic vaginitis or vaginal irritation - Bacterial vaginosis: alterations in microbial composition of vaginal flora, discharge, odor Tx: Metronidazole - Trichamonas: Clue cells, Metronidazole - Candida: Fluconazole PID - cervical motion, uterine, or adnexal tenderness - Cefotetan plus doxycycline is empiric treatment and needs hospitalization

What are the typical features of end-stage chronic liver disease?

- Encephalopathy - Varices - Ascites - Peripheral oedema - Jaundice - Gynaecomastia and testicular atrophy - Malnourishment

What is the treatment of arterial ulcers?

- Endovascular (PTA +/- stent) - Surgery: endarterectomy/bypass, amputation

What are the layers of the skin?

- Epidermis - Dermis

MRSA

- Erythromycin-Clindamycin D-Zone test evaluates resistance of Clindamycin for transitioning to oral. If D-Zone test POSITIVE then that means Clindamycin has high risk of RESISTANCE and SHOULD NOT be used or considered effective for MRSA - grows fast, within 24 often

Aortic Regurgitation

- Exercise is BEST tolerated with this valvulopathy - tolerated well bc of vasodilation allows more blood to move forward and tachycardia gives less time for regurg

What are the risk factors for gallstones?

- Female sex - OC pill, increasing parity - Obesity - Ileal disease - Cirrhosis - Cystic fibrosis - DM - Long term TPN - Periods of dieting on a low fat diet - Genetic factors

Acute Spinal Cord Injury

- First step is IV STERIODS within 8 hours - Confirmatory MRI is appropriate, but do not delay steroids if still in the 8 hour window

Menorrhagia

>18 days consider FIBROIDS and evaluation with ULTRASOUND <18 days consider luteal phase abnormality that you can fix with OCPs, so NO ULTRASOUND

What is an Ivor-Lewis oesophagectomy?

- For tumours of the middle and lower third of the oesophagus, the most often performed operation is the Lewis-Tanner (Ivor Lewis) operation - The oesophagus is then resected through a right thoracotomy. - The stomach is delivered up into the thorax via the diaphragmatic hiatus to anastomose with the divided oesophagus near the apex of the thoracic cavity.

Francisela Tularemia

- GN bacillus via Ticks and blood sucking insects or inhalation/ingestion can cause tularemia...can be inhaled and can be used in bioterrorist attacks via inhalation - causes hemorrhagic PNEUMONIA so precautions needed - NO MEDIASTIHUM WIDENING - can also be culprit of zoonosis infections, so suspect in hunters or those in contact w animals - chills myalgias arthralgias and ulverative rash at inoculation site - Tx: Tetracycline is usually ok but Stepromycin or gentamicin if severe - IF INHALED Tx: Cipro, meropenem and linezolid as cultures are pending

Hepatitis C

- Genotype 2 is very responsive to antiretroviral agents, sofosbuvir and ribavirin - if later in life, no treatment bc we opt NOT to treat hep C in patients with short life expectancy - though tx options are good, they take time

Cardiopulmonary Exercise Stress testing

- Gold standard to fitness assessment - Used to assess function prior to HEART TRANSPLANT - able to distinguish between cardio vs. pulmonary disease, often used to do so

Leptospira

- Gram negative - does NOT appear as a wound - systemic illness due to animal urine through mucous membrane or injured skin - myalgias, headaches, fevers - thrombocytopenia, LFTs, AKI

Pulmonary Hypertension

- Group 1 due to idiopathic, familial, drug induced, rare medical conditions like HIV - WIDELY split 2nd heart sound - Tx: PDE inhibitors and Bosentan only help Group 1 PAH patients - Group 2-5 all due to underlying disease ex: heart condition, lung condition - Tx: Oxygen therapy

Pulmonary Edema

- HIGH ALTITUDE pulmonary edema can occur not due to cardiogenic etiology but due to over exaggerated vasocontriction of pulmonary vasculature - dyspnea, cough, often open waking but sometimes while hiking up - Tx: supplemental oxygen, rest, and descent from altitude; vasodilators such as nifedipine can be used as adjunctive treatment

Behcet's

- HLA-B52 positive HLA-B51 can be associated as well - asians - oral ulcer, genital ulcer - ocular manifestations - can also have fever, CNS sx like aseptic meningitis or headache, thrombophlebitis - Dx is of exclusion so rule out other autoimmune things

Condyloma acuminatum

- HPV infection in the genital area, most often secondary to HPV 6 and HPV 11. - Tx: destructive techniques such as cryotherapy, cantharidin, podophyllin, laser therapy, and topical application of salicylic acid. Immune modulators such as imiquimod also can be used - if recurrent or non healing, BIOPSY is required to rule out malignancy PAP smears - 21 to 30 PAP q3 years and only do HPV is ASCUS - over 30 do PAP and HPV only once and if negative then q5 - if ASCUS and HPV positve then do colposcopy - stop at 65

Liddle syndrome

- HYPOKALEMIA with HYPERTENSION - AUTOSOMAL DOMINANT - due to persistent opening of epithelial sodium channel in the distal tubule

What is the presentation of bladder cancer?

- Haematuria - Irritative lower urinary tract symptoms (LUTS). - Incidental finding on imaging - Ureteric obstruction.

Methemoglobinemia

- Hb is oxidized and ferrous changes to ferric - triggered by some meds like Dapsone or analgesics - presents with cyanosis sx, hypoxia but ABG O2 can be normal - Dx: Monitor Pulse CO oximetry to confirm - Tx: Methylene blue and O2

Pityriasis rosea

- Herald patch which looks like a solitary oval fungal infection - 1-2 weeks after development of numerous small, oval, pink plaques in the trunk, extremities and neck - usually assymptomatic, but if itchy can use steroids - resolves on it's own 6-8 weeks but sunlight can speed up the process

What is a femoral hernia?

- Hernia into the femoral canal, below inguinal ligament but may override it, medial to the femoral vein within the femoral canal - Aetiology: pregnancy (weakness of pelvic floor), increased intra-abdominal pressure - Affects mostly females

Avascular Necrosis

- Hip pain radiating to thigh, get MRI of hips - no swelling or erythema externally, not really with changes in ROM just pain on ROM - high risk in antiphospholipid, sickle cell, long tern steroid use

CKD

- Hyperphosphatemia treated with Sevelamer - if calcium only mildly low, refrain from replacing bc that can driver worsening hyperphosphatemia and life threatening symptoms - JNC says target blood pressure of <140/90 mm Hg and ACE inhibitors or angiotensin receptor blockers as first-line agents for treatment of hypertension -__- - stage 4 and greater do not respond to thiazides, so switch to loop diuretics (lasix) - stage 4 and greater need PPSV-23 FIRST then one year later PCV-13. Within 5 years PCV-13 should be given 1 more time - once stage 4, go ahead and arrange for dialysis if anticipating in the next 6-12 months ex: av fistula with vascular surgery - dialysis dependent patient's need their peripheral vasculature preserved, so if we need IV access long term, pursue IJ central line preferably - those at increased risk (ex: DM) should be screened for protienuria and albuminuria, and if present, start on ACE or ARB - if inpatient setting, Vancomycin can still be used OPIODS - most are renally cleared but FENTANYL and METHADONE are OK with CKD patients

Tricuspid stenosis

- INCREASED GIANT A WAVES

Osteoporosis

- If bisphosphonate therapy can at least stabilize bone density, then that is considered appropriate to simply continue therapy without adding any new medications - bisphosphantes can cause severe bone pain and muscle pain within a month of starting; typically resolved with stopping med. Consider other options - Denosumab approved for POST MENOPAUSAL women who do not respond to bisphosphonates - Teriparatide indicated in those with severe disease (T-score < -3) or in those who do not response to bisphosphonates - before initiating bisphosphonates, rule out all secondary causes of osteoporosis including TSH ***Calcium and Iron can reduce absorption of levothyroxine***

Lung Cancer

- If stage 1 and nodule is growing in size, surgical resection with CT surgery is recommended. Can consider bronchoscopy, but again, if no evidence of spread to lymphnodes or anywhere else and the cancer is growing aggressively, go ahead and remove - FEV1 < 2L is the cutoff for surgery...if below 2L, do a VQ scan to assess respectability and risk vs. benefit - If stage 1 <3cm then resection is enough, no further treatment needed - If stage 1 >3cm then consider adjuvant chemo Small cell lung cancer - central, neuroendocrine, SIADH and HYPONATREMIA, dermatomyositis - CHEMO is main treatment modality then radiation therapy, both if caught early - regardless, it is considered a systemic disease at diagnosis even if no other lesions are found simply due to the nature of this type of cancer - those who experience a complete or near-complete response following treatment, PROPHYLACTIC CRANIAL IRRADIATION should be offered - surgical resection of a residual lung mass after chemotherapy and radiation therapy is NEVER performed with this type - potential surgical option only in select cases in which there is a very small primary tumor without associated lymphadenopathy Squamous Cell - central, cavitary - HYPERCALCEMIA - can have PTH related protein driving hypercalcemia (also for head, neck throat) Non Small Cell - if resectable lesion, Cisplatin-based adjuvant chemotherapy is always indicated following surgery regardless of histology - if evidence of metastatic disease, next step is EGFR mutation assessment. Treatment with tyrosine kinase inhibitors. can really effect outcome Adenocarcinoma - not associated with smoking - Hypertrophic Pulmonary OSTEOARTHROPATHY is a common paraneoplastic syndrome associated - clubbing or painful periosteal hypertrophy of long bones - areas of new bone growth - arthralgias - Tx: resection of tumor relieves paraneoplastic syndrome Bronchoalveolar Carcinoma aka Adenocarcinoma in situ - localaized and less than 3cm along alveolar stuctures without invasion, peripheral location - ASSOCIATED CLINICALLY via resp symptoms with SALTY TASTE LARGE CELL - peripheral - Brain mets with less than 3 lesions less than 3cm treated with STEREOTACTIC RADIATION - Brain mets with solitary lesion and overall is wellcontrolled, consider surgery - biopsy not needed if you have a good idea of where it is coming from

GI Bleed

- If upper GI bleed due to ulcer, Aspirin can be resumed in 3-5 days. Benefit>Risk - Recurrent bleeding ulcers: celecoxib plus twice-daily proton pump inhibitor therapy has decreased association of rebleed - Hiatal hernias can cause bleed sometimes - PUSH enteroscopy is reserved for those with suspected small bowel bleed - If initial evaluation is negative, the underlying cause of obscure gastrointestinal bleeding can often be found by repeating either upper endoscopy or colonoscopy depending on presenting features - if clean based ulcer, no endoscopic therapy needed and simply switch to oral PPI and DC - If upper and lower endoscopy don't reveal anything and GI bleed continues, can assess small bowel bleed with bleeding scan in the inpatient population but also consider ANGIOGRAPHY which can not only identify bleeding but also allows for therapeutic intervention with embolization - If on Warfarin and supratherapeutic, treat with vitamin K but also 4-factor prothrombin complex concentrate (4f-PCC) - 4f-PCC is a plasma-derived product that contains all four vitamin K-dependent coagulation factors (factors II, VII, IX, and X) - can be stored at room temperature and doesn't require cross and screen typing (like fresh frozen plasma) - if unavailable, then FFP will have to do LOWER GI BLEED - painless = diverticular bleed - painful = coilitis. Differential can be infections, inflammatory but also ISCHEMIC especially if patient a vasculopath.....do a CT!!! ISCHEMIC COLITIS - Crampy abdominal pain with blood - differentiate from diverticular bleeds which are painless - MAROON STOOL can present, but need to do ABDOMINAL CT w CONTRAST rather than EGD if patient has abdominal pain associated - Tx: supportive care BUT if patient has evidence of circumfrential hemorrhage on colonscopy, then abx like Metronidazole is indicated - Tx: surgical indications only if hemodynamically UNSTABLE with no evidence of active bleeding, isolated right sided ischemia, pancolonic ischemia or evidence of gangrene/necrosis

Trigeminal Neuralgia

ddx: young pt think pontine MS lesion

What is the clinical presentation of actinic keratosis?

- Ill-defined, scaly erythematous papules or plaques on a background of sun-damaged skin (solar heliosis) - Sandpaper-like, gritty sensation felt on palpation, often easier to appreciate on palpation rather than inspection - Sites: areas of sun exposure (face, ears, scalp if bald, neck, sun-exposed limbs)

What is the epidemiology of ependymomas?

- Incidence: 0.41/100 000 - rare - Location varies depending on age: tend to be intracranial in children, spinal cord in adults - Most common type is a Grade II ependymoma

What are the general risks of immunosuppression in transplant patients?

- Increased risk of infections - Increased risk of malignancy - Impaired wound healing (esp with mTOR inhibitors) Immunosuppression can mask clinical signs and symptoms, need a higher degree of suspicion compared to general population

What are the predisposing factors for varicose veins?

- Increasing age - Family history - Childbirth in women - Occupations requiring a lot of standing - Obesity

What is the clinical presentation of an SCC?

- Indurated erythematous nodule/plaque with surface scale/crust ± ulceration - More rapid enlargement than BCC - Sites: face, ears, scalp, forearms, dorsum of hands

What are the three phases of wound healing?

- Inflammatory: lasts from injury to 7 days, polumorphonuclear cells (neutrophils 24-48hrs), macrophages (after 48hrs), clot formation, exudates, get vasoconstriction followed by vasodilation - Proliferative: 5 days to 3 weeks, angiogenesis and collagen formation (immature type 3 collagen), granulation and epithelialisation - Remodeling: 3 weeks to 18 months, fibroblasts, collagen breakdown and remodeling (type 1 replaces type 3 collagen)

What are the classifications of peripheral artery disease?

- Intermittent claudication: reproducible pain on exercise - Critical limb ischaemia: pain at rest +/- tissue loss - Non salvageable limb requiring amputation:

What is the clinical presentation of superficial spreading melanoma?

- Irregular, indurated, enlarging plaques with red/white/blue discolouration, focal papules or nodules - Ulcerate and bleed with growth - If untreated, an invasive vertical growth phase supervenes, with progressive involvement of the deeper dermis and underlying tissues and the development of metastatic potential.

Bacterial Endocarditis

- Janeway lesions and Osler nodes, splinter hemorrhages - antithrombotics and anticoagulation CONTRAINDICATED because patient's who have multiple micro septic emboli, those small infected vessels have higher risk of bleeding. So if on even ASA or plavix, HOLD!

Cauda Equina

- LOW BACK PAIN with decreased rectal tone, incontinence/retention, sexual dysfunction, saddle anesthesia - state MRI, neurosurgery emergency - Tx: Decompression within 24-48 hours of diagnosis/symptom onset - pain relief provided but the above symptoms may be long term to a degree

Hand Schuller Christian Syndrome

- Langerhans cell histiocytosis - eosinophilic granulomatosis - lytic bone lesions, DI, exophthalmus - think of Christian hand tennis player Schuller whos eyes are buggin bc he keeps getting drilled by tennis balls causing lytic bone lesions

What is an indirect inguinal hernia?

- Lateral to inferior epigastric artery, originates in deep inguinal ring, often descends into scrotal sac (or labia majora) - Aetiology: congenital persistence of processus vaginalis in 20% of adults - Most common hernia in men and women (men > women) - <1% risk of recurrence

What are the branches of the inferior mesenteric artery?

- Left colic - Sigmoid arteries - Superior rectal artery

Aplastic Anemia

- Leukemia symptoms including bruises and lab findings but main diagnostic factor is that it is characterized by severe hypocellularity of the bone marrow and pancytopenia - Tx: Equine Antithymocyte Globulin (can cause serum sickness) ACQUIRED absence of hematopoietic stem cells (aplastic anemia) - sulfa drugs, valproate, chloramphenicol, viral infections including HIV

Hepatocellular Carcinoma

- MCC in US is alcoholic cirrhosis - if less than 5cm, chemo and radiation is the first line - heavily associated with PARANEOPLASTIC SYNDROMES like hypercalcemia, hypoglycemia, erythrocytosis, diarrhea, fevers of unknown origin

Otitis Externa

- MCC is Pseudomonas

Plantar Fasciitis

- MEDIAL heel pain - worse when running and waking up - Tx: Stretches, NSAIDS, arch support, sometimes injections and less running

Liver Disease

- MELD>15 needs transplant for better survival Primary sclerosing cholangitis (PSC) - multifocial stricturing and dilation of bile ducts - NO antimitochondrial ab - usually ASSYMPTOMATIC - associated with inflammatory bowel disease, UC but no other antibody for diagnosis. Total bili, ALT and AST can be mildly elevated, Alk Phos elevated alot more - need colonoscopy to assess for UC - Dx PSC with MRCP Primary biliary cirrhosis/cholangitis (PBC) - inflammation and destruction of interlobular bile ducts - ANTIMITOCHONDRIAL ANTIBODY in 95% but if not need liver biopsy - middle aged women - SYMPTOMS include fatigue, dry eyes, dry mouth, and pruritus - Alk phos elevated alot more and other tests mildly elevated - Tx: ursodiol slows disease progression

Hyperlipidemia

- MONOunsaturated fats dec LDL and inc HDL - high TG can have xanthomas - HIGH intensity statin for LDL > 190 - statin really on gives mild elevated in LFTs but regardless, if LFTs increase 3x the amount of normal, then either STOP or decrease dose - if 3x more than normal limit on statin, consider other causes for transaminitis RHABDO/Myopathy - increased with drugs that are CYP3A4 inhibitors, specifically GEMFIBROZIL, HIV meds, clarythromycin, cyclosporin, antifungasl - statin with amio or amlodipine - Simvastatin 10mg with CaChannel blockers - Simvastatin 20mg period - starting statin with uncontrolled thyroid issues...make sure euthyroid prior to starting ***CYP3A4 inhibitors are HIGHEST risk of statin induced myopathy compared to the others listed***

MYH-associated polyposis

- MYH gene - autosomal recessive

What are the clinical features of a hiatus hernia?

- Majority are asymptomatic - Typically elderly female patient >60yrs old - Large hernias are frequently associated with GORD due to decreased competence of the GO junction - Complications mostly assoc. with GORD: oesophagitis -> stricture, Barretts etc

What is an SCC?

- Malignant neoplasm of keratinocytes (primarily vertical growth) - Second most common type of cutaneous neoplasm - Primarily on sun-exposed skin in the elderly, M>F, skin phototypes I and II, chronic sun exposure - In organ transplant recipients SCC is most common cutaneous malignancy, with increased mortality as compared to non-immunocompromised population - Unlike BCC, SCC can metastasise, usually to the regional lymph nodes but also systemically, although this is unusual unless the lesions are large or neglected.

What is a BCC?

- Malignant proliferation of basal keratinocytes of the epidermis - Low grade cutaneous malignancy, locally aggressive (primarily tangential growth), rarely metastatic - Usually due to UVB light exposure, therefore >80% on face - Most common form of skin cancer

Babesia

- Maltese cross (intraerythrocytic inclusion) - hemolytic anemia - up north, fevers, rigors, pale - no rash - Dx: Blood smear, PCR - Moderate disease: Atovaquone/Azithro - Severe disease: Clinda/Quinine - Super Severe: Exchange Transfusion

Non Hodgkin lymphoma

- Mantle cell lymphoma is a rare form of non-Hodgkin lymphoma characterized by extranodal involvement and overexpression of CYCLIN D1 - B cell markers also noted, sometimes GI involvement, bone marrow involvement - also diagnostic is [t(11:14)] - associated with tumor producing Vit D (as is HL) - Those on immunosuppresion therapy are at risk for non-hodgkin lymphoma - lymphadenopathy in multiple sites and systemic B symptoms (night sweats, fever, and weight loss) PROGNOSIS - age>60 increase LDH and LN involvement considered - diaphragm is the boundary and LN limited to one side is better prognosis than if LN are top and bottom

What is the typical presentation of a cavernoma?

- Many asymptomatic and approx 40% present as incidental findings on MRI Other symptoms/signs: - Headache - Haemorrhage - Seizures - Progressive neurologic deficits and cranial nerve palsies

What are the typical clinical features of a hernia?

- Mass of variable size - Tenderness worse at end of day, relieved with supine position or with reduction - Abdominal fullness, vomiting, constipation - Transmits palpable impulse with coughing or straining

What are the indications for FFP transfusion?

- Massive transfusion - Cardiopulmonary bypass - Extra corporeal support techniques - Decompensated liver disease - Acute DIC - Haemorrhage wiht excessive warfarinisation, add Vit K

What is a strangulated hernia?

- Means that the blood supply of the contents has ceased due to compression at the hernial orifice - Initially lymph and venous channels are blocked -> oedema - When tissue pressure = arterial pressure, arterial flow ceases and tissue necrosis ensues - Serious complication and can lead to peritonitis (if intestine is involved) - Very tense and usually exquisitely tender to touch

What is a direct inguinal hernia?

- Medial to the inferior epigastric artery through Hessebach's triangle - Aetiology: acquired weakness of the transversalis fascia "wear and tear", increased abdominal pressure - 3-4% risk of recurrence

Rheumatoid Arthritis

- Methotrexate (nonbiologics, DMARDS) or Entanercept (biologics, tumor necrotic factor inhibitors) - If that loses effect, consider NON biologic lilke Leflunomide - Can interchange biologics, etanercept, tofacitinib BUT we don't like to do multiple biologics because of the suppressed immunity, prefer 1 biologic agent and consider addition of non biologic, or Leflunomide - most common cardiac manifestation is asymptomatic pericarditis RHEUMATOID LUNG - causes retrictive pattern, pulmonary fibrosis! - cavitary nodules, effusions - nodules show central necrosis and vasculitis RHEUMATOID Effusions - LOW glucose level - Protein and WBC normal Anemia of Chronic Disease - Inflammatory states produced HEPCIDIN overtime which inhibits iron absorption in GI tract, leading to microcytic anemia. EPO increases but no erythropoieisis can take place bc of Hepcidin inhibition of iron TOFACITINIB (biologics, TNF-α inhibitor) ADALIMUMAB - must monitor LIPID levels WITHIN 1 month and after - LFTs after 1 month and after **Biologics need pre initiation screen of TB, Hep, etc. LEFLUNOMIDE (NON biologic) - adverse effects include reversible hepatitis and syndrome - if patient has appearance of RA but deformities or reducible and no erosive evidence on XR, then this is a sign of SLE and Jaccoud arthropathy rather than a true RA POOR PROGNOSIS (high risk of extraarticular manifestations) is patient is RF positive and antiCCP positive! - Methotrexate and Bactrim cannot be used together bc it creates fatal pancytopenia Felty Syndrome - patients with rheumatoid arthritis present with fatigue or fever, lymphadenopathy and evidence of SPLENOMEGALY and NEUTROPENIA - Tx: treat underlying RA

What is the epidemiology of SAH?

- More common in women than in men (2:1) - The peak incidence 55 to 60 years old. - An estimated 5 to 15 percent of cases of stroke are related to ruptured intracranial aneurysms. - Aneurysmal SAH, has a 30-day mortality rate of 45 percent. - An estimated 30 percent of survivors will have moderate-to-severe disability

Depression

- Most SSRIs make you gain weight - Paroxetine and Bupropion to a lesser degree, but still can cause weight gain - VENLAFAXINE is the only one that does not cause weight gain - most antidepressants prolong QT - Paroxetine has the lowest risk and incidence of QT prolongation (but still monitor)

What is a seborrhoeic keratosis?

- Most common benign epidermal tumour - Common on trunk, face or limbs of middle aged/elderly - Well-demarcated waxy papule/plaque with classic "stuck on" appearance - Large variety in colour, size and shape - Over time lesions appear more warty, greasy and pigmented - Autosomal dominant inheritance

What is an epidermal/epidermoid cyst?

- Most common type of cyst - Inclusion cyst lined by fully differentiated epidermis, filled by laminated keratin which forms the characteristic, white, unpleasant-smelling content

What are the clinical features of meningioma?

- Mostly asymptomatic - Headache - Neurological deficit: cranial nerve, motor, sensory - Seizures - Obstructive hydrocephalus

Tuberculosis

- Mycobacterium tuberculosis - best diagnostic tool is PLEURAL BIOPSY PPD ***the more at risk, the lower the threshold to treat*** - immunocompromised or exposure >5mm is positive - intermediate risk like healthcare workers, diabetics or people in jail >10mm is positive - low risk/everybody else >15mm is positve - evidence of latent TB, Isoniazid - evidence of active infection, quadruple therapy, even empirically while we proceed with confirming workup - Isoniazid has liver toxicity and need to monitor regularly ONLY IF SYMPTOMATIC - if found to have <5x normal limit it is OK TO CONTINUE AS IS AND MONITOR - again, if no sx, NO REGULAR MONITORING otherwise indicated - if cultures NEGATIVE, no solitary cavitation or symptoms, then NO ACTIVE DISEASE...if PPD remarkable then prophylaxis is enough Place on AIRBORN precautions - Quadruple drug therapy. Contagious until 3 negative acid fasts or 2 weeks of treatment - Rifampin/Isoniazid for 4 more months - Tx: for active disease, quadruple drug therapy 2 months (or until no longer contagious) then 4 months of Iso/Rif to complete 6 months total - Pyrazinamide contraindicated with gout flare due to renal involvement, so if we can only give triple drug therapy, treat for 3 months then need to follow up with Rifampin/Isoniazid for 7 more months totaling 9 months Those with positive PPD but assymptomatic, check Chest XRAY for active disease (QFG only for active symptoms or highly suspicious). - if PPD positive but CXR normal, then treat LATENT assymptomatic TB with ISOniazid for 9 months *****Those with IMMUNODEFICIENCY and PPD >5mm they are considered POSITIVE...then assess for latent vs active infection as above - can effect joints and cause infection as an indolent process, often in the hip, knee, or spine (Pott disease) - ESR increased - Dx: aspiration but often culture is hard to yield AFB....therefore, GOLD STANDARD for TB arthritis is SYNOVIAL TISSUE BIOPSY, actually the ONLY form of arthritis that synovial tissue biopsy is helpful. So, if suspicious of TB arthritis and no growth on fluid, go for synovial tissue biopsy - if evidence of TB meningitis, give Dexamethasone for up to 3 weeks along with quadruple drug therapy - V/Q lung scan is the preferred and recommended initial study to evaluate for possible chronic thromboembolic pulmonary hypertension - often confused with Actinomyces but non-acid fast with Actinomyces - Patients with Silicosis have high risk of TB ADVERSE EFFECTS - all are hepatotoxic EXCEPT Ethambutol - Rifampin: red urine - Ethambutol: vision changes - Isoniazid: peripheral neuropathy

What are the side effects of antiproliferative agents?

- Myelosuppression, cytopenia Azothiaprine: interact with allopurinol to give severe myelosuppression Mycophenolate: diarrhoea

Paroxysmal supraventricular tachycardia

- NARROW complex tachy (whereas VT is the classic wide complex) - retrograde p wave - vagal maneuvers may terminate - Tx: Adenosine, vagals

Testicular Cancer

- NONSEMINOAS: AFP elevated and hCG only sometimes elevated, DO NOT respond to RT, MORE AGGRESSIVE, MOST COMMON TYPE - SEMINOMAS: AFP normal and LDH only sometimes elevated - histo pathology takes a backseat to tumor markers, so base treatment on tumor marker and seminomas vs nonseminoma - RadioTherapy indicated - 95% survival rate at 5 years - Tx: bleo/eto/cisplantain chemo - following treatment they have increased risk of metabolic syndrome, heart disease, kidney disease, peripheral neuropathy, chronic pulmonary toxicity, secondary malignancy, leukemias and sexual dysfunction - otherwise, good prognosis with the actual testicular cancer, but high risk of malignancy due to treatment regimen RECURRENT RELAPSING TUMORS - testicular cancer is the solid tumor cancers that respond to BONE MARROW TRANSPLANT ***NO STAGE 4*** Stage 1: Just the tesiticle Stage 2a: LN <2cm Stage 2b: LN 2-5cm Stage 2c: LN >5cm Stage 3: Metastasis

Von Willebrand

- NORMAL PT and NORMAL to minimally prolonged APTT - INCREASED Bleeding Time - Dx: if severe enough, platelet function analyzer assay - typically present as easy bruising, postsurgical bleeding, and heavy menstrual bleeding

Acute Trauma

- NSAIDS may increase risk of further BLEEDING into area of blunt or penetrating trauma

What are the clinical features of oesophageal perforation?

- Neck or chest pain - Fever, tachycardia, hypotension, dyspnea, respiratory compromise - Subcutaneous emphysema, pneumothorax, haematemesis

What are the side effects of calcineurin inhibitors?

- Nephrotoxicity - Diabetogenic - Hyperlipidaemia - Hypertension - Headaches, tremor, seizure (short term) Cyclosporin: gingival hypertrophy, hirsuitism

What instructions should you give to patients following inguinal hernia repair?

- No driving for approx 2 weeks - Avoid straining and lifting for about 4 weeks - Avoid very heavy physical work for 6-8 weeks

What is the risk to the donor in a nephrectomy?

- No physical benefits to donor - Potential psychological benefit - Major procedure with a 1/3300 chance of donor death (surgical error, PE) - ?ESKD - literature is conflicting

What is the treatment of sebhorrhoeic keratosis?

- None required, for cosmetics only - Cryotherapy, curettage

What is the management of anal fissures?

- Normalise stool form (bulking agents or laxatives) - Topical therapy to relax the anal sphincter: 0.2% nitroglycerin or 2% diltiazem for 6 weeks - Botox injections can also be used Surgical: - Lateral internal sphincterotomy

When should you give a blood transfusion?

- Not based on Hb alone - Major factor is clinical assessment - Consider transfusion in post-op patients with AMI or Hb 70 - Platelet counts >50 and INR <2 should allow for invasive procedures without serious bleeding risk (except for liver biopsy and ERCP)

What are the risk factors for melanoma?

- Numerous moles - Fair skin - Red hair - Positive personal/family history - Large congenital nevi - Familial dysplastic nevus syndrome - Multiple dysplastic nevi Most common sites: back (M), calves (F)

What are the skin changes associated with venous hypertension?

- Oedema - Skin pigmentation - Atrophie blanche - Varicose eczema - Lipodermatosclerosis - Venous ulceration

What is the treatment of haemorrhoids?

- Optimise stool form and toileting behaviour - Rubber band ligation for small to moderate haemorrhoids - Surgical haemorrhoidectomy for larger prolapsing haemorrhoids or those which do not respond to non-surgical therapy

Addison's Disease

- PRIMARY is due to adrenal insufficiency - SECONDARY is due to pituitary inability to make ACTH - hydrocortisone/Dexamethasone replaces gluccocorticoid cortisol portion mostly and mineralcoricoid only a certain degree - fludrocortisone replaces mineralcorticoid portion - patient's who improved in sx but still have low Na and high K, consider adding fludrocortisone ***increasing hydrocortisone may increase mineralcorticoid to a degree, but if other symptoms have improved and seems to be only a mineralcorticoid deficiency, increasing hydro may increase risk of Cushing! So Fludro!*** NOTE: during diagnostic workup, Dexamathasone does NOT interfere with assay, - so if patient presents with acute adrenal insufficiency and you think Addison's, opt for Dexa to replace gluccocorticoid and fludrocortisone to replace mineralcorticoid - this way, ACTH stim test will not be altered by Dexa, whereas Hydrocortisone, though helps with gluccocortidoid, will interfere with ACTH diagnostic tests - Dexa 4mg = Hydrocortisone 50-100 - of course in emergency situations, hydrocortisone challenge is fine and diagnostics later, but ideally, ***Dexa/Fludro and ACTH stim test simultaneously***

Disseminated Intravascular Coagulation

- PT and PTT elevated - fibrinogen decreased ***any question with woman with recent menses and possible infection, either TSS or DIC - Tx: Cryoprecipiate, FFP, platelets platelets platelets!

What are the symptoms of haemorrhoids?

- Painless bright red rectal bleeding - Prolapse - Mucous discharge - Often associated with skin tags - Usually no pain unless complicated by thrombosis

What are the clinical features of cholangitis?

- Patient severely septic and unwell - Jaundice - Right upper quadrant pain

What are the clinical features of gallstone ileus?

- Patients may have a history of previous cholecystitis and known gallstones - Small bowel obstruction (may be intermittent)

What is the treatment of achalasia?

- Pharmacologic: Ca channel blockers, nitrates - Endoscopic: Botox injection, pneumatic dilatation (usually require multiple), peroral endoscopic myotomy - Surgery: Heller's cardiomyotomy with fundoplication

Hypophosphatemia

- Phosphate < 2 - chronic alcohol use, malnutrition, or critical illness - weakness, myalgia, rhabdomyolysis, arrhythmias, heart failure, respiratory failure, seizures, coma, and hemolysis - Refeed syndrome cane occur with dextrose containing IV fluids; insulin response exacerbates the low phosphate - dangerously low phosphate can cause respiratory failure from impaired diaphragmatic contractility - complication of alcoholic keotacidosis upon hydration, their renal function gets overwhelmed and worsens, causing hypophosphatemia and rhabdo - patients with alcoholic ketoacidosis also at risk for RHABDO just like they are hypophosphatemia

Heart failure

- Placement of a left ventricular assist device is an option for patients with end-stage heart failure who are not candidates for heart transplantation Next step is heart transplantation - rheumatologic disease, severe pulmonary disease, liver failure), fixed severe pulmonary hypertension, diabetes mellitus with end-organ manifestations

What are the potential causes of decreased urine output post operatively?

- Poor renal perfusion (pre-renal failure: hypovolaemia and/or pump failure) - Renal failure (acute tubular necrosis) - Renal tract obstruction (post-renal failure)

What are the symptoms of achalasia?

- Progressive dysphagia - Regurgitation - Chest pain - Chronic cough - Aspiration/pneumonia

Where are oesophageal webs usually located?

- Proximal oesophagus (cervical portion) - Occur anteriorly and are usually eccentric not concentric

Coxiella Burnetii

- Q fever which is flu like illness, hepatitis and/or pneumonia diagnosed with serology - CATTLE born illness - pneumonia, hepatomegaly/inc LFTs - fever, cough, night sweats

Prolonged QT

- QT should be less than HALF of the RR - if longer than half the RR, likely prolonged QT and refrain from strenuous exercise

Right Bundle Branch Block

- RSR' V1

Cervical cancer

- Radical hysterectomy is appropriate for patients with stage I or nonbulky stage IIA cervical cancer, which includes invasion beyond the uterus but not extending to the pelvic wall or to the lower third of the vagina. - if invading the pelvic wall, then stage III-IV and best option is chemo and radiation

What are the risk factors for meningioma?

- Radiotherapy - X-rays - Family history: neurofibromatosis type II - Oestrogen (HRT) - Female - Breast cancer

What are the common post operative complications following hernia repair?

- Recurrence (15-20%) - Scrotal haematoma (3%) - Nerve entrapment: ilioinguinal, genital branch of genitofemoral - Stenosis/occlusion of femoral vein - Ischaemic colitis

What is an actinic keratosis?

- Represents a progressive dysplastic change in the epidermis and the underlying dermis as the result of exposure to UV light. - There is a build-up of excessive keratin and parakeratin, while the underlying dermis contains thickened elastic fibres (elastosis) produced by damaged fibroblasts.

What are the branches of the superior mesenteric artery?

- Right colic artery - Middle colic artery - Ileocolic artery - Ileal and jejunal branches

What are the clinical features of acute cholecystitis?

- Right upper quadrant pain - Fever - Murphys sign on examination - Occasionally mildly deranged LFT's (especially if Mirizzi syndrome)

Ostium primum atrial septal defect

- SOB, volume overload - combination of FIXED SPLITTING of the S2, a mitral regurgitation murmur, and left axis deviation on the electrocardiogram

RETROPHARYNGEAL ABSCESS

- STRIDOR - trauma, penetrating injury and organisms from the mouth seed the retropharyngeal space developing abscess - present with holding their necks in HYPEREXTENSION PERITONSILAR ABSCESS - group A strep, high fever, muffled voice or "HOT POTATOE VOICE", deviation of uvula away from abscess - Tx: Penicillin, I&D if able/needed

Work Exposures

- Silicosis: Predominantly Upper Lobe nodules and HILAR EGGSHELL CALCIFICATIONS. They have high risk of TB, so if PPD positive always consider prophylaxis. If no active disease, prophylaxis is enough - Asbestos: Predominantly peripheral calcifications...leads to pumonary fibrosis which has Interstitial infiltrates in LOWER LOBES - Benign asbestos pleural effusions (BAPE) occurs first (10 years ish) and only lasts 2-3 months - the rest of the manifestations like infiltrates, fibrosis, can take 20-30 years to manifest and stay the rest of life - leads to mesothelioma - Lymphangitic Carcinomatosis: Diffuse - Rheumatoid lung: Patchy throughout

What are the types of hiatus hernia?

- Sliding hiatus hernia: herniation of both the stomach and the gastroesophageal (GO) junction into thorax, 90% of oesophageal hernias - Paraoesophageal hiatus hernia: herniation of all or part of the stomach through the oesophageal hiatus into the thorax with an undisplaced GO junction - Mixed hiatus hernia: combination of types 1 and 2

What is the treatment of leiomyoma?

- Small, asymptomatic leiomyomas can be observed. - Surgical removal is warranted for symptomatic or large leiomyomas (>5 cm). Simple enucleation is performed. - Oesophageal resection is occasionally necessary for large or annular tumours.

What are the risk factors for TCC bladder cancer?

- Smoking. Intensity and duration increases risk. - Cyclophosphamide - Radiation therapy - Chemicals. Arylamines, polycyclic aromatic hydrocarbons. Many other chemicals have been identified as being carcinogenic and withdrawn from use. - Specific industries are associated with a higher incidence though individual chemicals in the workplace have not been identified e.g. Leather workers, blacksmiths, hairdressers, mechanics, miners, painters. The increased risk is low at < 30%.

Pulmonary Nodule

- Solitary nodule: Follow up 1 year then 18-24 months. If no growth in 24 months, no need to follow up - If minimal risk factors and nodule 6mm or LESS and described as calcification, no follow up needed and REASSURANCE only

What are the common pathogens that cause surgical wound infections?

- Staph aureus - E. coli - Enterococcus - Strep spp. - Clostridium spp.

What are the common sites of action of immunosuppressive drugs in the T cell?

- Steroids - Calcineurin inhibitors - TOR inhibitors - Purine synthesis inhibitors/anti-proliferative agents

What is the management of renal stones?

- Stones <5mm will usually pass spontaneously - The pain can be managed with NSAIDs and narcotic analgesics - An alpha blocker may facilitate passage of the stone - Stones that do not pass or are deemed too large to pass are removed surgically - Stents can be inserted after definitive treatment to prevent obstruction due to the trauma of surgery

What is the management of AAA?

- Stop smoking - Control BP - Surgical: open or endovascular (mainstay)

Hypereosinophilic syndrome

- Sx: skin, lungs, gastrointestinal tract, and heart - main causes of secondary eosinophilia: CHINA (connective tissue diseases, helminthic infection, idiopathic [HES], neoplasia, allergy) - Dx: elevated eosinophil count (>1500/µL [1.5 × 109/L]) and evidence of organ involvement without a secondary cause - Tx: Imatinib

Amyloidosis

- TYPES: immunoglobulin light chain (AL), hereditary (has MGUS), or secondary (AA) amyloidosis - Typing helps establish the correct type of amyloidosis syndrome and is absolutely critical, particularly in light of the high prevalence of MGUS, to avoid exposing a patient to inappropriate and potentially difficult therapy - infiltrative disease that causes skin thickening and is more often associated with development of petechiae and ecchymoses - can cause cardiomyopathy: LV hypertrophy with decreased, LOW voltage - infiltrative "granular sparkling" on echo - restrictive cardiomyopathy, unexplained proteinuria, abdominal pain/diarrhea - Congo Red

What is the blood supply any lymphatic drainage to the prostate?

- The arterial supply to the urethra and prostate is through the inferior vesical artery - Venous drainage is through the periprostatic plexus to the internal iliac veins - Lymphatic drainage is to the obturator and internal iliac nodes.

Contact dermatitis

- The potencies of topical glucocorticoids in the United States are designated by classification into one of seven groups, with group 7 (1% and 2.5% hydrocortisone) being the least potent and group 1 being the most potent (up to 600 times more potent than the group 7 agents) - Thinner more sensitive skin should use lower potency meds like Hydrocortisone - More potent preparations include Clobetasol, Betamethasone, Halobetasol ADVERSE EFFECT - topical steroids chronically can cause atrophy and straie on the skin

What are the components of a hernia?

- The sac consists of peritoneum which protrudes through the abdominal wall defect or 'hernial orifice', and envelopes the hernial contents. - The neck of the sac is situated at the defect. - The body is the widest part of the hernial sac - The fundus is the apex or furthest extremity

What is the treatment of superficial spreading melanoma?

- The treatment for superficial spreading melanoma is excisional biopsy with a margin that varies with the size of the primary lesion and subsequent assessment of depth of invasion. - Determined by the use of Clark's levels of invasion, which define six levels in terms of the anatomy, or by the thickness of the lesion. - High dose IFN for stage II (regional), chemotherapy (cis-platinum, BCG) and high dose IFN for stage III (distant) disease - Newer chemotherapeutic, gene therapies and vaccines starting to be used in metastatic melanoma - Radiotherapy may be used as adjunctive treatment

What are the main ways of reducing infection in surgical patients?

- The washing of hands - Adherence to antiseptic and asepsis rituals - Aggressive attention to basic surgical principles - Compliance with antibiotic guidelines - The adoption of universal precautions to prevent diseases due to blood-borne viruses

What is a pilar cyst?

- Thick-walled cyst lined with stratified squamous epithelium and filled with dense keratin - Forms from a hair follicle - Can be idiopathic or post-trauma, often familial - 2nd most common cutaneous cyst - F>M

Fever of Unknown Origin

- Thorough workup, including biopsy of any histological organ that may be of interest - if fever persists without specific cause, clinical observation until obvious clue of which route to go down diagnostically - An exception to performing blind biopsies is biopsy of the temporal artery, which may be indicated in older adult patients with FUO and an elevated erythrocyte sedimentation rate even if localizing signs are absent

Pleural Effusion

- Transudative: Heart failure, Cirrhosis, Nephrotic syndrome, pulmonary embolism Pleural/Serum protien <.5 Pleural/Serum LDH <.6 Pleural Fluid LDH <2/3 upper limit of normal - Exudative: malignancy, infection, TB, PE, pancreatitis, esophageal rupture, collagen vascular disease, chylothorax/hemothorax Pleural/Serum protien ≥ .5 Pleural/Serum LDH ≥ .6 Pleural Fluid LDH ≥ 2/3 upper limit of normal - Pleural Cholesterol elevation = infection, exudative - if malignancy suspected in the history and cytology negative, it is appropriate to analyze another sample - if TB suspected, check pleural fluid ADA level - Pleural LDH can def be elevated with infection but also can be falsely elevated with chronic diuresis, example: CHF patient. - So a CHF patient comes in SOB with effusion, LDH is high. Appears exudative at first glance, but how can we tell that this isnt just a false elevation due to chronic diuresis? And that patient does not have acute exacerbation? Of course clinical picture, but also ***PLEURAL CHOLESTEROL*** will be positive if INFECTIOUS process is going on - if CULTURE grows ANYTHING, then that is an indication for thoracostomy and drainage with tube per CT surgery, bc by definition it is now an EMPYEMA RHEUMATOID Effusions - LOW glucose level - Protein and WBC normal

Cocaine overdose

- Treat OD symptoms with Benzodiazepines

What is the treatment of SCC?

- Treatment of SCC is primarily surgical with excision to a margin of at least 0.5 cm in depth and laterally, as determined on clinical grounds, although this margin may be reduced in the head and neck because of cosmetic problems. - If lesser margins are used, frozen section should be utilised to ensure that complete excision of the lesion has occurred. - Ongoing follow up

Whipple's Disease

- Tropheryma whipplei - weight loss, diarrhea, abdominal pain, arthropathies increased hyperpigmentation at sun exposed spots - EGD may show whitish or yellowish plaques or LN biopsy with PAS staining positive, PCR can confirm - Tx: Ceftriaxone or penicillin for 2 weeks or Bactrim for 1 year

What is a meningioma?

- Tumour which arises from meningiothelial cells of arachnoid layer - Most commonly at sites of dural reflection: falx cerebri, tentorium cerebelli, venous sinuses - Most common brain tumour in people >35yrs - Usually benign - Slow growth may result in compression of surrounding brain and nerves

Parkinson's Disease

- Tx: Carbidopa, Levadopa - sudden withdrawal of dopaminergic medications can lead to parkinsonian-hyperpyrexia syndrome, an acute syndrome resembling neuroleptic malignant syndrome....acute altered mental status, hyperthermia, rhabdomyolysis, and extrapyramidal symptoms, including severe rigidity and dystonia. Be careful with surgery patients who have meds stopped or those who are NPO! Dantrolene won't help, but rather, restarting home meds - Tx: Deep Brain Stimulation can help those who enjoy benefits of dopamine agents but cannot titrate those meds any higher due to adverse effects

What are the indications for surgical management of gastric ulcers?

- Unresponsive to medical treatment (intractability): always operate if fails to heal completely, even if biopsy negative: could be primary gastric lymphoma or adenocarcinoma - Dysplasia or carcinoma: always biopsy ulcer for malignancy - Haemorrhage: 3x greater risk of bleeding compared to duodenal ulcers

Nephrolithiasis

- Uric acid stones uncommon: Hydration with up to 2L output per day is 1st line, then 2nd line is alkalinization of urine - Hyperoxaluria predisposes to calcium oxalate stone formation - paradoxical low calcium intake predisposes to calcium oxalate stones - Increased oxalate in foods such as chocolate, spinach, rhubarb, or green and black tea - Tx for recurrent calcium oxalate nephrolithiasis = bile salt binder cholestyramine, which also binds with oxalate in the gut, preventing absorption - Dx: Ultrasound first. If unremarkable but still high clinical suspicion, pursue non contrast CT

When is surgery indicated for GORD?

- Usually for recalcitrant reflux disease - Non-responsive to maximal medical management or contraindications to pharmacotherapy - pH testing and manometry should be performed preoperatively - Patients with reflux and obesity should be considered for surgery such as gastric bypass to treat both reflux and obesity

What are the clinical features of gallbladder abscess?

- Usually prodromal illness and right upper quadrant pain - Swinging pyrexia - Patient may be systemically unwell - Generalised peritonism not present

What are the contents of the spermatic cord?

- Vas deferens - Testicular artery/veins - Genital branch of genitofemoral nerve - Lymphatics - Cremaster muscle

Septic arthritis

- WBC > 50,000

Coccidioidomycosis

- West coast - Skin lesions - dissemination include bones, joints, and the meninges - Spherules with endospores - sometimes present with unilateral hilar lymphadenopathy, erythema nodosum lesions on the anterior lower extremities - Treat with FLUCONAZOLE

What is an obstructed hernia?

- When the neck is sufficiently narrow to occlude the lumen of the intestine contained within the sac - Nearly always irreducible and can progress to strangulation - Pt present with signs and symptoms of intestinal obstruction + tender irreducible hernia - Can be difficult to distinguish from strangulation so should be treated urgently

What is an irreducible hernia?

- When the sac cannot be completely emptied of its contents - Can progress to obstruction and strangulation - Usually painful

What is epithelialisation?

- Wounded skin undergoes epithelialisation - The surface of the skin is reformed when cells lose contact inhibition - This epithelialisation is from dermal appendages, hair follicles and sweat glands - Full thickness wounds also undergo migration of epithelium from the edges of the wound at a slow rate - Differentiation is the last stage when epithelial layers are formed - Delayed epithelialisation leads to a prolonged inflammatory phase A moist wound healing speeds up epithelialisation, a wet wound causes maceration, and a dry wound does not undergo epithelialisation

Alport syndrome

- X-linked hereditary nephritis, collagen IV disorder - asymptomatic "familial" hematuria - eyes and ear involvement - kidney failure may occur later in life. Thus, annual measurements of blood pressure, kidney function, and urine protein are reasonable

Breast Lump

- Young = USG; mammogram less sensitive in younger than 35 year old - Core Needle biopsy - OCPs reduce breast cysts

What are the three zones in a burn?

- Zone of coagulation: central and composed of nonviable tissue - Zone of stasis: the adequacy of the initial burn resuscitation will affect the extent and outcome of this zone - Zone of hyperaemia: surrounds the zone of stasis and contains viable tissue

Mycosis fungoides

- a form of cutaneous T-cell non-Hodgkin lymphoma (Sézary syndrome). Lymphomas expressing T-cell surface antigens (CD4) are among the more common forms of cutaneous T-cell lymphomas - CD4-expressing malignant T cells are large and have classic "cerebriform" appearing nuclei and clonal T-cell receptor gene rearrangements - dry rash, can eventually progress to organ damage, sepsis, etc. - Tx: Topical gluccocorticoids - if ineffective, add topical retinoids and psoralen and ultraviolet light therapy, sometimes combined with interferon alfa

Irritable Bowel Syndrome

- abdominal pain or discomfort that occurs in association with altered bowel habits over a period of at least 3 months - sensation of incomplete evacuation - IBS-D treated with Rifaximin - IBS-D associated with CELIAC DISEASE, work up is warranteed - IBS-C can be associated with mucous like stools - IBS-C treated with laxatives then 2nd line Linaclotide if needed. Otherwise, reassurance - Celiac workup is NOT warranted **note that NOCTURNAL frequency is NOT a feature of irritable bowel***

Lymphangiomyelmiocytosis

- abnormal prolifeation of smooth muscle cells leading to rare cystic disease in premenopausal women usually child bearing age - pneumothorax, chylous effusions can have renal angiomyolipomas (clinically silent) - CT shows cysts biopsy shows HMB-45, langerhans cells histio

Vasovagal Syncope

- about 10 percent can have myoclonic movements that observers may describe as seizure like activity - but if typical presentation with diaphoresis, warmth, from standing position, etc. then diagnosis is vasovagal - Tx: Increase fluids and salt

Mesenteric ischemia

- abrupt onset of central abdominal pain, emesis, forceful bowel evacuation, and severe hypotension along with an unremarkable abdominal examination - if suspected, immediate angiography and surgical consultation needed

Mitral Valve Prolapse

- associated with alot of diseases, but if no symptoms, no leaflet abnormalities and no regurg, then BENIGN and prognosis is great - Valsalva and standing INCREASES systolic murmur - HANDGRIP INCREASES murmur - squatting DECREASES murmur - mid systolic click HCOM - also increases murmur with Valsalva and standing, but no click - HANDGRIP DECREASES murmur

Langerhans Cells

- can cause eosinophilic granulomas in the lungs - typical presentation is spontaneous PNEUMOTHORAX - high risk in smokers - presents in UPPER LOBE disease with honeycombing, insterstitial changes, cystic changes

Asthma

- acute exacerbation shows acute respiratory alkalosis bc patient's hyperventilate to compensate - on repeat ABG after management begins, if there is a developing respiratory acidosis despite a continued high work of breathing, as reflected by the respiration rate, this suggests progressively impending respiratory collapse - IPRATROPIUM is best added for bronchodilation for patients with chronic beta blocker on board - uncontrolled asthma, give ICS and LABA to get under control, then on follow up if better controlled, consider stopping LABA - GERD can contribute to sx via microaspirations, so sometimes, difficult to control asthma patients are placed empirically on PPI only if they have symptoms of GERD - If improvedment on follow up, DC PPI Exerise induced - Dx: Spirometry first. If normal, Methacholine challenge is needed for diagnosis - Patients on theophylline cannot take ciprofloxaxcin bc cipro decreases theophylline clearance and patient can become N/V with toxicity - CIMETADINE is an antihistamine given to help INCREASE Theophylline levels, therefore reachig therapeutic levels more readily

Carotid Artery Dissection

- acute headache and neck pain associated with ischemic complications, such as transient monocular visual loss and Horner syndrome (miosis, ptosis, and anhidrosis) - increased risk of stroke, especially in those under age 50 due to thrombus formation at the site of dissection with subsequent artery-to-artery embolism - MRI or CT angio - start Aspirin Differential: SAH can cause similar presentation but instead of vision or eye issues, they have NAUSEA and VOMITING...in which case, opt for noncontrast CT

Subacute thyroiditis (De Quervain)

- acute onset of anterior neck PAIN following acute viral illness - swelling of thyroid gland, tender to palpation - if thyroid is TENDER, it is subacute thyroiditis - typically seen following a viral illness in the preceding months - can present hyper or hypo on labs, decreased uptake on scan - eventually go back euthyroid, NO INTERVENTION is needed - interestingly enough, AntiThyroglobulin Ab can be POSITIVE -___- - CT shows patchy infiltrate

Miliaria

- aka "heat rash," is characterized by the eruption of fine red papules and pustules specifically located on the back, typically after immobilization in the supine position - staph epi clogs of eccrine glands - Tx: cooling area, keeping it dry and sweat free

Osler-Weber-Rendu syndrome

- aka hereditary hemorrhagic telangiectasia - epitaxis growing up, GI bleed as adults - due to vascular malformations - telangiectasias on lips nasal mucosa and fingertips

Pyrophosphate Arthropathy

- aka osteoarthritis with calcium pyrophosphate deposits - patients often have osteoarthritis in joints not typically involved with traditional osteoarthritis, including non-weight-bearing joints such as the shoulders and wrists.

Lumbar Stenosis

- aka pseudoclaudication - bilateral leg weakness associated with walking or with prolonged standing; symptoms are aggravated by prolonged standing and are relieved with bending at the waist - some patients have absent deep tendon reflexes at the ANKLES, but reflexes at the knees and muscle strength are usually preserved - differentiate from PAD, which has abnormal ABI, decreased pulses, etc. - Dx: MRI - however, if no red flag symptoms and recent onset, consider conservative management based on CLINICAL DX only, with NSAIDS and PT - if persists, THEN pursue MRI

Ethylene glycol intoxication

- alcohol poisoning - central nervous system depression ***increased anion gap metabolic acidosis*** - kidney failure likely resulting from deposition of calcium oxalate crystals in the renal tubules - urine osmolality HIGH - urine CRYSTALS present - Tx: Fomepizole, hydration, bicarbonate Methanol intoxications - urine osmolality also HIGH but NO crystals - Tx: Fomepizole, hydration, bicarbonat

Animal Bite

- all have TETANUS risk, so if no TDap in the last 5 years, need to give another booster to patient - observe animal for 10 days and if up to date on vaccinations and no signs of rabies, no prophylaxis needed - Augmentin - if swelling and paresthesias, high risk of compartment syndrome so get surgery consult

Thin glomerular basement membrane (GBM) disease

- an inherited type IV collagen abnormality that causes thinning of the GBM and results in hematuria - Dx: history of persistent hematuria, normal kidney function, and positive family history of hematuria without kidney failure; biopsy is NOT typically required

Cushing Syndrome

- any condition that leads to hypercortisolism, nothing to do with pituaiary ACTH - must assess wit DEXA to check for osteoporosis - Dx: must be confirmed by a 1-mg dexamethasone suppression test, 24-hour urine free cortisol testing, and/or measurement of evening salivary cortisol levels - dexamethasone 1mg supression will have less than 1.8 morning level in normal, healthy patients - patients on OCPs can have inaccurate suppression test, so opt for 24 hour urine cortisol or salivary cortisol CUSHING DISEASE - hypercortisolism due to increase in pituitary excretion of ACTH

Marfan Syndrome

- aortic aneurysm (most life threatening systemic complication) can lead to an acute aortic syndrome (aortic dissection, rupture, or both) - ectopia lentis, high arched palate, pectus excavatum, and arachnodactyly - AHA recommends follow-up imaging 6 months after diagnosis, with annual surveillance thereafter if the aortic root is LESS THAN 4.5 cm in diameter and otherwise stable - if greater than 4.5 cm, consider every 6 months

PARVOVIRUS B19

- aplastic presentation with LOW RETICULOCYTES - DECREASES RBCs - severe anemia sx, fatigue, SOB

Alzheimer Disease

- apolipoprotein E gene (APOE ε4) located on chromosome 19 can be additive but NOT NEEDED FOR DIAGNOSIS - short term memory loss - Dx: Clinical, family hx NO HALLUCINATIONS

Hereditary Retinoblastoma

- as a child it presents - later on as adults, they are at increased risk of OSTEOGENIC SARCOMA

Jaccoud arthropathy

- associated with SLE arthritis and other inflammatory illnesses, including scleroderma, mixed connective tissue disease, and Sjögren syndrome, rheumatic fever - nonerosive arthritis characterized by reducible subluxation of the digits, swan neck deformities, and ulnar deviation of the fingers due to attenuation of the joint-supporting structures, but XRAY findings unremarkable - if patient has appearance of RA but deformities or reducible and no erosive evidence on XR, then this is a sign of SLE rather than a true RA

Liver abscess

- entamoeba histolytic - high risk in immigrants (or those around immigrants), prisoners, and gays - Dx: Serologies ***aspirating liver abscess is always dangerous

Zollinger Ellison Syndrome

- associated with increased Gastrin levels - +/- diarrhea and/or ulcers - Ulcers in the 2nd part of duodenum and beyond are common and this is the only condition where you get ulcers beyond the bulb - can treat with PPI but try to identify gastrinoma for removal which can be evasive on standard imaging - follow up endoscopic US to look at LN and head of pancreas - Dx: Gastrin levels fasting - chronic PPI can lead to B12 deficiency MEN Type 1 - ZE can be related if presence of gastroma (related to pancreatic tumor) - if signs or symptoms of MEN 1 including gastroma/pancreatic tumor, LIPOMAS, then always check for PTH and calcium, also consider Pituatary abnormality

Hypomagnesemia

- associated with kypokalemia - associated with resistance to PTH activity at the level of bone, contributing to hypocalcemia

Pseudomonas

- associated with nail through tennis shoes

Achalasia

- associated with squamous cell carcinoma Barrett's = adenocarcinoma

Chronic Eosinophilic Pneumonia (CEP)

- asthma patient with exacerbations, recent coughing and fevers, new eosinophilia, CXR can be described as "photographic negative of pulmonary edema" but actually appears as BILATERAL INTERSTITIAL INFILTRATES

Basal Cell Carcinoma

- asymptomatic translucent telangiectatic papules sometimes "pearly" appearing on sun-exposed areas in fair-skinned patient - can also be typical crater like lesions - Tx: Mohs micrographic surgery

Ankylosing Spondolysis

- at the time of diagnosis, imaging studies are warranted but after that, just follow clinically and no new studies may be needed if stable - treatment with a tumor necrosis factor α inhibitor is currently recommended if first-line therapy with NSAIDs is inadequate- - treat with BIOLOGICS like Enbrel, Etanercept or Humara (adalimumab) - DMARDS like Methotrexate do not work

Friedreich ataxia

- ataxia with dysarthria, sensory loss, weakness - autosomal recessive

Paraneoplastic limbic encephalitis

- autoantibodies - associated with underlying cancer - often present with neuro symptoms far before diagnosis of cancer - personality change, psychosis, and seizures

Anti-N-methyl-D-aspartate receptor (NMDAR) Encephalitis

- autoimmune encephalitis - present with psychiatric symptoms, seizures, autonomic instability, and choreoathetoid movements - Dx: Lumbar puncture with anti-N-methyl-D-aspartate receptor (NMDAR) antibodies in CSF

Schmidt Syndrome

- autoimmune polyendocrine syndrome includes HYPOTHYROIDISM and ADRENAL INSSUFFICIENCY - can sometimes have DM type 1 as well - sx of hypothyroidism with low BP, high normal potassium - Tx: Once diagnosed, replacement

Nevoid basal cell carcinoma

- autosomal dominant - multiple basal cell carcinomas and palmar and plantar pits - can also have cysts of mandible, bifid ribs, agenesis or corpus callosum, medulloblastomas - generally benign

Hereditary hemochromatosis

- autosomal recessive disease - HOMOzygous C282Y causes iron overload - elevated serum transferrin - ferritin can also be checked, usually over 1000 - Dx: liver biopsy - Tx: Phlebotomy (the treatment of choice) and iron chelation with deferoxamine (the typical treatment for secondary iron overload conditions)

Functional dyspepsia

- basically chronic GERD but not associated with food and no other obvious causes of chronic reflux episodes - PPI can help to a degree but next step is to ass low-dose tricyclic antidepressant when symptoms do not respond to monotherapy with proton pump inhibitor or H2-blocker therapy. - test for H Pylori H Pylori - Tx: OClAm triple therapy - alternatives include Bismuth quadruple therapy 14 days (bismuth + Metro +tetracycline + PPI) or OLAm (OmeprazoleLevawuinAmoxicillin)

Intertrigo

- basically the rash seen in the pannus of fat people. High risk in diabetics, often caused by candida - inflammatory process found in intertriginous areas in obese patients; the rash consists of confluent, well-demarcated erythema, generally symmetrically distribute - worse in heat - can have candida infection as well - Tx: keeping the areas dry and well ventilated, with avoidance of occlusive clothing and possibly the use of drying agents, topical gluccocorticoids and topical antifungal

Gilbert syndrome

- benign condition characterized by mild unconjugated hyperbilirubinemia but all other LFTs normal - triggered by dehydration, viral illnesses, fasting - congenital decrease in hepatic UDP glucuronyl transferase...mild elevation in bilirubin and yellow eyes but not other abnormalities Tx: reassurance, usually assymptomatic and self resolving

Adrenal Incidentaloma

- biochemical testing is needed to identify functional tumors secreting catecholamines, cortisol, regardless of symptoms (DM/osteoporosis) or not - dexamethasone suppression test and urine metanephrines - in those with symptoms of HTN, hypokalemia, but check for hyperaldosteronism

Cavenous Malformation

- bleeds are usually self limited and if NO MASS EFFECT, then no URGENT need for surgery. - Can elect for surgery if refractory seizures or if bleed continues to progress on repeat imaging

Alpha anytitrypsan one deficiency

- bullous emphesymatous changes - always consider when young patient presents with COPD symptoms and XR findings - consider transplant if severe

CREST

- calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia - CREST is a variant of LcSSc characterized by the presence of telangiectasias and esophageal dysmotility - Dx: positive antinuclear and anticentromere antibodies are helpful - annual echo!

Bacillus Anthrax

- can be inhaled and can be used in bioterrorist attacks via inhalation and show mediastinal widening with mediastinal LN, no interstitial disease - inhaled and incubated up to 6 weeks present with flulike illness then respiratory distress and shock sometimes infiltrates o CXR but no infectious pneumonia so no respiratory precautions from those infected causes enlarged mediastinal LN and can cause hemorrheagic mediastinitis so a big differentiating factor is WIDENED MEDIASTINUM - GP rods with "box car" appearance - Tx: Cipro, meropenem and linezolid as cultures are pending

TSH

>20 or 0 less likely to be ESS - 30% with initial abnormal value with have normal TSH on repeat in 6 weeks

Scleroderma

- can cause issues with GI tract as well including perstalsis and dysmotility in upper GI but also diverticula in other parts that increase risk of bacteral overgrowth syndrome, causing chronic diarrhea. Treat with RIFAXIMIN (antibiotic at combat diarrhea) - if exposed to steroids, patient has risk of developing scleroderma renal crisis where they get super hypertensive requiring DC of steroids and admission for ACE and maybe CaChannel blocker, monitoring other manifestations specifically MAHA DIABETIC SCLERODERMA - sleroderma skin findings of neck, shoulders, upper extremities in diabetics, no other systemic findings - does not correlate with DM control - high risk of plasma cell dyscrasias so check urine electrophoresis with any diabetic who has this

Ostium secundum atrial septal defect

- can have features of right heart volume overload but do not have mitral valve disease and thus systolic murmur no cyclically present usually - FIXED SPLITTING - RIGHT axis deviation

Glaucoma

- can have one sided vision changes - eye exam shows increased disc to cup ratio and notably looks more open and white, blurred edges of disc/optic nerve compared to normal eye

Neurofibromatosis

- can lead to malignancy, specifically the risk of sacromatous changes with their lesions

T-cell non-Hodgkin lymphoma

- can manifest as Sézary syndrome with mycosis fungoides, or cutaneous manifestations of CD4-expressing malignant T cells are large and have classic "cerebriform" appearing nuclei and clonal T-cell receptor gene rearrangements - dry rash, can eventually progress to organ damage, sepsis, etc. - Tx: Topical gluccocorticoids - if ineffective, add topical retinoids and psoralen and ultraviolet light therapy, sometimes combined with interferon alfa

Plasmacytoma

- can occur as lytic vertebral lesions - DO NOT confused with MGUS, as diagnosis is made from BONE BIOPSY with plasmacytoma *****if evidence of clonal cells or M spike period, they are at increased risk for progression to MM (where as MGUS, if M spike <3 and clonal cells <10, they are actually LOW RISK for progression)***** - gold standard treatment is radiotherapy as it is very sensitive along with high-dose glucocorticoid - monitor M spike and bisphosphonate for lytic lesions - decompressive surgery is reserved for patients with spinal instability or those who have severe neurological symptoms. Ultimately will still need radiotherapy

Diabetes Insipidus

- can occur following pituitary surgery - ultimately treat with desmopressin BUT there is a transient SIADH phase from dying cells that are still producing ADH - monitor fluid status and lab OSM values during transient stage and initiate desmopressin once conversion to central DI

Adrenal hemorrhage

- can occur in post operative state, abnormalities of hemostasis (such as heparin-induced thrombocytopenia or antiphospholipid antibody syndrome), and sepsis - symptoms and labs findings of low aldosterone and low cortisol - Dx: CT - Tx: stress-dose glucocorticoids (hydrocortisone, 50-100 mg intravenously every 6-8 hours) and supportive care with intravenous fluids and vasopressors as needed for hemodynamic compromise

Hemoperitoneum

- can present as BLUISH DISCOLORATION of umbilical area or flank area - results from tissue catabolism of hemoglobin from retroperitoneal blood dissecting along tissue planes - can be due to acute pancreatitis and fat necrosis due to liberated pancreati enzymes - can be due to other intraperitoneal bleeding like ruptured ectopic pregnancy

Toxic Shock Syndrome (TSS)

- can present as sepsis secondary to infected primary lesion like chicken pox - prodrome phase, fever, hypotension, rash, STRAWBERRY TONGUE (also in Kawasaki and Scaret fever) - can have systemic features like abdominal pain, nausea, vomiting, confusion, muscle pain - sometimes with nodules or macular erythematous rash with hyperemia on mucous membrans - can have pancytopenia and LFT elevation - staph aureus RARELY (<5%) grow on cultures - if culture grows something, MCC is group A strep (Pyogenes) ***any question with woman with recent menses and possible infection, either TSS or DIC

Multiple Myeloma

- can present as solitary lytic lesion on xray; if presents, then electrophoresis is in order, followed by immunofixation - if unremarkable, proceed with evaluation for Paget's with biopsy but do less invasive stuff first - plama cell tumor, evidence of hypercalcemia and anemia - renal dysfunction, hypercalcemia and hypophosphatemia, anemia - UA negative for proteinuria bc UA only detects negatively charged proteins like albumin...kappa and lambda LIGHT CHAINS are positive and NOT picked up on UA - can have metabolic acidosis due to renal dysfunction and though BG normal, UA shows glucosuria without protienuria - always order SerumProteinElectrophoresis (SPEP) and UrineProteinElectrophoresis (UPEP) to detect monoclonal protein - Dx: Urine and serum electrophoresis but clinically CRAB (hyperCalcemia, Renal failure, Anemia, Bone disease) criteria for a diagnosis of multiple myeloma requiring therapy are commonly used to determine the need to start chemotherapy - sometimes no lesions on XR but need to assess with MRI if concerned - Tx: Chemotherapy - Tx: AUTOLOGOUS BMT can prolong REMISSION following Chemo One of the only bone conditions that won't show anything on BONE SCAN (lytic lesions for MM do not enhance) SMOLDERING MM - M protein level of 3 g/dL or more or clonal plasma cells representing 10% or more of the total marrow cellularity on bone marrow biopsy but the absence of disease-specific signs or symptoms - monitor clinically bc progression to full disease likely in a few years time Fanconi Syndrome - renal dysfunction associated with MM - defects in proximal tubules (TYPE 2 RTA) - NON gap metabolic acidosis with NO DIARRHEA (makes sense!) - spills alot into the urine so hypoK hypoPHOS and hypoURICEMIA

Subarachnoid Hemorrhage

- can present like carotid artery dissection bc blood in meninges irritates neck and shoulder area - differentiate bc NAUSEA and VOMITING present with SAH whereas in carotid artery disection they have eye symptoms like vision, Horner, etc. - Dx: CT noncontrast for SAH - SAH can lead to acute pituitary dysfunction, specifically ACTH dysfunction - leads to low ACTH, low cortisol - results not only in hypotension but SIADH bc cortisol usually balances fluids with kidneys, but no cortisol = less excretion from kidneys, INCREASE SIADH - Tx: Hydrocortisone

ECMO (Extracorporeal Membrane Oxygenation)

- cardiopulmonary bypass - can be indicated for hypothermia in those patients who are hemodynamically unstable even with warming blankets. Works faster to warm the body

Bartonella

- cat scratch - lymphadenopathy near skin lesions - skin lesions from scratch usually vesicular at first and no symptoms then become papules after a few days and thats when LN is noticed - Tx: Bactrim

Serotonin syndrome

- characteristic MYOCLONUS with TREMOR - may also have rigidity - INCREASED REFLEXES - neurologic signs, including tremor, hyperreflexia, and clonus - Tx: Cyproheptadine, Benzos Neuroleptic Malignant Syndrome - characteristic muscle rigidity and neurologic signs, including tremor, hyperreflexia, and clonus - similar to serotonin syndrome WITH RIGIDITY and DECREASED REFLEXES - no mycolonus or tremor - can be caused by suddenly stopped L-Dopa meds - due to DECREASE IN DOPAMINE - induced by antipsychotics, stopping parkinson's meds - Tx: Dantrolene or Bromo, or simply stopping the drug Malignant Hyperthermia - AFTER ANESTHESIA - Tx: Dantrolene

Neuroleptic malignant syndrome

- characteristic muscle rigidity and neurologic signs, including tremor, hyperreflexia, and clonus - due to DECREASE IN DOPAMINE - similar to serotonin syndrome but WITH RIGIDITY and DECREASED REFLEXES - induced by antipsychotics - induced by withdrawal of parkinson's meds - combination of fever, encephalopathy, muscle rigidity and rhabdomyolysis - Tx: dantrolene or bromocriptine Serotonin Syndrome - characteristic MYOCLONUS with tremor - may also have rigidity - INCREASED REFLEXES - neurologic signs, including tremor, hyperreflexia, and clonus - Tx: Cyproheptadine, Benzos Malignant Hyperthermia - AFTER ANESTHESIA - Tx: Dantrolene

Paget disease

- characterized by focal areas of accelerated bone remodeling that ultimately causes overgrowth of bone at one or more sites that may impair the integrity of affected bone - ALK PHOS elevation with bone pain is diagnostic - Dx: Increased alk phos, Xrays - treat with bisphosphonates if symptomatic, otherwise clinical observation is ok - Paget's disease of the breast appears as nipple rash, mammo usually negative - Dx: Nipple BIOPSY

Spinal cord compression

- characterized by mid back pain and physical findings of lower extremity hyperreflexia and weakness. - other red flags like incontinence - if history of cancer, oncological emergency - treat with gluccocorticosteroids and emergent MRI

Metabolic Alkalosis

- check urine choline <15 - suggests reduction in extracellular volume and the presence of saline-responsive metabolic alkalosis - vomiting, remote use of diuretics, and post-hypercapnic metabolic alkalosis. >15 - saline resistant and can be caused by active diuretic use, stimulant laxative abuse, and rare renal tubular disorders such as Gitelman and Bartter syndromes - could be diuretic induced, mimicking Bartter and Gitelman syndromes - could be due to VOMITING in the context of GI losses. If so, volume contraction would indicated by low urine chloride (less than 15-20) - elevated serum bicarbonate, hypovolemic, orthostatic: given hypovolemia, normal patients would have low urine concentrations of sodium and chloride but diuretic abuse would actually show increased excretion of sodium and chloride despite the evident hypovolemia - check Urine diuretic studies

PRINZMETAL'S ANGINA (Variant angina)

- chest pain that with ST elevations that are short lived when given nitrates; ST elevation quickly resolves as does chest pain - Tx: Nitrates and Ca Channel blockers

RUQ pain

- choledocholithiasis, gallstone obstructing common bile duct - Sphincter of Oddi dysfunction is diagnosed in patients with biliary-type pain without an alternative explanation

Alopecia areata

- chronic autoimmune disease that results in smooth, hairless patches of skin, most commonly appearing on the scalp

Bronchiectasis

- chronic cough with purulent sputum and recurrent pneumonia (in both smokers and nonsmokers) - history of pertussis as a kid - PFTs can show obstruction - crackles or wheezes on exam

Hidradenitis suppurativa

- chronic inflammatory disease characterized by comedones, inflammatory papules, nodules, cysts, draining sinuses, and scarring of the axillae, breasts and inframammary creases, inguinal folds, and gluteal cleft

Acanthocytes (spur cells)

- chronic liver disease - chronic alcoholism

AMD

- chronic oxidative damage - dry AMD: difficulty reading and night driving - wet AMD: metamorphopsia 2/2 subretinal hemorrhage - Rx: smoking cessation daily vitamin and zinc -- wet : VEGF inhib and laser photocoagulation

SIADH

- clinical euvolemia, hypo-osmolar hyponatremia, and urine osmolality inappropriately GREATER than plasma osmolality - if assymptomatic, treat underlying cause and free water fluid restriction - can be induced by drugs such as SSRIs PITUITARY SURGERY - leads to permanent central DI - ultimately treat with desmopressin BUT there is a transient SIADH phase from dying cells that are still producing ADH - monitor fluid status and lab OSM values during transient stage and initiate desmopressin once conversion to central DI

Monoclonal gammopathy of undetermined significance (MGUS)

- clonal plasma cells represent less than 10% of the total marrow cellularity - DOES NOT meet CRAB (hyperCalcemia, Renal failure, Anemia, Bone disease) criteria for a diagnosis of MULTIPLE MYELOMA requiring therapy - Risk factors for progression include a non-IgG M protein, an M protein level of at least 1.5 g/dL, and an abnormal serum free light chain ratio - those without a plasma cell dyscrasia have normal ratios; abnormal ratios suggest incrfaesed risk of progression to clinically symptomatic disease and dictate the frequency of follow-up - if clonal cells less than 10% then yearly observation, blood work, urine studies

Hypertrophic Pulmonary OSTEOARTHROPATHY

- clubbing or painful periosteal hypertrophy of long bones - areas of new bone growth - arthralgias - associated with ADENOCARCINOMA of the lung - Tx: resection of tumor relieves paraneoplastic syndrome

Furuncle (boil)

- college aged, in grown hairs, wrestlers - I&D is the main treatment and no Abx really needed unless systemic disease or really severe cellulitis, super young or old, or immunocompromised

Multiple system atrophy (Shy Drager)

- combination of parkinsonism, cerebellar ataxia, and early postural instability and falls - autonomic symptoms like urinary issues or orthostatic hypotension

Tetralogy of Fallot

- common cyanotic heart defect and MCC of blue baby syndrome 1) VSD 2) RV outflow obstruction 3) Overriding Aorta 4) RVH

Nephrogenic diabetes insipidus

- enuresis as a kid - polyuria as an adult - Na borderline elevated and relatively low urine osmolality, no evidence of DM - minimal response to desmopressin - Tx: Thiazides

Reversible cerebral vasoconstriction syndrome

- commonly presents with thunderclap headaches that recur over several days or weeks. - thunderclap attacks occur spontaneously or be triggered by bathing, exertion, or Valsalva maneuvers - complicated by focal neurologic deficits with corresponding areas of stroke, parenchymal hemorrhage, or edema visible on neuroimaging studies - Tx: controlling blood pressure

Digoxin Toxcity

- commonly with JUNCTIONAL RHYTHM where P wave can be retrograde and not seen, but rhythm is still regular

Eisenmenger syndrome

- congenital - intracardiac right-to-left shunt - air filters and meticulous care of all intravenous lines should be instituted to prevent paradoxical air embolism - cyanotic heart disease patients have compensated erythrocytosis with stable hemoglobin levels; Hb and Hct elevated chronically to compensate, so after a major procedure they may need short term supplementation with iron to get the H&H but to the "normal" elevated compensation threshold

Bronchogenic cyst

- congenital, presents in the middle mediastinum in the 2nd decade of life

Yersinia enterocolitica

- consumption of chitterlings (pork intestines) - does not cause grossly bloody stools, hard to distinguish from other inflammatory diarrheas - diarrhea may be ABSENT with bacteria localizing to lymphoid tissue in Peyer patches and associated mesenteric lymph nodes - can cause enterocolitis which presents as abdominal pain that mimics appendicitis (LLQ) - high risk in IRON OVERLOAD patients who are on DEFEROXAMINE

Wolff-Parkinson-White

- could be caused by supraventricular tachycardia (orthodromic or antidromic reciprocating tachycardia) or preexcited atrial fibrillation - syncope episodes occur when there is hemodynamic instability during these episodes of palpitations - Dx: EP study if patient has history of hemodynamic instability - Tx: Ablation - Antiarrhythmic agents are reserved for second-line therapy and should be based on the type of arrhythmia , specifically for etiologies from accessory pathways located close to the atrioventricular (AV) node - If evidence of Delta waves, straight to EP consult!

Cavernous Sinus Thrombosis

- decreased function of trigeminal nerve v1 and v2 forehead and cheek - caused by acute sinus infections

Neuropathic Arthropathy

- decreased sensation - typically at the foot, 1st metatarsal - erythema, swelling, tender to foot or ane - non traumatic or minor trauma - Xrays show bone damage or periostits (regeneration of new bone due to previous injury) - no systemic features

Endophthalmitis

- decreased vision in one eye - fevers - seeded infection often from fungemia secondary to IV drug use - candida - white chorioretinal spots on eye exam - Ophthalmologic EMERGENCY so immediate referral - Tx: Vitrectomy and cultures

Progressive Multifocal Leukoencephalopathy - PML due to JC virus

- demyelination to parieto-occipital areas on MRI can be diagnostic but biopsy can confirm - decreased vision - Tx: upon resolution of immunodeficiency

Tinea Pedis (Athletes foot, onchomycosis)

- dermatophyte infections - treat with topical AZOLEs or Terbinafine

Bladder Pain Syndrome aka Interstitial Cystitis

- diagnosis of exclusion after other things like UTI has been ruled out - bladder pain, hematuria - review all work up to make diagnosis - cystoscopy adds to database but NOT needed for diagnosis

Disseminated gonococcal infection

- diagnosis with cervical or blood culture; joint cultures tend to be NEGATIVE

Chronic thromboembolic pulmonary hypertension

- due to chronic PE - best test is VQ scan, NOT CT scan - PCWP normal - PA and RA increased Pulm HTN can have systolic lift at left sternal border

Superior Vena Cava Syndrome (SVC)

- due to lung cancer more often than not but aggressive lymphoma, thymoma, and primary mediastinal germ cell tumors. Nonmalignant causes include thrombosis and fibrosing mediastinitis. - biopsy is the first thing to do, not emergent intervention - if already known history of aggressive cancer like SMALL CELL, then safe to assume without biopsy and proceed with CHEMO (treatment choice for small cell) - consider immediate radiation for nonsmall cell cancer - surgical consultation and stent placement if patient has complications like stridor, laryngeal edema, or mental status decline, unstable. - ENGORGED neckveins WITHOUT pulsation

Warfarin Induced skin necrosis

- due to protein C deficiency which is exacerbated - protein C deficiency can be acquired or inherited 1) stop warfarin, start heparin 2) give vitamin K 3) If needed, proceed to Protein C concentrate or FFP which has protein C

Atrial Fibrillation

- during cardiac ablations, pulmonary vein is cauterized. Down the line this could lead to PULM VEIN STENOSIS which presents with increasingly worsening SOB with no other explanation other than history - Dronedarone can be used for rate/rhythm control - Dabigatran as an anticoagulation should be dosed LOWER if used with Dronedarone - if WIDE COMPLEX TACHYCARDIA then patient may develop V fib if given normal drugs like betablockers or CaChannel blockers - for WCT with A fib, treat with procainamide or ibutalide - can have renal infarcts/embolization so if flank pain with RBC but high LDH, consider infarct over stone! - if new onset and young patient, rhythm control is a good option so if within 48 hours then TEE w/ cardioversion - if duration longer or unknown at time of presentation, 3 weeks of anticoagulation first then TEE (to rule out thrombus) and CARDIOVERSION as rhythm control is best option for new onset and younger patients - anticoagulation for another 4 weeks following cardioversion

Myelodysplastic syndrome

- dysplasia on BM biopsy (macrocytic, hypercellular dysplastic cells) - symptomatic pancytopenia - Pelger Huet abnormalities on granulocytes - if high risk with blasts >5% and patient is relatively healthy, allogeneic hematopoietic stem cell transplantation is the only curative option

Milwaukee Shoulder

- elderly women, no trauma, painful ROM - bloody tap - hydroxyapatite arthropathy aka basic calcium phosphate arthopathy - no crystals on aspiration with polarizing light microscopy - Alizarin red staining or electrom microscopy shows crystals - destructive arthropathy, bloddy tap - effusion but no inflammation

EMG

- electromyelography is used to diagnose RADICULOPATHY as well to prove it is a neuronal source of muscle weakness

Hemophilia A

- factor VIII deficiency, familial - activated partial thromboplastin time (aPTT) is prolonged but CORRECTS FULLY in a 1:1 mixing study and STAYS CORRECTED - if mixing study initially corrects but over 2 hours begins to prolong again, then it is an FACTOR INHIBITOR that is present, most common being Factor 8 INHIBITOR causing the bleed ***hemophilia B similar presentation but factor IX deficiency ***ACQUIRED hemophilia similar presentation with aPTT and mixing study but FACTOR VIII INHIBITOR IS PRESENT - associated with the postpartum state, malignancy, or autoimmune conditions, but 50% of cases are idiopathic - treatment is recombinant activated factor VII (VIIa)

Transfusions

- febrile nonhemolytic transfusion (due to leukocytes) reaction can be treated with STOPPING transfusion, then supportive care ie. Tylenol. Benadryl only for allergic reactions - Check DAT (direct antibody test) which if positive means acute hemolysis...if negative, then NON HEMOLYTIC is the dx and treat supportively - however, if evidence of SIRS (sepsis given the blood product) with fever, hypotention, tachycardia, rigors, stop transfusion, get cultures and start broad spectrum abx - ABO reaction happens within hours - RH reactions happens within a week - Febrile reaction without hemolysis is a Leukocyte reaction - patients with immunocompromised state due to things like chemo should get leukoreduced, IRRADIATED erythrocytes. The IRRADIATION process inactivates lymphocyte products that increase the risk of graft versus host complication in these immunocompromised patients

Bacterial Meningitis

- fever, typical presentation - but apparently consistent with facial nerve palsys and if suspicious patient needs ABX and DEXAMTHASONE NOW right after blood culture - bacterial meningitis with facial nerve palsy indicates increased pressure and LP may cause further herniation! - so first abx and dexamethasone, but then do CT to rule out herniation BEFORE proceeding with LP

Rocky Mountain Spotted Fever (Rickettsia)

- fevers, arthralgias, diarrhea, abdominal pain, macupapular to petechial rash on extremities (WRISTS AND ANKLES, PALMS AND SOLES) spreading to trunk - hyponatremia, pancytopenia, LFTs - Tx: Doxycycline

Plague (yersinia pestis)

- fleas, rodents - can be inhaled and can be used in bioterrorist attacks via inhalation and can cause pnuemonia so DO NEED precautions NO MEDIASTIHUM WIDENING - GN coccobacillus - Tx: Cipro, meropenem and linezolid as cultures are pending

Cryptogenic Oganizing Pneumonia

- flu like illness or pneumonia like illness that does not improve after 4 weeks - Dx: Tissue Biopsy - Tx: 6-12 months of steroids or immunosuppressive therapy

Colon Cancer

- following diagnosis and remission, surveillance of serum CEA levels every 3 to 6 months for the first 3 years and every 6 months during years 4 and 5. - Surveillance CT scans of the chest and abdomen are recommended annually for at least the first 3 years postoperatively - If ANY evidence of solitary, resectable lesions in lung or liver, assume it is metastatic from previous cancer and REMOVE....NO BIOPSY NEEDED ADENOCARCINOMA - Genotyping of K-ras or N-ras genes for mutations must be assessed bc it can dictate the type of chemo - If evidence of lymph nodes or liver mets and biopsy shows adenocarcinoma on unknown origin (scans and endoscopy unreveaing) treat under assumption dx of GI malignancy :-< - BRAF can be positive

Cycospora

- food bourne illness on fresh fruits or veggies

Epididymitis

- for the test, if clinically appears like acute Epididymitis, treat with levaquin/ceftriaxone - if no improvement, THEN ultrasound to rule out malignancy - take home: empiric treatment is appropriate

Blepharospasm

- form of dystonia - involuntary and sustained contraction of the orbicularis oculi muscle - Tx: Botulinum toxin injection

Limited cutaneous systemic sclerosis (LcSSc) aka CREST

- form of systemic sclerosis that is characterized by distal (face, neck, and hands) but not proximal skin thickening - can cause pulmonary HTN, with evidence of RVH and increase RV pressure. Patient's can present with fatigue and SOB - display features of the CREST (calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome and are more likely to develop Raynaud phenomenon early in the disease course - CREST is a variant of LcSSc characterized by the presence of telangiectasias and esophageal dysmotility as well as positive antinuclear and anticentromere antibodies. - Dx: positive antinuclear and anticentromere antibodies are helpful - can cause adverse effects on lungs like interstitial disease, treat with CYCLOPHOSPHAMIDE any lung related progressions of cutaneous systemic sclerosis - can cause scleroderma renal crisis where they have HTN urgency/emergency. Treat acutely with ACE inhibitor - annual echo!

Eosinophilic granulomatosis with polyangiitis

- formerly known as Churg-Strauss syndrome - patients with asthma - elevated eosinophils, IgE - pulm infiltrates, hemoptysis, rashes, mononeuritis multiplex (weaknesses in some muscles) - Dx: Biopsy shows PAUCI IMMUNE CRESCENTS - please note that other microscopic vasculitis have PAUCI IMMUNE CRESCENTS namely microscopic polyangiitis (pANCA) and C ANCA Wegener's

Reactive Arthritis

- formerly known as Reiter syndrome (eyes, genital discharge, joints....reactive arthritis RARELY presents with all 3) ***HLA B27*** - non infectious inflammatory arthritis 3-6 weeks after acute infection - oligoarticular lower extremity dactylitis, keratoderma (looks like psoriasis), uveitis - usually associated with chlamydia or after some sort of infection, usually asymmetric - Dx: Arthocentesis to exclude infection or crystals. Inflammation is present but nothing else - Tx: Can do systemic steroids or joint injection ONLY AFTER arthrocentesis confirms diagnosis

Seborrheic dermatitis

- fungal infection og scalp or folds of skin - associated sometimes with HIV or Parkinson's - Tx: Ketoconazole cream

Cryptococcus

- fungal infection usually in immunocompromised, usually presents in CNS source - if from a source outside the CNS, then patient's always need to be evaluated with LP, regardless of CNS symptoms or not

Mycobacterium fortuitum

- furunculosis that occurs with PEDICURES due to community whirlpool action

Mitral Regurg

- goal is AFTERLOAD REDUCTION

Listeria

- gram positive rods - diarrhea, fever - can have hyponatremia - ampicillin

What is the definition of microscopic haematuria?

>3RBC per high power field

PERITONSILAR ABSCESS

- group A strep, high fever, muffled voice or "HOT POTATOE VOICE", deviation of uvula away from abscess - Tx: Penicillin, I&D if able/needed RETROPERITONEAL ABSCESS - STRIDOR - trauma, penetrating injury and organisms from the mouth seed the retropharyngeal space developing abscess - present with holding their necks in HYPEREXTENSION

Delirium

- haloperidol first choice then quetiapine Avoid Haldol: - Parkinson's patients ~ elderly - those with prolonged QT bc can lead to Torsades

B CELL LYMPHOMAS

- have HIGH 1,25-dihydroxyvitamin D which leads to hypercalcemia seen in lymphoma

Cirrhosis

- hepatocellular carcinoma: patient with cirrhosis in the presence of lesions larger than 1 cm that enhance in the arterial phase and have washout of contrast in the venous phase - Milan criteria: up to three hepatocellular carcinoma tumors ≤3 cm or one tumor ≤5 cm - If Milan criteria is met, patient's meet criteria for liver transplant, regardless of MELD score

Insulinoma

- high c-peptide and insulin levels, hypoglycemia - fasting exacerbates symptoms - Endoscopic ultrasound is sensitive for detecting insulinomas, which are typically small and solitary and should be evaluated if not seen onF CT cross-sectional imaging

Cholesterol atheroemboli

- high risk after any vascular procedures esp those with comorbidities - differentiate from renal embolization which is due to A fib and can present like pyelonephritis (but with increased LDH)

Methamphetamines

- high risk of STDs due to side effects like libido and arousal

Myasthenia gravis

- history of fluctuating proximal weakness with ocular and bulbar involvement - reflexes diminished - months to develop - can be exacerbated with fluroquinolones - associated with 40-50 yo patients who can develop thymomas - myasthenia crisis: plasmapharesis or IV IGG DIFFERENTIATE FROM: - GBS, which occurs more acutely - reflexes are SPARED

Antiphospholipid antibody syndrome

- history of thrombosis, miscarriages Livedo reticularis - subtle, lacy network of faintly blue or purple vessels, usually seen on the lower legs, caused by the prominence of the vasculature under the skin - Associated conditions include autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis), vasculitis (polyarteritis nodosa, giant cell arteritis), paraproteinemias (multiple myeloma, cryoglobulinemia), hematologic diseases (polycythemia vera, thrombocytosis), and infections

Hypothyroidism

- hyperprolactinemia can be a result of untreated hypothyroidism - Iron supplementation can interfere with Levothyroxine absorption can worsen hypothyroid symptoms so don't take at the same time - LOW UPTAKE due to HIGH IODINE - Amiodarone composed of iodine, so causes thyroid disease with DECREASED UPTAKE **We pop so many piiillls, we got iodine poisoning** Pimp C no longer here and on scan nothing shows up ***Calcium and Iron can reduce absorption of levothyroxine***

Postprandial (reactive) hypoglycemia after gastrectomy

- hypoglycemia induced after high carb meals in patients with partial or complete gastrectomy - due to food reaching small bowel too fast and surge of insulin response is over exagerated

Hashimoto Thyroiditis

- hypothyroidism, treated with Levothyroxine - in chronic patients, they can eventually develop Primary Thyroid Lymphoma presenting with rapidly enlarging goiter, weight loss, and night sweats, and imaging reveals a diffusely enlarged thyroid. Dx: Biopsy Tx: Chemo

TIA

- if CT head negative, next step is carotid dopplers; if greater than 50% stenosis, hospital admission and full workup required - Echo is the next step in the ER after Carotid US - greater than 70% extracranial internal carotid artery atherosclerotic stenosis have the highest risk of stroke in the 2 weeks after a TIA

CAD

- if EKG does not show anything that interferes with ST segment, (namely LBBB, LVH, pacer, WPW) first step to evaluate chest pain is exercise stress test - Vasodilator limits these abnormalities, so if they do have one of the above, ADENOSINE STRESS TEST/VASODILATER NUCLEAR PERFUSION STUDY WITH IMAGING - If unable to person exercise, DOBUTAMINE STRESS ECHO - ASA, statin, BB. Also ACE is protective especially if hypertensive - stop BB prior to stress test (but not in real life per Avelar!) - if typical chest pain sx but Exercise EKG is unremarkable (low risk), consider beta blocker or Calcium Channel Blocker empirically. However, those with moderate to high risk based on exercise EKG, evaluate with *cath* - If exercise stress test indeterminant (ex: less than 2mm ST elevation), consider repeat stress echo prior to invasive cardiac cath - following MI, aspirin indefinitely but dual anti platelet therapy for 1 year (in the context of DES) - if over 50 and typical angina presentation, then GREATER THAN 90% chance of CAD ACUTE MI - If stable then sudden chest pain, think RV infarct with acute right HF. Patient cannot perfuse left heart and ultimately rest of the body...these patients are PRELOAD dependent in order to keep cardiac output up. PCWP is LOW, but PA and RA is high - Biventricular failure you get low CO but high PCWP high RA. INOTROPIC dependence - patients who get tPA should be on ASA and Plavix as well! - instrumentation during cath can cause atheroembolism of cholesterol crystals - these cause vascular obstruction but also trigger an inflammatory response - causes AKI, eosinophilia, blue toe syndrome - livedo reticularis (areas of lace-like mottled and purplish skin over the legs and thighs) - Tx: NONE, just supportive - SIMvastatin should not be higher than 40mg because adverse muscle effects. Atorvastatin is the best moderate dose statin - Heart block: If acute MI and not complete block, proceed with PCI. If complete heart block and patient unstable, consider transvenous pacing first to stabilize then cath

CVA

- if TPA given and worsening or new symtoms, repeat CT to make sure no conversion - ASA within 24-48 hours - ASA and dipyridamole is superior to ASA alone for reducing recurrent stroke - ASA and Plavix actually NOT a good look - if large infarct and new atrial fibrillation, holf off on anticoagulation for 4-14 days and just do aspirin - cryptogenic ischemic stroke require prolonged cardiac monitoring to detect atrial fibrillation ***VASCULAR NEUROCOGNITIVE DISORDER - cognitive changes PLUS a previous clinical stroke or neuroimaging evidence that confirms the existence of cerebrovascular disease - Cerebral vasospasm is a potential complication of subarachnoid hemorrhage that most often occurs 5 to 10 days after the hemorrhage and is best detected by CT angiography of the brain - if dysphagia persists, rule out other causes including neuro like ALS or cancer with barium swallow, but ultimately patient will need PEG tube

Gout

- if URATE CRYSTALS evident on fluid analysis, this is diagnostic of gout **regardless of biferengence study** - weight loss, reduction of high-fructose and high-purine foods, alcohol restriction, and INCREASED low-fat dairy intake - diet and lifestyle advised but not always enough, main goal is URATE LOWERING THERAPY - Febuxostat - maintenance gout med to lower urate IF ALLOPURINOL IS NOT AN OPTION. It is a xanthine oxidase inhibitor ***Contraindicated in those taking Azathioprine bc Azathioprine actually uses xanthine oxidase inhibitor for metabolism....leads to dangerously high levels of Azathioprine*** - and if febuxostat does not work in acutely lowering uric acid levels during flare, initiate IV pegloticase - Allopurinol>Febuxostat>Pegloticase - Febuxostat - NOT FOR ACUTE FLARE - interesting fact, ASIANS (especially those with CKD) need to be tested for HLA-B58 bc if positive they can be hypersensitive to Allopurinol and we should AVOID using - Colchicine is metabolized by liver so any CYP45 enzyme inhibiting meds will make colchicine a poor option - Specifically, CLARITHROMYCIN can cause DEATH, but also consider erythromycin, verapamil, dilt, ketoconazole, itraconazole, tamoxifen...if one of these is needed, STOP COLCHICINE - Indomethacin is not good if renal function is poor - Prednisone is the next best option but sometimes we can opt for local injection if systemic immunosuppresion is a concern - GOAL is uric acid below 6 - keep titrating allopurinol and CONTINUE COLCHICINE following acute flare as you titrate to below 6, THEN consider discontinuing RISK FACTORS - obesity, overweight, HTN, alcohol, renal dysfunction, seafood, red meat, purine or high fructose foods, specific meds like HCTZ or CYCLOSPORINE PSEUDOGOUT - positive biferengence - choncrocalcinosis noted on XR due to calcium pyrophosphate deposition (hyperlucencies on cartilage in the joint space)

Familial adenomatous polyposis (FAP)

- if diagnosed, total colectomy - annual sigmoidoscopy to assess for postoperative rectal polyp burden - upper endoscopy every 1-5 years ***if lesions in upper GI, biopsy. If biopsy is benign then repeat EDG with FRONT and SIDE views every 1-3 years. - If dysplasia or high risk malignancy on EGD biopsy, surgical removal is indicated HNPCC (Lynch) - personal and family history of ovarian, endometrial, and colon cancer should undergo testing for genetic mutations - if family history of HNPCC (Lynch syndrome), flex sig statring teenage years is appropriate, but yearly colonoscopy starting at age 25

Tetanus

- if exposed and unvaccinated/unknown, treat with vaccine, immunoglobulin, BUT ALSO METRONIDAZOLE -___- - if previous immunization on file, Immunoglobulin is NEVER indicated - if wound appears dirty and vaccine >5 years ago, then treat with VACCINE (no immunoglobulin) - otherwise, within 10 years, no treatment needed

Pancreatic cancer

- if functional status ok, then multiagent chemotherapy should be aggressively entertained - if resectable mass and the patient is a good candidate, ERCP for tissue sampling is not generally required, just go straight to surgery

End Stage Kidney Disease (ESDR)

- if hyperkalemia and EKG changes: 1) Calcium Gluconate 2) Insulin and d50 3) Dialysis

Acute renal failure

- if hyperkalemia and EKG changes: 1) Calcium Gluconate 2) Insulin and d50 3) Dialysis - rhabdo can even cause ARF PRERENAL AZOTEMIA - common with NSAIDS - improved w fluids - hyaline casts - FeNA < 1 ACUTE TUBULAR NECROSIS - muddy brown granular casts - FeNA > 2 - in the context of sepsis, due to prerenal BUT does not improve initially w fluids, can sometimes take 1 week sometimes several months

Hyperprolactinemia

- if hypothyroidism is present, treat that first then reevaluate for other causes - Bromo is the treatment for prolactinoma, which is usually present if prolactin >200 - if less than 200, prolactinoma less likely so CHECK TSH! - also check TSH first before giving bromo/caber if patient has hx or FH of autoimmune diseases

CAP

- if immunocompromised, cover psuedomonas - cefepime with gentamycin

Dental Caries

- if infection spreads, cover anaerobic bugs but also aerobic; metronidazole and penicillin

Ventricular Tachycardia

- if known hx of heart disease and patient develops SUSTAINED V tach, regardless of EF, they meet criteria for ICD Wide Complex - treat with amiodarone (CaChannel blockers play NO role) SVT with aberancy (Narrow complex) - adenosine acts on the AV node If unstable, cardiovert always

Pituatary Incidentaloma

- if less than 1 cm, likely causes HYPERSECRETION so screen with IGF-1, dexamethasone suppression test, 24 hour corticol. prolactin - if greater than 1 cm, likely BLOCKING SECRETION so check ACTH stimulation, TSH - question will often give some symptoms from patient and his presentation to tip you off which labs should prob be checked

BPH

- if malignancy is ruled out with CT and cystoscopy, BPH can be a cause of painless hematuria. - alpha one blocker, finasteride

Hyponatremia

- if neuro sx, DO NOT increase more than 9 in the first 24 hrs or more than 16 in the first 48 hrs - can do 6 within first 6 hours to improve neuro sx - chronic asymptomatic hyponatremia due to volume depletion causes an appropriate elevation in ADH secretion, which would retain the free water the patient would be drinking to maintain hydration - volume repletion leads to supression of ADH and may overcorrect hyponatremia - Overcorrection: increase of >8.0 within the first 24 hours or >16 within the first 48 hour - osmotic demyelination syndrome and should be reversed using desmopressin with 5% dextrose - SIADH syndrome: clinical euvolemia, hypo-osmolar hyponatremia, and urine osmolality inappropriately GREATER than plasma osmolality - Oxcarbazepine is associated with hyponatremia

Pneumonia

- if not responding to treatment, pursue chest CT to detect parenchymal abnormalities. If no improvement and if warranted, proceed with bronchoscopy - strept throat followed by consolidative pneumonia weeks later = classic chlamydia pneumoniae - Tx: macrolides or tetracyclines 10-14 days - chlamydia pstittaci = associated with parrots and extensive interstitial pattern on CXR, myalgias ESBL (including klebsiella), ventilator associated - beta lactamase producing organisums have more resistance - treat with Carbapenem (MEROPENEM) RESISTANT CAP - age greater than 65 years, alcoholism, immunosuppression, certain medical comorbidities (COPD, chronic liver or kidney disease, cancer, diabetes, functional or anatomic asplenia, chronic heart disease), and recent (within the past 3-6 months) antimicrobial therapy - if patient meets any of these, consider Fluroquinolone empirically or Doxy

Venous Stasis Ulcer

- if there is venous stasis rash, then that is the cause of the ulcer

DVT

- if unprovoked DVT or PE, anticoagulation INDEFINITELY for those with low-moderate risk of bleeding bc high risk of reoccurrence - In some patients like Dispain with fluctuating INRs while taking warfarin, daily supplementation with low-dose vitamin K can help STABILIZE the INR PREOPERATIVELY/PREPROCEDURALLY - NOAC should be discontinued 2 to 3 half-lives beforehand (generally, 24 hours), and in procedures with high bleeding risk, 4 to 5 half-lives beforehand (36-48 hours) - no bridge needed SUPRATHERAPEUTIC - if INR less than 9, no signs of bleeding, simply hold dose and monitor - if INR above 9, then treat with vitamin K. Otherwise, guidelines advise against regular Vitamin K use - ACUTE DVTs require FIVE days of heparin and INR therapeutic for 24 hours -____- what

Pruritis

- if without skin lesions and negative workup, check CXR for systemic causes including HODGKINSLYMPHOMA

Necrotizing fascitis

- immunocompromised, particularly those with liver disease, are at risk for nec fas due to VIBRIO. Can be associated with shellfish and hemorrhagic bullae are the classic cutaneous manifestation - if recognized on the test, we need to go straight to SURGERY and forego any delay with imaging studies

Bursal fluid analysis

- in all patients with prepatellar bursitis > 50k WBC raise suspicion for septic bursitis compression dressings 24-48hr

Takayasu Arteritis

- large vessel vasculitis - presents with type B sx age less than 40, CLAUDATION, decreased pulses, difference in systolic BPs betwen arms, bruit noted, angio with evidence of atherosclerotic disease, sometimes leukocytosis, anemia, thrombocytosis - ESR/CRP

Preventative Medicine

- in patients in their 30s or younger who receive any kind of chest radiation therapy (example treatment of Hodgkin Lymphoma), they are at increased risk of breast cancer - annual mammograms and breast MRIs PNEUMMOCOCCAL - only with immunocompromised (over 65), asplenia, DM, lung disease, heart disease, liver disease - PCV13 then PPSV23 - below 65: repeat PCV13 if 5 years have elapsed since last pneumo vaccine - 65 or older: repear PCV13 if 1 year has elapsed since last pneumo vaccine VACCINES - Tdap, HPV, Varicella, MMR, Hep A, Hep B ***HPV contraindicated for pregnancy - Tdap for adults over 7 - DTap for childer under 7 - Zoster > 60 - Pneumococcal . 65 or those high risk VACCINES in pregnant - if no prior immunization, TDap is 3 times: 0 weeks, 4 weeks then 6-12 months. THEN boosters - always do TDAP - no live vaccines like influenza, varicella, MMR, varicella, rota, rabies PAP smears - 21 to 30 PAP q3 years and only do HPV if ASCUS - over 30 do PAP and HPV only once and if negative then q5 - if ASCUS and HPV positive then do colposcopy, if negative then repeat 6-12 months - Low grade or high grade = colposcopy - stop at 65 - Pulse palpation for age >65 to screen for A Fib - AAA screen with US x1 - Age 50 > Mammo > US if needed > MRI - MRI only if younger with dense tisue - PVCs picked up in healthy individuals can be NORMAL Hypertension and Prehypertension - lipid panel yearly LIPID panel yearly - no PSA screen over 75

Recurrent UTI

- in premenopausal women, prophylactic antibiotics long term - in men and postmenopausal women, anatomical anomalies must be ruled out with cystoscopy

Influenza

- inactivated subQ vaccine - live vaccine is only nasal mist and for 2-49yo

Calcium Oxalate Kidney stones

- inc risk with Crohn's patients or anyone who has had gastric bypass/gastric resection

Cryoglobulinemia

- increase in cryoglobulins, symtoms involving the kidneys, skin, and nerves and can less commonly affect the lungs

OCPs

- increased risk of thrombosis, liver disease, breast cancer, migraine with aura, and uncontrolled hypertension - OCP does NOT interact with cyp450 or INR/coumadin!!! - patients with history of migraines WITH aura have higher risk of stroke, so avoid OCPs - those with higher risk, of VTE, progesterone IUD is the best choice. Progesterone only pills have lower risk of VTE compared to estrogen containing pills, but still has a risk. SEIZURES - Levetiracetam is the only anti epileptic that does not interfere with liver enzymes and can be given to women who are on OCPs

Pertussis

- incubation stage 1-2 weeks Then: 1) Catarrhal 2) Paroxysmal 3) Convalescent - Catarrhal stage first week or so presents like EVERY OTHER URI - Paroxysmal stage has the whooping cough distinguishing factor

Cholinergic Urticaria

- induced by increased in body temp, presents with welts after exercise or warm showers - Tx: Reassurance, cold showers

Scabies

- infestation usually involves the hands (including the palms and interdigital spaces) and feet as well as "folds" of the body (neck, axillary folds, waist, and upper thighs) - areola/breast in women and the male genitals (glans, penile shaft, and scrotum) - usually in homeless or those in close quarters - Tx: Ivermectin or Permethrin

Sjögren syndrome

- inflammation of exocrine glands, including the major and minor salivary glands, lacrimal glands, and, less commonly, other exocrine glands such as the pancreas - cyclosporine eye drops for sx relief of keratoconjunctivitis sicca aka dry eyes - punctal occlusion can also be performed, basically plugs the tear ducts - significant risk of developing LYMPHOMA, the most common being NON HODGKIN, diffuse B-cell and mucosa-associated lymphoid tissue (MALT) lymphomas; adenopathy needs to be BIOPSIED - HIGH RISK of TYPE 1 RTA and tubulointerstitial nephritis, less commonly TYPE 2 RTA

Hemochromatosis

- iron overload - hyperpigmentation, decreased testosterone, diabetes, arthritis due to increased iron - hepatomegaly - metacarpophalangeal and wrist joints usually involved bilaterally, resemble OA with bony changes - Check transferrin level, diagnostic if elevated. Can also check liver biopsy and genetic testing for C282Y mutation of the HFE gene (Autosomal recessive) but not cost efficient - Tx: Phlebotomy or chelation for those who can't tolerate phlebotomy - patients with ANY iron overload syndrome should avoid shellfish bc they have a high risk of SEVERE VIBRIO infection, mechanism not really known but higher risk of sepsis and death - Fungal infections via Aspergillus fumigatus and mucor. V. vulnificu also triggered by shellfish - Escherichia coli, Yersinia enterocolitica, Listeria monocytogenes, cytomegalovirus, hepatitis B and C viruses, and HIV as well - associated with Calcium Pyrophosphate Deposition Disease

Cutaneous larva migrans (parasitic hookworm)

- itchy - treatment with Ivermectin

Osteoarthritis

- joint WBC <2000 and confirms NON INFLAMMATORY arthritis, like OA - can have morning stiffness - usually the presentation with larger joints - can present in thumb with pain with use but also pain on palpation - Patients older than 75 should preferably be on topical NSAIDS to reduce GI toxicity - involved DIP and PIP whereas RA does NOT - those on chronic oral NSAIDS should be on prophylactic PPI 20mg - those with previous GI bleeds can opt for DULOXETINE as it is a proven alternative and significantly reduces pain and improves physical functioning in patients with knee osteoarthritis - If NSAIDS dont work as well, consider joint injection - Though TYLENOL is an analgesic and not NSAID, still a 1st line pain reliever for OA

Guttate Psoriasis

- just memorize picture and that is can follow sunburn OR strep pharyngitis infections

Clarithromycin

- king of all drug interactions, P450 - significantly increases levels of multiple drugs - most notably, causes DEATH with colchicine

Autosomal dominant polycystic kidney disease (ADPKD)

- large kidneys, multiple kidney cysts, and patients may have resulting chronic, mild abdominal discomfort; in some cases, palpable abdominal masses occur - family history autosomal dominant originating in the renal collecting duct - 15% of patients with ADPKD have spontaneous mutations with no family hx - present with pain, hematuria - MR of the head only indicated with family history of aneurysm or subarachnoid hemorrhage, those with a previous rupture, or those with high-risk occupations in which a rupture would affect the lives of others

Gallbladder polyp

- larger than 1 cm is an indication for cholecystectomy - even if no stones and no symptoms - no further imaging studies needed

Hyperparathyroidism

- make sure Vitamin D repleted up to 30 to help prevent further parathyroid hormone stimulation - Cholecalciferol is in the form of lower doses for patients with level >10 - Ergocalciferol is up to 50,000 units for those with level <10 - signs of hypercalcemia include abdominal pain, nausea, vomiting, hyporeflexia and decreased tone, **DECREASED QT interval**, confusion, constipation - PTH does not need to be elevated for diagnosis...if CALCIUM IS ELEVATED and PTH is inappropriately NORMAL, then this could also represent HYPERparathyroisim. Elevated Ca leads to things like stones - associated with Calcium Pyrophosphate Deposition Disease

Tumor lysis syndrome

- massive release of uric acid, potassium, and phosphate into the blood from rapid lysis of malignant cells - Causes AKI with hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia, DIC - usually occurs after initiating chemo, but can start spontaneously - Tx: fluids, fix electrolytes and give Rasburicase to correct hyperuricemia in patients with AKI (faster acting than allopurunol, which is more prophylactic)

Perirectal abscess vs pustule

- may appear the same, like superficial pustules - however, true pustules like systemic findings and can be treated with I&D - if presents with fevers and other systemic findings, then likely ABSCESS and needs surgical DEBRIDEMENT

Raynaud phenomenon

- may be the initial symptom of an underlying connective tissue disease - predictive factors include: prolonged vasospastic episodes, asymmetric involvement of the digits, and abnormal nailfold capillary examination and/or digital pitting - clinical observation is ok until symptoms progress to a picture suggesting connective tissue disease

Porphyria cutanea tarda

- may develop from extensive alcohol use, hemochromatosis, or hepatitis C virus infection - skin fragility and small, transient, easily ruptured vesicles in sun-exposed areas such as on the hands

Vitamin D

- measure same time each year - increase PTH leads to calcium withdrawal from bones - 40- 60% have low vitamin D levels - Phenytoin & Phenobarb increase metabolism of Vitamin D to inactive form = more frequent screening 50,000 IU for 8 weeks

Meningitis

- meningitis due to Streptococcus pneumoniae should be treated with Abx of course, but also dexamethasone - dexamethasone decreases inflammation in the CNS and leads to lower mortality, fewer short-term neurologic sequelae, and decreased hearing loss in pneumococcal meningitis - Tx: Vancomycin and ceftriaxone (3rd gen) for most patients - Tx: for patients OVER 50 need Listeria coverage, so older patients need AMPICILLIN in addition to Vanc and Ceftriaxone - Temporal brain lesions are due to HERPES SIMPLEX ENCEPHALITIS and treated with Acyclovir. LP the first few days may be falsely negative but if high suspicion, continue Acyclovir and repeat LP in 3-7 days

Bulemia

- metabolic ALKALOSIS - hypokalemia - parotid gland swelling, petechiae

Bartter Syndrome

- metabolic alkalosis with normotension, hypokalemia, elevated renin/aldosterone, hypomag - mutation of tri-transporter in the ascending loop of henle - hereditary - MIMICS furosemide abuse Differentiate from Gitelman Syndrome - similar but with HYPOCALCIURIA - MIMICS hctz abuse - mutation in co-transporter in distal tubule

Clostridium difficile

- metronidazole first choice, oral for mild to moderate disease - on recurrence, if still only mild to moderate, repeat metronidazole - for recurrent episodes in elderly or multiple comorbidities, can treat with oral vanc for 6-8weeks w taper ***2018 oral vanc oral fidaxomicin is now first line for ALL c diff, mild moderate or severe SEVERE - WBC > 15,000 - Cr > 1.5 - abdominal pain on palpation :-< - Treat with Oral Vanc COMPLICATED - hypotension, ileus, or megacolon - Treat with oral Vanc as well as IV metro

ring enhancing lesion

- mets do not causes restriction on DWI on MRI - abscess homogenous restricted diffusion - first steroids - ppx AED 1 week post craniotomy with taper - whole brain rads for multifocal disease

Goodpasture Syndrome

- microscopic polyangiitis - pulmonary renal syndrome that can present like Wegener's but anti-GBM is positive - also note that pANCA can be positive in Goodpasture Syndrome but nonspecific- antiGBM is diagnostic of Goodpasture, confirm w biopsy MICROSCOPIC POLYANGIITIS - pANCA is also same category as Goodpasture, presents as pulmonary renal sydrome and best diagnosis is renal biopsy bc bronch with lung biopsy is NOT enough tissue for dx

Impetigo

- mild localized = mupirocen - moderate = MRSA drugs, keflex

Nafcillin

- monitor CBC, LFTs, Creatinine

West Nile Virus

- mosquitos - focal neuro symptoms with meningoencephalitis or as an isolated myelitis - Fever, headache, and focal limb weakness - IgM antibody in the cerebrospinal fluid

IgA deficiency

- most asymptomatic except for recurrent sinus infections; treat w normal abx - anaphylaxis with transfusion - no regular treatment needed, just clinical observation Hyper IgE Syndrome - nothing to do with allergic reactions, but rather recurrent infections as well - however, with IgE, more feel lung infections and bronciectasis rather than sinus

Hodgkin lymphoma

- most common lymphoma to involve the mediastinum - associated with tumor producing Vit D (as is NHL) - better cure rate than non hodgkin - ReidSternberg Cells - associated with PRUITIS without lesions; if patient has unexplained pruitis, check CXR! - anterior mediastinum masses in younger patients 20-30 yo patients - Tx: Chemo (ABVD) and RADIATION for HL - Autologous hematopoietic stem cell transplantation is indicated for patients with RECURRENT Hodgkin lymphoma that comes back even after remission with chemo - Goal is to accumulate hematopoietic growth factors, with or without chemotherapy, to mobilize, collect, and store hematopoietic progenitor cells and once CD34 >3million we can resume more chemo more efficiently - high risk of constrictive pericarditis, accelerated CAD, Myelodysplaysia with evidence of Pelger Huet anamoly on granulocytes, other cancers s/p chemo, AML

Acute Liver Failure

- non alcoholic, non acetaminophen induced, non infectious: N-acetylcysteine IV is beneficial as we wait for transplace, REGARDLESS of tylenol use or not!! wtf!!

Salmonella

- non bloody diarrhea - can also be due to iguanas and reptiles - self limiting, fever gone in 3 days and sx gone in 7

Polyarteritis nodosa (PAN)

- most common medium-sized vasculitis that affects the mesenteric and renal arteries, abdominal bruits present - Often associated with HEPATITIS B - fever, arthralgia, myalgia, skin findings, abdominal pain, weight loss, TESTICULAR involvement with decreased libido and peripheral nerve manifestations - Gohan has to bust nuts to make PAN - AKI and glomerulonephritis due to decreased blood flow - blood on UA but NO RBC CASTS (unlike ANCA) also spares lungs unlike ANCA - Dx: Biopsy showing necrotizing arteritis or CT with characteristic medium-sized artery aneurysms and stenoses of the mesenteric or renal arteries...yes, even biopsy a testi if tender and suspecting PAN

Mesothelioma

- most commonly present with symptoms of a slowly enlarging pleural effusion - asbestos is a risk factor, presents with calcifications on peripheral lung. - If findings consistent with asbestos but ASSYMPTOMATIC then simply monitor clinically ASBESTOS - Predominantly peripheral calcifications...leads to pumonary fibrosis which has Interstitial infiltrates in LOWER LOBES - Benign asbestos pleural effusions (BAPE) occurs first (10 years ish) and only lasts 2-3 months - the rest of the manifestations like infiltrates, fibrosis, can take 20-30 years to manifest and stay the rest of life - leads to mesothelioma

Prostatitis

- most commonly results from an ascending urethral infection, although bacterial cystitis or epididymo-orchitis may be an underlying source of infection - fever, chills, malaise, nausea and vomiting, dysuria, urgency, frequency, and pain in the lower abdomen, perineum, and rectum, prostate is tender - fluoroquinolone is at least 14 days and up to 4 weeks

Erythema Nodosum

- most commonly tested about association with SARCOIDOSIS and INFLAMMATORY BOWEL DISEASE - also with streptococcal infections, TB and drug allergies

Primary thyroid lymphoma

- most often occurs in elderly women with a long-standing history of Hashimoto thyroiditis - Rapid onset of symptoms and goiter, so thyroid studies normal sometimes - Tx: chemotherapy and/or radiation therapy. Thyroidectomy is usually not needed.

Sarcoidosis

- multiorgan inflammatory disease characterized by tissue infiltration by mononuclear phagocytes, lymphocytes, and noncaseating granulomas - diagnosis of exclusion based on multisystem involvement and BRONCHOSCOPY for histologic evidence of noncaseating granulomas when all other causes are ruled out - can have neuropathies - diagnosis can be clinical only in the context of specific syndromes: ***Löfgren syndrome (hilar lymphadenopathy, acute oligoarthritis, and erythema nodosum) loldafuq - self limiting - Tx: NSAIDS ***Heerfordt syndrome (uveitis, parotid gland enlargement, and fever) - Hypercalcemia with normal Phoshate...Vit D high too Granulomatis disease - Hypercalciumia due to increased Vitamin D - Low PTH - Hilar adenopathy, khmao Tx: Methotrexate, high-dose prednisone, or a tumor necrosis factor α inhibitor such as adalimumab are reserved for patients with chronic, organ-damaging forms of sarcoidosis Erythema Nodosa of the shins is not specific but IF associated with Sarcoidosis is actually a GOOD PROGNOSTIC FACTOR DIFFERENTIATE with Berylliosis - similar presentation with hilar and mediastinal lymphadenopathy, presents with SOB - need to perform berylium lymphocyte proliferation test aka lymphocyte transformation test on bronch to differentiate/diagnose

STILL disease

- multisystem inflammatory disease characterized by high spiking fevers, arthritis, rash, high neutrophil counts, ESR CRP, organomegaly and markedly elevated serum ferritin - salmon colored rash - Diagnosis requires fulfilling at least five criteria, two of which must be major and based on exclusion of infection, malignancy, or other rheumatologic diseases

Polycythemia vera

- myeloproliferative neoplasm that results in excessive and unregulated erythrocyte production, is associated with very LOW serum erythropoietin levels - Increases risk for AML, myelofibrosis - MAY PRESENT WITH chronic hypoxia and elevated carboxyhemoglobin concentrations due to tobacco use, hepatocellular carcinoma and pheochromocytoma - MAY PRESENT WITH generalized pruritus that often worsens after bathing, erythromelalgia (a burning sensation in the palms and soles), and hypermetabolic symptoms such as fever, weight loss, and sweating) hepatosplenomegaly, plethora - MAY PRESENT WITH hepatomegaly, increased H&H and abdominal pain, concerning for thrombosis in the setting of increased risk of Budd-Ciari (so get US!) - Dx: JAK2 mutation testing 1) FIRST check O2 sat to see if chronic hypoxia led to PCV, before proceeding with further workup 2) If O2 ok, then check Epo levels, check JAK2, check bone marrow - Tx: phlebotomy/hydroxyurea, ASA - High risk of Budd-Chiari syndrome due to hepatic vasculature thrombosis - Tx: Anticoagulation on top of phlebotomy/hydroxyurea - highest risk of thrombosis is previous thrombosis and age over 60 - if erythropoietin levels are elevated, consider erythropoietin releasing tumor, NOT PCV

Supraventricular tachycardia

- narrow-complex tachycardia ASSESS Stable? Vagal maneuvers, adenosine, amiodarone. Unstable? Cardioversion Atrioventricular nodal reciprocating tachycardia (AVNRT): rhythm is regular and no obvious P waves are visible - neck pulsations, which are caused by simultaneous contraction of the atria and ventricles - Tx: Vagal maneuvers, Adenosine - if no P waves, narrow, and responds to adenosine, proceed with EP evaluation - CaChannel blockers and Flecainide, other antiarrythmetics as alternatives

Nonallergic Rhinitis

- nasal congestion WITHOUT itch, sneeze, eye involvement - no esponse to antihistamines - no allergens identified - Tx: Nasal steroids

Retinal detachment

- new floaters and lighting flashes - ophthalmology EMERGENCY evaluation asap by eye doctor - visual acuity changes happen later on

Preeclampsia

- new-onset hypertension after 20 weeks of pregnancy AND end-organ damage such as proteinuria, kidney dysfunction, thrombocytopenia, abnormal liver chemistry tests, pulmonary edema, and cerebral or visual symptoms - if BP prior to 20 weeks, then it is chronic HTN that was previously undiagnosed - delivery at 37 weeks has been shown to optimize both maternal and neonatal outcomes. Monitor risk vs. benefit prior to 37 weeks

Acquired cystic kidney disease (ACKD)

- no family history - small kidneys, cysts in the renal parenchyma - once ESRD, patient at significantly increased risk of renal cell carcinoma

Zenker's Diverticulum

- no risk of malagnancy - outpouching can trap medications, and as a results, meds can sometimes be less effective - Dx: Barium swallow! - EGD = inc risk of perforation

What is the absolute risk of developing oesophageal adenocarcinoma with Barrett's?

0.12%/yr This is 30x higher than the general population

Hypercalcemia

- normal 9-10.5 - check PTH, thyroid function ***in patients with conditions causing hyperalbuminemia or paraproteinemia (ex: MS), could be false elevation due to protien binding of calcium. With these patients, first step is to check IONIZED CALCIUM level - in patients with level 18 or higher with neuro symptoms and AKI, treatment requires DIALYSIS Consider familial hypocalciuric hypercalcemia: - mutation in a specific calcium-sensing receptor in the parathyroids and kidneys, and results in an upward shift in the range of calcium and PTH leading to PTH upper limit of normal and increased calcemia level - family history - need to check 24 hour urine calcium and creatinine - Dx: Total urine calcium of less than 200 mg/24 h (5 mmol/24 h) and a calcium-creatinine ratio less than 0.01 - Important to diagnose to avoid removal or parathyroid gland - Tx: None. Does not require therapy to lower serum calcium levels

Kallmann Syndrome

- normal karyotype - can have longer wingspan - only sometimes do they present with indeterminant sexual features - LH and FSH are low, decreased sense of smell

Hyper IgE Syndrome

- nothing to do with allergic reaction - increased lung infections, bronchiectasis

Budd-Chiari syndrome

- obstruction of hepatic venous outflow, can occasionally present with acute liver failure but has ascites as a predominant clinical manifestation. - Dx: JAK2 mutation - Polycythemia vera patients have increased risk of Budd Chiari - Dx: JAK2 mutation - Tx: Anticoagulation on top of phlebotomy/hydroxyurea

Cytomegalovirus (CMV)

- occurs often with transplant patients due to immunosuppression or HIV patients - nonspecific febrile syndrome - nonspecific systemic symptoms, cytopenias, and hepatitis - esophagitis or colitis or in the eye as retinitis - hepatitis, gastritis, and small bowel enteritis may also occur, although less often - Tx: Valgancyclovir, Gangcyclovir - if suspected especially in HIV patient, go ahead and treat empirically

ACANTHOSIS NIGRICANS

- of course with insulin resistance but heavily associated with STOMACH ADENOCARCINOMA

Hyperkalemia

- often induced by BACTRIM, especially with elderly or CKD patients

Abdominal compartment syndrome

- oliguria or increasing serum creatinine levels who have had abdominal surgery, who have received massive fluid resuscitation, who have a tense abdomen, or who have liver or pancreatic disease with ascites - measure abdominal pressure or bladder pressure for diagnosis - treatment is surgical decompression

Hypersensitivity Pnuemonitis

- on exposure to work place toxins like hay, actinomyces - multi lobe involvement, recurrent pneumonias - classically at the APEX of the lung with alveolar filling pattern - chronic issue ***Increased risk of PULMONARY FIBROSIS*** - first thing is to avoid irritants for several months - if no resolution, THEN bronch or maybe lung biopsy but first just stay away from work exposure

Zika Virus

- only 20% have symptoms - fever, rash, joint paint - men abstain from sex for 6 months - women abstain from sex for 8 weeks - Test PCR serum/urine for those who are symptomatic with history OR those who are asymptomatic with possible exposure. NOT recommended for routine screening

Huntington disease

- onset earlier in life like 30s or 40s - caudate nuclei atrophy, HTT gene, AD - poor prognosis - personality and chorea (snake like and quick jerks) - Tx: Haloperidol to block dopamine can help manage the movements ADVERSE Haloperidol can lead to prolonged QT and due to hypomag can cause WPW Differentiate with SYNDENHAM CHOREA where it is mostly children, post infection with group A strep or rheumatic fever

Creutzfeldt-Jakob disease

- onset later in like like 60s of 70s - rapidly progressive dementia, ataxic gait, and myoclonus rapidly progressive dementia, ataxic gait - MRI with multiple abnormal difussions, EEG shows 1-2 Hz sharp dischaged on slowed background, patient has JERKING movements rather than choreoform movements Variant CJD - same presentation but can have Parinaud upward gaze

Pyelonephritis

- oral treatment with BACTRIM - for pyelo, Macrobid is insufficient. Macrobid empirically only for UTIs - if still febrile after 72hrs of abx, consider further imaging to rule out perinephric or intrarenal abscess...in which case, surgical debridement and reculture is appropriate

Mixed connective tissue disease

- overlap syndrome that includes features of systemic lupus erythematosus, systemic sclerosis, and/or polymyositis - postive Anti RNP

Carbon Monoxide poisoning

- pO2 can be normal, they just can bind be CO binds - Carboxyhemoglobin level elevated - headaches, n/v, SOB, headache, syncope, tachycardia, if super high level it can present with cheyne-stokes respirations or resp failure, loss of consciousness, seizures, brain damage, cardiac arrest, death - even short exposure can cause permanent neurocognition and functional impairments - Tx: high concentration O2, hyperbaric o2

Acute angle closure glaucoma

- pain, n/n - colorful halos, decreased vision - ophthalmic emergency, gonioscopy

Fixed drug eruption

- painful purple patch that occurs in the same location - Common drug culprits are over-the-counter medications such as NSAIDs, pseudoephedrine, sulfonamide medications, and other antibiotics

Bladder cancer

- painless hematuria should be evaluated with CYSTOSCOPY - cyclophosphamide can predispose to bladder cancer URINALYSIS - Hemoglobinuria is distinguished from true hematuria by the absence of erythrocytes on urine microscopy - those with bladder cancer have true erythrocytes on urine microscopy - hemoglobinuria could likely be due to hemolysis due to heart valve, but again, no erythrocytes will be noted on UA SUPERFICIAL BLADDER CANCER - stage 1 - Tx: transurethral resection of the bladder tumor (TURBT), followed in most patients by either bacillus Calmette-Guérin (BCG) or mitomycin infused directly into the bladder - high rate or recurrence so if recurs in 6-12 months, patient needs CYSTECTOMY

Guillain-barré syndrome

- paradoxical breathing, subacute onset weakness - go ahead and intubate as there is no oxygenation issue, more of a ventilation issue once weakness of diaphragm hits - aka acute inflammatory demyelinating polyradiculoneuropathy (AIDP) following acute illness

Sickle Cell

- patients higher risk of getting Parvovirus B19 as are those who are asplenic - acute crisis presents with inc LDH and inc reticu count Acute PARVOVIRUS B19 - aplastic presentation with LOW RETICULOCYTES - severe anemia sx, fatigue, SOB - DECREASES RBCs - some patient's need deferoxamine due to IRON OVERLOAD - high risk Yersinia infection and can cause enterocolitis which presents as abdominal pain that mimics appendicitis (LLQ)

Preoperative management

- patients with ICD: reprogram to asynchronous pacing and disable shocking function - PFTs required if surgery in close proximity to diaphragm - if not, and if lung disease well controlled, no PFTs needed - FEV1 < 2L is the cutoff for surgery...if below 2L, do a VQ scan to assess resectability of lung lesion - CT surgery requires cardiac risk assessment since high risk surgery so at the very least, chemical stress test if sedentary, proceed with angio if indicated prior to surgery if elective (AAA is elective)

Felty Syndrome

- patients with rheumatoid arthritis present with fatigue or fever, lymphadenopathy and evidence of splenomgaly, and neutropenia

Becker Muscular Dystrophy

- pattern of weakness is predominantly proximal, and calf hypertrophy is present - starts as a child - Dx: biopsy

Fitz Hugh Curtis syndrome

- perihepatitis - PID ascends to fallopian tubes and seeds liver capsule causing RUQ pain

Cluster Headaches

- periorbital, ipsilateral tearing, ptosis, tearing, and/or rhinorrhea; he also exhibits motor restlessness during headache episodes - Oxygen therapy and subcutaneous sumatriptan are the most effective acute treatment - VERAPAMIL for daily prophylaxis

Eosinophilic Fasciitis

- peripheral eosinophilia noted on evaluation - scleroderma like reaction with thickening of skin but sparing the hands ***reaction to vigrous exercise***

Vitamin B12 (Cobalamine) deficiency

- peripheral neuropathy, inc MCV (isolated Folate deficiency alone rarely associated with peripheral neuropathy) - actually takes months for B12 to be low, so check METHTLMALONIC ACID LEVEL - Methylmalonic acid is elevated in 98% of people with cobalamin deficiency

Lynch Syndrome

- personal and family history of ovarian, endometrial, and colon cancer should undergo testing for genetic mutations caused by Lynch syndrome - treat present cancer as such, but if genetic testing reveals mutation for the AD condition, then appropriate cancer screening for patient and genetic screening for family can be considered - flex sig starting in teenage years but yearly colonoscopy starting at 25

Hereditary spherocytosis

- personal or family history of anemia, jaundice, splenomegaly, or gallstones - can present with symptomatic aplastic crisis precipitated by an acute parvovirus B19 infection - Spherocytes and the direct antiglobulin (Coombs) test is negative - Dx: osmotic fragility test with 24-hour incubation

Androgen insensitivity

- phenotypically female - scant pubic and axillary hair - shortened vagina - ABSENT UTERUS - Dx: Karoyotype to confirm genetic male

Black hairy tongue

- poor oral hygiene in the context of tobacco use among other things - no workup needed, just aggressive tongue brushing and better oral hygiene

Platypnea-orthodeoxia syndrome

- positional symptoms of cyanosis and dyspnea that generally occur when the patient is sitting and resolve in the supine position - Right to left shunt rarely causes these symptoms but can be exacerbated in certain situations like patent foramen ovale that is being stretched by worsening heart failure new onset

Autoimmune Hemolytic Anemia

- presence of antibodies directed toward antigens on the surface of erythrocytes; they are further classified by the type of immunoglobulin involved and the resulting tendency of hemolysis to occur in warm or cold environments - use DIRECT abs - DIRECT IgG binds to erythrocytes at 37degrees or high causing warm autoimmune hemolytic anemia - DIRECT IgM binds at lower temps causing cold agglutinin; can be primary disorder or be associated with lymphoproliferative disorders, infections, etc. DIFFERENT than INDIRECT Coombs test which detects antierythrocyte antibodies in the serum and is used primarily before blood transfusion and in prenatal testing of pregnant women

Radiation pneumonitis

- present with cough and/or dyspnea approximately 6 to 12 weeks after the exposure (especially after chemo/radiation therapy) - more prone if underlying lung disease prior to exposure - Straight line on XR or straight line-ish opacities on CT

Hyperglycemic Hyperosmolar nonketotic state

- presents like DKA but NO ACIDOSIS - main treatment is fluids bc patient's get into this state due to poor fluid intake....can present as homeless patient or elderly for example - can also treat with insulin after fluids

Essential Thrombocytosis

- presents like PCV - highest risk of thrombosis is previous thrombosis and age over 60 - headache and vision changes could signify microvascular thrombosis - Tx: Cryoreductive therapy like Hydroxyurea, ASA

Pituitary apoplexy

- presents like meningitis with hypotension and hemianopsia - CT scan shows lesion to pituitary/dense lesion to sella - Tx: Neurosurgery for decompression, buy time with cortisol level and GCs

Renal papillary necrosis

- presents like pyelonephritis but no WBC on UA - passage of necrotic papilla - due to chronic NSAIDS, repeated infection, DM, Sickle cell

Giardia

- presents with steatorrhea, abdominal distention, and weight loss - common in travelers and outdoor enthusiasts, who may become infected from drinking contaminated water - 4 weeks - Dx: ELISA for antigen in stool, sometimes STRING test - Tx: Nitazoxanide or Tinidazole

Complex regional pain syndrome

- previously reflex symphathetic dystrophy severe pain following minor insult with evidence of tissue damage - often ATROPHY of surrounding tissues - xrays sometimes show osteopenia - Tx: PT NSAIDS lidocaine, gaba, amitriptyline

Syphilis

- primary syphilis has painless genital chancre - secondary syphilis has skin rashes that looks like pityriasis rosea on the trunk and back, looks like psoriasis plaques on body Tx: Primary (genital lesion), secondary (rash) and EARLY latent syphilis can be treated with 1 time dose of Benz long acting penicillin (or 2 weeks of Doxy if allergic) Tx: Tertiary (gummas) or Latent syphilis needs Penicillin x 3 qweek Tx: Neurosyphilis Penicillin G IV for 10-14 days

Chronic traumatic encephalopathy

- progressive neurodegenerative disorder triggered by repetitive mild head injury that has most often been described in military combat veterans and athletes with a history of multiple concussions and subconcussions - years or decades after repeated head trauma and present insidiously - depression, suicidal ideation, apathy, and irritability. Disinhibition, impulsivity, and aggression can also occur in the later stages. Cognitive symptoms include problems with memory, attention, concentration, and executive function, poor insight, eventually Parkinson's

Chronic inflammatory demyelinating polyradiculoneuropathy

- progressive weakness, areflexia, and sensorimotor neuropathy with a slow progression extending beyond 8 weeks since onset - Tx: glucocorticoids and other forms of immunomodulatory therapy

Typhoid fever

- progressively rising fever accompanied by abdominal pain, initial constipation followed by diarrhea, and relative bradycardia; tender hepatosplenomegaly is common - anemia, leukopenia, thrombocytopenia, and elevated liver enzymes and bilirubin levels. - supported with serologic assays but blood or stool cultures needed for Dx - salmon-colored blanching maculopapular lesions on the trunk or abdominal wall - Salmonella, gram neg bacilli

Essential Tremor

- propranolol and primidone are FDA approved first-line therapies

Dermatitis herpetiformis

- pruritic rash autoimmune disorde - associated with gluten-sensitive enteropathy, or CELIAC disease

Spondyloarthritis

- psoriasis, inflammatory bowel disease, preceding infection, sacroiliitis, uveitis and enthesitis at the Achilles tendon - HLA-B27 can help with diagnosis of peripheral or axial SA only in the absence of other sufficient manifestations. Otherwise, not really helpful.

Nocardia

- pulmonary and/or CNS complaints in immunocompromised patients, acid fast bacteria - nodules on skin, CXR nodule lesion, CT brain has RING ENHANCING LESION - filamentous branching, gram positive - only in soil so if grows anywhere, esp lungs, that IS the cause of infection - Tx: Sufa (bactrim) - often confused with Actinomyces but non-acid fast with Actinomyces

Fabry Disease

- rare X-linked inherited disorder in which there is deficiency of α-galactosidase A - leads to progressive deposit of globotriaosylceramide (Gb3) in lysosomes, lysosomal storage disorder - present with stroke and neuopathy - leads to CKD in younger adults - associated clinical features include premature coronary artery disease, severe neuropathic pain, telangiectasias, and angiokeratomas

Tuberous sclerosis

- rare genetic disease that causes benign tumors in brain but also other organs - intelectual disability, seizures, developmental delay, psych issues, skin/lung/kidney issues

Rhinitis Medicamentosa

- rebound phenomenon when you use nasal decongestants too much. Smear is clean ALLERGIC RHINITIS - smear usually has eosinophils or sometimes leukocytes (but no one really does a smear)

Paroxysmal nocturnal hemoglobinuria

- red cells on dip stick but NEGATIVE microscopy - anemia, decreased haptoglobin with increased reticulocyte count - consider in those with hemolytic anemia, pancytopenia, or unprovoked atypical thrombosis - hemolytic anemia, hypocellular bone marrow, and lack of CD55 and CD59 - mutation of PIG-A gene - Dx: flow cytometry with lack of CD55 and CD59

Fanconi Syndrome

- renal dysfunction associated with MM **glucosuria WITHOUT hyperglycemia - defects in proximal tubules (TYPE 2 RTA) - NON gap metabolic acidosis with NO DIARRHEA (makes sense!) RTA type 2* - spills alot into the urine so hypoK hypoPHOS and hypoURICEMIA - Sjögren syndrome high risk of Type 2 RTA Fanconi

AL amyloidosis

- secondary to a plasma cell dyscrasia - amyloid resulting from monoclonal lambda or kappa light chains is termed AL amyloid - nonspecific systemic symptoms such as fatigue or weight loss, but most commonly presents with symptoms associated with infiltration of different organ systems - Dx: biopsy shows deposits that stain apple green on Congo red staining

Celiac disease

- serum tissue transglutaminase testing and biopsy - IgA TTG and IgA antiendomysial abs - associated with IBS-D - dermatitis or sometimes dermatitis herpetiformis, anorexia, abdominal distension - unexplained elevated serum aminotransferase levels - IRON DEFICIENCY ANEMIA so pay attention on ROS for patients with heavy menstrual periods - Dx: ttg and history help, but need to confirm with biopsy definitively Tx: Gluten free diet - at risk for other autoimmune disorders, thyroid/esophageal cancer, lymphoma, osteoporosis, neuropathies OLMESARTAN - can cause profuse watery diarrhea and causes VILLOUS BLUNTING but all other studies are otherwise negative - Tx: stop ARB

Klinefelter syndrome

- sexual dysfunction and generalized fatigue, small firm testes, tall stature (Klimbing!) is a common finding but not always. - FSH and LH is actually HIGH bc testes don't respond appropriately - may fail to achieve puberty or may present after sexual maturation with azoospermia, breast development, hypergonadotropic (high/normal FSH and LH) hypogonadism Differential Dx: - those with HYPOgonadotropic hypogonadism, consider pituatary mass - Kallmann syndrome can also have long wing span but trouble smelling and FSH and LH are LOW

Pseudohyperparathyroidism

- short 4th an 5th digit due to decreased tissue response to PTH - high PTH low calcium high phosphate

Wilson's Disease

- should be considered in all patients younger than 40 years of age who have unexplained liver disease - congenital disorder of copper excretion. - Copper leads to hemolytic anemia - acute liver failure with younger patients or chronic liver disease with older patients presenting with neurologic manifestations - Kayser-Fleischer rings, ceruloplasmin level, and elevated urine copper excretion but diagnosis is made with LIVER BIOPSY - Tx with copper chelating agents such as D-PENACILLAMINE and TRIENTINE - Patients with acute liver failure due to Wilson disease rarely recover and should be urgently referred for liver transplantation

Nephrotic Syndrome

- significant protein loss in the urine, hypoalbuminemia, and edema Membranous Glomerulopathy: - Primary MG is associated with the antibody to phospholipase A2 receptor (PLA2R) on the podocyte surface in up to 80% of patients - Secondary causes of MG include MALIGNANCIES (solid organ cancers, especially lung, colon, and breast), autoimmune diseases (such as lupus or mixed connective tissue disease), infections (hepatitis B and C), and medications (penicillamine, gold, and NSAIDs) - always screen for cancer if membranous glomerulopathy ***Similar to other forms of nephrotic syndrome but has HIGH RISK OF THROMBOSIS*** - DVTs, RVTs (renal vein thrombosis) - RVTs present like stones but with markedly worsening of renal function Primary Focal Segmental Glomerulosclerosis - idiopathic - Dx: low serum albumin level and extensive foot process effacement on kidney biopsy - Patients usually present with hypertension, hypoalbuminemia, and some degree of kidney failure with proteinuria. - could be due to HIV infiltrating the glomeruli - Tx: immunosuppressive therapy typically offered to patients with this diagnosis Secondary Focal Segmental Glomerulosclerosis - thought to be due to obesity - minimal edema - Dx: Biopsy showing enlarged glomeruli with focal segmental sclerosis; immunofluorescence is nonspecific, and electron microscopy shows mild foot process effacement - Treatment: ACE inhibitor, weight loss

Amyotrophic lateral sclerosis (ALS)

- simultaneous upper and lower motoneuron signs in multiple body regions - Dx: needle electrode examination - Tx: Riluzole can increase the survival of affected patients by a modest average of 3 months - Edaravone is another option

Amyopathic dermatomyositis

- skin lesions WITHOUT muscle weakness or pain, and NEGATIVE workup - photodistributed violaceous poikiloderma - violaceous periorbital rash - lesions over extensor surfaces and small joints - Tx: glucocorticoids and immunosuppressive agents

Papillary thyroid cancer

- slow onset, usually with NODULE rather than a goiter. Usually good prognosis - Surgical resection if isolated - if evidence of spread into vasculature, consider RADIOACTIVE IODINE THERAPY POOR PROGNOSTIC FACTORS - size >4cm - age >40 - obviously if locally invasive, metastases, poorly differentiated - Papillary - LN to mediastinum or Cervical LN - Follicular - capsular or vascular invasion

Inclusion body myositis

- slowly progressive, often assymertric, inflammatory myopathy that predominantly affects distal upper extremity flexors and quadriceps - can effect both DISTAL and PROXIMAL muscles at the same time, weakness - elevated CPK but NO PAIN just WEAKNESS - age 50 or over - EMG with fibrillations and short large/small motor potentials - Dx: Biopsy with rimmed vacuoles and intracellular amyloid deposits

Esophageal spasm

- solids and liquids but especially COLD LIQUID can trigger intermittent dysphagia due to spasm - Barium swallow usually normal but can give off CORKSCREW appearance - Tx: Reassurance, can try CaChannel blockers or antispasmodics - sometimes may be due to reflux, even if patient does not present with typical reflux symptoms and EGD clear - consider 24 HOUR PH MONITOR to see any signs of reflux, as controlling this could eliminate spasms

Chlamydia pneumoniae

- strept throat with URI symptoms followed by consolidative pneumonia 3-4 weeks later!!! Classic presentation - Tx: macrolides or tetracyclines 10-14 days

Wernicke Encephalopathy

- subacute - ocular symptoms, ataxia, confusion (don't need all 3!) - treat with thiamine - note that even when given thiamine, chronic amnesia can still persist

Dehydration

- sweat is hypotonic, so we do lose Na but more water than Na - patients will be HYPERnatremic and urine will be HYPERosmolar (makes sense) - only hyponatremic if drank alot of water during the race

Horner Syndrome

- sympathetic chain compression leading to miosis, ptosis, and anhidrosis - pupils are abnormal but when given agents like atropine or pilocarpine, they illicit normal response. HOWEVER, given something like cocaine eye drops WILL NOT illicit a response because sympathetic chain is compromised - associated with non small cell lung cancer

Idiopathic pulmonary fibrosis

- the need for supplemental O2 and objective decline in 6 minute walk test substantially increase risk for the development of respiratory failure ***Interstitial infiltrates in LOWER LOBES*** - Tx: Lung transplant - Tx: Nintedanib and Pirfenidone can slow progression of worsening FVC in these patients, O2 can help if hypoxic

Hemolytic Uremic Syndrome HUS

- thrombotic microangiopathy characterized by fever, hemolytic anemia, consumptive thrombocytopenia, neurologic findings less likely but can occur, and kidney failure - COMPLEMENT mediated - presents like TTP but without neurological findings and more pronounced renal injury - look for food exposure, diarrhea and abdominal pain - ADAMTS13 is NEGATIVE ***when patients present, empiric treatment with plasmapharesis is reasonable as we await ADAMTS13....if negative, then HUS. Discontinue plasmapharesis - Tx: Monoclonal anticomplement agent Differentiate from TTP - ADAMTS13 is negative in HUS - COMPLEMENT mediated in HUS - does not respond to plasmapharesis

Thrombocytopenia

- transfuse if below 50.000 and evidence of bleeding - transfuse if below 10,000 period - prefer HLA matched in adults - acute illness can lead to UREMIA - UREMIA leads to platelet dysfunction - Tx: DESMOPRESSIN can reverse platelet dysfunction in acutely UREMIC patients - example patient needs emergent surgery but has thrombocytopenia, BUN elevated, give DESMOPRESSIN to reduce bleeding

Temporal Arteritis (Giant cell arteritis)

- treat now with steroids even empirically - treat now with ASA bc high risk of MI/CVA due to chronic inflammation

Idiopathic intracranial hypertension

- treat with acetazolamide

Giant cell arteritis

- treat with high dose prednisone 60mg then taper - treat even before biopsy to preserve vision

Vancomycin

- trough level is 15 to 20 µg/mL - MIC needs to be less than 2 to be effective against MRSA. Otherwise, Daptomycin is the better alternative - AKI due to vanc typically occurs after 7 to 10 days of antibiotic therapy and the urine sediment does not show cells

ASCVD

<5% = Low Risk 5-7.5% = Intermediate >7.5% = Severe If indetermediate, consider: - Coronary Artery Calcium score greater than 300 or greater than 75% for age - C-reactive protein level (hsCRP) above 2 mg/L - Ankle-brachial index below 0.90 - LDL cholesterol level 160 mg/dL - Family history - HIGH intensity statin for LDL > 190 regardless of risk

Mastocytosis

- tryptase level elevated - mast cell proliferation, prophylactic reactions - Tx: Epi of course, antihistamines, leukotriene inhibitors and CROMOLYN is a mast cell stabilizer SYSTEMIC Mastocytosis - maybe the same thing? - urticaria of course but with involvement of GI tract is the key to SYSTEMIC - antihistamine induced hypersecretion of gastric acid leading to ULCERS - sometimes splenomegaly and hepatomegaly

Rosacea

- two types, erythematotelangiectatic (vascular) and papulopustular (inflammatory) rosacea - Vascular rosacea presents as persistent flushing, especially of the central face, with prominent telangiectasias - Inflammatory rosacea has pustules and papules but in contrast to acne, rosacea pustules are not follicular based - Eye involvement, with dry, gritty-feeling eyes and conjunctival injection, is common - Angiofibromas (fibrous papules of the nose) are common solitary lesions - Sebaceous hyperplasia present as small papules found on the face

Allergic Reactions

- type 3 immune complex based reactions: usually cleared by mononuclear phagocytes (reticuloendothelial system) but unable to clear in type 3 ALLERGEN SKIN TESTING - good PPV for INHALANTS - poor PPV for FOODS - overall great NPV for both - so good to identify inhalants and rule out allergens

Rectal Cancer

- typically adenocarcinoma for which resection is the initial therapeutic step followed by chemo ANAL CANCER - the above is opposed to anal cancer which is typically squamous cell. If stage 1-2 or 3, radiation and chemo is preferred method, NO SURGERY

Glucose-6-phosphate dehydrogenase deficiency

- typically leads to episodic hemolysis in response to oxidant stressors (infections or drugs such as dapsone, trimethoprim-sulfamethoxazole, and nitrofurantoin) - bite cells, heinz bodies (single dot in the cell) - Heinz bodies also present in splenectomy patients

Calciphylaxis

- typically occurs in patients with advanced kidney dysfunction and an elevated calcium-phosphorus product - results from abnormal deposition of calcium within the lumen of the arterial vasculature, compromising blood flow with distal ischemia resulting in painful tissue necrosis - Treat with sodium thiosulfate of anything that lowers calcium - Hyperbaric oxygen, careful debridement, and bisphosphonates may also be helpful

early idiopathic Parkinson's

- uncommon under 40 - non-motor: daytime somnolence, mood disturbance, anosmia, and constipation - REM sleep behavior disorder (15-47%)

Campylobacter jejuni

- undercooked poultry - treatment for bacterial gastroenteritis is controversial, for example with Salmonella, it can actually prolong disease course - May consider empiric treatment with fluroquinolones when patients are at risk for extraintestinal complications because of advanced age or immunocompromise, or when symptoms are particularly severe, the benefits outweigh the risks ****Most bacterial gastroenteritis are self limiting and resolve without treatment****

Charcot-Marie-Tooth disease

- uniform demyelination on nerve conduction studies - distal extremities

Hypoparathyroidism

- urine calcium goal is less than 300 mg/24 hours (7.5 mmol/24 h) and serum calcium goal is between 8.0 and 8.5 mg/dL so supplementation dictated by these values

OSA

- usually STOPBANG is the first step - in the patient who shows exacerbation of undiagnosed OSA with anesthesia postoperatively (ex: hypoxia, needing intubation in recovery, all the risk factors) then go straight to sleep study to avoid reintubation

Vitamin A toxicity

- usually at levels 10 fold greater than recommended daily allowance - HYPERCALCEMIA and OSTEOPENIA - leads to increased bone resorption, causing bone pain - can have hepatic dysfunction, dry skin, nausea, headache, fatigue, ataxis, alopecia, hyperlipidemia, irritability

Appendicitis

- usually can go to surgery with clinical diagnosis but if multiple issues going on and multiple comorbidities CT is needed to confirm diagnosis and rule out ruptured appendix

Alveolar-arterial gradient

- usually get pO2 from ABG - AlveolarO2 = 150 - (pCO2 x 1.25) - Normal AlveolarO2 - pO2 = (5-20) INCREASED in PE NORMAL in hyperventilation, hypoventilation, altitude

Polymyositis

- usually presents with WEAKNESS and not pain - increased risk for lung disease - CK elevated - Dx: biopsy - infiltration, hypercellular, necrotic cells - Dx: Anti Jo 1 - Tx: High dose steroids then taper to low dose long term - if symptoms come back, actually stop steroid to assess for true flare vs. glucocorticoid-induced myopathy PMR: CK normal, no Anti Jo, PAINFUL without weakness

Gardner Syndrome

- variant of FAP with both intestinal and extratentinal benign growths like osteomas, soft tissue etc and will transform to malignant if untreated

Perioral dermatitis

- variant of rosacea - itchy erythematous rash around mouth - Tx: Mild gets topical metro and Mod-Severe gets oral Doxy or Mino

Mycobacterium Marinum

- water infection - NODULAR cellulitis, can present similar appearance to Sporothrix infections - can be chronic - Commonly DIFFICULT to CULTURE!!! Differentiate from other nodular cellulitis: Sporothrix: soil Erysipelothrix: soil to water, responds to Clinda whereas Marinum does not

Seborrheic keratosis

- waxy or scaly texture and often have a "stuck-on" appearance - itch or bleed often times - benign in nature and NOT at risk of BECOMING malignant, but can be a sign of INTERNAL MALIGNANCY (Leser Trelat sign)

Myotonic Dystrophy

- weakness, fatigue, and a myopathic waddling gait who also have muscle stiffness and delayed grip relaxation - Dx: EMG - Tx: aggressive management of its cardiac complications, which can increase mortality

Orlistat

- weight reduction agent by increasing GI output of fat basically - calcium oxalate crystals within the tubules and the interstitium leading to acute oxalate nephropathy if patient is volume down

ASA

- within 48hr of stroke reduce risk of recurrent stroke within 2 weeks without increasing hemorrhage - hold warfarin for large thromboembolic stroke for 4 days to 2 weeks.

Wiskott-Aldrich syndrome

- x linked - thrombocyteopenia, atopic dermatitis, recurent infections - may need BMT - high risk of lymphomas or leukemias

Bicuspid Aortic Valve

0.5-2% of population eccentric AVR enlarged sinuses of Valsalva elliptical valve opening annual TTE TEE to confirm diagnosis - ascending aortic dilation 2/2 intrinsic abnormal tissue - reassess at 4cm (interval depends on rate of progression and family history) annual if > 4.5 cm - repeair if greater than 5.5 cm or progress is greater than 0.5 cm - New symptoms or pregnant Increased risk of AIE -AVR if area < 1cm2

Chronic Metabolic Alkalosis

0.7 mm Hg increase in paCO2 for every 1 of bicarb

Surgical Management of brain bleeds

1 cm from calvarium

Wilson disease

1 in 30k births young = acute liver failure consider in all patients under 40 copper release from liver cells induce hemolytic anemia low alk phos (Cu interferes with synthesis) low ceruloplasmin elevated urinary CU execretion Liver Biopsy Penicillamine Trietine now 1st line Zinc supplement

Stroke in nutshell

1) Acute ABCs 2) Cause 3) Risk Factors 4) Complications HTN Treat MAP > 130, BP > 220/120 - intervention up to 6 hours - can get after tPA - Cardiothrombolic: AC - Large Vessel: > 70% CEA or stent - Hemorrhage < 140 - tPA <185/110 then 180/105

Dysphagia

1) Oropharyngeal Dysphagia - occurs immediately with swallowing, causes coughing, choking, and nasal regurgitation - neuromuscular or anatomic: neurologic symptoms like dysphonia, diplopia, and muscular weakness - Dx: videofluoroscopy (modified barium swallow) - Tx: dietary adjustment and incorporation of swallowing exercises with the assistance of a speech pathologist 2) Esophageal Dysphagia - often has an intraluminal cause, such as strictures, Schatzki rings, or masses - Manometry is helpful but diagnosis is with upper endoscopy. If upper endoscopy unremarkable, BARIUM SWALLOW can help visualize the lower esophageal rings or extrinsic compression of the esophagus

ARDS

1) acute onset of diffuse bilateral infiltrates 2) PaO2 ratio < 300 3) Respiratory failure NOT due to cardiac issue - history of decreased air movement, crackles, chest radiograph shows extensive patchy areas of opacification of the lung fields - Tx: increase positive end-expiratory pressure (PEEP) level that achieves adequate oxygenation with an FIO2 of less than 0.6 and does not cause hypotension - PRONE positioning provides optimization of ventilation-perfusion matching and increases survival of patients with severe ARDS - history of drowning - CVP goal 4-6 as conservative fluid-management strategy is associated with more rapid improvement in lung function, shorter duration of mechanical ventilation, and shorter ICU length of stay - lung-protective ventilator strategy, with low tidal volume (360 ml) and low plateau pressure (<30 cm H2O), even if this results in hypercapnia Factors that DECREASE MORTALITY - tidal volume goal of 6ml/kg of ideal body weight - plateau pressure (<30 cm H2O), even if this results in hypercapnia

Ataxia Telangiectasia

1) ataxia early, neurodegeneration 2) immunodeficiency with IgA, IgE, IgG specifically so alot of URI, sinus issues, bronciectasis 3) high risk malignancy later in life bc DNA repair defect Dx: ATM gene on ch11 Other manifestations can occur: - oculomotor issues, telangiectasias, delay in puberty, dysarthria, DM, hair or skin changes Differentiate from Friedreich ataxia, which has NO immunodeficiency, just ataxia, dysarthria, weakness, sensory loss

acute neurological deficit pathway

1). CT head 2). tPA? - MC contraindcations I. small deficits II. unknown duration of symptoms III. rapid recovery 3). ASA within 48hrs 4). DVT ppx ASAP

anemia of chronic kidney disease

1). Correct Fe deficit - non ESRD Fe def is Trans Sat < 20% and/or Ferritin < 100 ng/mL (less than 200 in ESRD) - goal 20-50%; ferritin 200-500

Slceroderma lung

1). IPF in up to 80% - Diffuse 2). PH - injury to endothelium - decreased DLCO - TTE - RHC - the big C

Transverse Myelitis

1-2 Segments Acute onset of prog weakness after infectious AI: lupus, Sjogren, NMO MRI with gad and NMO ab

Fat Embolism Syndrome

1-3% with 1 long bone fracture 33% with bilateral femur fractures - acute neurological abnormalities, hypoxemia and petichial rash

What are the different methods of surgical haemostasis?

1. Application of a haemostatic clamp to a blood vessel and then ligation with a surgical ligature 2. Suture ligation of a vessel 3. Diathermy coagulation 4. Localised pressure for several minutes to allow coagulation to occur naturally 5. Application of surgical materials (e.g. oxidised cellu- lose, Surgicell) which promote coagulation. 6. Application of topical agents to promote vasoconstriction (e.g. adrenaline) or coagulation (e.g. thrombin). 7. Packing of a bleeding cavity with gauze packs as a temporary measure until definitive haemostasis can be achieved

What are the common surgical antiseptics?

1. Aqueous chlorhexidine (0.5%) is used to disinfect mucous membranes and parts of the body adjacent to structures which would be adversely affected by more stringent antiseptics (e.g. the skin around the eyes). Aqueous chlorhexidine is bactericidal and has low tissue toxicity. 2. Cetrimide (2%) is bactericidal. 3. Iodine-based antiseptics (e.g. povidone iodine (10%) [Betadine], alcoholic iodine solution) destroy a wide range of bacteria, especially staphylococci, by iodisation of microbial proteins. 4. Alcohol-based (70%) antiseptics kill bacteria by evaporation

What investigations should be considered when suspecting oesophageal cancer?

1. Barium swallow identifies the location and length of oesophageal narrowing, mucosal irregularity, dilatation of the proximal oesophagus, and the 'shouldering' impression made by the upper border of the tumour 2. In earlier lesions, endoscopy with biopsies together with brush cytology improve the diagnostic accuracy. The application of Lugol's iodine stain helps direct biopsies to dysplastic or early mucosal lesions, since only normal oesophageal mucosa is stained brown, and the interested areas will remain unstained. 3. CT, Endoscopic ultrasonography, PET scans and bronchoscopy may be useful in TNM staging

What areas of the oesophagus are most commonly damaged by caustic ingestion?

1. Cricopharyngeus area 2. Mid-oesophagus at the level of the aortic arch and left main bronchus 3. Immediately above COJ

What investigations should be considered in varicose veins?

1. Doppler ultrasound - Site of incompetence - Deep vein evaluation 2. Duplex scan

Pooled Cohort

<5% low risk 5-7.5% intermediate risk 7.5% or greater high risk

What are the immunologic risks of blood transfusions?

1. Febrile non-haemolytic reactions: approx 7% of transfusions, inflammatory cytokines from WBCs in stored blood cause reaction 2. Plasma reactions: preformed antibodies to non-cellular blood components, causes type 1 hypersensitivity reaction 3. Post-transfusion purpura: occurs 5-10 days after transfusion, secondary to development of platelet specific antibodies causing thrombocytopenia 4. ABO incompatability reactions 5. Transfusion associated acute lung injury (TRALI)

What is the arterial supply to the duodenum?

1. Gastroduodenal 2. Pancreaticoduodenals (superior off gastroduodenal, inferior off superior mesenteric)

What are the 3 most widely used methods for DVT prevention?

1. Graduated compression stockings: these stockings reduce venous pooling in the lower limbs and prevent venous stagnation. 2. Heparin: this drug can be used in its conventional un- fractionated form or as one of the newer fractionated low-molecular-weight derivatives. The fractionated low-molecular-weight heparins offer the convenience of once-daily dosing for the majority of patients. It must however be remembered that the anticoagulant effect of the low-molecular-weight heparins cannot easily be reversed and, where such reversal may be important, standard unfractionated heparin should be used. 3. Mechanical calf compression devices: these machines work by intermittent pneumatic calf compression and thereby encourage venous return and reduce venous pooling.

What is the arterial supply to the stomach?

1. Lesser curve: right and left gastric 2. Greater curve: right gastroepiploic (off gastroduodenal) and left gastroepiploic (off splenic) 3. Fundus: short gastrics (off splenic)

What is the treatment of varicose veins?

1. Reassurance or explanation 2. Leg elevation, avoid prolonged sitting/standing, weight loss 3. Compression hosiery 4. Injection sclerotherapy (C1, C2) 5. Surgery (C3-6): high ligation/stripping, multiple venous avulsion, injection sclerotherapy, endovenous saphenous vein surgery (laser or radiofrequency treatment)

What is the treatment of venous ulcers?

1. Simple measures: - Elevate limb - Avoid prolonged periods of dependency 2. Compression (Teds etc) 3. Surgery: - Debridement/SSG for superficial system - Deep system - very limited options

What is the arterial supply to the pancreas?

1. Splenic branches 2. Pancreaticoduodenals

What is the arterial supply to the small intestine?

1. Superior mesenteric branches: jejunal, ileal, ileocolic

What is the arterial supply to the large intestine?

1. Superior mesenteric branches: right colic, middle colic 2. Inferior mesenteric branches: left colic, sigmoid, rectal

What are the goals of pre-operative assessment?

1. To identify important medical issues in order to - Optimise their treatment. - Inform the patient of the risks associated with surgery. - Ensure care is provided in an appropriate environment. 2. To identify important social issues which may have a bearing on the planned procedure and the recovery period. 3. To familiarise the patient with the planned procedure and the hospital processes.

What is the classification of adenocarcinomas around the gastro-oesophageal junction?

1. Type I tumours are lower oesophageal (many are Barrett's) adenocarcinomas 2. Type II centres at the cardia 3. Type III are subcardiac cancers. It is suggested that the three types differ in pathologic and clin- ical features.

What is the initial pathway of management of testicular cancer?

1. US imaging - Confirms physical findings and may be helpful in differentiating painful swollen testis 2. Tumour markers - Do prior to orchidectomy as decay is useful in monitoring progress 3. Inguinal orchidectomy - This route is done to avoid tumour contamination of scrotal skin and inguinal lymph nodes. 4. Sperm Storage - All males wishing to consider fertilisation should undergo sperm storage. Decrease in semen quality is common after treatment. 5. Metastatic survey - PET/CT Abdo + chest 6. Radiation and chemo follow up depending on stage and seminoma/non-seminoma

dihydropyridine CCB

1/3 get edema

Guillian Barre Syndrome

1/3 have no antecedent illness back pain can be a presenting feature of GBS (proximal nerves and nerve roots of Cspine or Lspine attacked) - also some sensory problems - dysautonomia tachycardia, diaphoresis and sluggish pupils - LP may take a week - Rx: IVIG and Plasmaphoresis

hyponatremia

1/3 on thiazide diuretics SSRIs Carbamazepine

FRAX

10 year risk for patients valid in 40-90 yo who are not already on treatment risk of major osteoporotic fracture > 20% risk of hip fracture > 3% then patient benefits from therapy Rx = Calcium, Vit D and stop smoking AED is considered high risk med

adrenal incidentaloma

10% of imaging studies identify clinical & biochemical excess determine risk of malignancy > 10 Hounsfield units, Larger than 4 cm and retention of contrast > 50% after 10 minutes

Adrenal Incidentalomas

10-15% are functional One quarter of incidentally noted adrenal masses autonomously secrete hormones (cortisol 6%-10%; catecholamines 5%; aldosterone 1%z) most are subclinical cortisol and catecholamines in all renin and aldo in hypetensives - low dose LDST is most sensitive positive = >5 aldosteronomas are usu < 2cm Suspicious for Pheo--> plasma metanephrines No suspicion Urine Metanephrines imaging favors non malignant = repeat eval in 3-6 months then annual 1-2 years (adenomas usu don't grow more than 1 cm a year) Screening for hypersecretion is usually done q4 years 8% subclinical CS in patient thought to have nonfunctioning adenomas

What % of gallstones are symptomatic

10-30%

What is the rate of recurrence of a hernia following surgery?

15-20% Risk factors: - Recurrent hernia - Age >50 - Smoking - BMI >25 - Poor pre-op functional status - Associated medical conditions (T2DM, hyperlipidaemia, immunosuppression, any comorbid conditions increasing intra-abdominal pressure Less common with mesh/'tension-free' repair

RA pressure

<6-7 > JVD when greater than 7

common causes of Peripheral neuropathy

18% of Diabetics 50% with "idiopathic" have prediabetes

C Diff Infection

1st recurrence is likely from germination of persistent spores and not drug resistance Critically Ill, ileus or severe

Ovarian cancer

2 TYPES Germ Cell (choriocarcinoma) - positive AFP and beta hCG Epithelial - negative AFP and beta hCG. Most common cause! Also BRCA and CEA present - Germ Cell is rare but more prevalent in younger females - Epithelial more prevalent in older females - present similar to PCOS in that they have hirsutism and DHEA but also these patients will have SUPER INCREASED TEST, increased virulization which is not present in PCOS. - virulized patients later in life you have to think ovarian cancer bc other variant is congental which would be shortly after postnatal period - Tx: Cytoreductive surgery (debulking, removing ovaries, tubes etc.) followed by platinum based chemotherapy - sometimes patients present with abdominal carcinomatosis of unknown origin, in which case you treat as ovarian cancer until proven otherwise SO COMPLETE SURGICAL REMOVAL

Cushing's Syndrome

2-3 per million two abnormal 1st line screening for diagnosis LDST, Late night salivary cortisol 24hr UFC LDST: 1 mg Dex at 11pm or midnight serum free cortisol - avoid in patients on AEDs, rifampin pioglitazone - avoid i patients with altered CBG: malnutrition, cirrhosis or nephrotic syndrome 24hr UFC: normal 20-25mg/kg/24hr in men, 15-20 mg/kg/24hr in women for Cr - abnormal = > 45 mcg/24hr greater than 3x ULN is diagnostic - falsely low in CKD or CS is subclinical or mild 24 hour UFC and LN salivary cortisol tests should be performed twice meds: Ketoconazole, Metyrapone, etomidate

Urticaria

20% of adults often arcuate forms Cs and Ss lass less than 24hr meds, foods, insects, non allergic responses

Cervical Cancer screening

21-65 yo cytology alone = every 3 years no more = 3 consecutive negative Paps or 2 negative Pap + HPV DNA

PH in SCD

25-30% will have suggestive abnormalities on TTE of those 25% have PH on RHC increase in TVR velocity a/w increase in mortality LE ulcers higher LDH high Cr high alk phos high Pro BNP higher NYHA functional class also a/w morality

Heart Block

2nd Degree AV block - P waves grow and eventually drop - 2:1 AV block is every other P wave does not reach the ventricle - 2 types, Mobitz 1 (Wenkebach) actually improves conduction with exercise and improves, Mobitz 2 does not improve with exercise Indications for pacing - symptoms, asystole - new bundle branch - Mobitz type 2 - if patient has any history in the Northeast and has prodrome phase months prior then suddenly develops HEART BLOCK, consider LYME - Pregnant patients who have Anti-Ro/SSA abs increase risk of congenital heart block

Sinuses of Valsalva

3 aortic dilatations just above the aortic valve cuspes two of three are origins of coronary arteries Regurgitant flow fills them aneurysm and rupture will allow flow into RA or RV continuous systolic & diastolic murmur loudest at 2nd ICS Decompensated heart failure more common in L or R coronary cusps than noncoronary cusp

Perioperative management of ICD

3 questions: 1. what type of device 2. is pt pacemaker dependent 3. surgery with instruments that result in electromagnetic interference near device or leads ICD = pacer with extra capabilities DOO - asynchronous mode - device will not sense cardiac response avoiding suppression of pacing 2/2 electrical interference Disable ICD by applying magnet

CLL

30% of leukemia B symtpoms anemia, thrombocytopenia C19, CD20, CD23 AIHA in 11% purine analogs fludarabine, cladribine and pentostatin

anti GBM antibodies

30-40% pulm involvement 90% die in untreated disease

Thrombophilia Testing

4Ps: - Patient selection - Pretest counseling - Proper lab test interpretation - Provision of education & advice none in provoked VTE minor RFs: hormone OCP, Pregnancy or minor immobility or minor surgery

GB polyps

> 1cm = cut it out even if ASx found on 5% of USG any size with stones PSC

FNA

> 2 cm if lacking suspicious USG features 5mm if family history of thyroid cancer or XRT

Aortic Valve replacement

> 40 mm Hg < 1 cm2

Coarctation of Aorta

50% bicuspide aortic valve (70% of which will require repair) 50% ascending aortic aneurysms recurrent in 20% (refractory HTN occurs in 75% check pulses)

Carbidopa-levodopa

50% have motor fluctuations after 5 years Dystonia- painful; common and spontaneous early in disease - Morning "" feet 2/2 to low dopa levels

What is the definition of an aneurysm?

50% increase in normal artery diameter

Ascites

50% of cirrhotics in 10 yr cardiac total protein > 2.5 SAAG > 1.1 = PHTN Total Protein > 2.5 either Cardiac or Budd Chiari Aldactone more effective at mobilizing ascites >5L paracentesis give 8 gm/L albumin stop Beta Blocker in refreactory ascites TIPS MELD less than 15-18 Tbili less than 4 no OHE, PH or HF

Pulm Periop Management

50% of surg AEs higher mortality and cost respiratory failure & PNA RFs: - Emergent Surgery - Prolonged >3hr - Thoracic, Head & Neck, Abdominal and Aortic - General Anesthesia - Advanced Age, ADL limitations, ASA class 2 or greater, COPD, smoking in last year, PH, OSA, sepsis - models don't capture OSA or PH - All surgical patients should be screened with STOP BANG - greatest benefit is to quit smoking 8 weeks prior to surgery. - IS, deep breathing, PEP and CPAP all help risk but no benefit to multiple modalities

Presbycusis

50% over 75yo possibly 80% over 80 low SES, HTN, DM, Vascular disease and smoking sensorineural hearing loss progessive, symmetrical high frequency hearing loss secondary symptoms of tinnitus, vertigo & hyperacusis whisper voice test finger rub test hearing loss questionnaire hand held audiometry

Stopping smoking how long before surgery significantly reduces the risk of complications?

6 weeks

nonresponsive pneumonia

72hrs after treatment Chest CT - parenchymal abnormalities -- abscess -- cavitary lesions -- occult empyema THEN get Bronchoscopy

stress incontinence

8 % weight loss = 50% improvement in symptoms PFMT repetitive Kegels

Porphyria Cutanea Tarda

80% acquired Liver disease: ETOH, Hemachromatosis, decreased hepatic Scarring numerous milia uroporphyrinogen decarboxylase

AIHA

80% in SLE 2/2 warm agglutinin spherocytosis

Paragangliomas

80% intra-adrenal MC location outside adrenal is abdomen almost always secret catecholamines (0.5% of patients with hypertension) 5% of adrenal incidentalomas - NE secretion - orthostasis - 10% of pheo is malignant - 20-50% of paragangliomas are malignant - MEN2A&B but also NF1 and VHL - CT abdomen pelvis is best initial study - PET for METs - MIBG - Phenoxybenzamine titrate to 130/80 seated and greater than 90 mmHg standing

What is the sensitivity of triple testing for breast cancer?

99.4% 73% of cancers will have a positive result on all components of the triple test but 7% will only be positive on only one component Do not need all components to be positive to diagnose breast cancer

steroids on the day of surgery

< 10 mg = no stress dose - take normal daily dose > 10 mg > 3 weeks + high risk - IV hydrocortisone 50-100 mg before induction then q8hr for 48hr

AAA

< 4cm = < 0.5% risk of rupture 4-4.9 0.5%-5% risk 5-55.9 = 3-15% risk < 3.5 cm = USG q 3-5 yrs larger = q 6-12 mo Repair: > 5.5 cm in Men 5 in women or > 0.5 cm increase within 6 month interval or symptomatic abdominal tenderness or back pain

Aneurysm

<12 mm and located in the anterior circulation suggests a low risk of rupture

Abdominal Aortic Aneurysm

<4cm low risk, US every 2-3 years 4cm-5.4cm need 6-12 month monitoring Over 5.5cm = SURGERY HIGH RISK surgery so need cardiac evaluation with AT LEAST chemical stress test if sedentary and angio if indicated...elective procedure so if myocardium at risk, DEFER surgery If symptomatic over 5cm in men or 4.5cm in women = SURGERY - Cholesterol atheroemboli are high risk after any vascular procedures esp those with comorbidities - differentiate from renal embolization which is due to A fib and can present like pyelonephritis (but with increased LDH)

PVC

>10% all beats 1/3 develop PVC induced CMP BB or CCB amiodarone in the elderly refractory = ablation

11. A 23-year-old man presents with acute onset of copious purulent discharge from the eye, pain, and decreased vision. The crusts shut in the morning and the other eye is perfectly normal. How would you make the diagnosis and how would you treat the patient?

A 23-year-old man presents with acute onset of copious purulent discharge from the eye, pain, and decreased vision. The crusts shut in the morning and the other eye is perfectly normal. How would you make the diagnosis and how would you treat the patient? The patient has hyperacute bacterial conjunctivitis. Although this may be difficult to distinguish from Staphylococcal disease (the most common cause of bacterial conjunctivitis), the fact that this person is young requires that questions regarding sexual activity be asked to assess risk for gonococcus since GC can perforate the cornea. Cultures should be taken as well as cultures from the pharynx, anus and urethra to maximize yield. The treatment of choice would be an IM shot of ceftriaxone, but with rising resistance dual ceftriaxone/azithromycin therapy is being used in some high resistance areas.

41. A 25-year-old man presents with sudden onset of scrotal pain with nausea and vomiting. Examination reveals the painful testis is elevated and the longitudinal axis is oriented transversely. You note a lot of edema. The pain is worse when the testis is elevated. How would you manage this patient?

A 25-year-old man presents with sudden onset of scrotal pain with nausea and vomiting. Examination reveals the painful testis is elevated and the longitudinal axis is oriented transversely. You note a lot of edema. The pain is worse when the testis is elevated. How would you manage this patient? A stat ultrasound needs to be done to diagnose torsion of the testicle and surgical decompression needs to be immediate.

12. A 25-year-old with a recent upper respiratory tract infection developed a red eye. There has been copious watery discharge from the eye and a few days later the opposite eye became involved. The patient noticed crusting after sleep, mild photophobia, itching, and a diffuse foreign body sensation. What is your diagnosis and how would you manage it?

A 25-year-old with a recent upper respiratory tract infection developed a red eye. There has been copious watery discharge from the eye and a few days later the opposite eye became involved. The patient noticed crusting after sleep, mild photophobia, itching, and a diffuse foreign body sensation. What is your diagnosis and how would you manage it? The diagnosis is likely viral conjunctivitis since it came after an upper respiratory tract infection. By moving to the other eye it is more likely viral although bacterial can do that too as both are highly contagious. The treatment is supportive, cold compresses and artificial tears without any antibiotics. The diagnosis would be more certain if another person recently had conjunctivitis in their household or at work. If the person is a food handler or a healthcare provider they are contagious for 2 weeks after the second eye becomes involved and should have work restrictions placed on them.

52. A 30-year-old presents with acute onset of low back pain and tenderness over the L3 spinous process. The patient has a history of injection drug use. What diagnosis will you consider?

A 30-year-old presents with acute onset of low back pain and tenderness over the L3 spinous process. The patient has a history of injection drug use. What diagnosis will you consider? Vertebral osteomyelitis or epidural abscess

51. A 32-year-old woman presents with a breast lump. She doesn't have any family history of breast or ovarian cancer. The skin overlying the lump is normal and there is a little milky discharge from the nipple. She says that the lump has been there for a little while and changes in size with her cycles. You find the lump to be round, mobile and soft. Her breasts feel a little dense on exam. How would you manage her situation?

A 32-year-old woman presents with a breast lump. She doesn't have any family history of breast or ovarian cancer. The skin overlying the lump is normal and there is a little milky discharge from the nipple. She says that the lump has been there for a little while and changes in size with her cycles. You find the lump to be round, mobile and soft. Her breasts feel a little dense on exam. How would you manage her situation? Unfortunately, despite all of the benign sounding findings in the above case, imaging study is needed and with denser breasts in younger women, or in a young woman who might be pregnant, the ultrasound is the test of first choice.

59. A 35-year-old presents with right elbow pain. The patient is right handed and works in computer technology. The pain radiates to the dorsum of the hand and is worse at night. The pain increases with forced extension of the wrist. What is your diagnosis?

A 35-year-old presents with right elbow pain. The patient is right handed and works in computer technology. The pain radiates to the dorsum of the hand and is worse at night. The pain increases with forced extension of the wrist. What is your diagnosis? Tennis elbow or lateral epicondylitis

65. A 40-year-old woman presents with prolonged anovulation. Her pregnancy test is negative. She has no evidence of any chronic organ system disease. Her physical exam and most recent Pap smear are up to date and normal. How would you manage her situation?

A 40-year-old woman presents with prolonged anovulation. Her pregnancy test is negative. She has no evidence of any chronic organ system disease. Her physical exam and most recent Pap smear are up to date and normal. How would you manage her situation? Women with anovulatory bleeding have unopposed estrogen. A progestational agent can be used for the last 2 weeks to promote withdrawal bleeding. However, since she is over age 35 years old an ultrasound needs to be done to make sure the endometrial stripe is not too large and if it is greater than or equal to 5 mm endometrial biopsy should be done before initiation of medical therapy.

26. A 45-year-old who has worn eye glasses since childhood reports having some floaters, flashes of the eye and then a peripheral visual defect described as a black curtain that suddenly appeared. What is your diagnosis and management?

A 45-year-old who has worn eye glasses since childhood reports having some floaters, flashes of the eye and then a peripheral visual defect described as a black curtain that suddenly appeared. What is your diagnosis and management? A retinal detachment is seen in individuals with myopia and the patient should be urgently referred to ophthalmology. Sometimes the floaters in the case might be described as cobweb-like floaters.

14. A patient has severe rheumatoid arthritis and is going to have an elective surgical procedure with general anesthesia. What might you assess preoperatively?

A patient has severe rheumatoid arthritis and is going to have an elective surgical procedure with general anesthesia. What might you assess preoperatively? C-spine films to be sure that there is odontoid-axial stability. This occurs at C1 and C2.

46. A 55-year-old man presents with lower urinary tract symptoms. He has had this over the course of the last year. He has received courses of antibiotic therapy even though cultures have been negative. Prostate exam does not show exquisite tenderness. The prostate gland is not enlarged. A cystometrogram was done and showed no evidence of hyperactivity of the bladder. What is your diagnosis?

A 55-year-old man presents with lower urinary tract symptoms. He has had this over the course of the last year. He has received courses of antibiotic therapy even though cultures have been negative. Prostate exam does not show exquisite tenderness. The prostate gland is not enlarged. A cystometrogram was done and showed no evidence of hyperactivity of the bladder. What is your diagnosis? Chronic prostatitis/chronic pelvic pain syndrome and the treatment options are not often effective but include alpha blockers and nonsteroidal anti-inflammatory drugs after a failure of a single course of antibiotics.

43. A 55-year-old man presents with scrotal pain. Examination reveals tenderness in the epididymal area and the pain is relieved when you lift the testicle. The patient endorses frequency and burning with urination and the prostate exam is tender. A urinalysis shows pyuria and bacteruria. How would you treat this patient?

A 55-year-old man presents with scrotal pain. Examination reveals tenderness in the epididymal area and the pain is relieved when you lift the testicle. The patient endorses frequency and burning with urination and the prostate exam is tender. A urinalysis shows pyuria and bacteruria. How would you treat this patient? If the patient is very sick you might admit for acute epididymitis and start a third generation cephalosporin. In the outpatient area a chloroquinolone could be considered. If the patient is sexually active you could use levofloxacin as that will treat both the sexually transmitted infections as well as the gram negative rods except for pseudomonas.

66. A 60-year-old woman who was menopausal at age 52 presents with some mild vaginal bleeding. Physical exam and ultrasonography are normal. Is any further evaluation necessary?

A 60-year-old woman who was menopausal at age 52 presents with some mild vaginal bleeding. Physical exam and ultrasonography are normal. Is any further evaluation necessary? All postmenopausal women must have endometrial cancer ruled out for any uterine bleeding. A biopsy is necessary.

24. A 65-year-old patient with a history of sun tanning, smoking, diabetes and intermittent steroid use for COPD presents with a loss of red light reflex and opacification of the lens. She is on warfarin for atrial fibrillation. What preoperative precautions need to be taken prior to removal of her cataract?

A 65-year-old patient with a history of sun tanning, smoking, diabetes and intermittent steroid use for COPD presents with a loss of red light reflex and opacification of the lens. She is on warfarin for atrial fibrillation. What preoperative precautions need to be taken prior to removal of her cataract? None as this is a local anesthetic procedure and warfarin and aspirin can be continued during it.

What is a Littre's hernia?

A Meckel's diverticulum lies within the hernial sac. Littre ́'s hernia occurs most commonly in a femoral or inguinal hernia.

PREGNANCY

A No risk in controlled human studies B No risk in other animal studies C Risk not ruled out; adverse effects in animals D Positive evidence of risk in humas X Contraindicated in pregnancy - KEEP KEPPra and def STOP VALPROATE ACID - seizure meds controversial, sometimes can keep on the drug and titrate to the lowest dose possible (except VALPROATE ACID) but ideally, defer to neuro - Labetelol is ok. STOP ACE and ARB - SLE: Prednisone and hydroxychloroquine ok, STOP Mycophenolate Mofetil and Methotrexate - RA: Prednisone, hydroxychloroquine and others ok, even biologics!! STOP Methotrexate - Insulin and Metformin is ok - STOP Atorvastatin - STOP Coumadin, start Lovenox (LMWH) - MS drug fingolimod needs to STOPPED - HIV: Efavirenz SHOULD NOT be used in child bearing age women - Continue HAART therapy!!!!!!!!!!!!!! Zidovudine for baby after birth Isotretinoin for Acne - Pregnant patients should be off for ONE MONTH before conceiving - HPV vaccine CONTRAINDICATED - can develop acute carpal tunnel due to mild wrist edema - Coumadin crosses placenta, but heparin does not and is safe DURING pregnancy - Warfarin and low-molecular-weight heparin are considered safe for use by women requiring anticoagulant therapy who wish to BREASTFEED AFTER delivery - for suspicion of PE, best test is LE Dopplers to avoid radiation. If evidence of clots, pursue VQ scans and only do CT angiogram if that is the only option - Laparoscopic cholecystectomy can be safely performed during pregnancy, particularly in the second trimester Normal physiologic changes - increased cardiac output - significantly decreased systemic vascular resistance and LOW blood pressure - pregnancy is one of the few indications for screening for bacteriuria in asymptomatic patients due to increased risk of pyelo - treat safely with penicillins or cephalosporins BREAST CANCER - chemo is ok AFTER 1st trimester SEIZURES - Carbamazipine LYME - Tx: usually doxy or amoxicillin, but with pregnant patients we use macrolide (Erythromycin or Azithro) NSAIDS - remember, INDOMETHACIN is used to close patent ductus arteriosus if needed in premature babies - Generally avoid NSAIDS otherwise, as there is risk for premature closure - prefer TYLENOL over NSAIDS during pregnancy for this reason EMPTY SELLA SYNDROME - multiple pregnancy episodes can create an "empty sella" - blood flow increases to pituitary during pregnancy and space and glalnd enlarge temporarily. If repeated multiple pregnancies, this space can remain large, pituitary can get displaced or "hidden" on CT and appears to be empty. If no evidence of pituitary dysfunction, then this is completely a benign finding POSTPARTUM THYROIDITIS - hyperthyroid for about the first month and they can be lit, then eventually hypothyroid for a few months and normalize - after several months some can remain hypothyroid with pseudonodules. Check TSH if symptoms then proceed with normal workup - must consider if hypothyroid symptoms persist, and if negative then proceed with post partum blues which typical onset is actually about month 1 but can persist into 3 months, 6 months, even up to 1 year SUBCLINICAL HYPERTHYROIDISM - presents with hyperthyroid sx but labs normal - simply recheck in 4 weeks, no emergent intervention BREASTFEEDING - Coumadin and Warfarin OK - MMR and active infection with them is OK - ACTIVE and UNTREATED TB is CONTRAINDICATED in breastfeeding....however, interestingly enough, if on treatment, breastfeeding OK - so TB drugs OK VACCINES - TDap should ALWAYS be given, regardless of the timeframe of the last pregnancy - if no prior immunization, TDap is 3 times: 0 weeks, 4 weeks then 6-12 months. THEN boosters - no live vaccines like influenza, varicella, MMR, varicella, rota, rabies Acute Fatty Liver of Pregnancy - presents acutely late in pregnancy and with N/V and liver dysfunction Antibiotics - Macrolides are safe (Erythromycin, Azithromycin) - Mycins are Nice ones for pregnant women - Penicillins are ok and actually preferred HTN - systolic >160 - diastolic >110 - otherwise don't treat - metoprolol not well studied, only labetelol AORTIC DISECTION - can occur spontaneously in 3rd trimester - upper aorta = surgical emergency - distal aorta = medical management if stable SLE - increased miscarraiges if anitphospholipid ab - presence of Anti-Ro/SSA abs increase risk of congenital heart block

48. A bright red smooth tongue without any visible taste buds, so called atrophic glossitis, can be seen with what deficiency?

A bright red smooth tongue without any visible taste buds, so called atrophic glossitis, can be seen with what deficiency? Vitamin B12 deficiency, although other vitamin B deficiencies could do it too.

What is a major burn?

A burn greater than 10% of total body surface area is considered a major burn

7. A female patient in your practice who enjoys her Jimmy Choo shoes presents with metatarsalgia. She points to the area between the third and fourth metatarsal heads where she has a burning sensation. What is your diagnosis?

A female patient in your practice who enjoys her Jimmy Choo shoes presents with metatarsalgia. She points to the area between the third and fourth metatarsal heads where she has a burning sensation. What is your diagnosis? Morton neuroma

What is the typical presentation of a femoral hernia?

A femoral hernia presents as either discomfort in the groin together with a lump, or as intestinal obstruction with or without strangulation. A small hernia may be difficult to palpate, especially in the obese patient. The hernia is frequently irreducible and may not have a cough impulse.

What causes a hernia?

A hernia occurs because of (a) weakness or defect in the abdominal wall, and (b) positive intra-abdominal pressure (IAP) (which is often raised) forces the viscus into the defect.

What gene has been associated with melanoma?

A melanoma gene has been mapped to chromosome Ip36, and a second, des- ignated CMM2, to chromosome 9p21, with the cell cycle regulator CDKN2A as the candidate gene

What is a para-umbilical hernia?

A para-umbilical hernia in an adult is an acquired condition and quite distinct from the umbilical hernia of childhood. A para-umbilical hernia protrudes through one side of the umbilical ring, while the umbilicus still retains its fibrous character within the linea alba, although it becomes effaced by the pressure of the hernial contents and has an eccentric crescentic furrow. Para-umbilical hernias initially contain extraperitoneal fat but, as the hernial orifice enlarges, omentum enters the sac. The contents typically adhere to the sac so that the hernia becomes loculated and irreducible.

64. A patient falls on an outstretched right hand and has some tenderness to palpation just distal to the radius. X-ray of the wrist is within normal limits. What is your course of action?

A patient falls on an outstretched right hand and has some tenderness to palpation just distal to the radius. X-ray of the wrist is within normal limits. What is your course of action? This patient should be evaluated for and very likely treated for a scaphoid fracture as a lack of treatment could lead to avascular necrosis.

65. A patient has known rheumatoid arthritis and wrist pain. You perform the Finkelstein test which is making a fist over fully flexed thumb and then deviating the hand in the ulnar direction with pain just distal to the radial styloid process. What is your diagnosis?

A patient has known rheumatoid arthritis and wrist pain. You perform the Finkelstein test which is making a fist over fully flexed thumb and then deviating the hand in the ulnar direction with pain just distal to the radial styloid process. What is your diagnosis? De Quervain tenosynovitis or inflammation of the abductor pollicis longus. This can be seen in pregnancy with calcium apatite deposition and repeated use syndromes.

15. A patient is scheduled to have cataract surgery in the next few weeks. What preoperative assessment needs to be done?

A patient is scheduled to have cataract surgery in the next few weeks. What preoperative assessment needs to be done? None. This is a low risk procedure and even warfarin and aspirin are continued during this procedure.

44. A patient notices a scrotal mass. Comes to your clinic and the area feels fluctuant and transilluminates readily. You cannot feel any bag of worms or solid mass in the area and there is no evidence of a hernia. How would you confirm this diagnosis?

A patient notices a scrotal mass. Comes to your clinic and the area feels fluctuant and transilluminates readily. You cannot feel any bag of worms or solid mass in the area and there is no evidence of a hernia. How would you confirm this diagnosis? An ultrasound will confirm the diagnosis of a hydrocele. The bag of worms is the varicocele. Typically the bag of worms of a varicocele is on the left and better in a supine position and again an ultrasound is the test of choice. It could lead to infertility. Once you have felt these two in the clinic, you won't even need an ultrasound anymore to distinguish them.

24. A patient of yours decides to purchase orlistat for weight reduction over the counter. What side effects would you inform them and what precaution might you take?

A patient of yours decides to purchase orlistat for weight reduction over the counter. What side effects would you inform them and what precaution might you take? Inform them of the gastrointestinal side effects including fecal incontinence especially when they are consuming a high fat diet. Tell them that there are rare reports of severe liver injury. Vitamin supplementation is advisable as fat soluble vitamins A, D and E can become malabsorbed.

35. A patient on a PDE-5 inhibitor develops sudden loss of vision in one eye. What is your diagnosis?

A patient on a PDE-5 inhibitor develops sudden loss of vision in one eye. What is your diagnosis? Nonarteritic anterior optic neuropathy, in other words, a vascular optic neuropathy that is not associated with a vasculitis such as giant cell arteritis.

2. A patient presents to your clinic with an ankle sprain. It was an inversion and plantar flexion injury. The patient is unable to weight bear since the accident and is brought in on crutches by a family member. The pain is in the lateral malleolar area. What are the Ottawa ankle and foot rules and does this patient meet them to warrant a radiograph?

A patient presents to your clinic with an ankle sprain. It was an inversion and plantar flexion injury. The patient is unable to weight bear since the accident and is brought in on crutches by a family member. The pain is in the lateral malleolar area. What are the Ottawa ankle and foot rules and does this patient meet them to warrant a radiograph? A patient who cannot walk after the inversion injury and continues to be unable to walk into the emergency department or in your office and who has malleolar pain meets the Ottawa rules standard. Other standards include pain on the posterior edge or tip of the lateral or medial malleolus, pain on the navicular bone and pain at the base of the 5th metatarsal which can avulse with this type of injury. The Ottawa rules are good because they are highly sensitive for ruling out a fracture so if all these features are absent, the patient has a very low likelihood.

5. A patient presents with acute onset after a stop and go sport of Achilles tendon pain. You kneel the patient on a chair with their feet hanging off and squeeze the thigh and do not notice any plantar flexion of the foot. What is your diagnosis?

A patient presents with acute onset after a stop and go sport of Achilles tendon pain. You kneel the patient on a chair with their feet hanging off and squeeze the thigh and do not notice any plantar flexion of the foot. What is your diagnosis? This is a positive Thompson test with very high sensitivity and specificity showing an Achilles tendon rupture.

69. A patient presents with anterior knee pain, worse with prolonged sitting, and with walking up and down stairs. The pain is reproduced by applying pressure to the surface of the kneecap with the knee in extension. What is your diagnosis and treatment?

A patient presents with anterior knee pain, worse with prolonged sitting, and with walking up and down stairs. The pain is reproduced by applying pressure to the surface of the kneecap with the knee in extension. What is your diagnosis and treatment? In this case no x-ray is necessary as the patient has patellofemoral pain syndrome and after the acute phase icing and NSAIDs and activity modification, quadriceps and hip abductor muscle strengthening and stretching is what usually is done.

67. A patient presents with lateral hip pain. There is tenderness approximately 1 inch posterior and superior to the greater trochanter but no tenderness on the greater trochanter itself. There are no symptoms over the distal lateral thigh. What is your diagnosis and treatment?

A patient presents with lateral hip pain. There is tenderness approximately 1 inch posterior and superior to the greater trochanter but no tenderness on the greater trochanter itself. There are no symptoms over the distal lateral thigh. What is your diagnosis and treatment? Greater trochanteric bursitis which is the most common cause of lateral hip pain treated with heat, stretching and steroid injection. The paresthesias and burning distal on the lateral thigh is meralgia paresthetica or lateral femoral cutaneous nerve syndrome.

6. A patient presents with midfoot pain and paresthesias in the midfoot. They inform you that two years ago they had an ankle fracture. You percuss posterior to the medial malleolus and an electric shock sensation is perceived in the foot and you also note sensory loss on the plantar surface of the foot. What is your diagnosis?

A patient presents with midfoot pain and paresthesias in the midfoot. They inform you that two years ago they had an ankle fracture. You percuss posterior to the medial malleolus and an electric shock sensation is perceived in the foot and you also note sensory loss on the plantar surface of the foot. What is your diagnosis? Tarsal tunnel syndrome with tibial nerve impingement at the level of the ankle.

12. A patient presents with muscle symptoms and has been on a statin. The records show a failure to see what the baseline symptoms were. The statin is discontinued and two months later the patient still has symptoms. What other diagnoses would you consider?

A patient presents with muscle symptoms and has been on a statin. The records show a failure to see what the baseline symptoms were. The statin is discontinued and two months later the patient still has symptoms. What other diagnoses would you consider? Hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, other medications, fibromyalgia, and primary muscle diseases.

61. A patient presents with pain at the elbow with flexion that radiates to the hand and also has paresthesias and sensory loss in the 4th and 5th fingers. Weakness in the adductor digiti minimi is noted. What is your diagnosis?

A patient presents with pain at the elbow with flexion that radiates to the hand and also has paresthesias and sensory loss in the 4th and 5th fingers. Weakness in the adductor digiti minimi is noted. What is your diagnosis? Ulnar entrapment syndrome or cubital tunnel syndrome entrapping the ulnar nerve at the elbow. Splinting and NSAIDs are the treatment and sometimes surgical decompression.

29. A patient presents with sudden onset of hearing loss, noted upon awakening in the morning. The patient has a Weber test done and the tuning fork is best heard in the unaffected ear. What are the potential causes of this sudden hearing loss?

A patient presents with sudden onset of hearing loss, noted upon awakening in the morning. The patient has a Weber test done and the tuning fork is best heard in the unaffected ear. What are the potential causes of this sudden hearing loss? The Weber test tells us that this is a sensorineural hearing loss. Viral infection, bacterial meningitis, Lyme disease, migraine, Ménière disease, acoustic neuroma, head injury, drug reaction, neurosarcoidosis and even a stroke can cause these but most of the time no diagnosis is made. When it is idiopathic, some clinicians offer steroids but the studies are inconclusive. Some clinicians also offer valacyclovir and treat it like a Bell's palsy of the 8th nerve as perhaps some Herpes simplex are present, but again, that is highly controversial and was not even in MKSAP.

13. A patient presents with type 2 diabetes at the age of 50 with an LDL of 100 and a 10 year atherosclerotic cardiovascular disease risk of 5%. Would you use a moderate- or high-intensity statin?

A patient presents with type 2 diabetes at the age of 50 with an LDL of 100 and a 10 year atherosclerotic cardiovascular disease risk of 5%. Would you use a moderate- or high-intensity statin? A moderate-intensity statin can be used according to ATP4 unless the 10 year risk is greater than 7.5%.

16. A patient presents with what you feel is an upper airway cough. The patient is not a smoker nor is the patient taking an ACE inhibitor. What might be your first type of management?

A patient presents with what you feel is an upper airway cough. The patient is not a smoker nor is the patient taking an ACE inhibitor. What might be your first type of management? First generation antihistamine and decongestant might be a reasonable starting point.

50. A patient who is age 70 and has known degenerative arthritis presents with low back pain, an abnormal Romberg test, a wide-based gait and more pain when walking, particularly down stairs, and less pain when sitting. What diagnosis does this suggest?

A patient who is age 70 and has known degenerative arthritis presents with low back pain, an abnormal Romberg test, a wide-based gait and more pain when walking, particularly down stairs, and less pain when sitting. What diagnosis does this suggest? Spinal stenosis. Patients with spinal stenosis enjoy leaning on their shopping cart or leaning forward to help reduce the pain whereas things that cause hyperextension of the back tend to increase the pain.

71. A patient who is an avid triathlete presents with lateral knee pain worse walking up and down steps. There is tenderness at the lateral femoral epicondyle. What is your diagnosis?

A patient who is an avid triathlete presents with lateral knee pain worse walking up and down steps. There is tenderness at the lateral femoral epicondyle. What is your diagnosis? Iliotibial band syndrome and it is treated with rest, stretching, NSAIDs and perhaps avoidance of overuse from running or cycling.

36. A patient who likes to clean their ears a lot with Q-tips and bobby pins presents with a red external auditory canal. There is purulence there but no necrosis. The patient does not have diabetes. On exam it is difficult to see the tympanic membrane. How would you treat this?

A patient who likes to clean their ears a lot with Q-tips and bobby pins presents with a red external auditory canal. There is purulence there but no necrosis. The patient does not have diabetes. On exam it is difficult to see the tympanic membrane. How would you treat this? My recommendation is treatment with a topical fluoroquinolone and hydrocortisone drops. Topical acetic acid is also useful. Although neomycin is cheaper, this drug is sensitizing and if the tympanic membrane is perforated, then you could cause hearing loss. I see no role anymore for neomycin being placed in the ear. If this patient had been compromised or had diabetes and had significant involvement, then the patient might need to be hospitalized for a malignant form of otitis externa for antipseudomonal therapy, MRI to r/o invasion and debridement.

25. A patient with atherosclerotic risk factors and atrial fibrillation presents with vertigo, headache and a gait abnormality. What is your diagnosis and what tests would you use to prove it?

A patient with atherosclerotic risk factors and atrial fibrillation presents with vertigo, headache and a gait abnormality. What is your diagnosis and what tests would you use to prove it? Diagnosis is cerebellar infarction and MRI with angiography is the preferred test. Anyone with central vertigo needs urgent evaluation.

13. A patient with recent Mycoplasma pneumonia comes to your office with a subconjunctival hematoma. How would you manage this patient?

A patient with recent Mycoplasma pneumonia comes to your office with a subconjunctival hematoma. How would you manage this patient? Offer reassurance as this is benign, related to the cough and does not typically predict a coagulopathy.

51. A present presents to you with a history of having a pacemaker and a cauda equine syndrome. What is the test of choice?

A present presents to you with a history of having a pacemaker and a cauda equine syndrome. What is the test of choice? CT myelogram

57. A returning veteran will often have a history of traumatic brain injury. What is the treatment for PTSD?

A returning veteran will often have a history of traumatic brain injury. What is the treatment for PTSD? Early intervention, psychotherapy and pharmacotherapy often with SSRIs which help with the hyperarousal and flashback symptoms. Cognitive behavioral training is the key.

What is a sliding hernia?

A sliding inguinal hernia is a variant in which part of a viscus (usually the colon) is adherent to the outside of the peritoneum forming the hernial sac beyond the hernial orifice. Thus, the viscus and the hernial sac, which may contain another abdominal viscus, lie within the inguinal canal

What is an epigastric hernia?

An epigastric hernia is a protrusion of extraperitoneal fat, with or without a small sac of peritoneum through a defect in the linea alba anywhere between the xiphisternum and the umbilicus.

What is involved in angioplasty?

A thin guide wire is introduced into the blood vessel and passed through the narrowed segment under X-ray control A balloon is then introduced over the wire and inflated to dilate the vessel Balloon angioplasty can be applied to nearly all the blood vessels in the body and often prevents conventional surgery or bypass

19. A woman is on postmenopausal estrogen for severe hot flashes. What would you do with this medication preoperatively?

A woman is on postmenopausal estrogen for severe hot flashes. What would you do with this medication preoperatively? Discontinue it several weeks before surgery. Oral contraceptives can be continued with an increased level of DVT prophylaxis.

5. A woman presents with chronic dull pelvic pain, worse with prolonged standing, improved by lying down and elevating the legs. What diagnosis would you consider and how would you diagnose and treat it?

A woman presents with chronic dull pelvic pain, worse with prolonged standing, improved by lying down and elevating the legs. What diagnosis would you consider and how would you diagnose and treat it? Combined transabdominal and transvaginal ultrasound to diagnose pelvic varices. Treated with medroxyprogesterone.

6. A woman presents with dysuria, urgency, frequency and repeatedly negative urine cultures. Prior antibiotic trials have failed to alleviate her symptoms. How would you confirm her diagnosis?

A woman presents with dysuria, urgency, frequency and repeatedly negative urine cultures. Prior antibiotic trials have failed to alleviate her symptoms. How would you confirm her diagnosis? Cystoscopy can confirm the diagnosis of the interstitial cystitis symptom complex. MKSAP notes that some gynecologists will just use GnRH agonists to treat chronic pelvic pain since it can be efficacious for endometriosis and improve the pain of interstitial cystitis. In that matter invasive diagnostic testing can be avoided. The American College of Obstetrics and Gynecology recommends add-back therapy with estrogen or progesterone to mitigate the detrimental side effects of GnRH therapy, particularly on bone density.

56. A woman with a seizure disorder has a new partner and wants to go on oral contraceptives. Her carbamazepine was changed this past week to Keppra. What would you advise her?

A woman with a seizure disorder has a new partner and wants to go on oral contraceptives. Her carbamazepine was changed this past week to Keppra. What would you advise her? She may go on oral contraceptives but the carbamazepine effect may last for a month and a second type of contraception should be used until the P450 enzymes in the liver are no longer being induced, which take about a month.

4. A woman with prior PID and pelvic surgery for a tubo-ovarian abscess presents with chronic pelvic pain. What is your diagnosis and how would you confirm and manage it?

A woman with prior PID and pelvic surgery for a tubo-ovarian abscess presents with chronic pelvic pain. What is your diagnosis and how would you confirm and manage it? This patient might have pelvic adhesions which can be diagnosed and treated with laparoscopy and adhesiolysis.

What is a hernia?

An abnormal protrusion of a viscus or part of a viscus through a defect either in the containing wall of that viscus or within the cavity in which the viscus normally is situated.

40. An absent cremasteric reflex in a patient with acute scrotal pain may indicate which diagnosis?

An absent cremasteric reflex in a patient with acute scrotal pain may indicate which diagnosis? Testicular torsion

What activity level (in METs) is generally considered fit for surgery?

An activity level of 4 METs, which is equivalent to carrying shopping bags up two flights of stairs, is generally considered adequate for most surgery

What is an incisional hernia?

An incisional hernia is a protrusion of the peritoneum (the sac) and abdominal contents into the subcutaneous plane through a defect at the site of a scar following an abdominal operation. The true incidence is difficult to ascertain, but is in the order of 5% at 5 years and 10% at 10 years. Male > female

Perioperative diabetes

A1c of 9 before elective surgery

PAD

ABI exercise ABI if high pretest and negative resting ABI Segmental limb plethysmography- localize stenosis (cuffs placed at upper & lower thigh, calf and ankle-->drop in 20 mmHg BP idenfies zone of disease) If ABI > 1.40 --> toe pressure & TBI Tx:CLEVER = exercise improved walking distance better than stent or medical therapy alone (Class I) Cilostazol - PDE3 inhibitor; contraindicated in HF or LVEF less than 40% because similar to Milrinone increased mortality with long term use in HF # also reduces restenosis after revascularization Pentoxifylline- xanthine derivative better than nothing Statin: duh progress to critical limb ischemia and limb loss at 5% a year

ARNI

ACC/AHA 2016: substitute in NYHA II/III in pt who have tolerated ACE or ARB well check pro-BNP hypotension

ABE ppx

ACC/AHA recs dose, duration, virulence 1). Prosthetic valves 2). Previous ABE 3). CHD unrepaired cynotic or with 6 months or residual defects 4). transplant with valvulopathy

drug induced hyperkalemia

ACE inhibitor ARB K sparing diuretic TMP Sulfa NSAIDs Salt Substitute Heparin

Bactrim

ACUTE INTERSTITIAL NEPHRITIS - WBC casts, maculopapular rash, Cr increase - can cause .5 increase in Creatinine due to interference with clearance; not true AKI, so continue therapy if still in reference range and it should resolve following completion - can also cause K to increase so monitor

4. AHRQ recommends screening for incontinence in the frail elderly and some groups also recommend screening for women 65 years and older. What are the 5 types of incontinence described by MKSAP?

AHRQ recommends screening for incontinence in the frail elderly and some groups also recommend screening for women 65 years and older. What are the 5 types of incontinence described by MKSAP? a.Urge incontinence b.Stress incontinence c.Mixed urge and stress d.Overflow incontinence e.Functional incontinence

Bullous Pemphigoid

AI blistering disease older people urticarial plaques to blisters mucosal 10-40% Peripheral Eosinophilia subepidermal = tense bullae Abs to Collagen XVII 2 biopsies lesion and perilesion normal skin

EASE trial

AIE surgery within 48hr Large Veg > 1cm reduced embolic events decreased 6 mo mortality rates

GERD

ALARM SYMPTOMS - dysphagia, anemia, weight loss, vomiting, age over 55 - PPI can cause chronic tubulointerstitial disease; discontinue if increasing creatinine and abnormal UA - PPI can cause sporadic fundic gland polyps and do not require excision or surveillance as long as no dysplasia noted on histology - SURGICAL Fundoplication in those who cannot take PPI or want to get off PPI and symptoms persist, those who have had PPI trial and it works but once they are off, sx persist. Especially younger patients who already have signs of esophagitis/impending Barrett's - chronic PPI can lead to B12 deficiency - chronic reflex can lead to PEPTIC STRICTURE and slowly worsening dysphagia of solid foods; think of this in patient's who present but with no history of weightloss, alcohol or smoking - Fluoroquinolones should NOT be taken with antacids (or milk, ice cream, high calcium foods)

Leukemia

ALL - usually kids but can present in elderly too - medial deviation of an eye due to 6th nerve palsy - pancytopenia, blast cells - TdT, CD19 and CD20 AML - blast cells - Auer rods (Azurophilic needle shaped crystals in the cytoplasm of immature white cells) - Myeloperoxidase postive - gingival bleeding/hyerplasia CML - young adult to middle aged adult - insidious onset of fatigue, neutrophilia; early satiety and progressive weight loss associated with splenomegaly; and a peripheral blood smear demonstrating myelocytes, metamyelocytes, and basophils - Low LAP score (Leukocyte Alkaline Phosphatase) - BCR-ABL mutation (9,22) - Tx: If no blast cells, simply hydrate, hydroxyurea than tyrosince kinase inhibitors. If blast cells, then assess WBC if greater than 50,000 then leukophoresis first. APL - acute promyelocytic leukemia - PML-RAR protein mutation - AML with presence of a (15;17) gene translocation - AML but with microangiopathic hemolysis with ***schistocytes and DIC*** - Sudan black stain is positive - All-trans retinoic acid (ATRA) should be administered as soon as possible (without confirmation of dx), followed by chemotherapy CLL - median age of 70 years - associated with HEMOLYTIC ANEMIA (anemia, total bili elevated) **SMUDGE CELLS** - "Autoimmune Hemolytic Anemia" - diagnosed usually with incidental lymphocytosis - Flow cytometry: mature B cells co-expressing CD5 and CD23 - can be associated with assymptomatic ITP - poor prognosis if thrombocytopenia (stage 4) and 17p deletion - often assymptomatic but can be severe with lymphadenopathy and splenomegaly - Tx: 1st line rituximab and multiagent chemotherapy - If resistant, consider Hematopoietic stem cell transplantation CLL RAI STAGES 0 - lymphocytosis 1 - lymphadenopathy 2 - lymphadenopathy and splenomegaly 3 - anemia 4 - thrombocytopenia - if WBC greater than 50,000 during a BLAST CRISIS then hyperleukocytosis and need urgent LEUKAPHERESIS - WBC can build up and block microvasculature - if no blast crisis, simply hydrate, hydroxyurea than tyrosince kinase inhibitors HAIRY CELL - CD103, DRY tap - CD 11 CD 20 - splenomegaly, pancytopenia - BRAF mutation - Tx: Not curable but purine analogs like cladrabine and pentostatin

Transfusion

AML only less than 10k or bleeding hospitalized patients ppx transfusion <10k 2/2 BM failure

Autoimmune Hepatitis

ANA ASMA LKM-1 LC-1 tend to have false positive HCV antibody

early surgery native AoV Replacement

ANY heart block new conduction defect confirms to perivalvular tissue (ABX don't work well) heart failure from valve problems left sided endocarditis by Staph aureus, fungal or highly resistant organisms annular or aortic abscess destructive penetrating lesion persistent bacteremia or fever lasting longer than 5-7 days Relapsing prosethetic valve IE recurrent emboli & persistent vegetations mobile vegetations > 1cm in length

False positive biochem test for Pheo

APAP Buspar antipsychotics TCA MAOi Amphetamines cocaine caffeine Sinemet Sudafed Reserpine clonidine ETOH illicits

Factor V Lieden

APC resistance test cheaper than genetic

PFO

ASA post stroke 25-35% of adults first stroke only close if: O2 desat from R-L shunt thrombus trapped in PFO recurrent stroke close if failure of warfarin Warfarin for recurrent PFO stroke or thrombophilia atrial aneurysm increases risk of stroke compared to PFO alone surgical excision of ASA and warfarin fail

58. An elderly patient with diabetes and hypothyroidism presents with pain over the deltoid area and loss of range of motion in the shoulder. What is your diagnosis?

An elderly patient with diabetes and hypothyroidism presents with pain over the deltoid area and loss of range of motion in the shoulder. What is your diagnosis? Adhesive capsulitis or frozen shoulder. Movement disorder such as Parkinson disease, stroke and prior trauma are also risk factors for this.

Bicuspid Aortic Valve

ASSYMPTOMATIC: - If severe aortic valve stenosis (<1cm) then replace. Otherwise, monitor clinically - If the aortic root or ascending aortic diameter is dilated greater or equal to 4.5 cm, then you need annual imaging. If >4.0cm, guidelines recommend reassessment frequency based on history . If <4.0cm then no repeat imaging until symptomatic - If ascending aorta diameter is greater than or equal to 5.5 cm or progressive dilatation occurs at a rate of 0.5 cm per year or greater, SURGERY is indicated, even in assymptomatic SYMPTOMATIC: Endocarditis and indications for surgery - presence of a new conduction block is an indication for surgical therapy in patients with native valve infective endocarditis - valve stenosis, regurgitation with heart failure, staph/fungal or highly resistant infection, annular or aortic abscess, vegetation greater than 10mm in length

Pulmonary Valve Replacement

ASx 60mmHg gradient; 40 mmHg regurg symptoms 50/30 small annulus severe subvalvar pulmonary stenosis

Ventilator management

AUTO-PEEP - breath stacking with obstructive disease which causes an intrathoracic pressure has risen to the point of impairing her central venous return, so decreased cardiac output due to decreased preload, decreased oxygenation - Treatment: disconnect the endotracheal tube from the ventilator circuit and reconnect it after a few seconds - The ventilator settings should then be adjusted to allow for more effective exhalation to avoid further air trapping. Slowing the respiration rate, decreasing the tidal volume, and increasing the inspiratory flow rate while tolerating respiratory acidosis are ways to increase the exhaled volume with each cycle - Ex: Asthma exacerbation, patient's are hyperventilating so high risk of auto peep so LOW tidal volumes and increased expiratory phase ARDS: Factors that DECREASE MORTALITY 1) tidal volume goal of 6ml/kg of ideal body weight 2) plateau pressure (<30 cm H2O), even if this results in hypercapnia CRITICAL ILLNESS MYOPATHY - normal sensation - small action potentials CRITICAL ILLNESS NEUROPATHY - decreased sensation - large action potentials

Pancreatitis

AUTOIMMUNE PANCREATITIS - typically presents in older men - Dx: imaging features (focal pancreatic enlargement with a featureless rim and a nondilated pancreatic duct), increased serum IgG4 level, and extrapancreatic organ involvement (sclerosing cholangitis or IgG4-associated cholangitis) - Tx: Steroids CHRONIC PANCREATITIS - pancreatic enzymes, pain meds - if persists or worsens, pregabalin (or a low-dose tricyclic antidepressant) for celiac plexus nerve block can be tried ACUTE PANCREATITIS - Enteral nutrition via nasojejunal tube should be started within 72 hours - evidence of necrosis and peripancreatic fluid collections dictate at least moderate pancreatitis, but usually resolve in their own. If present at 4 weeks, now a pseudocyst and can be drained - if patient resolves then comes back with necrotic pancrease, start abx (carbepenem, metro, quinolone) and supportive care. If no improvement, consider CT guided FNA to culture and get more specific speciation Psuedocyst - presents weeks after acute pancreatitis - enzymes elevated to a lesser degree - cyst noted on imaging - Tx: THE SAME supportive care, serial CT imaging for resolution Gallstone obstruction - if evidence of stones on US and patient has ongoing obstruction on evaluation with high likelihood for common duct stone, on the test, go straight to ERCP for both dx and tx (skip MRCP, even though in real life we don't do it this way) - Mesalamine can increase risk of acute pancreatitis

Ezetimibe

Abdominal Pain, fatigue, Myositis elevated liver enzymes

What is a cerebral aneurysm?

Abnormal focal outpouchings of cerebral arteries Most common in the anterior communicating artery

ACD

Abundant Fe in Macrophages on prussian blue stain but not in RBC precurors -IDA can co-exist with it (in difficult cases BMBx can distinguish)

What is a massive transfusion protocol and when is it activated?

Activated when: - Loss of one patient blood volume in 24hrs - Actual or predicted transfusion of 4U of PRBC in <1hr - Blood loss of >1L in 1hr Activated by a senior clinician Blood bank sends: - Pack 1: 4U PRBC + 4U FFP + 4U Cryo - Pack 2: 4U PRBC + 4U FFP + 4U Cryo + 1 pooled PLT

Pearl on strokes

Acute exacerbations of neurological deficits may happen in conjunction with acute infection or metabolic derangement

Sweet's Syndrome

Acute febrile neutrophilic dermatosis is a skin disease characterized by the sudden onset of fever, an elevated white blood cell count, and tender, "juicy" red papules, plaques, or nodules with sharp borders, appearing on the upper trunk and proximal extremities in the setting of fevers that show dense infiltrates by neutrophil granulocytes on histologic examination. - Treat w steroids or it could lead to infection

Which type of oesophageal cancer is more common in Australia?

Adenocarcinoma of the lower oesophagus has overtaken SCC in line with increased rates of GORD and obesity

IV Lines in Congenital Heart Disease

Air filters with Eisenmenger's syndrome because of increased risk of paradoxical air embolus

Cluster

Alarm clock HA wakes you in the night High Flow O2 7L or more

Constipation Alarm Symptoms

Alarm symptoms require secondary work up

HRS

Albumin is 1st line for AKI in Cirrhotic Cocktail for people who definitely have HRS

24. All patients presenting with dizziness should have orthostatic hypotension. When trying to differentiate central from peripheral vertigo, what brainstem or cerebellar findings will you seek to elicit?

All patients presenting with dizziness should have orthostatic hypotension. When trying to differentiate central from peripheral vertigo, what brainstem or cerebellar findings will you seek to elicit? Diplopia, dysarthria, dysphagia, focal numbness, gait abnormalities or headache

34. Although many individuals no longer treat equivocal otitis media, for persons with progressive otitis media despite amoxicillin therapy, what treatment would you offer and what complications are you hoping to prevent?

Although many individuals no longer treat equivocal otitis media, for persons with progressive otitis media despite amoxicillin therapy, what treatment would you offer and what complications are you hoping to prevent? In order to cover the beta-lactamase-producing organisms if a patient progresses on amoxicillin over 2-3 days then amoxicillin clavulanate should be used. You are trying to prevent the complications of hearing loss, tympanic membrane perforation, mastoiditis, meningitis and brain abscess.

1. An individual with a prior medial meniscus tear presents after full recovery from the tear with a mild knee effusion and sense of fullness in the popliteal fossa area. This is noted on the physical exam. The knee is not warm, red or tender and has full range of motion. What is your diagnosis?

An individual with a prior medial meniscus tear presents after full recovery from the tear with a mild knee effusion and sense of fullness in the popliteal fossa area. This is noted on the physical exam. The knee is not warm, red or tender and has full range of motion. What is your diagnosis? Baker's cyst. Baker's cyst can be seen with any form of arthritis of the knee such as rheumatoid arthritis or Lyme. It often has a knee effusion. Beware of the ruptured Baker's cyst which can look like a pseudothrombophlebitis with calf pain and swelling which can even cause some compression in the veins.

What is an obturator hernia?

An obturator hernia is rare. It protrudes through the obturator canal or foramen, which is a normal anatomical structure between the obturator groove on the inferior aspect of the superior pubic ramus and superior border of the obturator membrane. It is more common on the right side. The hernia occurs most often in elderly females, particularly in those who have become debilitated and lost weight rapidly.

26. An overnight polysomnography may help to diagnose what conditions in a patient with insomnia?

An overnight polysomnography may help to diagnose what conditions in a patient with insomnia? Obstructive sleep apnea, restless leg syndrome, or periodic limb movements of sleep.

What is the incidence of a congenital umbilical hernia?

An umbilical hernia in a child is a congenital defect in which a peritoneal sac protrudes through a patent umbilical ring and is covered by normal skin. Approximately 5-10% of Caucasian infants have an umbilical hernia at birth. About one-third of hernias close within a month of birth, and they rarely persist beyond the age of 3-4 years.

What are the symptoms of an anal fissure?

Anal pain which is severe at the time of defaecation Bright red rectal bleeding An anal skin tag might be noted

At what size should you consider intervention for an AAA?

Aortic diameter <3 cm — no further testing Aneurysm 3 to 4 cm — annual ultrasound Aneurysm 4 to 4.5 cm — ultrasound every six months Aneurysm >4.5 cm — referral to a vascular specialist Consider intervention when AAA >5.0 cm or >0.5 cm expansion within 6 months OR Symptomatic

What are the daily fluid, sodium and potassium requirements for an adult?

Approx 3L fluid volume daily 80mmol Na (154mmol in 1L normal saline) 70mmol K

What is the blood supply to the bladder?

Arterial supply to the bladder and the lower ureters is via the internal iliac artery, and lymphatic drainage parallels venous drainage to the internal iliac nodes.

What are the general rules for ceasing antibiotics?

As a general principle, antibiotic therapy should cease after 5 days when there is no clinical evidence of infection, the patient has been afebrile for 48 hours, and there is a normal polymorphonuclear neutrophil count.

26. At what CD4 count may live attenuated vaccines be used in HIV patients?

At what CD4 count may live attenuated vaccines be used in HIV patients? CD4 count of greater than 200

8. At what age does the U.S. Public Health Service Task Force recommend initial screening for men and women?

At what age does the U.S. Public Health Service Task Force recommend initial screening for men and women? Age 35 for men and 45 for women, although the guidelines do mention that men and women can be screened at the age of 20 initially if they have increased cardiovascular risk. The National Cholesterol Education Program recommends screening beginning at age 20.

13. At what age should men and women be screened for hyperlipidemia?

At what age should men and women be screened for hyperlipidemia? U.S. Public Health Services Task Force recommends greater than or equal to 35 years old for men and greater than or equal to 45 years old for women unless there is an increased cardiovascular risk, then younger ages can be considered for screening.

21. At what age should screening mammography be discontinued for women?

At what age should screening mammography be discontinued for women? Women 75 years and older as there has been no evidence for benefit.

49. At what older age cutoff is the evidence for screening mammography for women lacking?

At what older age cutoff is the evidence for screening mammography for women lacking? Age 75 years and older

What is the pathophysiology of peripheral vascular disease?

Atherosclerosis PVD is regarded as a manifestation of cardiovascular disease.

Breast Cancer

Atypical ductal hyperplasia - high risk lesion of becoming cancerous, anti-estrogen chemoprophylactic indicated ***TAMOXIFEN for 5 years*** following the diagnosis - Tamoxifen with HR+ cancers is ***just as effective as chemo*** Lobular Carcinoma In Situ has the same high risk as Atypica ductal hyperplasia and also get ***TAMOXIFEN for 5 years*** following the diagnosis/biopsy report - Tamoxifen with HR+ cancers is just as effective as chemo Triple negative (negative for estrogen receptor, progesterone receptor, and HER2 amplification) should be treated with removal if early stage then adjuvant chemotherapy, typically ANTHRACYCLINE-based chemotherapy - Triple therapy is usually BRCA positive - Estrogen/Progesterone positive cancers should be treated with adjuvant anti-estrogen agents. Tamoxifen has been the standard treatment in premenopausal women - Tamoxifen with HR+ cancers is just as effective as chemo - Aromatase inhibitors are good for anti-estrogen agents in post menopausal, like anastrozole. However, arthralgias may occur If they do, try another aromatase inhibitor. If still having myalgias, start TAMOXIFEN bc it is still effective in post menopausal - Tamoxifen with HR+ cancers is just as effective as chemo - Minimal to moderate lytic bone lesions still opt to treat with aromatase inhibitors; radiation therapy only for palliative measures or severe bone conserving therapy FYI Radium 223 is ONLY for prostate, everything else, normal radiation - HER2 positive treated with trastuzumab-based chemotherapy - BRCA testing in patients with diagnosis before age 45, family history or triple negative under age 65 - test BRCA prior to any intervention if patient qualifies - BRCA 1/2 mutation holds higher risk of ovarian cancer - Tx: If noted, patient should have bilateral salpingo-oophorectomies by the age of 35 or after child bearing - s/p resection and on appropriate therapy, if patient is ASSYMPTOMATIC, no need for intensive imaging studies, just follow clinically - when there is evidence of metastatic lesions, biopsy to assess for HER2 and other genetic variances, even if it is a liver lesion. This can help with adjuvant treatment regimen. Note, bone lesions cannot be tested for hormone sensitivity variances. - If no spread evidence and <1cm, after resection no chemo is needed. Maybe only adjuvant hormonal therapy if needed and adjuvant chemo only if markers (HER2) are evident - Age 50 > Mammo > US if needed > MRI - MRI only if younger with dense tissue - BRCA associated in up to 50% of inherited breast cancers - if family member has it, you are 3x as likely to develop - Brain mets with less than 3 lesions less than 3cm treated with STEREOTACTIC RADIATION - Brain mets with solitary lesion and overall is wellcontrolled, consider surgery - biopsy not needed if you have a good idea of where it is coming from

hgbEP

B-thal = slightly increased A2 and residual hemoglobin F chromo 11 - low level hemolysis - alpha thal = normal A2 chomo 16

tPA odds & ends

BP < 180/105 in 1st 24hr (less than 185/110 before tPA) - avoid ASA in 1st 24hr after - NPO for 1st 24hr - wait 24hr to start IV heparin

Where does pancreatitis tend to refer pain to?

Back

What is Barrett's Oesophagus?

Barrett's oesophagus is a condition in which the squamous epithelium of the distal oesophagus is replaced by a columnar epithelium characterised by the presence of specialised intestinal metaplasia.

What is the association between Barrett's oesophagus and oesophageal cancer?

Barrett's oesophagus is pre-malignant change. The prevalence of adenocarcinoma in patients with Barrett's oesophagus averages about 13%, equivalent to at least a 30-fold increase in the risk of cancer compared to the general population.

Where does a ruptured aortic aneurysm tend to refer pain to?

Between shoulder blades

Akinetic Mutism

Bilateral frontal lobe lesions - Catatonia keep same posture for long time

Coal Miner lung

Black lung big large Nodules

Saroidosis

Blacks and Vikings majority asymptomatic bil LAD potato nodes steroids 4-6 weeks ACE nondiagnostic

Pneumococcal pneumonia

Blood Cultures ABx CT LP

focal dystonia

Botox

Mets to thyroid

Breast Melanoma Renal Cell

Lymphatic Carcinomatosis

Breast Cancer typical Pulm Mets: multiple, peripheral subpleural nodules typically adenocarcinoma of lung, breast or GI tract) also melanoma, lymphoma and leukemia Best test: HRCT

TMP SMX

deadly interaction with MTX blocks ENac in distal tubule bad drug in elderly same as amiloride CKD is risky too risks on ACEI or ARBS no warfarin, no MTX, no allergy or renal insufficiency

Tramadol

decrease seizure threshold worst in geriatrics

What are the treatment options for a femoral hernia?

Surgical treatment should always be advised because of risk of obstruction and strangulation. A truss cannot prevent herniation through the femoral ring and has no place in the management of a femoral hernia.

TBI

Symptomatic = prohibit cognitive rest for 3-7 days in patients with concussion.

What are the causes of oesophageal perforation?

Iatrogenic (most common): - Endoscopic, dilatation, biopsy, intubation, operative, NG tube placement Barogenic: - Trauma, epeated, forceful vomiting (Boerhaave's syndrome), convulsions, defecation, labour (rare) Ingestion injury: - Foreign body, corrosive substance Carcinoma

What are the genetic mutations associated with bladder cancer?

Multiple molecular pathways are associated with bladder cancer. -Mutations in FGFR-3 and TP53 are important early events -Loss of heterozygosity on Chromosome 9 -Alterations in retinoblastoma (Rb),PTEN and P16 are common in high grade invasive cancers.

What is the clinical presentation of a pilar cyst?

Multiple, hard, variable sized nodules under the scalp, lacks central punctum

Vertebrobasilar TIA

N,V,N,V Nausea, Vomiting, Nystagmus and vertigo

intermediate risk for ASCVD

CAC > 300 or 75% for age High sensitivity CRP above 2 mg/L ABI below 0.90 LDL > 160 mg/dL FH Male < 55 year old or female < 65 year old stress testing in low pretest probability = false positive

Combo treatment for HTN

CCB-ACE inhibitor is superior to ACEI and diuretic

Eosinophilic Pustular Folliculitis

CD4 less than 300 pruritic papules in areas of concentrated sebaceous glands 50% eosinophilia

AIE treatment

CA-native valve - Vanc & Gent Nosocomial - Vanc & Gent and Rifampin Vanc + Gent + Carbapenam or Cefepime Prosthetic Valve- Vanc Gent or Rifampin

Ocular Exam

CENTRAL RETINAL ARTERY OCCLUSION - sudden PAINLESS monocular/unilateral blindness - elderly, carotid disease - due to atherosclerosis in the ipsilateral carotid artery - pallor with CHERRY-red spot on macular - EMERGENT ophthalmologist consult! RETINAL VEIN OCCLUSION - would show hemorrhage Acute ANGLE CLOSURE GLAUCOMA - due to compromised outflow - painful - "blood and thunder" fundus, multiple hemorrhages aka multiple dot blot and flame shaped hemorrhages RETINAL DETACHMENT - rays of light - black dots or floaters - curtain coming down - partial rather than complete blindness - evidence of retinal separation

Berylliosis

CMI response Hilar Lymphadenopathy ddx: Sarcoid MTX or steroids

endomyocardial biopsy

CMP doxorubicin toxicity transplant rejection - low NPV for sarcoidosis - not for ETOH CMP

What is the commonest virus transmitted by blood transfusion?

CMV

Bleeding Mets

CTMR (the two tests Neurologists order) Choriocarcinoma Thyroid Ca Melanoma RCC

Food poisoning

CYCLOSPORA - food bourne illness on fresh fruits or veggies STAPH - vomiting shortly after ingestion - can present with similar foods to Bacillus Cereus, within the FIRST FEW HOURS of ingestion. If B. Cereus is not an option, pick staph aureus NOROVIRUS - common cause of non bloody diarrhea or vomiting due to picnic style foods as well, but incubation period is 12-24 hours to onset of symptoms

29. Can MMR be used during pregnancy?

Can MMR be used during pregnancy? No, it is contraindicated

What is the treatment of dermoid cysts?

Can be treated by excision but are less readily enucleated than epidermal cysts.

Where do SCCs of the oesophagus typically occur?

Can occur anywhere in oesophagus but mostly in middle 1/3

Peripheral Artery Disease

Can present in upper extremities - notable with difference of systolic pressure in each arm up to 15mm hg - Patients with an ischemic but viable extremity on clinical examination should undergo urgent ANGIOGRAPHY to plan surgical or percutaneous revascularization - any evidence of PAD patient should be on moderate-high intensity statin

Narrow Spectrum AEDs

Carbamazepine Gabapentin Oxcarbazepine Phenobarbital Pregabalin Epilepsy - Dilantin can acutely treat Generalized tonic clonic seizures but can worsen generalized seizure with chronic treatment

Synthroid

Cations Calcium & Iron - Aluminum and Magnesium too - Binders - Antacids Questeran - Sucralfate - PPI reduce absorption by 1/3 - assess compliance - new meds - achlorhydria and sprue

SBP treatment

Cefotaxime Albumin: - sCr > 1 - TBili > 4 - BUN > 30 1.5g/kg IV 25% albumin day 1 1 gm/kg on day 3 Cipro for secondary prevention

What is the main pathogen associated with cellulitis?

Cellulitis is a spreading inflammation of connective tis- sues that is often due to β-haemolytic Streptococcus. The invasiveness of this organism is due to the production of hyaluronidase (dissolution of the intercellular matrix) and streptokinase (dissolution of the fibrin inflammatory barrier).

What antibiotics are normally used as surgical prophylaxis?

Cephazolin +/- metronidazole

Crohn's in Pregnant patient

Certolizumab old way 1 5-ASA 2 Azathiopurine or 6-MP 5-ASA sucks Pegylated has no crossing the placenta Budesonide is a class C and isn't effective for Left sided colitis????

Constrictive Pericarditis

Chronic 2/2 inflammation, fibrosis and calcification XRT, Surgery trauma post myocardial infarction, CT dz, Malignancy, Tb Sx: fatigue from reduced CO Signs: elevated JVP prominent x & y descents Kussmal sign pericardial knock pulsus paradoxus Pleural effusion congestive hepatomegaly cath: equalization of diastolic pressures Dx: TTE; if indetermination CC BNP minimally eleavated Tx: Surgical Pericarectomy

Pulmonary Embolism

Chronic thromboembolic pulmonary hypertension - patient with hx of PE and down the road has increasing SOB, maybe TV regurg, echo shows RVH - PCWP normal - PA and RA increased - Dx: V/Q lung scan is the preferred and recommended initial study Alveolar-arterial gradient INCREASED - usually get pO2 from ABG - AlveolarO2 = 150 - (pCO2 x 1.25) - Normal AlveolarO2 - pO2 = (5-20) Acute PE - outpatient treatment is fine as long as patient does NOT need supplemental oxygen, intravenous pain medications, or management of comorbid conditions that may contribute to rapid clinical deterioration or if home circumstances make outpatient therapy unfeasible - RV strain = submassive PE = heparin - Hemodynamic collapse/cardiogenic shock = tPA - Trop elevation simply means higher risk of death but does not decide between tPA or not EKG: S1Q3T3 S in Lead 1 is bigger Q wave present in Lead 3 T wave inverted in Lead 3

Statins

Clarithromycin sucks Fibrates (gemfibrozil 15x >> fenofibrate) amiodarone (doubles Simvastatin and lovastatin) azoles erythromycin/macrolide Protease inhibitors Verapamil Diltiazem ( can double level of statin) Fewest drug interactions with Pravachol moderate intensity for: > 75 yo, CKD, meds known to interact with statin Rhabdomyolysis (0.01%) Hepatotoxicity rare Myalgias (5-18%) transaminase elevation with statins is background noise Stop the liver monitoring

What is the typical presentation of pseudo-obstruction?

Classically, pseudo-obstruction occurs in the elderly patient who has recently undergone surgery for a fractured NOF. The condition is also often seen where there has been extensive pelvic or retroperitoneal injury and sometimes the condition appears to be more related to the use of opiate analgesia rather than the type of surgery itself. The atony, with abdominal distension and absence of bowel function, tends to occur 2-3 days after surgery (or from the time the injury was sustained). If the condition does not resolve spontaneously, colonoscopic decompression is usually successful. Occasionally, surgical intervention is required to prevent caecal perforation.

What is the CEAP classification?

Classifies severity of venous disease C: Clinical manifestations E: Aetiologic factors A: Anatomic distribution of involvement P: Underlying pathophysiologic findings (reflux or obstruction)

Squamous Cell Carcinoma

NECK SCC - following resection, consider chemo AND radiation therapy to the neck - can have PTH related protein driving hypercalcemia (also for head, neck throat)

What are the different classifications of wounds in terms of infection risk?

Clean: No contamination from exogenous or endogenous sources. The wound infection rate should be less than 2%. Clean-contaminated: The gastrointestinal, urinary, res- piratory or genital tracts are entered under controlled conditions. The wound infection rate should be less than 5%. Contaminated: There is either gross intraoperative soiling, or an emergency procedure involves entry into an unprepared gastrointestinal tract. The wound infection rate may be as high as 30%. Dirty: The presence of gross soiling prior to surgery (e.g. heavily contaminated wound, faecal peritonitis). The wound infection rate may exceed 30%.

What are varicose veins?

Clearly visible, dilated, tortuous and possible prominent subcutaneous veins of the lower extremities Secondary to a loss of valvular efficiency (incompetent valves)

What are the clinical features of biliary colic?

Colicky abdominal pain, worse postprandially, worse after fatty foods

What are the causes of cerebral aneurysms?

Commonly IA are attributable to a connective tissue disorder. These include: - Autosomal dominant polycystic kidney disease 5 to 40 percent - fibromuscular dysplasia - Marfan's syndrome - Ehlers-Danlos syndrome type IV

Triptan Contra-indications

Complicated Migraine CAD Stroke Uncontrolled HTN Pregnancy

Mylopathies

Compressive (DJD) Infectious /Inflammatory Metabolic

What are haemorrhoids?

Congested or enlarged anal "cushions" (submucosal vascular tissue) Typically three areas of expanded submucosa in the anal canal Very common (>50% of the population)

heart failure made simple

Coreg is well tolerated in COPD patient's but less so in asthma

Coma

Cortical Brainstem Meds Metabolic Problem

AC joint degeneration

Cross arm test pain with cross arm abduction above 120 degrees radiograph NSAIDs and

What is the arterial supply to the gallbladder?

Cystic artery (off the right hepatic artery)

30. Name 6 classes of drugs associated with erectile dysfunction.

Name 6 classes of drugs associated with erectile dysfunction: a.Antidepressants b.Benzodiazepines c.Opioids d.Anticonvulsants e.Antihypertensives f.5-alpha-reductase inhibitors

IDA in CHD

Symptomatic IDA- short Fe course # microcytes are more rigid and increase risk of stroke - 1 tab and repeat hgb in 7-10 days

22. Name 7 categories of drugs that cause weight gain.

Name 7 categories of drugs that cause weight gain: a.Atypical antipsychotic agents b.Antidiabetic drugs such as sulfonylureas and TZD as well as insulin c.Corticosteroids d.Tricyclic antidepressants e.SSRIs f.Anticonvulsants g.Beta blockers

Thyroid Cancer

POOR PROGNOSTIC FACTORS - size >4cm - age >40 - obviously if locally invasive, metastases, poorly differentiated - Papillary - LN to mediastinum or Cervical LN - Follicular - capsular or vascular invasion

Valve disease

Symptoms = surgery

PLATO Trial

Ticagrelor better than plavix

coagulopathy of liver failure

decreases factor V and VII (vit k initially affects VII then later II, XI & X) (PT then PTT)

GPA

Tissue biopsy from active site of disease (kidney) negative ANCA does not exclude GN pauci-immune segmental necrotizing GN - Lung generally requires VATS - nasal biopsy has low yield

Toe Brachial index

Toe Systolic Blood pressure less than 40 mmHg TBI less than 0.70 PAD ABI following exercise with decrease by 20% is consistent

SAAG < 1.1

Total Protein < 2.5 Nephrotic syndrome & Myxedema > 2.5 Infections, Malignancy, Tb and pancreatic ascites

What are the types of bladder cancer?

Transitional Cell carcinoma (TCC) - 90%. Arises from stem cells adjacent to basement membrane Squamous Cell carcinoma - 5% of bladder cancer. Adenocarcinoma - 2%. Arises from urachal elements. Frequent in bladder extrophy.

hyperandrogenism

DHEAS and Testosterone

Travel diseases

Dengue - characterized by sudden high fever, frontal headache and retro-orbital pain, myalgias and arthralgias, severe lower back pain, and rash that appears as the fever abates - Aedes mosquito Chikungunya - high fever, which often recurs after a brief afebrile period ("saddle-back fever"); more significant polyarticular and migratory joint pains involving the small joints of the hands, wrists, and ankles; and much less thrombocytopenia - Aedes mosquito Leptospirosis - like dengue but involves more organ systems, including the pulmonary, renal, hepatic, and central nervous systems. - conjunctival suffusion occurs but rash is rare - Aseptic meningitis is a common feature - severe form: icteric leptospirosis (Weil syndrome), presents with profound jaundice, hepatic necrosis, kidney disease, and pulmonary manifestations

Boney Mets and Treatment

Denosumab: RANKL antibody binder - better than Zometa for solid tumors & bone mets - not recommended for multiple myeloma - correct hypocalcemia and vitamin D deficiency

What is the clinical presentation of an ependymoma?

Depends on the site - Symptoms of raised ICP - Cranial nerve palsies VI-X - Seizures or focal neurological deficits if supratentorial - Spinal cord: local pain causing nocturnal wakening, sensory dysesthesias, muscular weakness

What is a dermoid cyst?

Dermoid cysts are rare, congenital inclusion cysts that rise from inclusion of epidermis along embryonal cleft closure lines (esp on face). Their structure differs from epidermal cysts in that they show multiple skin appendages rather than epidermis alone

35. Describe the rule of double effect.

Describe the rule of double effect: In an individual who might be terminally ill, a patient might receive morphine to make them more comfortable, even if the morphine might hasten their death. Thus, there is a double effect, comfort versus hastening of death. In this case, comforting the patient is a more important goal.

What is the most common cause of non-traumatic amputations?

Diabetic ulcers Diabetes 40x increased incidence of amputation

Pradaxa

Direct Thrombin Inhibitor dabigatran

What are the risk factors for wound dehiscence?

Disruption of fascial layer, abdominal contents contained by skin only Local: technical failure of closure, increased intra-abdominal pressure (e.g. COPD, ileus, bowel obstruction), haematoma, infection, poor blood supply, radiation, patient not fully paralyzed while closing Systemic: smoking, malnutrition (hypoalbuminemia, vitamin C deficiency), connective tissue diseases, immunosuppression, pulmonary disease, ascites, poor nutrition, steroids, chemotherapy, obesity, other (e.g. age, sepsis, uraemia)

Drug induced hyperuricemia

Diuretics Niacin Cyclosporine Ethambutol & Pyrazinamide

What is involved in primary closure of a wound?

Done with: - Sutures - Staples - Steristrips Must be: - Tension free - Avoid inverting skin edges

Pseudothrombocytopenia

Due to clumping - recheck blood draw

Diabetes

Dx: 2 of the 3 following criteria 1) Random glucose 200 or greater with symptoms 2) Fasting BG 126 or greater 3) 2 hour OGTT 75g 200 or greater - if only 1 of these 3 criteria met and is BORDERLINE with NO other symptoms, REPEAT the test on another day 4) A1c > 6.5 Diabetic amyotrophy aka proximal lumbosacral radiculoneuropathy - subacute pain and weakness in the proximal lower extremities - diffuse areflexia - patient's with infections are prone to pseudomonas infection - so if patient for example otitus externa presents and outpatient treatment does not work and is getting worse, consider hospital admission for IV antipseudomonal abx to dec risk of osteomyelitis, meningitis, brain abscess - patients are at increased risk of CKD so should be screened for protienuria and albuminuria, and if present, start on ACE or ARB - sudden monocular blindness? Consider central artery occlusion secondary to ipsilateral carotid disease....always get carotid US with monocular blindness evaluation esp with DM patients - new recommendations say to START METFORMIN (unless renal function impaired GFR<30) with new diagnosis bc lifestyle mods are hard w patients - high risk of PSEUDOMONAS - Otitis Externa MCC is pseudomonas CONTRAINDICATIONS - Metformin if GFR<30 - Glitazones if CHF Diabetic-limited joint mobility syndrome *Regardless of how well controlled!* - positive prayer sign - frozen shoulder - duputren contractures like RA but no hx of RA - carpal tunnel syndrome - tendinitis, calcifications - trigger finger - pseudoscleroderma with some sclerodactyly but no systemic findings DIABETIC SCLERODERMA - sleroderma skin findings of neck, shoulders, upper extremities, no other systemic findings - does not correlate with DM control - high risk of plasma cell dyscrasias so check urine electrophoresis with any diabetic who has this - those with Mucormycosis have high mortality bc it can invade bone and brain tissue

COPD

Dx: FEV1/FVC < 70 FEV1 < 80 Increased TLC - Trial of BIPAP for those who can tolerate, but if obtunded, go straight to intubation - Once they improve, extubation followed by BIPAP support may decrease the ICU length of stay and improve survival. Note that BIPAP is not really indicated post extubation in other patients, but those with COPD and hypercapnia, this decreased ICU stay - Roflumilast is a phosphodiesterase-4 inhibitor that is used as add-on therapy to reduce exacerbations in patients with severe COPD (those with chronic bronchitis, recurrent exacerbations, max medical therapy) - HOSPICE: poor prognosis when FEV1 of less than 30% of predicted, oxygen dependence, multiple hospital admissions for COPD exacerbations, significant comorbidities, weight loss and cachexia, decreased functional status, and increasing dependence on others - Acute exacerbation: IPRATROPIUM is best added for bronchodilation for patients with chronic beta blocker on board - continuous O2 the only thing that decreases mortality - Pulse ox below 89 - but also meet criteria for CONTINUOUS O2 if evidence of corpulmonale. Chronic hypoxia can lead to pulm HTN and increased pulm pressure noted on echo and diagnosis of cor pulmonale, meeting criteria for CONTINUOUS O2 rather than just ambulatory O2 - inactivated influenza vaccine, pneumococcal vaccine *PCV13 then PPSV23 - below 65: repeat PCV13 if 5 years have elapsed since last pneumo vaccine - 65 or older: repear PCV12 if 1 year has elapsed since last pneumo vaccine - Pulmonary Rehab recommended for those with FEV1 less than 50% of predicted OR those with FEV1 greater than or equal to 50% of predicted with exercise induced SOB - SURGERY, LUNG REDUCTION - FEV1<45, TLC over 100 and age less than 75 particularly those with upperlobe predominant disease Improve SURVIVAL - smoking cessation - O2 - lung reduction surgery - lung transplant Cancer patients FEV1 < 2L is the cutoff for surgery...if below 2L, do a VQ scan to assess resectability

HSV

Dx: PCR or DFA Viral Culture previous gold standard useful for resistant or recalcitrant infections

Urticarial Vasculitis

Dx: skin biopsy joint pains and low grade fever painful wheals that last more than 24hours and leave bruises SLE? AI?

DPLD

Dyspnea, Diffuse Disease on CXR, decreased DLCO Occupational History Hobbies Family History hypersensitivy panels

Iron Overload Pathogens

E. Coli, Vibro, Yersenia, Listeria, CMV, Hep B & C, and JIV. Aspergillus fumigatus and mucur V. Vulnificus in seafood

What is a keratoacanthoma?

Keratoacanthoma is a lesion that presents on the cheek, nose, ear or back of the hand in the elderly as a rapidly growing nodule which develops a characteristic central keratin plug. The lesions usually develop to several centimetres in diameter over the course of a few weeks and regress spontaneously and rapidly. Debate over the classification of KA as a benign, spontaneously resolving tumour versus a variant of cutaneous SCC with a rare potential for metastasis

ICD

EF less than 35% for 3 months NYHA II or III #NYHA IV not warranted unless transplant candidate

Stridor

EPIGLOTTITIS - tripod, LEANING FORWARD, cherry red epiglottis, sore throat, odynophagia, drooling, muffled voice - thumb sign consistent with enlarged epiglottis - haemophilus influenzae type B LUDWIG'S ANGINA - swelling and upper displacement of the tongue caused by lack of dental care - brawny edema in neck area, tender mandible - tongue edema and mediastinitis causing woody cellulitis (no abscess) - peptostreptococcus mixed with anaerobes - Tx: Augmentin RETROPHARYNGEAL ABSCESS - trauma, penetrating injury and organisms from the mouth seed the retropharyngeal space developing abscess - present with holding their necks in HYPEREXTENSION

Thrombocythemia

ESSENTIAL - Treatment indicated if over 60, over 1,000,000 or hx of thrombosis - Tx: Hydroxyurea and ASA

Silicosis

Egg Shell calcification (thin fragile calcifications) upper lobe/lung fields increases risk of Tb Independent RF for Lung Cancer

What are the advantages of endoscopic surgery?

Endoscopic surgery is performed by inserting a micro- chip video camera with a light source and specially crafted long-handled surgical instruments into a body cavity by way of small incisions. The advantages of endoscopic or 'closed' surgery are: - Reduced post-operative pain and analgesic requirements - Earlier discharge from hospital - Earlier return to normal function.

16. Episcleritis tends to go away on its own but scleritis can be sight threatening and give evidence for an underlying disease. What underlying diseases might be present?

Episcleritis tends to go away on its own but scleritis can be sight threatening and give evidence for an underlying disease. What underlying diseases might be present? A number of collagen vascular diseases including rheumatoid arthritis and infection such as tuberculosis or syphilis.

What is the histopathological stain that will be positive in a meningioma?

Epithelial membran antigen (EMA) and vimentin positivity is found in all meningiomas

Intoxications and Antidote or Treatments

Ethylene Glycol - Tx: Fomepizole TCAs - Tx: Sodium Bicarb Cocaine - Tx: Benzos Opiods - Tx: Naloxone Anticholinergics - Tx: Physiostigmine Benzos - Tx: Flumazenil

What investigations should you consider in AAA?

Examination - 30% of asymptomatic AAA discovered during routine PE - Not overly sensitive Ultrasound - User dependent - Non invasive - Good for determining size and follow-up - Not best test for iliac arteries CT/MR/Angiography - Planning for intervention - Invasive - Detect other pathology

What is the management of an epidermal cyst?

Excise completely before it becomes infected. If already infected, treat with incision and drainage, with later excision to avoid recurrence

COPD diagnosis

FEV1/FVC ratio = assess airflow obstruction (less than 70) reduction in FEV1 characterize degree of obstruction 80-50 moderately reduced 34-50% Severe less than 34% very severely reduced only 15-20% of smokers develop COPD FEV1 < 50% start to worry about hypoxemia FEV1 < 40-35% hypercapnia Cor Pulmonale several years

What are the pros and cons of FNA vs core needle biopsy for a breast lump?

FNA - Relies on interpretation of clusters of cells - Accurate - Allows wide sampling of a lesion - Rapid answer Core Biopsy - Allows histological diagnosis - More accurate than FNA - Can differentiate in situ from invasive disease - Receptors - Delay in results

Osteopenia

FRAX > 20% for major osteoporotic fracture or > 3% hip fracture = treatment

Which types of hernia are more likely to strangulate?

Femoral >> indirect inguinal > direct inguinal Small, new hernias more likely to strangulate

What are the indications for cryoprecipitate transfusion?

Fibrinogen deficiency

Bisphosphonate

Fibromyalgia like pain lasts forever as high a 5% of people

Hyperthyroidism

First step is to do uptake scan to differentiate Graves vs. Thyroiditis GRAVES - Pretibial myxedema, characteristic thickening of the skin - Tx is Methimazole to normalize thyroid levels - Graves ophthalmopathy: external-beam radiotherapy is reserved for treatment only if symptoms do not improve after achieving euthyroid - radioactive iodine actually makes eye symptoms WORSE. This is due to increased levels of antibody. Avoid in those with moderate to severe GO, but if needed, you can give steroids before to compensate the acute rise in antibodies - Surgical decompression is also an option to control active GO that doesn't improve once medically treated, particularly if there is compression of the optic nerve - Monitor T4/T3 bc TSH takes MONTHS to normalize and remains repressed Hypokalemic periodic paralysis - secondary to thyrotoxicosis - generalized flaccid muscle weakness from a sudden intracellular potassium shift precipitated by strenuous exercise or a high carbohydrate meal - if clinically suspected, go ahead and GIVE BETA BLOCKADE NOW, then proceed with workup (US) - on that note, if clinically hyperthyroid and no evidence of dysphagia or trachea deviation, can skip US and do scan/uptake right away -____- - HIGH UPTAKE due to IODINE DEFICIENCY - LOW UPTAKE with known hx of hyperthyroidism, T4 high, then IODINE EXCESS DeQuervian Thyroiditis - uptake scan is decreased - tender to palpation Silent Thyroiditis - thyrotoxicosis, new diagnosis and presentation - free T3 is HIGH, uptake scan initially LOW - can sometimes present with depression or apathy like hypo, but will have other sx like weightloss, tachy, tremor, etc.

What is the difference between a skin flap and a skin graft?

Flap: a composite piece of tissue that is moved from one site to another and takes with it its own blood supply Graft: a piece of tissue that is moved from one site to another but relies on the blood supply of the donor site for its survival

FCR for aphasia

Fluent Comprehends? Repeats? conduction can't repeat arcuate fasciculus

MG crisis

Fluroquinolones decrease NMJxn transmission admit to Unit NIF and VC IVIG start high dose steroids after IVIG aminoglycosides, beta blockers, CCB

29. Following a bariatric procedure that leads to malabsorption, what screening is recommended?

Following a bariatric procedure that leads to malabsorption, what screening is recommended? Twice yearly monitoring for vitamin D, calcium, phosphorus, parathyroid and alk phos levels. Ferritin, B12, folate, vitamin D and calcium should be assessed every 6 months for the first two years and annually thereafter. Bone mineral density is recommended yearly until stable.

63. For a woman with severe postmenopausal vasomotor symptoms refractory to all other interventions, what precautions would you take in considering estrogen therapy?

For a woman with severe postmenopausal vasomotor symptoms refractory to all other interventions, what precautions would you take in considering estrogen therapy? a.Use the lowest dose possible b.Consider using it for a limited period of time, and only in women under age 60 years old c.Warn the women that the risk of stroke is no different if she is under or over age 60 years old although coronary heart disease largely occurred in the Women's Health Initiative in the older age groups. d.Tell the women that there is a risk of breast cancer and that the breast cancer might be invasive, cause more mortality and have lymph node positivity e.Realize that breast density is going to be increased, making mammogram interpretation more difficult f.A progestational agent is absolutely necessary to prevent cancer in a women with an intact uterus g.Advise this treatment only to women at low risk for coronary heart disease, stroke, or invasive breast cancer and if started try to discontinue the therapy in 3-5 years

57. For each of the following exam findings, name the syndrome in the shoulder: a.Pain between 60 and 120 degrees of abduction b.Pain with more than 120 degrees of abduction c.A positive Yergason test (elbow flexed to 90 degrees with forearm pronated) d.A positive drop-arm test

For each of the following exam findings, name the syndrome in the shoulder: a.Pain between 60 and 120 degrees of abduction - Rotator cuff impingement b.Pain with more than 120 degrees of abduction - AC joint pathology c.A positive Yergason test (elbow flexed to 90 degrees with forearm pronated) - Biceps tendon instability or tendinitis d.A positive drop-arm test - Rotator cuff tear with supraspinatus tendon being the most commonly affected

68. For each of the following tests, what is the area being assessed? a.Anterior drawer sign b.Lachman test c.McMurray test d.A varus stress test e.A valgus stress test

For each of the following tests, what is the area being assessed? a.Anterior drawer sign - Anterior cruciate ligament b.Lachman test - Anterior cruciate ligament c.McMurray test - Medial and lateral meniscus injury d.A varus stress test - Lateral collateral ligament e.A valgus stress test - Medial collateral ligament

54. For each of the following, list a key side effect: a.Mirtazapine b.Tricyclic antidepressants c.Venlafaxine d.SSRIs e.Bupropion

For each of the following, list a key side effect: a.Mirtazapine - Weight gain or sedation b.Tricyclic antidepressants - Anticholinergic effects or cardiac toxicity with an overdose c.Venlafaxine - Hypertension d.SSRIs - Sexual side effects e.Bupropion - Seizure risk

22. For each of the following, name the disease: a.The most common cause of vertigo with episodes lasting seconds often due to rapid change in head position, exacerbated by the Dix-Hallpike maneuver and not associated with tinnitus or hearing loss b.Associated with a viral infection, nausea and vomiting. There are no brainstem symptoms present. It often resolves within a week but full recovery may take longer as residual dizziness can last for months c.Patient with vertigo, unilateral low frequency hearing loss and tinnitus

For each of the following, name the disease: a.The most common cause of vertigo with episodes lasting seconds often due to rapid change in head position, exacerbated by the Dix-Hallpike maneuver and not associated with tinnitus or hearing loss - Benign paroxysmal positional vertigo b.Associated with a viral infection, nausea and vomiting. There are no brainstem symptoms present. It often resolves within a week but full recovery may take longer as residual dizziness can last for months - Vestibular neuronitis. If there is hearing loss it is called labyrinthitis. c.Patient with vertigo, unilateral low frequency hearing loss and tinnitus - Meniere disease. Initially only vertigo may be present but after repeat attacks the hearing loss occurs.

ECG and Stress Testing

LBBB LVH with repol abnormalities paced preexcitation even if you have ST depression on exercise if you have baseline abnormalities these findings are less reliable Exercise Echo

5. For each of the following, select one of the 5 causes of incontinence as the cause: a.A patient has incontinence while lifting, exercise, sneezing or coughing b.A patient has incontinence when they come home after an evening out and are fumbling with their keys at the front door having a feeling that they need to go to the bathroom c.A patient who has known BPH or a urethral stricture d.A patient who has dementia and some mobility issues

For each of the following, select one of the 5 causes of incontinence as the cause: a.A patient has incontinence while lifting, exercise, sneezing or coughing - Stress incontinence b.A patient has incontinence when they come home after an evening out and are fumbling with their keys at the front door having a feeling that they need to go to the bathroom - Urge incontinence c.A patient who has known BPH or a urethral stricture - Overflow incontinence d.A patient who has dementia and some mobility issues - Functional incontinence as they cannot get to the bathroom on time

1. For geriatric patients ready for hospital discharge, how much time must they be able to participate in therapy each day in order to make it into an inpatient rehabilitation unit as opposed to a skilled nursing facility?

For geriatric patients ready for hospital discharge, how much time must they be able to participate in therapy each day in order to make it into an inpatient rehabilitation unit as opposed to a skilled nursing facility? Greater than or equal to 3 hours per day; whereas, skilled nursing facilities have trained nursing personnel and provide care for those who are able to participate in rehabilitation for less than 3 hours per day.

42. For patients on prednisone, at what daily dosage does a patient need stress steroids for surgery?

For patients on prednisone, at what daily dosage does a patient need stress steroids for surgery? Prednisone greater than 10 mg. a day for at least 3 weeks. Baseline steroids can be started 2 days postoperatively. If there is any suspicion for dehydration, the patient should be well hydrated prior to surgery as Addison's disease is a salt losing state.

23. For which 3 cancers does the U.S. Public Health Service Task Force recommend screening?

For which 3 cancers does the U.S. Public Health Service Task Force recommend screening? a.Breast cancer women over age 50 b.Cervical cancer c.Colon cancer age 50 to 75 years of age

22. For which infectious diseases does the U.S. Public Health Services Task Force recommend screening for individuals who are at increased risk for sexually transmitted infections?

For which infectious diseases does the U.S. Public Health Services Task Force recommend screening for individuals who are at increased risk for sexually transmitted infections? a.HIV b.Hepatitis C c.Chlamydia in women d.Gonorrhea in women

31. For which of the following behavioral areas does the U.S. Public Health Service Task Force recommend screening? a.Domestic violence b.Sexual behavior c.Alcohol use d.Tobacco use

For which of the following behavioral areas does the U.S. Public Health Service Task Force recommend screening? a.Domestic violence: Yes as studies suggest that screening may improve health outcomes in this population b.Sexual behavior: Yes as the Task Force recommends that providers take a sexual history and perform risk assessment during periodic and other health visits, particularly for high risk patients. The Task Force recommends high intensity counseling targeted to sexually active adolescents and adults at risk for STI's. c.Alcohol use: Task Force recommends screening and counseling for all adults for alcohol use and abuse, identifying the quantity, frequency of drinking, adverse consequences, and patterns of use. d.Tobacco use: Current recommendations are that all clinicians assess tobacco use at every visit given the likely need for repeated quit attempts and importance of reinforcing positive behavior. However, MKSAP 16 did not mention that this was Public Health Service Task Force recommended nor did it recommend that diet and physical activity counseling was recommended by the U.S. Public Health Service Task Force. We'll have to look into this in our own studies.

20. For which patients might you continue aspirin for a preoperative elective surgery?

For which patients might you continue aspirin for a preoperative elective surgery? Continue if a recent myocardial infarction in the last six months, a cardiac stent or in a patient at high risk for a cardiac event.

58. For which syndrome are you more likely to order central nervous system imaging: unilateral hearing loss or bilateral hearing loss?

For which syndrome are you more likely to order central nervous system imaging: unilateral hearing loss or bilateral hearing loss? Unilateral hearing loss to make sure there is no tumor or acoustic neuroma, particularly in an older individual.

16. For whom does the U.S. Public Health Service Task Force recommend screening for type 2 diabetes in asymptomatic adults?

For whom does the U.S. Public Health Service Task Force recommend screening for type 2 diabetes in asymptomatic adults? For individuals with sustained blood pressure greater than 135/80. However, the American Diabetes Association recommends screening all adults age 45 and older without risk factors and all adults with a BMI of greater than or equal to 25 and those who have gestational diabetes, hypertension, hyperlipidemia and a family history of type 2 diabetes.

20. For whom does the U.S. Public Health Services Task Force recommend screening for Chlamydia infection?

For whom does the U.S. Public Health Services Task Force recommend screening for Chlamydia infection? All women 24 years of age or younger who are sexually active and all women over age 24 who are at risk for infection such as a history of STI, new or multiple sexual partners, inconsistent condom use or exchanging sex for drugs or money.

Eosinophilic Granuloma

Formerly Histiocytosis X Smoker DI lytic leason

What are the different types of skin grafts?

Full thickness have a better cosmetic result but is more difficult to take and needs a very receptive bed

What are the consequences of gastric dilatation post surgery?

Gastric dilatation is rare and when it occurs, tends to be associated with surgery of the upper digestive tract. It may occur suddenly 2-3 days after the operation and is associated with massive fluid secretion into the stomach, with the consequent risk of regurgitation and inhalation. Treatment is by insertion of a nasogastric tube and decompression of the stomach.

perforation of TM

MC in perf is Staph, Pseudomonas and Pneumococci Strep pneumo and non typable HI

It's raining MEN

MEN2A (RET protooncogene) = Primary hyperparathyroidism, Medullary thyroid carcinoma, pheochromocytoma MEN1 = MEN1 gene = Insulinoma, prolactinoma and parathyroid adenoma

Gastric cancer

Gastrointestinal stromal tumor - most common sarcoma of GI tract - Location outside the stomach, larger size, and higher mitotic index constitute relative high-risk factors for recurrence after resection...require 3 years of IMATINIB - Colon cancer solitary mass with lymph nodes: Stage 3 treatment includes resection followed by chemotherapy with capecitabine and oxaliplatin (CAPOX) or leucovorin, 5-fluorouracil, and oxaliplatin (FOLFOX) as appropriate adjuvant therapy STOMACH CANCER - usually addenocarcinoma and ASSOCIATED with ACANTHOSIS NIGRICANS

What factors can increase the risk of breakdown of a wound?

General factors: - Diabetes mellitus - Immunosuppression - Malignancy - Malnutrition Local factors: - Adequacy of wound closure - Infection - Anything that might put mechanical stress on the wound.

Topiramate

Generalized Seizures weight loss and HA ppx high risk of kidney stones

What are the common causes of microscopic haematuria?

Glomerular - IgA nephropathy - Thin membrane disease Non-Glomerular - Bladder cancer - Urinary stone disease - BPH

Wegener granulomatosis

Granulomatosis with polyangiitis - Resp and GU symptoms - Pupura rash at times - diagnosis with antiproteinase 3 antibodies - scleritis associated with alot of autoimmune disorders - sinus symptoms, abnormal urinalysis suggestive of glomerulonephritis, and scleritis = c-ANCA vasculitis - Dx: Biopsy shows PAUCI IMMUNE CRESCENTS - Tx: High dose steroids and cyclophosphamide...Mr. Harland!!! - please note that other microscopic vasculitis have PAUCI IMMUNE CRESCENTS namely microscopic polyangiitis and Churg Strauss

Where does renal colic tend to refer pain to?

Groin

Refractory to Platelet transfusion

HLA matched platelet

Central Sleep apnea

Heart Failure and Cheynes stokes increasingly recognized as associated with opiates treatment should first target identified modifiable risk factors adaptive servoventilation

What happens to bilirubin levels with a prehepatic, intrahepatic or post hepatic cause of jaundice?

Hepatocellular: Elevated bilirubin + elevated ALT/AST Cholestatic: Elevated bilirubin + elevated ALP/GGT ± duct dilatation upon biliary U/S Hemolysis: Decreased haptoglobin + elevated LDH

Pericarditis

High Risk Features: Fever, Leukocytosis Acute Trauma Immunocompromise oral anticoagulant large effusion evidence of tamponade

Barrett's Esophagus

High-grade dysplasia, salmon colored, constant reflux symptoms. Treat with endoscopic ablation or mucosal resection Low-grade dyspasia - management is to repeat upper endoscopy in 3 to 5 years. Fundoplication in those who cannot take PPI or want to get off PPI and symptoms persist

What is the prognosis of an ependymoma?

Higher grade is associated with poor outcomes (Grades 3 and 4) Ten year survival rates in adults for treated ependymomas: intracranial - 50-77% and spinal cord - 75%

one pinpoint pupil

Horner's lateral medulla of wallenberg

53. How are the best outcomes obtained in treating depression?

How are the best outcomes obtained in treating depression? Pharmacologic and psychotherapy have fairly equivalent outcomes in randomized trials but most recommend that a combination of the two be used to achieve the best outcomes.

18. How do you manage long-acting insulin in a person with type 1 diabetes who is undergoing general anesthesia?

How do you manage long-acting insulin in a person with type 1 diabetes who is undergoing general anesthesia? Give one-half to two-thirds of the dose. Oral hypoglycemic and short-acting insulin can be stopped. We always err on the side of allowing some hyperglycemia but avoiding hypoglycemia.

26. How does an FEV1 help the evaluation of a patient with known COPD preoperatively?

How does an FEV1 help the evaluation of a patient with known COPD preoperatively? It is not of any help. Spirometry is helpful in patients with undiagnosed dyspnea but otherwise does not seem to portend postoperative prognosis for COPD.

28. How long after surgery is prophylactic anticoagulation initiated and for how long is it continued postoperatively to prevent venous thromboembolic disease?

How long after surgery is prophylactic anticoagulation initiated and for how long is it continued postoperatively to prevent venous thromboembolic disease? Prophylactic anticoagulation is withheld for at least 12 hours postoperatively. In neurosurgical patients postoperative pneumatic compression devices can be used alone if there is a risk of bleeding. Anticoagulation can be used for up to 5 weeks postoperatively in patients with orthopedic, abdominal or gynecologic surgery for malignancy and previous venous thromboembolic disease.

12. How many times should a man who has smoked in the past or currently between the ages of 65 and 75 be screened for abdominal aortic aneurysm?

How many times should a man who has smoked in the past or currently between the ages of 65 and 75 be screened for abdominal aortic aneurysm? Once

55. How often should liver and muscle enzymes be ordered on a patient who is asymptomatic on a statin?

How often should liver and muscle enzymes be ordered on a patient who is asymptomatic on a statin? There is no need to order these tests

41. How would you manage a patient for whom you are providing thyroid replacement and has mild or subclinical hypothyroidism and is awaiting elective surgery?

How would you manage a patient for whom you are providing thyroid replacement and has mild or subclinical hypothyroidism and is awaiting elective surgery? They can proceed with their elective surgery. Severe hypothyroidism should delay elective surgery until replacement has begun.

12. How would you manage a patient with suspected pertussis?

How would you manage a patient with suspected pertussis? Obtain a culture from a nasopharyngeal aspirate or swab and treat with a macrolide antibiotic if positive

Carpal Tunnel syndrome

MILD to MODERATE: If no evidence of weakness, atrophy, or active motor denervation on nerve conduction studies, supportive care with meds and splint is ok SEVERE: Active denervation on nerve conduction studies and have muscle weakness and atrophy on clinical examination should undergo decompression surgery to prevent irreversible motor weakness

30.

How would you manage a pre-op patient with intermediate or high risk for venous thromboembolic disease on warfarin? Stop the warfarin 4-5 days preoperatively and 1-2 days after last dose of warfarin begin the bridge with a heparin compound. If low molecular weight heparin is used it should be stopped 24 hours preoperatively. Unfractionated heparin stopped 4-6 hours preoperatively. Either heparin compound can be used as early as 12-24 hours postoperatively depending on the risk of the patient for bleeding. If the patient is intermediate risk, prophylactic low molecular weight heparin can be the initial dose whereas high risk individuals should be on therapeutic doses. Warfarin should be restarted when the patient is at low risk for bleeding and bridging is discontinued when the INR is therapeutic. An individual who is younger than 40 years old and has had venous thromboembolic disease greater than 12 months ago and no additional risk factors (see risk factor list in answer to question 29) is low risk. An individual with atrial fibrillation with a CHADS2 score less than or equal to 2 without a prior stroke is low risk.

33. How would you manage aspirin or clopidogrel in an individual who has active heart problems in the preoperative situation?

How would you manage aspirin or clopidogrel in an individual who has active heart problems in the preoperative situation? Patients receiving antiplatelet therapy for a recent myocardial infarction or stent placement should not have this therapy interrupted if they are within six weeks of a bare metal stent or an MI or within one year of a drug eluting stent. Low risk surgery can be performed while on antiplatelet therapy and other elective surgery should be delayed to get beyond these time frames. For neurosurgery, since postoperative hemorrhage would be catastrophic, antiplatelet therapy is usually avoided if the neurosurgery cannot be avoided. Aspirin therapy is recommended before CABG although other antiplatelet agents should be discontinued before an elective CABG.

38. How would you manage patients who are having a biopsy of a non-major organ or a dental procedure on chronic warfarin therapy?

How would you manage patients who are having a biopsy of a non-major organ or a dental procedure on chronic warfarin therapy? Similar to cataract surgery, continue the warfarin and target the INR between 1.3 and 1.5 perioperatively.

47. How would you manage short-acting dopamine agonists in a patient with Parkinson's on the day of surgery?

How would you manage short-acting dopamine agonists in a patient with Parkinson's on the day of surgery? The medication should be given preoperatively with a small amount of water. There may be abrupt withdrawal findings postoperatively until oral medications are absorbed. Severe rigidity could occur.

34. How would you treat the following disorders with thrombocytopenia preoperatively? a.A platelet count of under 50,000 b.A patient with ITP c.A patient with TTP

How would you treat the following disorders with thrombocytopenia preoperatively? a.A platelet count of under 50,000 - Platelet transfusion to increase the quantity above 50,000 b.A patient with ITP - Steroids, intravenous immunoglobulin or Rho(D) immune globulin preoperatively c.A patient with TTP - Plasmapheresis preoperatively

Huntington Disease

Hunting 4 Food

What is the treatment and prognosis of lentigo maligna?

Hutchinson's freckle itself requires no specific treatment apart from regular observation, but lesions demonstrating suspicious changes should be removed by excisional biopsy. If malignant on biopsy, the entire lesion should be widely excised. Prognosis is good, with at least 95% disease-free survival at 10 years. There is a tendency for lateral and superficial spread of tumours long before vertical invasion occurs.

Chronic Cutaneous lupus erythematosus

Hydroxycloroquine initial approach is Topical steroids

What are the causes of calcium stones?

Hypercalcaemia - Hyperparathyroidism (Calcium phosphate) Hypercalcuria and normal serum calcium - Idiopathic - Renal tubular acidosis (calcium phosphate) Hyperoxaluria - Intestinal malabsorption - Intestinal by-pass Normal serum and urinary calcium - ?deficient urinary crystal inhibitors (citrate).

PTU

Hyperthyroidism in pregnancy Mtheimazole causes choanal atresia and aplasia cutis

What are the causes of Uric acid stones?

Hyperuricaemia - Gout association Hyperuricosuria - Dietary protein Low urinary pH. - <pH 6.

45. I would suggest looking at pictures to be able to diagnose the following for the Boards: Kaposi sarcoma of the palate, Hairy leukoplakia with white raised spots on the side of the tongue Thrush Herpes simplex of the mouth or throat Lichen planus (note the fine white lines or Wickham's striae).

I would suggest looking at pictures to be able to diagnose the following for the Boards: Kaposi sarcoma of the palate, Hairy leukoplakia with white raised spots on the side of the tongue Thrush Herpes simplex of the mouth or throat Lichen planus (note the fine white lines or Wickham's striae).

Hypertrophic Cardiomyopathy (HCOM)

ICD placement for patients with risk factors for sudden cardiac death: (1) massive myocardial hypertrophy (wall thickness ≥30 mm) (2) previous cardiac arrest due to ventricular arrhythmia (3) blunted blood pressure response or hypotension during exercise (4) unexplained syncope (5) nonsustained ventricular tachycardia on ambulatory electrocardiography (6) family history of sudden death due to HCM - Q waves, ST depressions, T wave inversions - BIFID pulse - increases murmur with Valsalva and standing - differentiate from MVP: HCOM has no click and HANDGRIP DECREASES murmur Tx: BB for symptomatic patients Surgery reserved for those whole are still symptomatic with maximal medical therapy and significant outflow obstruction DIFFERENTIATE from Long QT syndrome - hereditary prolongation in QT which can also present as young athlete who has syncopal episode for several minutes and wakes up normal

HOCM

ICD: massive wall thickness > 3cm, previous VT or SCA, blunted BP response on exercise, unexplained syncope, NSVT, FH of SCD - 11% appropriate discharge rate per year Septal Reduction Therapy: drug refractory severe symptoms

intracerebral Hemorrhage

ICH SAH Epidural Subdural cardene gtt

CN VII Palsy

IF not better in 3 months MRI (70-90% achieve remission in 3 months) ddx: DM, Lyme, Vasculitis, HIV, Sarcoidosis, Paraproteinemia, Sjogren Syndrome) early antiviral therapy is favored by some experts artificial tears and eye patch Roids within 72 hours sequelae: Synkinesis aberrant re-innervation

52. If a woman has a palpable breast mass and the ultrasound or mammography are negative, what is your next step?

If a woman has a palpable breast mass and the ultrasound or mammography are negative, what is your next step? A definitive diagnosis is obtained through tissue sampling as 10-20% of palpable breast cancers are undetectable by ultrasound or mammography. Whereas FNA is used for cystic lesions and cytopathology, a core biopsy is used as a test of choice for most solid lesions as invasive status and hormonal receptor status can be obtained from a core biopsy.

New onset LE edema

If pretest probability high and no real explanation by USG get a pelvic MRI

Endocarditis

If valve is infected: 4-6 weeks antibiotics URGENT SURGERY - new conduction defect confirms extension of the infection into the perivalvular tissues - valve stenosis or regurgitation resulting in heart failure - left-sided endocarditis caused by Staphylococcus aureus, fungal, or other highly resistant organisms - annular or aortic abscess - persistent bacteremia or fever lasting longer than 5 to 7 days after starting antibiotic therapy - recurrent emboli and persistent vegetations - mobile vegetations greater than 10 mm in length

3. In a 40-year-old woman with chronic pelvic pain that is worse with menstruation and also has dyspareunia and dysmenorrhea, what is the most likely cause and how would you manage it?

In a 40-year-old woman with chronic pelvic pain that is worse with menstruation and also has dyspareunia and dysmenorrhea, what is the most likely cause and how would you manage it? Most likely cause is endometriosis and the diagnosis is made by laparoscopically or just empiric treatment with a GnRH agonist. Treatment is done with GnRH agonist, and for women with significant dysmenorrhea combination oral contraceptives. Women who are treated for endometriosis with a GnRH agonist or aromatase inhibitor require calcium and vitamin D supplementation. Laparoscopic surgical destruction can also be used.

59. In a healthy host who has had sinus fullness, purulent nasal discharge for greater than 10 days, and facial pain, what imaging study would you use to confirm sinusitis?

In a healthy host who has had sinus fullness, purulent nasal discharge for greater than 10 days, and facial pain, what imaging study would you use to confirm sinusitis? None, as empiric therapy can be offered, although probably still only 60% of adults have bacterial disease.

45. In a man with pelvic pain, what diagnoses should you consider?

In a man with pelvic pain, what diagnoses should you consider? In addition to prostatitis, consider urethritis, urethral stricture, testicular sources of pain, rectal masses, hemorrhoids, and neurologic disease of the bladder. Urinary tract infection needs to be ruled out.

21. In a patient for whom you do a preoperative evaluation and has no revised cardiac risk factors but cannot tell you of any exercise that reaches 4 METs, what would you do for an elective surgery?

In a patient for whom you do a preoperative evaluation and has no revised cardiac risk factors but cannot tell you of any exercise that reaches 4 METs, what would you do for an elective surgery? Nothing, individuals who have cardiac risks and can exercise to 4 METs or more or have no cardiac risks and cannot exercise to 4 METs do not need any further intervention.

46. In a patient on an anticonvulsant, what should be done on the day of surgery and postoperatively if NPO?

In a patient on an anticonvulsant, what should be done on the day of surgery and postoperatively if NPO? The oral anticonvulsant can be given on the day before and hopefully levels have been therapeutic if elective surgery was planned. Postoperatively, a parenteral choice might be needed to avoid a seizure since the patient might not absorb oral therapy.

45. In a patient on baclofen who is heading for abdominal surgery and will be NPO for a few days, what might be the recommendation?

In a patient on baclofen who is heading for abdominal surgery and will be NPO for a few days, what might be the recommendation? Benzodiazepines to prevent postoperative withdrawal seizures.

29. In a patient on warfarin therapy, when might you not offer any bridging heparin prior to surgery?

In a patient on warfarin therapy, when might you not offer any bridging heparin prior to surgery? If the procedure is minor surgery, the patient is under 40 years old and there are no additional VTE risk factors such as heart failure, nephrotic syndrome, pregnancy, estrogen use, use of a general anesthesia, acute respiratory failure, active cancer, stroke with paresis, history of venous thromboembolic disease >12 months ago and no other risks, afib with CHADS2<2 w/o prior CVA, acute infectious illness, a thrombophilia, acute rheumatic disease, inflammatory bowel disease, obesity, trauma, institutionalization and immobility.

14. In a patient who does not meet the 4 standard groups for benefit with statins such as those with a 10 year risk of less than 7.5%, what other factors might you consider in starting statin therapy?

In a patient who does not meet the 4 standard groups for benefit with statins such as those with a 10 year risk of less than 7.5%, what other factors might you consider in starting statin therapy? Family history of premature atherosclerotic disease, LDL of greater than 160, high sensitivity C-reactive protein of greater than 2, a coronary calcium score of greater than 300 Agatston units or greater than the 75th percentile for age, sex, ethnicity and an ankle brachial index of less than 0.9.

37. In a patient who has not had a recent stent (bare metal within 6 weeks, drug eluting within 1 year) or myocardial infarction within 6 weeks, what should be done with aspirin and clopidogrel preoperatively if they are having a procedure with medium or high risk for bleeding?

In a patient who has not had a recent stent (bare metal within 6 weeks, drug eluting within 1 year) or myocardial infarction within 6 weeks, what should be done with aspirin and clopidogrel preoperatively if they are having a procedure with medium or high risk for bleeding? Antiplatelet therapy can be safely discontinued to 7-10 days preoperatively and restarting 24 hours post-op unless there is an elevated risk for bleeding.

60. In a patient who is otherwise healthy and has an isolated nose bleed, what laboratory studies would you order?

In a patient who is otherwise healthy and has an isolated nose bleed, what laboratory studies would you order? None, unless this bleeding is very severe or there are clues to systemic disease.

What is the best imaging modality to diagnose cavernomas?

MRI - MRI: "popcorn" pattern with haemosiderin ring - CT: irregular hyperdensity (non-specific)

21. In a patient who is overweight but not obese with a waist circumference as a man greater than 40 inches or as a woman greater than 35 inches, what are the associated diseases for which they are at increased risk?

In a patient who is overweight but not obese with a waist circumference as a man greater than 40 inches or as a woman greater than 35 inches, what are the associated diseases for which they are at increased risk? Type 2 diabetes, dyslipidemia, hypertension and heart disease. Others for obesity include stroke, osteoarthritis, sleep apnea, gallbladder disease, endometrial, breast and colon cancer and overall mortality.

17. In a patient with an upper airway cough syndrome who does not smoke and is not on an ACE inhibitor and who has failed antihistamine and decongestant therapy, what would be the next course of management?

In a patient with an upper airway cough syndrome who does not smoke and is not on an ACE inhibitor and who has failed antihistamine and decongestant therapy, what would be the next course of management? Evaluate for asthma and if there is no evidence of asthma on pulmonary function tests with bronchoprovocation then check for sputum eosinophilia. If risk factors are present consider treatment of GERD.

37. In a patient with benign prostatic hypertrophy and some overactive bladder symptoms and a post-void residual of greater than 250 ml, what therapies might you consider?

In a patient with benign prostatic hypertrophy and some overactive bladder symptoms and a post-void residual of greater than 250 ml, what therapies might you consider? A combination of alpha blockade for BPH and an anticholinergic therapy such as oxybutynin for the overactive bladder. Be sure to be able to recognize the difference between these two lower urinary tract syndromes. Overactive bladder patients have detrusor muscle hyperactivity causing nocturia, frequency and urgency. Obstructed patients tend to have a decrease in stream, urinary retention, incomplete bladder emptying and incontinence. The test will give you the symptoms and not what the name of the syndrome is, so best to learn these. Don't forget about behavior altering advice such as limiting fluids before sleep, double voiding, anticipatory voiding, bladder training, pelvic muscle exercises and avoiding mild diuretics such as ETOH and caffeine.

54. In a patient with cauda equine syndrome and a radiosensitive tumor, what should be the management within the first 12 hours?

In a patient with cauda equine syndrome and a radiosensitive tumor, what should be the management within the first 12 hours? Urgent emergent surgical decompression. Radiation can be an adjunct therapy but no time should be wasted to decompress the area.

19. In a patient with metabolic syndrome what would be antihypertensives that the American Heart Association would recommend prescribing?

In a patient with metabolic syndrome what would be antihypertensives that the American Heart Association would recommend prescribing? ACE inhibitor and angiotensin receptor blockers as beta blockers and thiazide diuretics can worsen glucose tolerance.

35. In a patient with otitis externa who presents with facial paralysis, what diagnoses would you consider?

In a patient with otitis externa who presents with facial paralysis, what diagnoses would you consider? Herpes zoster from Ramsay Hunt syndrome (zoster oticus) or malignant otitis with invasion of pseudomonas or Staph aureus into the bone although this bacterial disease seen in the elderly, immune compromised or people with DM usually has high fever and a lot of pain and may have vertigo, much more necrosis and bone and CNS invasion.

7. In a patient with severe postherpetic neuralgia, what medications might you consider?

In a patient with severe postherpetic neuralgia, what medications might you consider? Gabapentin and if that isn't effective consider adding nortriptyline

What is Courvoiser's law?

In a pt with painless obstructive jaundice with a palpable gallbladder - the diagnosis is unlikely to be gallstones (more likely to be due to malignancy)

30. In addition to dehydration, what are some causes for orthostatic hypotension due to dysautonomia?

In addition to dehydration, what are some causes for orthostatic hypotension due to dysautonomia? Parkinson's disease, diabetes, amyloidosis, Shy-Drager syndrome and lower motor neuron injuries

52. In an immunocompetent patient who is in their 50's with acute bronchitis, which antibiotic would you prescribe?

In an immunocompetent patient who is in their 50's with acute bronchitis, which antibiotic would you prescribe? None if it is uncomplicated.

58. In an individual who has compulsive repetitive behavior such as handwashing, checking to make sure doors are locked, ordering things, counting, fear of germs and persistent ideas, thoughts, or impulses associated with significant anxiety or distress, what is the treatment of choice?

In an individual who has compulsive repetitive behavior such as handwashing, checking to make sure doors are locked, ordering things, counting, fear of germs and persistent ideas, thoughts, or impulses associated with significant anxiety or distress, what is the treatment of choice? Individuals with obsessive-compulsive disorder are best treated with cognitive behavioral therapy.

23. In an individual with COPD, what are the highest risk surgeries?

In an individual with COPD, what are the highest risk surgeries? Thoracic surgeries, abdominal aortic aneurysm repair and abdominal surgery.

Which part of the oesophagus are SCCs and adenocarcinomas typically found?

In countries where increase in adenocarcinomas is not observed, the majority of squamous cell cancers are located in the middle or lower portions of the oesophagus, while adenocarcinomas are mostly gastric cardia in position. This is in contrast to the West, where most adenocarcinomas are found in the lower oesophagus and gastric cardia.

68. In depressed elderly treated with an SSRI, what side effects might occur?

In depressed elderly treated with an SSRI, what side effects might occur? a.Increased risk of upper gastrointestinal bleeding b.Increase in SIADH

53. In individuals with syncope, what do the following tests have in common should they be considered in the evaluation? a.Head CT scan b.Carotid Doppler ultrasonography c.EEG d.Cardiac enzymes

In individuals with syncope, what do the following tests have in common should they be considered in the evaluation? a.Head CT scan b.Carotid Doppler ultrasonography c.EEG d.Cardiac enzymes These can all be omitted from the work-up unless something points to particular diagnoses at the site.

What is the treatment of Barrett's oesophagus?

In patients with Barrett's oesophagus, the premalignant dysplastic stages allow endoscopic surveillance to be carried out; however the optimal interval, benefits and cost-effectiveness are uncertain since most patients with oesophageal carcinoma present without a history of Barrett's oesophagus. Endoscopic ablation of Barrett's mucosa by laser, photodynamic therapy or other means followed by intensive acid suppressive therapy or fundoplication has been advocated in order to revert the epithelium to a squamous type. Whether such strategies can halt the progression to cancer is still under investigation.

62. In preoperative evaluation of a patient who is having elective procedure and no positive past medical history, what is the role of laboratory tests, chest x-ray and EKG?

In preoperative evaluation of a patient who is having elective procedure and no positive past medical history, what is the role of laboratory tests, chest x-ray and EKG? They are not necessary as they should be based on suspected comorbidities gleaned from the history.

61. In seronegative women, which vaccines should be administered at least 4 weeks prior to conception?

In seronegative women, which vaccines should be administered at least 4 weeks prior to conception? Rubella and varicella

When does paralytic ileus tend to develop post surgery?

In the acutely ill patient who has undergone surgical intervention for peritonitis, paralytic ileus may be present from the first post-operative day. Otherwise, it tends to make its presence felt about 5 days after operation, and the patient may have been making an apparently uneventful recovery. Abdominal distension occurs and the patient may vomit. Oral fluid restriction should be instituted and intravenous replacement may be required. Most cases resolve spontaneously.

What is the link between dysplastic naevus and melanoma?

In the majority of cases there is a strong family history of such naevi and sometimes an additional family history of melanoma. Where there is an established family history of melanoma in association with DN, the trait is inherited in an autosomal dominant fashion. The management of such patients requires excisional biopsy of a typical lesion to establish the diagnosis, with genetic studies where appropriate and regular review with photographs and measurement of lesions for comparison, allowing excision of suspicious lesions at an early stage.

What are the treatment options for incisional hernias?

Incisional hernias should be repaired because (a) they increase in size with time and may be very difficult to repair when large, (b) they are at risk of becoming irreducible, obstructed and strangulated, especially if the neck is narrow, and (c) patients request repair because of discomfort and unsightly appearance. An abdominal support or binder may be helpful in very large hernias or in patients unfit for surgery.

Inflammatory Bowel Disease

Increased risk of colon cancer, patient should recieve screening 8 years after diagnosis then every 1-2 years Associated with seronegative spondyloarthropathy (presents like Ankylosing Spondylosis) Ulcerative Colitis - inflammation typically begins in the rectum and extends proximally in a circumferential manner - continuous lesions - Mesalamine (can increase risk of acute pancreatitis), prednisone - if symptoms persist or get worse, either intravenous glucocorticoids or an anti-tumor necrosis factor agent (infliximab, adalimumab, and golimumab) - Primary sclerosing cholangitis (PSC) is associated with UC but no other antibody. Total bili, ALT and AST can be mildly elevated, Alk Phos elevated alot more (need colonoscopy to assess for UC) - regardless of disease severity, if evidence of HIGH GRADE DYSPLASIA on biopsy, high risk of cancer and patient should go for SURGERY, complete colectomy - other indication for SURGERY is of course a mass lesion Crohn's Disease -PATCHY colitis (known as skip lesions) with some large, deep ulcers and rectal sparing - ESR elevated, heme positive - can have abdominal colicky pain, night sweats, subjective fevers - need to quit smoking - high risk of calcium oxalate kidney stones - if MILD disease and in the right colon to ileum, Budesonide works best specifically in these areas and is a good starting steroid for mild disease - Prednisone, Mesalamine (can increase risk of acute pancreatitis) - Azathioprine or 6-mercaptopurine if a patient requires repeated courses of glucocorticoids....they work as maintenance meds during remission post steroid treatment - Increase to Anti-TNF if needed with either inflixiMAB, adalimuMAB, and certolizuMAB ****Anti-TNF agents are SAFE in PREGNANCY**** - Methotrexate for maintenance - if presence of strictures, SURGERY is indicated for resection of that area Pyoderma gangrenosum - extraintestinal cutaneous manifestation of Crohn's - painful pustules that rapidly ulcerate and expand, with edematous, rolled, or undermined borders that may have a violaceous hue MESALAMINE can cause REVERSIBLE INFERTILITY in men (decreases sperm count). Stop med and restart once they have conceived - (Mesalamine can increase risk of acute pancreatitis)

Mitral Valve Replacement

Indications - symptomatic severe regurg with left ventricular (LV) ejection fraction greater than 30% - asymptomatic severe regurg with mild to moderate LV dysfunction (ejection fraction of 30%-60% and/or LV end-systolic diameter ≥40 mm) - surgical valve repair is generally preferred to valve replacement, but it may not be possible with extensive calcification of the valve leaflet or annulus, prolapse of more than one third of the leaflet tissue, or extensive destruction of the chordal apparatus - Mechanical valve with those who can tolerate anticoagulation - Bioprosthetic valve for those who cannot tolerate anticoagulation SEVERE - greater than 5 mm Hg to 10 mm Hg in severe mitral stenosis, valve area is usually less than 1.5 cm2 in severe mitral stenosis and 1.0 cm2 or less in very severe mitral stenosis - Tx: Percutaneous BALLOON Mitral Valvuloplasty ***Mitral Stenosis due to Rheumatic Fever in the past*** PREGNANCY - Although warfarin poses an increased risk of teratogenicity and fetal loss, it appears to be the most effective option for reducing thromboembolism risk in the mother -___-

What are the indications and contraindications to NG tube insertion?

Indications: gastric decompression, analysis of gastric contents, irrigation/dilution of gastric contents, feeding (only if necessary due to risk of aspiration naso-jejunal tube preferable) Contraindications: suspected basal skull fracture, obstruction of nasal passages due to trauma

What are the two phases of immunosuppresion regimes?

Induction - Once off dose given at the start, can be depleting or non-depleting - Depleting: rATG (polyclonal antibody) - Non-depleting: Basiliximab, binds IL-2 receptor and prevents T cell activation Maintenance - Continues for the life of the graft - Compliance is very important - Usually give a combination of calcineurin inhibitor, antiproliferative agent, steroid

How are infection stones formed?

Infection Stones arise due to the action of urease splitting urinary urea to the insoluble magnesium ammonium phosphate. Urease is produced by many bacteria most notably proteus. These stones may grow rapidly and can form complete casts of the calyceal system (Staghorn calculus). Recurrence rates depend on complete elimination of the calculi and prevention of recurrent infection.

What is the most common site for an Aortic Aneurysm?

Infrarenal

What is the treatment of ependymomas?

Intracranial 1. Maximal safe resection followed by adjuvant radiotherapy 2. Chemotherapy in young children or in patients with residual disease Spinal Cord 1. Gross total resection - Limited evidence for radiotherapy or chemotherapy

3. Is there any methodology to reduce polypharmacy in the elderly?

Is there any methodology to reduce polypharmacy in the elderly? The good palliative-geriatric practice algorithm for drug discontinuation has been shown to be effective in reducing polypharmacy and improving mortality and morbidity in nursing home patients. In other words, a drug review evaluation should be done periodically, perhaps twice a year or more frequently, depending on the complexity of the regimen.

Constrictive Pericarditis

JVD Kassmaul knock pulsus

What is a juvenile naevus?

Juvenile naevus (Spitz naevus) is most common in children and adolescents but may also occur in adults. It presents as a pink nodule that rapidly increases in size and on excision shows frequent mitoses and cellular pleomorphism which may raise questions of malignancy but is benign.

AED & Pregnancy

Keppra or Lamictal can consider stopping in no Seizure for 2 years unless Epilepsy disorder likely to cause seizure

Tick bite

LYME - Borrelia - can have Bell's Palsy, but with Lyme's patients can also develop bilateral nerve palsy - eythema migrans, central clearing, no ulcerations - ERYTHEMA MIGRANS is characteristic of Lyme's when differentiating tick bites - NORTHEAST - if patient has prodrome phase then suddenly develops HEART BLOCK, consider Lyme - Tx: Doxy or amoxicillin for 28 days - if pregnancy, Macrolide - if persistent with neuro sx and no response to oral, then IV ceftriaxone TULAREMIA - tick bite or rabbit - ULCEROglandular, glandular, oropharengeal, oculoglandular, typhoidal, pneumonic - Ulcers are indicative - Arkansas - Francisela Tularemia GN bacillus via Ticks and blood sucking insects or inhalation/ingestion can cause tularemia...can be inhaled and can be used in bioterrorist attacks via inhalation and causes hemorrhagic PNEUMONIA so precautions needed NO MEDIASTIHUM WIDENING - chills myalgias arthralgias and ulverative rash at inoculatio site - Tx: Tetracycline is usually ok but Stepromycin or gentamicin if severe - IF INHALED Tx: Cipro, meropenem and linezolid as cultures are pending EHRLICHIOSIS (aka Anaplasma according to Awesome Review) - Arkansas, Missouri (MidWest) ***MISSOURI, PANCYTOPENIA, TICK BITE*** - severe headache and systemic sx ***maculopapular or petechial rash, no ulcers*** - destruction of monocytes so usually monocytes absent - LFTs elevated and low platelets ANAPLASMA - Arkansas, Missouri (MidWest) - severe headache and systemic sx - destruction of PMNs so usually PMNs absent BABESIA - Maltese cross (intraerythrocytic inclusion) - hemolytic anemia - up north, fevers, rigors, pale - no rash - Dx: Blood smear, PCR - Moderate disease: Atovaquone/Azithro - Severe disease: Clinda/Quinine - Super Severe: Exchange Transfusion

Broad Spectrum AEDs

Lamictal Keppra Topiramate Depakote Zonisamide

Immunodeficiency

Late complement component deficiency - C5, C6, C7, C8, C9 - recurrent, invasive meningococcal or gonococcal infections Common variable immunodeficiency (CVID) - B-cell and T-cell abnormalities - hypogammaglobulinemia - recurrent bacterial infections (sinus, skin, etc.) - nodular lymphadenopathy, splenomegaly - low IgG and IgA - recurrent sinus and URI but also recurrent Giardia - high risk to encapsulated organisms - Tx: Immunoglobulins monthly Selective IgA deficiency - B-cell immunodeficiency - asymptomatic or have sinopulmonary infections, seasonal allergies, chronic diarrhea - GI symptoms, IBD, sprue like symptoms, deliac disease, Giargiasis Classical complement pathway - C1, C4, C2 deficiencies - associated with rheumatologic disorder Herpes Zoster - contact precautions for all but those with immunodeficiency should have airborn precautions too bc it can disseminate to resp tract - if immunocompromised, no live vaccines like Varicella-zoster. IF CONCERNED ABOUT EXPOSURE you give Varicella-zoster immunoglobulin only. Immunocompent can get vaccine and globulin but immunocompromised only the immunoglobulin for prophylaxis - Tx: Valacyclovir can actually decrease the length of post herpetic neuralgia - Those on immunosuppresion therapy are at risk for non-hodgkin lymphoma - lymphadenopathy in multiple sites and systemic B symptoms (night sweats, fever, and weight loss) Splenectomy - Increased risk for SNH Kleb - StreptNeisseriaHaemophilus and Kleb PPD testing - anyone over 5mm is POSITIVE (but also anyone with EXPOSURE and over 5mm is also POSITIVE) Progressive Multifocal Leukoencephalopathy - PML due to JC virus - demyelination to parieto-occipital areas on MRI can be diagnostic but biopsy can confirm - decreased vision - Tx: upon resolution of immunodeficiency Large B-cell Lymphoma - high risk in those on chronic T cell immunosuppressive agents

What is the arterial supply to the liver?

Left and right hepatic arteries (branches of the hepatic proper)

What are the most common benign oesophageal tumours?

Leiomyomas

What is a leiomyoma?

Leiomyomas are benign smooth-muscle tumours arising in the oesophageal wall. They are usually solitary, well en- capsulated with an intact overlying mucosa, and grow slowly. Most small (<5 cm) leiomyomas are asymptomatic and are an incidental finding on barium study.

What is lentigo maligna?

Lentigo maligna occurs in elderly patients, usually >70yrs, M>F It appears as an extensive melanotic lesion (Hutchinson's melanotic freckle) on the cheek or temple. Characteristically dark brown in colour and develops over many years as a superficial impalpable lesion unless malignant change occurs. Malignant change is manifested by the development of palpable darker nodules within an irregular edge, and this change is often multicentric.

Post Menopausal

Lichen Sclerosis: marked inflammation and epithelial thinning that is pruritic, pain during intercourse - Dx: biopsy - treat with topical high-potency glucocorticoid (class I or II), such as clobetasol, mometasone, or betamethasone - Hormone therapy no longer advised due to increased risk of adverse effects, though some patients still accept risk - if TG level significantly increases, it is due to liver first pass effect and need to STOP OCPs and switch to transdermal patch instead to lower TG level - UNOPPOSED ESTROGEN regimens increase risk for ENDOMETRIAL CANCER, so unopposed estrogen should only be used in patients WITH HYSTERECTOMY!!

What is the treatment of hiatus hernia?

Lifestyle modification: - Stop smoking, weight loss, elevate head of bed, no meals <3h prior to sleeping, smaller and more frequent meals, avoid alcohol, coffee, mint and fat Medical: - Antacid, H2-antagonist, proton pump inhibitor, prokinetic agent Surgical (<15%): - If failure of medical therapy, oesophageal stricture, severe nocturnal aspiration, Barrett's oesophagus - Anti-reflux procedure (usually laparoscopic) e.g. Nissen fundoplication - Fundus of stomach is wrapped around the lower oesophagus and sutured in place, 90% success rate

Prostate Cancer

Low risk, Early onset (No clinical evidence of spread, PSA level less than 10 and a Gleason score less than 8) DO NOT need further imaging studies Higher risk, more progressive (Clinical evidence of spread, PSA level of 20 or higher OR a PSA level of 10 with Gleason score of 8 or higher) - staging scans should include BONE SCAN - after resection and remission, if PSA remains elevated above 10, high likelihood of harboring distant metastatic disease and should be started on ANDROGEN DEPRIVATION THERAPY - ANDROGEN therapy typically can controll progression, but if it progresses to the bone, consider bisphosphonate and bone-seeking radiopharmaceutical agent - RADIUM-223 is associated with improvement in both symptoms and overall survival when used to treat patients with bone-limited or bone-predominant symptomatic metastatic prostate cancer - 5 alpha reductase inhibitors (Finasteride) proven to decrease incidence and contribute to prevention in some studies of patient's who have no been diagnosed but are at increased risk due to family hx etc...though, controversial :-< - no PSA over 75

Anemia

MACROCYTIC - folate level may be delayed - elevated homocysteine level is 90% sensitive for folate deficiency, making this measurement the most sensitive diagnostic marker in suspected folate deficiency when the serum folate level is normal - MMA elevated in B12 deficiency - chronic PPI can lead to B12 deficiency - Tx with B12 can normalize Hb in about 2 months, neuropathy in several months. But need to monitor POTASSIUM bc once you start treatment and we start making new RBCs, K gets used up and we need to be careful about hypokalemia MICROCYTIC - Iron deficiency is the most common cause of hyporesponsiveness to erythropoietin for ESRD, and KDIGO guidelines recommend intravenous rather than oral iron replacement among hemodialysis patients who require iron, KDIGO wants ESRD patients to have Ferritin over 500. If becoming more anemic, consider IV iron rather than increasing erythropoietin - Iron deficiency anemia can lead to a reactive thrombocytosis that is generally well tolerated - can be caused by CELIAC disease - Iron supplementation can interfere with Levothyroxine absorption can worsen hypothyroid symptoms so don't take at the same time - TARGET CELLS in both iron def and thalassemia, so always do iron studies and RDW to differentiate (INC with iron deficiency, DEC with thalassemia) - Chronic disease: Inflammatory states produced HEPCIDIN overtime which inhibits iron absorption in GI tract, leading to microcytic anemia. EPO increases but no erythropoieisis can take place PURE RED CELL APLASIA - could be congenital but often presents post viral infections - notably Parvo B19 (low RBCs!) in immunocompromised like HIV or sickle cell - Epo will be decreased but RBC morphology is NORMAL (vs hypochromic or schiztocytes) SEQUESTRATION - hypersplenism (splenomegaly) with aplastic anemia among many etiologies - means increased RBCs packing the spleen so Reticulocyte could is INCREASED but morphology should be NORMAL

Osteomyelitis

MRI is the most sensitive and specific imaging modality for diagnosing osteomyelitis - with CHRONIC WOUND or chronic draining sinus, the demonstration of microorganisms coupled with characteristic features of osteomyelitis eliminates the need for MRI confirmation of the diagnosis - for chronic wounds, bone biopsy and culture is best to guide treatment

What is the classical presentation of Boerhaaves syndrome?

Macklers triad: - Retrosternal chest pain - Subcutaneous emphysema - Vomiting May only be present in 15-30% Diagnosis is commonly delayed post 12hrs

What is the embryologic defect responsible for oesophageal cysts?

Maldevelopment of the posterior division of the primitive foregut The lining of the cyst can vary and can include squamous columnar, cuboidal, pseudostratified, ciliated and gastric mucosae

What is a melanoma?

Malignant neoplasm of pigment forming cells (melanocytes and naevus cells) Classified into: - Lentigo maligna - Superficial spreading - Nodular - Acral lentiginous

PE classification

Massive = 40 mm Hg drop for greater than 15 minutes unavailable or critically ill = emergent bedside TTE remember to get biomarkers

Skin Cancers

Melanoma - BRAF mutation - prognosis can be predicted best by lesion DEPTH - If depth <.76cm then 1cm excision is sufficient - If depth >.76cm then excision with 1cm borders plus sentinel node biopsy - even if 1 lesion, surgical removal must be followed by sentinel node biopsy

Colitis

Microscopic Colitis - chronic, watery diarrhea - elderly - hx of NSAID use - contrast to inflammatory bowel disease, MC is more common in older persons and does not cause endoscopically visible inflammation - Dx: Lymphocytic and collagenous colitis are the two subtypes of MC, and they are distinguishable only by histology, BIOPSY - Collagenous biopsy shows thickening of the subepithelial collagen band - Lymphocytic biopsy shows increased intraepithelial lymphocytes, NO thickening - supportive care for mild persistent disease, bismuth subsalicylate for moderate disease, or NSAIDS and budesonide for severe disease ****Crohn's Disease: for MILD disease and in the right colon to ileum, Budesonide works best specifically in these areas and is a good starting steroid for MILD CROHN'S****

Midpoint fixed pupils and both

Midbrain Barbiruates Anoxia Atropine Hypothermia

Status Migrainosus

Migraine attack extending beyond 72 hours - persistent severe pain that often is accompanied by protracted nausea with vomiting and profound sensory sensitivities. Hormonal factors are extremely common as inciting events. Life stressors, mood or anxiety disorders, and acute medication overuse may be other contributing factors - Triptans unsuccessful - Can treat with steroids or IV dihydroergotamine

What are the types of gall stones?

Mixed stones 80% Cholesterol stones 20% Pigment stones (rare)

osteoporosis

Modifiable RFs: smoking, ETOH and sedentary lifestyle, Meds, Vit D and calcium, Estrogen non mod RFs: age, post menopausal, low body weight, white or asian, malabsorption, Hypercortisolism, Hyperthyroidism, Hyperparathyroidism use the average bone density at L1-L4 you can use peripheral bone density in really fat people and metal implants also forearm measurement is recommended for hyperparathyroidism (bone turnover is increase in cortical bone over cancellous) Z score is used to identify bone loss 2/2 factors other than aging (pre-menopausal women) age appropriate screening: 65 years old 1 or more Rfs earlier DXA - hip most accurate for risk of hip fracture - lumbar best for monitoring also earliest response to therapy

Farmer's Lung

Mold in Hay Bails avoid the trigger severe talk about systemic steroids

What is the management of a meningioma?

Monitoring - The majority of incidental meningiomas show minimal growth; thus, they may be observed without surgical intervention unless specific symptoms appear of the tumour demonstrating growth - MRI or CT every 6-12months Surgical intervention - Younger patients - Symptomatic Radiotherapy - Adjuvant may be considered for higher grade meningiomas, partial resection - Primary therapy in elderly or in locations such as cavernous sinus

DRESS

Morbilliform exanthema Type IV HS rxn = delayed onset usu 10 days to several weeks meds: SUlfa, ABX, allopurinol and AEDs CBC & CMP LAD internal organ involvement atypical lymphocytosis or eosinophilia Bx: lymphocytic infiltrate & edema

What is the clinical presentation of an AAA?

Most asymptomatic 60-70% Symptomatic - Pain alone (recent acute expansion) (abdominal/back) - Pain in association with rupture - Thromboembolism to lower extremities - Compression of adjacent organs Ruptured AAA: Triad of abdominal or back pain, hypotension, and pulsatile abdominal mass

Minimal Change Disease

Most common cause of idiopathic nephrotic syndrome in children, good portion of adults, can be with diabetes - significant loss of protein in urine - oval fat bodies on UA - acute onset of edema and weight gain due to fluid retention - foot podocytes can be seen on biopsy which is diagnostic - 1st line = Prednisone 3 months - 2nd line = cyclophosphamide

Where do dermoid cysts most frequently occur?

Most commonly found at lateral third of eyebrow or midline under nose

55. Most patients with neck pain recover with conservative therapy. For whom would you obtain an x-ray or do a further evaluation?

Most patients with neck pain recover with conservative therapy. For whom would you obtain an x-ray or do a further evaluation? For an individual who is greater than 50 years old you might want to look for malignancy or osteoarthritic changes. In individuals with anterior neck pain another etiology may indeed be present as that would uncommonly be due to cervical spine disease. In any patient with a history of cancer, pain should be urgently evaluated even without neurologic findings, whether the pain be in the neck, thoracic or lumbar spine.

68. Most younger women with dysmenorrhea have no underlying pelvic pathology; however, 10% of women do have underlying pathology. What is the most common cause when pathology is present?

Most younger women with dysmenorrhea have no underlying pelvic pathology; however, 10% of women do have underlying pathology. What is the most common cause when pathology is present? Endometriosis which can cause cyclical and noncyclical pain.

Chemotherapy

NEOADJUVANT chemotherapy: given before curative-intent surgery ADJUVANT chemotherapy: given after curative-intent surgery CONVERSION chemotherapy: given with the intention to shrink a tumor to surgically resectable size PALLIATIVE chemotherapy: given to prolong life, understanding that cancer is incurable, unresectable and is given without realistic curative intent. ADVERSE EFFECTS EGFR inhibitors (Cetuximab, Erlotinib) - acne rash Doxorubicin - CHF Vincristine - Tendon reflexes, nephrotox VinBLASTine - myelosuppressive Taxanes/carboplatin/monoclonal abs - infusion reactions Cisplastin - ototoxicity, nephrotox, mag wasting CycloPHOSPHAMIDE - hemorrhagic cystitis Cyclosporin - inc risk of uric acid, GOUT EGFR inhibitors - acne like rash

Polyuria

NEPHROGENIC DI - enuresis as a kid - polyuria as an adult - Na borderline elevated and relatively low urine osmolality, no evidence of DM - minimal response to desmopressin - minimal response to water deprivation - Tx: Thiazides CENTRAL DI - no lifelong history like nephrogenic patients - urine concentrates with vasopressin - Tx: vasopressin, desmopressin, chlorpropamide to stimulate ADH Psychogenic Polydypsia - hyponatremia - Tx: Water restriction

Primary CNS Lymphoma

NHL MC supratentorial often affects optic radiations CSF only diagnostic in 10% slit lamp Brain biopsy Rx: MTX based CTX & WBRT resection can worsen outcomes Dexamethasone should be avoided before biopsy because it can decrease yield focal photon is more appropriate for other brain tumors

Statistics

NNT = 1/ARR ARR = Risk in placebo group - Risk in control Sensitivity = TP/(TP+FN) High Sensitivity = SNOUT = good RULE OUT test High Sensitivity = High NPV Specificity = TN/(TN+FP) High Specificity = SPIN = good RULE IN test High Specificity = High PPV Positive Likelihood Ratio Sensitivity/(1-Specificity) Negative Likelihood Ratio (1-Sensitivity)/Specificity Odds Ratio - numerator = intervention - denominator = control = 1 means control and intervention the same <1 means control is better >1 means intervention is better Confidence Interval - large interval means LOW precision - small interval means MORE precision - if it crosses 1 then NOT STATISTICALLY SIGNIFICANT

Metabolic Acidosis

NORMAL ANION GAP - consider laxatives/GI losses via diarrhea vs RTA - If no diarrhea, then Type 2 or 3 RTA!!!! - inability of the kidney to excrete acid (renal tubular acidosis) or loss of bicarbonate, usually through the gastrointestinal tract (diarrhea) - measure URINE STUDIES (Na+K) - Cl....if Chloride negative, then GI losses. If Chloride positive, kidney losses - This is due to Choride measurement goes with ammonium measurement, which is excreted in an attempt to acidify urine from acidic body HIGH ANION GAP ACIDOSIS - Bicarb low...decrease in bicarb should be about the same as change in anion gap. - If change in Bicarb is MORE than gap change then consider concomitant NORMAL ANION GAP METABOLIC ACIDOSIS (ex: laxatives/GI losses via diarrhea) - If change in Bicarb is LESS than gap change then consider concomitant METABOLIC ALKALOSIS (VOMITING, diuretic induced, mimicking Bartter and Gitelman syndromes)

SSRIs

NSAIDs plus SSRI increase UGIB risk AGA recommends gastroprotection RR increase 3-4 highest with elderly Hyponatremia - elderly - female - diuretic - low body weight

6. Name 3 contraindications to NSAID therapy.

Name 3 contraindications to NSAID therapy: a.Peptic ulcer disease (many recommend a proton pump inhibitor to reduce gastric toxicity of chronic NSAID use) b.Chronic kidney disease c.Heart failure

38. Name 3 groups of individuals who may present with acute myocardial infarction but less likely with classic symptoms.

Name 3 groups of individuals who may present with acute myocardial infarction but less likely with classic symptoms: a.Women b.The elderly c.Individuals with diabetes

32. Name 3 hormonal disorders associated with erectile dysfunction.

Name 3 hormonal disorders associated with erectile dysfunction: a.Hypogonadism b.Hypothyroidism c.Hyperprolactinemia

2. Name 3 medications that are most likely to lead to hospitalization due to unintentional overdose and a fourth medication that also commonly leads to emergency department visits:

Name 3 medications that are most likely to lead to hospitalization due to unintentional overdose and a fourth medication that also commonly leads to emergency department visits: Oral hypoglycemics, warfarin and insulin lead to unintentional overdose; whereas, oral antiplatelet agents lead to emergency department visits either from their own effect or by being combined with warfarin.

42. Name 3 physical findings that would be evident in a patient with pneumothorax.

Name 3 physical findings that would be evident in a patient with pneumothorax: Decreased chest expansion, decreased breath sounds and hyperresonance to percussion all on the affected side. You also could have looked for deviation of the trachea to the unaffected side for tension pneumothorax.

17. Name 3 screening tests for diabetes.

Name 3 screening tests for diabetes: a.Fasting plasma glucose b.Hemoglobin A1c c.A 2 hour 75 gram oral glucose tolerance test

27. Name 4 diseases in obese patients that improve or resolve with bariatric surgery.

Name 4 diseases in obese patients that improve or resolve with bariatric surgery: a.Diabetes b.Hypertension c.Obstructive sleep apnea - resolved d.Hyperlipidemia - improved in a majority of patients

24. Name 4 live attenuated vaccines that are recommended for all adults.

Name 4 live attenuated vaccines that are recommended for all adults: a.Influenza, although inactivated vaccine can be used instead of flu mist b.Varicella for persons born after 1980 or healthcare workers or persons with increased risk of disseminated varicella without documented vaccination or immunity c.Herpes zoster for adults greater than 60 years old d.Measles, mumps and rubella for adults born after 1957 without documented vaccination or immunity. A second dose is indicated for healthcare workers, international travelers, college students and post exposure prophylaxis.

36. Name 5 causes of cardiac chest pain.

Name 5 causes of cardiac chest pain: a.Acute coronary syndrome b.Aortic dissection c.Myocarditis d.Pericarditis e.Aortic stenosis

46. Name 5 drugs that can cause bilateral lower extremity edema.

Name 5 drugs that can cause bilateral lower extremity edema: a.Nifedipine b.Amlodipine c.Thiazolidinediones d.NSAIDs e.Fludrocortisone

TUNA FISH for back red flags

Trauma Unexplained Neuro symptoms Age > 50 Fever IVDA/Immunocompromised Steroids History of Cancer/HIV

25. Name 7 inactivated vaccines that may be recommended for adults

Name 7 inactivated vaccines that may be recommended for adults: a.Inactivated influenza vaccine b.Tetanus, diphtheria and acellular pertussis every 10 years with a one-time acellular pertussis and every 10 years just for the Tetanus and diphtheria c.Pneumococcal vaccine for adults aged greater than or equal to 65 or adults 19 to 64 with risk factors d.Human papilloma virus for females 11 to 26 year old and men 11 to 21, although permitted up to age 26 e.Meningococcal vaccine for adolescents, persons living in dormitories or individuals with HIV or asplenia f.Hepatitis A vaccine for travelers to endemic areas, men who have sex with men, users of illicit drugs or persons with chronic liver disease. The latter two are important as injection drug users have a hepatitis A risk even though it is not a blood-borne disease and individuals with chronic liver disease cannot afford to have hepatitis A infection. g.Hepatitis B for adults with increased risk of transmission, morbidity or exposure, although universal hepatitis B vaccine has become more common as all children receive it.

30. Name 7 vaccines that all healthcare workers should obtain.

Name 7 vaccines that all healthcare workers should obtain: a.Hepatitis B b.Varicella c.Measles d.Mumps e.Rubella f.Influenza g.Tetanus, diphtheria and acellular pertussis

8. Name a non-pharmacologic therapy for stress incontinence and urge incontinence.

Name a non-pharmacologic therapy for stress incontinence and urge incontinence: Pelvic floor muscle training or Kegel exercises are effective for stress incontinence. Bladder training and urge suppression techniques are effective for urge incontinence. Prompting of voiding can be helpful and anticipatory voiding can be helpful too.

10. Name clues to aberrant drug taking behaviors that might be associated with substance abuse.

Name clues to aberrant drug taking behaviors that might be associated with substance abuse: a.Multiple episode of prescription loss b.Repeated request for doses increase or early refills c.Drug request by name d.Missed appointments e.Repeatedly seeking prescriptions from other clinicians f.Not following through on other aspects of the treatment plan g.Aggressive complaining about needing more of the drug

60. Name medications that are potential teratogens and need to be used carefully and perhaps with effective birth control in women who might be considering childbearing.

Name medications that are potential teratogens and need to be used carefully and perhaps with effective birth control in women who might be considering childbearing: ACE inhibitors, carbamazepine, fluoxetine and paroxetine, folate antagonists, lithium, phenytoin, primidone, statins, tetracycline, valproate, vitamin E derivatives and warfarin.

34. Name tests that should be rarely used in the evaluation of a patient with syncope and thus not to be selected as a choice on your Board exam. (4)

Name tests that should be rarely used in the evaluation of a patient with syncope and thus not to be selected as a choice on your Board exam: CAT scan of the head, carotid Doppler, EEG, measurement of cardiac enzymes

15. Name the 4 lifestyle modifications you would add to statin therapy in a patient at risk.

Name the 4 lifestyle modifications you would add to statin therapy in a patient at risk: a.Healthy heart diet b.Regular exercise c.Avoidance of tobacco d.Maintenance of healthy weight

2. Name the anti-nausea agent described below: a.A dopamine agonist with prokinetic activity through the cholinergic system. Is available intravenously, subcutaneously or orally b.A serotonin antagonist effective for chemotherapy related pain c.A cannabinoid effective for chemotherapy related nausea and age related wasting d.A progestational agent used to improve appetite and weight gain

Name the anti-nausea agent described below: a.A dopamine agonist with prokinetic activity through the cholinergic system. Is available intravenously, subcutaneously or orally - metoclopramide b.A serotonin antagonist effective for chemotherapy related pain - ondansetron c.A cannabinoid effective for chemotherapy related nausea and age related wasting - dronabinol d.A progestational agent used to improve appetite and weight gain - megestrol

60. Name the causes of olecranon bursitis.

Name the causes of olecranon bursitis: Repetitive trauma, gout, rheumatoid arthritis, infection

28. Name the conditions in which a booster at 5 years for the 23-valent pneumococcal polysaccharide vaccine should be used.

Name the conditions in which a booster at 5 years for the 23-valent pneumococcal polysaccharide vaccine should be used: a.HIV infection b.Chronic kidney disease or nephrotic syndrome c.Malignancy such as leukemia, lymphoma or generalized malignancy d.Use of immunosuppressive medications such as corticosteroids, antirejection medication or radiation e.Multiple myeloma f.Congenital or acquired immune deficiency g.Functional asplenia such as sickle cell anemia or other hemoglobinopathies h.Anatomical asplenia i.Chronic cardiovascular disease* j.COPD* k.Diabetes mellitus* l.Chronic liver disease* m.Alcoholism* n.Cigarette smoking* o.CSF leak* p.Cochlear implant* *For these individuals a single vaccination is recommended with a booster at age 65 or 5 years after the initial vaccination whichever is later; however, if they were vaccinated after the age of 65 no booster is recommended. Therefore, remember that revaccination after 5 years is recommended for those who are asplenic, immunocompromised or have kidney failure.

15. Name the most common causes of upper airway cough syndrome.

Name the most common causes of upper airway cough syndrome: a.Asthma b.Non-asthmatic eosinophilic bronchitis c.GERD This is in patients who have cough unrelated to smoking or ACE inhibitors

ABE ppx (who doesn't need it)

Native valve disease MVP rheumatic heart disease Bicuspid aortic valve

What antibiotics are recommended in appendicitis?

Need to cover: - Gram negatives (eg, E coli) - Anaerobes (eg, Bacteroides) Most commonly used options include: - Gentamicin, Ampicillin, Metronidazole ("triples") -> Gentamicin - aminoglycoside - covers gram negatives -> Ampicillin - penicillin - covers enterococcus species -> Metronidazole - covers anaerobes - Ceftriaxone and metronidazole ->Ceftriaxone - third generation cephalosporin - covers gram negatives; does not cover enterococcus -> Metronidazole - covers anaerobes

What is the only known risk factor for ependymomas?

Neurofibromatosis Type II - risk for intramedullary spinal cord ependymoma

12. What advantage does staging of a pressure ulcer have?

What advantage does staging of a pressure ulcer have? It is helpful in guiding appropriate therapy.

Should steroids be stopped pre surgery?

No If long term steroids, will need periop replacement, usually with an increased dose to counteract the surgical stress If not given, an Addisonian crisis may occur (hypotension, hyponatraemia, hyperkalaemia) because the adrenal glands have been suppressed by long term use and cannot respond to the added stress of surgery

Post Parathyroidectomy

No PTH = No 1,25 diOH VitD must be on Calcium and Calcitriol Urine Calcium < 300 mg/24hr with SCa in normal range if higher 1st decrease calcium Hypercalciuria could mean decreased GFR and nephrocalcinosis

How long before surgery should a patient be fasted?

No solid food - 6 hours No clear fluids - 2 hours

What is the sensitivity of CT in SAH?

Non-con CT brain is the gold standard (reference) - Almost 100% sensitive in 1st 6 hours, 92% in first 24 hours Lumbar puncture is advised if strong clinical suspicion and negative CT scan

What is the treatment of bladder cancer?

Non-muscle invasive - Low grade: Intravesical chemotherapy given at the time of cystoscopy. Surveillance interval based on recurrence rate. Typically 4 months, 6 months then annual. - High grade: Repeat cystoscopy and re-biopsy both tumour site and other areas. Intravesical BCG. Given as a weekly induction for 6 weeks. The addition of a 12 monthly maintenance programme improves results with reduced recurrence rate. Muscle invasive: - Cystectomy +/- chemotherapy, lymph node dissection - External beam radiotherapy +/- chemotherapy

Cardiac Transplant

Normal HR in transplant heart is 90-110 BPM Dyspnea: rejection usu with in 1 year low after 1st year unless noncompliant with antirejection meds endomyocardial biopsy cardiac allograft vasculopathy 50% at 5 years MC cause of mortality 1 year post graft vasculopathy and ischemia will be silent because of denervation

Dementia

Number of domains executive function perception language behavior

Bioprosthetic valve

OAC for 1st 3 mo

Spirometry

OHS - BMI > 30 (usu 40) pCO2 > 45 mm Hg, & pO < 70 mm Hg

Osteomalacia

ONCOGENIC Osteomalacia - bone pain, increased alk phos, hypophosphatemia with kidney phosphate wasting in the setting of low 1,25-dihydroxy vitamin D and normal 25-hydroxy vitamin D concentrations - fibroblast growth factor 23

rhinitis medicamentosa

OTC nasal decongestants tachyphylaxis - limit to 5 days - benzalkonium chloride preservative irritates

What further investigations would you consider in a patient with non-glomerular haematuria?

Once evidence of glomerular bleeding is excluded investigation to detect other pathology is done Urinary tract imaging. - CT urogram is the best investigation. Urine Cytology - Most useful in detecting poorly differentiated cancer cells. High false negative with low grade malignancy Cystoscopy - Mandatory in all patients > 40 especially if has risk factors.

2. One divided by the absolute risk increase equals: Needed numbers to harm

One divided by the absolute risk increase equals: Needed numbers to harm

1. One divided by the absolute risk reduction equals:

One divided by the absolute risk reduction equals: Needed number to treat

When does microscopic haematuria need investigation?

Only if it is a persistent finding. Transient findings need no investigation

What is a Richter's hernia?

Only part of the circumference of the bowel (usually the anti-mesenteric border) is trapped within the hernial sac. The herniated part may become ischaemic. Because the lumen of the bowel is not occluded, intestinal obstruction does not occur, and there are few symptoms until the ischaemic part perforates.

Dyspepsia Alarm Features

Onset > 50 years old Anemia Dysphagia Odynophagia Vomiting Weight loss Family history of GI Cancer PMH of PUD Gastric Surgery Abdominal Mass or LAD on exam

Medication Overuse Headache

Opioids more than 10 days a month Nitrates PDE inhibitors hormones must be susceptible to headache consider in patients taking simple Ergot, Triptan or anything

What is the management of BCC?

Optimal treatment for nodular BCC depends on size. - Lesions less than 1 cm in diameter are rarely deeply invasive and can be treated by electro-desiccation with curettage, by cryosurgery or by excision with a narrow margin in terms of depth and width. - Radiotherapy is an alternative form of therapy but not in areas close to cartilage. - Lesions greater than 1 cm in size are best treated by excision with perioperative confirmation of the margins of excision, which should not be less than 1 mm.

What is the prognosis of oesophageal cancer?

Overall prognosis remains poor with oesophageal cancer because of late disease presentation. In large Western series, it has been suggested that overall survival in patients with adenocarcinomas is better that those with squamous cell cancers.

Tricyclic antidepressants

Overdose - progressive somnolence, hypotension, widening of the QRS interval, seizure, and anticholinergic signs (fever, tachycardia, mydriasis, reduced bowel sounds) - Tx: Sodium bicarbonate

Sebhorrheic Dermatitis

PD HIV CD4 less than 400 cell/mcL

Erectile Dysfunction

PDE5 inhibitors for ED can cause hearing loss, so if symptoms, patient needs to be switched to Alpro penile injection therapy

Knee Pain

PES ANSERINE BURSITIS - pain at the anteroMEDIAL knee worsened with running or climbing stairs ILIOTIBIAL BAND SYNDROME - also due to overuse, pain that is at the LATERAL knee PREPATELLAR BURSITIS - pain anteriorly, can be warm with swelling just below patella PATELLOFEMORAL SYNDROME - diffuse anterior knee pain as well just below patella - but pain elicited upon compression of patella onto the femur

Lateral Medullary Syndrome of Wallenberg

PICA Dysphagia Ipsilateral: Horner's (autonomic tracts) facial numberness (CN V) Ataxia (inferior cerebellar peduncle) Contralateral decreased pain and temperature (spinothalamic tract)

Hypertension

PREHYPERTENSION - lifestyle and recheck in 1 year - lipid panel yearly - Increasing the dose of one agent is less effective in reducing blood pressure than the addition of a second agent at low dose, which also avoids the risk of side effects more commonly seen at higher doses. - COMBINATION antihypertensive therapy is appropriate for patients who are >20/10 mm Hg above their target blood pressure goal (stage 2 HTN) - CKD: JNC 8 recommends a blood pressure target goal of <140/90 mm Hg - stage 4 and greater do not respond to thiazides, so switch to loop diuretics (lasix) - AMBULATORY checks: 125/75 mm Hg corresponds to a clinic blood pressure measurement of 130/80 mm Hg, and an average 24-hour ABPM of 130/80 mm Hg corresponds to a clinic blood pressure of 140/90 mm Hg so initiate treatment accordingly - For khmaos, AMLODIPINE or HCTZ - If on statin medication, amlodipine also interferes with CYP45 receptors and can cause adverse effects so HCTZ is actually preferred agent -___- - Long term NSAIDS can contribute to HTN diagnosis, so discontinue if BP elevated and able to come off OLMESARTAN - can cause profuse watery diarrhea and causes VILLOUS BLUNTING but all other studies are otherwise negative - Tx: stop ARB Eye Exam - hemorrhages or exudates PREGNANT PATIENTS - systolic >160 - diastolic >110

Neuroendocrine tumor (Carcinoid Tumors)

PRIMARY site is always GI tract (small and large colon). Never stomach. If evidence anywhere else, it is due to metastasis - carcinoid tumors can be found incidentally with liver lesions - lesions can resolve and come back like that - radiolabeled octreotide scan to assess somatostatin receptors, LFTs, serotonin level - if small and assymptomatic, relatively normal labs, no urgent intervention needed, simply serial imaging to monitor progression for lesion sizes and receptor activity - if high grade tumor on biopsy, proceed with PLATINUM base chemo, now! - octreotide can stabilize increasing somatorstatin receptors

Malaria

PROPHYLAXIS - if 4 weeks AFTER LEAVING endemic area, can use Doxy (photosensitive) - Doxy needs to be continued for 4 weeks after arrival - if traditional prophylaxis prior to going, ***Atovaquone/proguanil(Malarone)**** is appropriate for SOUTHEAST ASIA travel (Chay is A Pro going to Cambodia so he gets Malaria prophylaxis) - gametocyte on smear - Tx is IV Quinidine as first line for severe malaria, consider Clinda - look at other pics - If liver involvement, then Primaquine is the first line

how to deal with elevated PSA?

PSA values have log-linear relationship with prostate volume

Myopathies

PT/OT and reduce steroids - rhabdo typically 5k or above

56. Pain in the shoulder region that is present with active but not passive range of motion testing suggests what?

Pain in the shoulder region that is present with active but not passive range of motion testing suggests what? Extra-articular pain

What is Homan's sign?

Pain on dorsiflexion of the foot Sign of DVT

fixed drug eruption

Painful purple patch same spot every time might be a bullae dc the drug NSAIDs, sudafed, Sulfa, ABX

What are the treatment options for para-umbilical hernias?

Para-umbilical hernias are treated surgically because of the risk of obstruction, strangulation and, rarely, excoriation and ulceration of the skin overlying the hernia. The classic operative procedure is a Mayo repair, but repairs with mesh are performed increasingly.

MSA

Parkinson's Plus i.e. Shy-Drager acting out during sleep RBD synucleinopathy higher risk for falls dysautonomia sleep complications nocturnal stridor

What formula is used for fluid replacement in burns injuries?

Parkland formula 4mls/kg/%TBSA Hartmann's solution over first 24hrs Half over 8hrs, half over next 16 hours (from time of injury)

Drug induced edema

Parmipexole Gabapentin and pregabalin young women in omeprazole

Pyoderma Gangrenosum

Pathergy (trauma = wound) IBD rapid response to steroids diagnosis of exclusion biopsy results are nonspecific

Multiple Endocrine Neoplasms

Patients with MEN, specifically with Medullary Thyroid Cancer should get checked for pheochromocytoma via 24 hour urine metanephrines MEN TYPE 1 - multiple LIPOMAS - Pitutary adenoma, Pancreatic tumor, hyPerparathyroidism - pancreatic tumors and gastromas: hx of peptic ulcer disease, gotta think possible Zollinger Ellison Syndrome -___- Just associate!! - with these patients, always check Calcium and PTH

31. Patients with vasovagal and orthostatic syncope both are typically standing when the syncope occurs. When syncope occurs in the supine position, what would you consider?

Patients with vasovagal and orthostatic syncope both are typically standing when the syncope occurs. When syncope occurs in the supine position, what would you consider? Arrhythmia

Where does appendicitis tend to refer pain to?

Periumbilical and then to RLQ

Asbestosis

Pleural plaques BAPE Diffuse pleural thickening Rounded Atelectasis radiographic changes >10 years Latency 20-40 years thick white poles oval opacities shaggy heart

Pinpoint pupils

Pontine hemorrhage or stroke opiates

Hypersensitivity Pneumonitis

Poorly formed Granulomas or mononuclear infiltrate fleeting infiltrates ddx: PNA Birds Grain Dust Air Conditioning Systems history of "recurrent pneumonias" BAL lymphocytosis

B12

Position and vibration sometimes with normal B12 level too treat check MMA, Homocysteine. G

HIV Vacuolar Myelopathy

Posterior columns

Cerebellar Stroke

Posterior fossa Call neurosurgery Compression of 4th ventricle

What is the ankle brachial index?

Pressure at the ankle/Pressure at the brachial artery Note: patients with diabetes + renal failure will have calfcified arterial walls which can falsely elevate their ABI

What is superficial spreading melanoma?

Superficial spreading melanoma is the most common form of melanoma (60-70% of all melanomas) and can occur in any site and at any age, although it is most common in middle age and commonly arises from a pre-existing naevus. Atypical melanocytes initially spread laterally in epidermis then invade the dermis

Adrenal Insufficiency

Primary - fatigue, unintentional weight loss, nausea, and vomiting, family auto immune history, hyperkalemia - increased ACTH (can be primary or secondary), skin pigmentation - need both glucocorticoid and mineralocorticoid replacement - prednisone 5 mg once daily (glucocorticoid replacement) and fludrocortisone 0.05 mg (mineralocorticoid replacement) once daily ***Dexamethasone is an appropriate mineralocorticoid option IF WORKUP IS PENDING bc unlike other steroids (prednisone, hydrocortisone, methylprednisone) Dexamathasone does not interfere with HPA*** - adrenal insufficiency is diagnosed with cortisol morning levels (normal = 5-25) if low, then go ahead and treat with replacement therapy with no further workup - check ACTH only if cortisol level is nondiagnostic (4-12 range) but nonetheless start supplementation

Hepatitis B

Prodromal phase: rapid-onset symmetric polyarthritis, rash, and elevated aminotransferase levels CHRONIC INFECTION - e Antibody but persistent surface antigen - screen every 6 months for HCC via imaging

What is the prognosis of testicular cancer?

Prognosis depends on histologic subtype, stage, tumor marker and type of metastases

What is the prognosis of SCC?

Prognosis is good, with at least 95% disease-free survival at 5 years. Local recurrence is rare as long as surgical excision has been adequate in the first instance. Local recurrence is unusual with lesions less than 4 mm in thickness and metastasis is more common in lesions which are greater than 10 mm in thickness

Aortic Stenosis

Progression factors high BNP LVEF less than 50% PH moderate to severe calcification of valve Bicuspid valve = 50% or coarc

What are the common causes of macroscopic haematuria?

Prostate - BPH, Prostate cancer Bladder - Transitional cell carcinoma - Radiation cystitis Kidney - Malignant renal cell carcinoma, transitional cell carcinoma - Benign Angiomyolipoma Urinary stone disease

neurogenic claudication

Pseudoclaudication relieved with bending at waist 50% absent S1 reflexes

IIH

Pseudotumor Cerebri HA, blurry vision, papilledema worse in morning worse with valsalva Obese F, OCP steroids Vitamin A OD untreated causes blindness

Heart sounds

Pulmonary Hypertension - WIDENED split S2 ASD - true FIXED splitting Paradoxical Splitting - aortic stenosis, pacemaker, LBBB

MS Relapse

Pulse dose steroids IV 1 gram day for 3-5 days hastens recovery immunosuppresive or immunomodulatory treatement doesn't hasten recovery rarely rescue therapy with plasmapheresis

ASD

Px: fatigue, exertional dyspnea, A fib, paradoxical embolus Cx: JVD, parasternal impulse, Systolic flow murmur left 2nd ICS large shunts cause diastolic flow rumble Fixed splitting of S2 Dx: TTE - R heart enlargement TVR from annular dilation agitated saline to diagnose Eisenmenger CC to diagnosed Qp:Qs for complicated ASD 2) Ostium Primum 15-20%: RV flow murmur fixed S2 split throughout cardiac cycle Mitral regurg from cleft mitral valve LAD, 1st degree AVB and interventricular conduction delay 1) Ostium Secundum 75%: NO MV disease ECG: RAA, RAD, Ist degree AVB incomplete RBBB Complications: Afib and Right heart enlargement rarely PH 3) Sinus Venosus: RV overload no Mitral valve disease ECG: normal or 1st degree AVB and incomplete RBBB Treatment: Right sided chamber enlargement indication for closure consider if: POS intracardiac shunt before pacer page age, defect size, location, a/w mod HTN, TVR small ASD (Qp:Qs < 1.5:1.0) and no structural abnl watch isolated secundum and right structural issues PCI with device closure PAH and L2R shunt: closure standard Medical thearpy for PAH

EKGs

RAD - QRS in Lead 1 negative and aVF positive LAD - QRS in Lead 1 positive Lead 2 and aVF negative LBBB - Lead I and V6 with broadened QRS - V1 inverted complex, Q wave (upside down bump following p wave) RBBB - bunny ears Right Superior AD - QRS in Lead 1 and aVF negative V Tach = WIDE COMPLEX tachycardiac - often due to structural heart disease - CaCh blockers have NO ROLL in emergent situations and can actually make it worse if structural disease with WIDE COMPLEX - V tach due to coronary spasm can benefit from CaCh blockers - PVCs picked up in healthy individuals can be NORMAL PEs: S1Q3T3 S in Lead 1 is bigger Q wave present in Lead 3 T wave inverted in Lead 3 Canon A waves or sometimes LARGE A waves - occurs anytime Atrium contracts against a resistant ventricle, like TV or MV stenosis, heart block, V tach, etc. LARGE V waves and A waves - CHF Rapid X and Y descent - constrictive pericarditis

What are the hallmarks of glomerular bleeding?

RBC morphology - Requires a fresh specimen examined within 3 hours by experienced staff. Cells assume abnormal shapes Proteinuria - If dipstick positive quantify with 24 hour estimation. Renal function - Serum Creatinine and eGFR <30 mL/min. Urinary tract ultrasound - Exclude other pathology.

adrenal hemorrhage

RFs: AC, postoperative state, abnormalities in hemostasis (HIT or APAS) and Sepsis uncommon CT stress dose steroids

Where does a perforated ulcer tend to refer pain to?

RLQ (right paracolic gutter)

McConell's Sign

RV dilation and fee wall hypokinesia with sparing of apex on Echo

What is the emergency treatment of hyperkalaemia?

Rapid infusion of a 1 L solution of 10% glucose with 25 units of soluble insulin. At the same time 20 mmol of calcium gluconate can be given to help stabilise cardiac membranes.

What is achalasia?

Rare motility disorder with degeneration of the myenteric plexus (Auerbach's plexus) in the GOJ resulting in aperistalsis of the lower oesophagus and failure of the GOJ to relax

What is the treatment of oeseophageal perforation?

Supportive if rupture is contained: - NBM, vigorous fluid resuscitation, broad-spectrum antibiotics, possible percutaneous drainage Surgical: - <24 h: primary closure of a healthy esophagus or resection of diseased esophagus - >24 h or non-viable wound edges: diversion and exclusion followed by delayed reconstruction

type B aortic syndrome

Surgery actually is indicated for complicated refractory pain rapid aneurysmal expansion malperfusion syndrome

What are the treatment options for an epigastric hernia?

Surgery is undertaken to relieve symptoms. Linea alba is also repaired during surgery.

9. Regarding asymptomatic individuals, which of the following are true? a.The sexual partner of a woman with Trichomonas vaginalis should be given an empiric course of oral metronidazole without even requiring a clinic visit b.A woman who had a follow-up culture done of her vaginal secretions after being treated for Candida is now asymptomatic and the culture shows Candida. Should repeat treatment be offered? c.An HIV positive woman who was treated with metronidazole for Trichomonas is now asymptomatic. Should she have any follow-up sampling?

Regarding asymptomatic individuals, which of the following are true? a.The sexual partner of a woman with Trichomonas vaginalis should be given an empiric course of oral metronidazole without even requiring a clinic visit - Yes, the partner should be treated b.A woman who had a follow-up culture done of her vaginal secretions after being treated for Candida is now asymptomatic and the culture shows Candida. Should repeat treatment be offered? No, 10-20% of women carry Candida and the culture just should not have been done in the first place. c.An HIV positive woman who was treated with metronidazole for Trichomonas is now asymptomatic. Should she have any follow-up sampling? Probably since persistent coinfection with Trichomonas could increase shedding of HIV and viral transmission and there is a treatment failure rate.

Where does biliary colic tend to refer pain to?

Right shoulder or scapula

Duke Criteria

Risk unexplained fever for 48hr known valve disease or prosthesis 1 Coxiella + BCx or IgG Ab titer > 1:800

1st seziures

Risk of Recurrence: Provoked? after single unprovoked seizure risk is 40% RF: previous head trauma with LOC, focal brain lesion on MRI, postictal Todd paralysis

What is the risk of transformation of an actinic keratosis?

Risk of transformation of actinic keratosis (AK) to SCC (~1/1000), but higher likelihood if AK is persistent

What is the clinical presentation of an epidermal cyst?

Round, yellow/flesh coloured, slow growing, mobile, firm, fluctuant, nodule or tumour Occur most commonly on the face, the scalp, the back and the scrotum Milia are tiny multiple epidermal cysts that occur on the face, particularly around the eyes

What is Rovsings sign?

Rovsings sign - palpation of LIF elicits RIF tenderness

What is Boerhaaves synfrom?

Rupture of the oesophagus that usually occurs in the setting of increased intraoesophageal pressure which causes barogenic trauma. Usually occurs after profuse vomiting or retching but also reported following trauma, Heimlich manoeuvre, weight lifting and status epilepticus. Usually single, longitudinal tears 1-8cm occuring in the left posterolateral distal oesophagus.

Lumbosacral Myelopathy

S1- Sole of foot is sacral Medial L4 Foot drop - L5 S1

Headache red flags

S: systemic features N: Neuro deficits O: older than 50 yo O: Sudden and maximal P: progression of HA, pattern of HA

What are the risk factors for SCC bladder cancer?

SCC (Situations associated with chronic inflammation) - Long term catheterisation - Schistomiasis

Psychiatric Disorders

SCHIZOPHRENIA - those started on HALDOL can have dystonic reaction, which requires IM or IV benzotropin or benadryl - 1st gen (aZine) has higher risk of tardive dyskinesia (simply stop drug, monitor, titrate 2nd generation antipsychotic) - 2nd gen (aPines) has lower risk but have their own adverse effects HIGH RISK SWALLOWING - among all the items they ingest, a battery would be highest risk bc of the electrical current and risk of rapid perforation, so if it is present then urgent endoscopic removal is indicated Persistent Depressive Disorder - previously dysthymic disorder/chronic depression - 2 years long at least of sx - differentiate with MDD which is 2 weeks of sx - sometimes patients will have MDD episodes, refer to this as double depression :-<

Drug Interactions

SEIZURES - Carbamazepine metabolized by liver enzymes - Phenobarbital induces enzymes so will decrease concentration of Carbemazepine - Valproate inhibits enzymes so increases concentration of Carbamazepine - Lamotriginen no effect - Levetiracetam renally metabolized so no effect BIPOLAR - Lithium level can go up or down if you start CALCIUM CHANNEL BLOCKER so monitor - most other HTN meds actually INC Lithium level - sx of Lithium toxicity include diarrhea, N/V, ataxia, rigidity, fasiculations, hyperreflexia ANTIPLATELET THERAPY - ASA uses cyclooxygenase to decrease platelet function - NSAIDS also bind to cyclooxygenase and can actually block desired effect of ASA's antiplatelet purpose if given at the same time - Opt for 2b/3a receptor inhibtors if needed **FYI Plavix = ADP Inhibitor to decreased platelet aggregation** IRON DEFICIENCY - Iron supplementation can interfere with Levothyroxine absorption can worsen hypothyroid symptoms so don't take at the same time ANTICOAGULATION - GINGKO BILOBA interferes with WARFARIN - Dronedarone can be used for rate/rhythm control. Dabigatran as an anticoagulation should be dosed LOWER if used with Dronedarone - OCPs do NOT interfere with INR, but Acetaminophen as little as 3 tablets can throw off INR SUNLIGHT - photosensitivity with tetracyclines - photosensitivity with FLUROQUINOLONES - Methotrexate and Bactrim cannot be used together bc it creates fatal pancytopenia ASTHMA - Patients taking Theophylline cannot take Ciprofloxaxin bc Cicpro decreases clearance and patient can have Theophylline toxicity where they present with N/V - CIMETADINE is an antihistamine given to help INCREASE Theophylline levels, therefore reaching therapeutic levels more readily Atrial Fib - Dronedarone can be used for rate/rhythm control - Dabigatran as an anticoagulation should be dosed LOWER if used with Dronedarone Antibiotics - Fluoroquinolones should NOT be taken with antacids (or milk, ice cream, high calcium foods)

Geriatric

SEIZURES: Lamotrigine, levetiracetam, and gabapentin are generally better tolerated and thus good first-line options because they are metabolized better than phenytoin DRIVING - can be impaired due to visual, auditory and mental decline - also ARTHRITIS is enough to limit elderly driving

28. So, in summary, what are the conditions that require emergent ophthalmology consideration?

So, in summary, what are the conditions that require emergent ophthalmology consideration? a.Any central retinal or vascular occlusion, venous or arterial b.A perforated corneal ulcer c.Acute-angle closure glaucoma, remember with the headache and pain d.Acute vision loss of any type to rule out a number of these causes and acute retinal necrosis e.Endophthalmitis, particularly after cataract surgery where it most commonly occurs. It also occurs in bacteremic patients. These bacteria in the vitreous need to be immediately removed with vitrectomy and intravitreal antibiotics instilled f.Herpes zoster ophthalmicus and they will show you a picture of shingles of the forehead and involvement of the inner part of the nose, the nasal ciliary branch with a red eye. These patients require immediate antivirals g.Optic neuritis h.Orbital cellulitis to make sure there isn't retro-orbital disease i.Retinal detachment j.Scleritis which remember is a painful loss of vision with a red eye k.Uveitis which is going to have the ciliary flush and perhaps a hypopyon l.Trauma to the globe or lid

Colonoscopy Guidelines

SERRATED POLYPOSIS SYNDROME 1 year: serrated polyposis syndrome (multiple) 3 years: sessile serrated polyps > 10mm 5 years: sessile serrated polyps < 10mm 10 years: Nothing COLORECTAL CANCER - once resected and adjuvant chemotherapy: 1 year follow up, then 3 year follow up, then 5 year intervals - if large (>2cm) adenoma then surveillance 3 to 6 months in patients JUVENILE POLYPS - based on biopsy - no future health risk once the polyp is removed and do not require surveillance endoscopy 3 years Patients with (1) an adenoma 10 mm or larger, (2) three to ten adenomas, (3) an adenoma with a villous component (such as a tubulovillous or villous adenoma), or (4) an adenoma with high-grade dysplasia are considered high risk for colon cancer If any high risk polyp is removed by "PIECEMEAL" rather than straight polypectomy, then repeat scope in 3-6 months to assure resection was complete, then repeat 3 years as above FAMILY HX - screen every 5 years - start at 40 or 10 years prior to onset - NOAC should be discontinued 2 to 3 half-lives before colonoscopy (generally, 24 hours for low to moderate risk procedures) - FYI in procedures with high bleeding risk, 4 to 5 half-lives beforehand (36-48 hours) - no bridge needed

Acute Hyponatremia

SIADH from non osmotic release of vasopressin from stress

Cholinesterase inhibitors

SLUD avoid in PUD and Seizures Insomnia try a different one

What type of LUTS symptoms would you get in a storage problem?

STORAGE SYMPTOMS: - Frequency - Nocturia - Urgency - Dysuria

gaze preference

STroke Towards Seizure away stroke causes depression of motor function causing relative hyperactivity on oppositve side

What are the risk factors for an AAA?

Same as coronary artery disease but mainly - Family history - Tobacco

Pain Crisis

Scheduled opiates

What is the Alvarado score?

Scoring system to help stratify risk of appendicitis Interpretation: - 1-3 = low risk of appendicitis - 4-6 = equivocal risk - 7-10 = High risk

Screening for SAH is indicated in which patient groups?

Screening is controversial Indicated for: - People who have two immediate relatives with intracranial aneurysms - All patients with autosomal dominant polycystic kidney disease

10. Sensitivity divided by one minus the specificity equals what?

Sensitivity divided by one minus the specificity equals what? This is the positive likelihood ratio. Positive likelihood ratio is sensitivity over one minus specificity. Sensitivity is always in the numerator. If it is a positive likelihood ratio then it is just sensitivity in the numerator. If it is a negative likelihood ratio then it is one minus sensitivity in the numerator and specificity in the denominator.

owned on Lemierre's Syndrome again

Septic thrombophlebitis of the IJ round opacities: septic thromboemboli, fungi - rarely needs intubated or RRT Septic pulmonary emboli is extremely common - Empyema or Septic arthritis - Osteomyelitis in fewer than 3% - DIC is common

PSC

Serum Alk phos 3-10x ULN ALT&AST 2-3x ULN ANA & Anti smooth muscle ab in 20-50% Dx: MRCP beads on string 80% have UC ERCP for choledocholiasis 10-25% dominant stricture 5-10%

Mitral Valve replacement

Severe Symptomatic and LV Greater than 30% Severe with EF 30-60% and LV end systolic dimension >4cm

when to replace asymptomatic aortic stenosis?

Severe with EF less than 50% already getting CABG

Diarrhea

Shiga toxin-producing E. coli (STEC) serotype - supportive care with fluids - the most common cause of acute bloody diarrhea in the US - differs from other causes of dysentery in that fever is distinctly uncommon - cause disease through ingestion of contaminated food or, as in this case, unpasteurized milk - diagnosis via peripheral blood smear showing microangiopathic hemolytic process as indicated by the presence of schistocytes - supportive care, may need acute dialysis ***Antibiotic and antimotility therapies are both associated with increased risk for HUS and should not be prescribed when there is clinical concern for STEC Vibrio - seafood, particularly shellfish, and can be severe in patients with ***liver dysfunction*** - bloody stools, vomiting, fevers - sepsis, skin lesions in LE like boils or bullous lesions Yersinia enterocolitica - consumption of chitterlings (pork intestines) - does not cause grossly bloody stools, hard to distinguish from other inflammatory diarrheas - diarrhea may be ABSENT with bacteria localizing to lymphoid tissue in Peyer patches and associated mesenteric lymph nodes - can cause enterocolitis which presents as abdominal pain that mimics appendicitis (LLQ) - high risk in IRON OVERLOAD patients who are on DEFEROXAMINE Malabsorption with steatorrhea - due to either small bowel mucosa abnormality or pancreatic insufficiency - D-xylose can differentiate: if normal (>5g excreted in urine after administration) then likey pancreatic insufficiency - If abnormal (<5g) then nonspecific so EGD and biopsy vs GES

Grapefruit Juice

Simvastatin and Lovastatin Nifedipine Cyclosporin levels Grapefruit juice lasts 24 hours Put on Crestor

Myalgias

Simvastatin worst Fluvastatin is best Check TSH - hypothyroidism increase risk of statin myalgias) - more common in low vitamin D, low BMI, Asian - Co Q10 sucks

Hereditary Hemochromatosis

Skin - Hyperpigmentation MSK - chondrocalcinosis GI - elevated hepatic enzymes Endocrine - cardiac infections - listeria, Vibro, Yersinia enterocolitica GU - 45% secondary hypogonadism

What are the risk factors for oesophageal cancer?

Smoking and alcohol intake are the main aetiological agents, though in certain areas, other dietary factors are implicated

What are the normal daily requirements of sodium and potassium?

Sodium: 100-150 mmol Potassium: 60-90 mmol

What is a Spigelian hernia?

Spigelian hernias are rare. A Spigelian hernia occurs through the transversus abdominis aponeurosis of the anterior abdominal wall, usually below the level of the umbilicus.

What is the arterial supply to the spleen?

Splenic artery

Papillary Thyroid cancer

Stage I&II: TSH 0.1-2.0 Stage III&IV: < 0.1 Preg & OCP cause increase in CBG and TBG

Alzheimer's Dementia

Starts in temporal and parietal areas progress to frontal and occipital

Heart Transplant

Symptoms of dyspnea years down the road? - rejection and cardiac allograft vasculopathy - patients can have ischemic event in new heart without typical angina symptoms because the heart may lose some innervation during the time it is being transferred to donor - all patients with dyspnea and even the smallest evidence of HF should have cardiac cath

What is Transfusion associated acute lung injury (TRALI)?

Syndrome of clinical and laboratory features - Occurs within 6 hours - Incidence 1:200 transfusions - Signs and sx: dyspnoea, hypoxia, fever, hypotension - Associated with the presence of HLA specific antibodies in donor blood - Treatment is supportive

PARTNER trial

TAVR has survival benefit 30.7% v. 50.7 with medical arm consider in patients with STS risk score greater than 8% can't do in patients with: Bicuspid valve concomitant valve disease like Aortic regurg or mitral valve disease

Aortic valve replacement

TAVR treatment of choice for intermediate to high risk patients with symptomatic severe aortic stenosis Surgical aortic valve replacement is the treatment of choice for low-risk patients with symptomatic severe aortic stenosis Once sx occur with AS, then prognosis is poor

Warfarin

TMP-Sulfa!!!!!!!! - decreases binding of warfarin to albumin and inhibits metabolism - Erythromycin - Amiodarone - Propafenone - Diflucan - itraconazole - flagyl possible (especially in polypharmacy) - Cipro - omeprazole (inhibits metabolism) - Clarithromycin - Amoxicillin? - Norfloxacin Changes in 3 days APAP has a reaction with warfarin. affects metabolism of warfarin (has to be daily) - over 9 grams a week means 10 fold chance of increase in INR over 6

Orthopedics

TOTAL HIP/KNEE - prophylaxis with 14 days of ASA 325mg BID OR - prophylaxis with anticoagulation for 35 days If worsening joint pain presents after replacement, you always have to consider infection. XR can show lucency where prosthetic and joint interact, need to pursue ASPIRATION for culture If evidence of 2nd or 3rd degree heartblock, pacemaker first McMurray sign = Meniscus tear

Lemierre syndrome (FUSOBACTERIUM)

TRIAD 1) 4 week sore throat 2) septic pulmonary thromboembolic 3) internal jugular vein thrombophlebitis OR Fusobacterium positive culture

Jod-Basedow Phenomenon

TSH receptor mutation = autonomous function iodine load from contrast

thyroid hormones in Preggers

TSH takes an initial dip FT4 slightly goes up TBG and Total T4 initial go up (increased E2) Screen those with AI disorders and those on synthroid guiter previous head & neck surgery positive TPO and TSI antibiodies older than 30

Thrombotic thrombocytopenic purpura (TTP) vs. Immune thrombocytopenic purpura (ITP)

TTP - anemia, schistocytes on smear, increased serum lactate dehydrogenase level, and thrombocytopenia - SOMETIMES with fever, kidney manifestations such as hematuria, elevated creatinine level, and proteinuria; and fluctuating neurologic manifestations - triggered by drugs, especially quinine, ticlopidine, mitomycin C, cyclosporine, or gemcitabine - antibodies directed against the protease ADAMTS-13 can sometimes be seen - NORMAL COAG STUDIES - Tx: Plasmapharesis...FFP in the meantime - plasmapharesis does not work in patients s/p chemo or stem cell transplant - plasmapharesis does not work in drug induced TTP, rather, removal of agent and supportive care ITP - thrombocytopenia with no other organ involvement - can be with CLL but usually assymptomatic - if no other symptoms other than rash, no bleeding and platelets stable at least 30,000-40,000 then just follow clinically, regular CBCs

cardiac transplant meds

Tac or cyclosporine (calcineurin inhibitor) Mycophenolate sirolimus or everolimus Prednisone AE: HTN (90%), Diabetes 20%

What is the leading cause of early failure following kidney transplant?

Technical causes

What is the typical presentation of testicular cancer?

Testicular mass - This represents the commonest presentation. - Testis tumours may undergo spontaneous haemorrhage and present as an acute painful testicular swelling. They may be difficult to distinguish initially from epididymitis but continued follow up will reveal the correct diagnosis - Ultrasound may be helpful. Metastatic Disease - Metastatic lesions may indicate there origon following biopsy if the primary in initially undetected.

Thyroglobulin

Tg is sensitive and specific for residual thyroid tissue - measure TgAb because it can falsely lower Tg - Calcitonin used in medullary thyroid carcinoma

What is a material risk in terms of consent for a procedure?

That which a reasonable person would attach significance to eg blindness in the contralateral eye, irrespective of the low incidence

36. The Endocrine Society recommends against the use of androgen therapy in which patients?

The Endocrine Society recommends against the use of androgen therapy in which patients? Those with breast or prostate cancer, a probable prostate nodule or induration on exam, a PSA of greater than 4 or greater than 3 in men at high risk for prostate cancer, a patient with hematocrit greater than 50, untreated severe obstructive sleep apnea, severe lower urinary tract symptoms or uncontrolled or poorly controlled heart failure.

48. The USPSTF recommendation for screening for each of the following is what? a.Carotid artery stenosis b.COPD c.Hereditary hemochromatosis d.Peripheral artery disease

The USPSTF recommendation for screening for each of the following is what? a.Carotid artery stenosis - None b.COPD - None c.Hereditary hemochromatosis - None d.Peripheral artery disease - None

6. The above forms of incontinence relate to detrusor overactivity, problems with sphincter incompetence as seen in stress incontinence, obstructive issues or mobility or cognition issues. What are potentially reversible causes of incontinence?

The above forms of incontinence relate to detrusor overactivity, problems with sphincter incompetence as seen in stress incontinence, obstructive issues or mobility or cognition issues. What are potentially reversible causes of incontinence? Delirium, UTI, atrophic vaginitis, medications, depression, hyperglycemic, impaired mobility and fecal impaction

What is the normal length and course of the ureter?

The adult ureter is approximately 25 cm in length in adult life and runs retroperitoneally before swinging medially at the level of the ischial spine to pass through the bladder wall

What is the treatment of keratoacanthoma?

The approach to the management of KA is debatable since lesions can resolve without treatment. However, the well-accepted difficulty in distinguishing KA from cutaneous squamous cell carcinoma, a common tumour associated with a risk for metastasis, leads many clinicians (including UpToDate) to recommend treatment. Surgical excision - first-line Other therapeutic options for solitary KA include electrodesiccation and curettage (ED&C), intralesional injections, radiation, and topical therapy.

51. DSM V criteria for the Boards.

The criteria by DSM V for depression require 5 of the listed symptoms being present during the same 2 week period and they have to represent a change from previous functioning and at least 1 symptom is either the first listed depressed mood or the second loss of interest or pleasure. In addition, symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning and symptoms are not due to direct physiologic effects of substance, drug, medication, or general medicine condition such as hypothyroidism. Here is the list from which the 5 can be selected. a.Depressed mood b.Markedly diminished interest or pleasure c.Significant weight loss when not dieting or weight gaining d.Insomnia or hypersomnia nearly every day e.Psychomotor agitation or retardation f.Fatigue or loss of energy g.Feelings of worthlessness or excessive inappropriate guilt h.Diminished ability to think or concentrate i.Recurrent thoughts of death, not just fear of dying, recurrent suicidal ideation or a suicide attempt or specific plan for committing suicide

What is the typical presentation of an epigastric hernia?

The defect is characteristically small, often about 1 cm in diameter. Patients are frequently fit young males who present with epigastric pain, which may be confused with peptic ulceration or biliary disease. Patients should be examined in both standing and lying positions. The hernia is usually easier to feel than to see, and is diagnosed by palpation of a small, often very tender, lump in the linea alba. Epigastric hernias are usually irreducible and may be multiple.

4. The degree to which the investigators conclusions are supported by a study is?

The degree to which the investigators conclusions are supported by a study is? Internal validity

5. The generalizability of a study is?

The generalizability of a study is? External validity

What is a Maydl's hernia?

The hernial sac contains two loops of intestine. The loop of intestine within the abdominal cavity may become obstructed or strangulated, and this may not be recognised unless the hernial contents are inspected and returned to the abdominal cavity ('reduced') completely

What is the typical appearance of a junctional neavus vs a compound neavus?

The junctional naevus is impalpable, pale to dark brown in colour and is usually small, rarely being more than 1 cm in diameter. In contrast, compound naevi are palpable, because of the size of the collection in the papillary dermis. These naevi are usually darker in colour than junctional naevi. The transitional phase between junctional and compound naevus means that some lesions show the characteristics of both.

What is the blood supply to the kidney?

The kidneys are normally are supplied by single renal arteries, although up to 30% of people may have multiple arteries. The renal vein is again normally single on each side, draining into the inferior vena cava. Renal lymphatics drain to the para-aortic nodes.

What spinal vertebral level do the kidneys usually lie at?

The kidneys lie retroperitoneally at the level of L1-2

What is the course of the male urethra?

The male urethra passes through the prostate and is joined by the ejaculatory ducts.

23. The patient with primary open-angle glaucoma is treated with latanoprost. What symptoms might they have from this medication?

The patient with primary open-angle glaucoma is treated with latanoprost. What symptoms might they have from this medication? Flu-like symptoms, joint and muscle pain since this is a prostaglandin analogue.

33. The patient with tinnitus for whom you hear a bruit, what types of diagnoses might you consider?

The patient with tinnitus for whom you hear a bruit, what types of diagnoses might you consider? Arterial venous malformation, atherosclerosis, carotid artery disease, and a glomus tumor.

19. The presence of what features should make one look for other causes in the patient for whom fatigue has been attributed to chronic fatigue syndrome?

The presence of what features should make one look for other causes in the patient for whom fatigue has been attributed to chronic fatigue syndrome? Fever, lymphadenopathy or muscle wasting.

What are universal precautions?

The principle of universal pre- cautions is to establish a physical barrier between the patient and the carer to prevent direct contact with any potentially infected body fluid or tissue in either direction

What is a neavus?

The term naevus should refer by definition to any congenital lesion of the skin, but by convention is used to describe any congenital or acquired neoplasm of melanocytes.

20. The treatment for chronic fatigue syndrome is largely nonpharmacologic or pharmacologic?

The treatment for chronic fatigue syndrome is largely nonpharmacologic or pharmacologic? Lifestyle modifications, sleep hygiene, graded activity, and cognitive behavioral therapy are nonpharmacologic therapies used for chronic fatigue syndrome. Patients should be monitored for their symptoms, support and validation and to help them avoid unnecessary diagnostic and treatment interactions.

HRT

There is some evidence that transdermal estrogen may be associated with less thromboembolic risk than oral estrogen by avoiding the hepatic first-pass effect.

What is the management of actinic keratosis?

They can be managed by cryotherapy, the application of cytotoxic creams (eg 5-fu cream) or by surgical excision if there is any suspicion that malignant change has already occurred.

Wernicke's

Thiamine ETOHism, PEM, malabsorption, dialysis Amnesia Confabulate Mammillary bodies Memories

What investigations should be performed in a patient with macroscopic haematuria?

This finding is associated with significant disease in 50% of patients. Therefore all require - Upper tract imaging (CT, Retrograde pyelogram) - Urine cytology - Cystoscopy

Pitted Keratolysis

Treated with erythromycin lotion or clindamycin lotion - small indented pits on a background of hyperkeratosis - results from increased sweating or perspiration of the feet - superficial bacterial infection secondary to Kytococcus sedentarius, Corynebacterium, or Actinomyces spp. - Oral therapy with clarithromycin or erythromycin also can be used

What is the treatment for C. Diff enterocolitis?

Treatment includes the cessation of broad-spectrum antibiotic therapy and the introduction of either oral metronidazole or oral vancomycin.

Optic Neuritis

Triad Pain with eye movement central scotoma Marcus Gunn Pupil

Cluster Headache

Trigeminal Autonomic Cephalgia severe unilateral pain cluster = short cycles then long remission first division of Trigeminal nerve (periorbitial, frontal or temporal regions) one autonomic features, ptosis, tearing, rhinorrhea motor restlessness 1-8 events/day less than 3 hours each event young middle aged male smokers O2 and Imitrex for abortive Verapamil for ppx 2nd line glucocorticoid

8. True positive results divided by true positive plus false negative results equals what?

True positive results divided by true positive plus false negative results equals what? Sensitivity as the proportion of patients of disease with a positive test

9. True positive tests divided by the true positive plus false positive rate is what?

True positive tests divided by the true positive plus false positive rate is what? Positive predictive value is the proportion of patients with a positive test who have the disease

What is an ependymoma?

Tumours that arise from ependymal cells. From the ependyma - the epithelial lining of central canal and ventricles. A type of glial cell, controls and regulates CSF flow.

Renal Tubular Acidosis (RTA)

Type 1: - NON GAP metabolic acidosis WITHOUT sx of diarrhea - autosomal recessive, so maybe family history - HEARING LOSS!!!!!!!!!!!!!!!! Fam hx of stones - distal tubule defect, so acidification is off and URINE PH > 5.5, leads to KIDNEY STONES - serum calcium NORMAL, urine calcium (if noted) is high - urine gap negative - Sjögren syndrome high risk of Type 1 RTA tubulointerstitial nephritis Type 2: - proximal tubule defect, so distal acidification is intact and URINE PH < 5.5 - urine gap zero or positive - NON GAP metabolic acidosis WITHOUT sx of diarrhea FANCONI SYNDROME - glucosuria WITHOUT hyperglycemia - renal dysfunction associated with MM or metal exposures - defects in proximal tubules (TYPE 2 RTA) - NON gap metabolic acidosis with NO DIARRHEA (makes sense!) - spills alot into the urine so hypoK hypoPHOS and hypoURICEMIA - Sjögren syndrome high risk of tubulointerstitial nephritis and less commonly Type 2 RTA Type 4: HYPERkalemia - normal anion gap metabolic acidosis, and impaired urine acidification, but with the ability to maintain the urine pH to <5.5 - caused by aldosterone deficiency or resistance - DM patients who are started on ACE or ARB can develope Type 4 since they inhibit RAAS - makes sense! - can also be cause by OBSTRUCTIVE uropathy with anuria and hyperKa, metabolic acidosis...place foley to alleviate!

Aortic Disection

Type A dissections or intramural hematomas involve the ascending aorta or aortic arch Tx: ALWAYS needs surgery Type B syndromes begin distal to the left subclavian artery Tx: Hypertension management is enough if uncomplicated - If complicated (occlusion of a major aortic branch leading to end-organ damage, persistent severe hypertension or pain, propagation of the dissection (which may be manifested by persistent or recurrent pain), aneurysmal expansion, and rupture) then surgery is indicated - can present with new onset aortic regurg murmur severe HTN, pain radiating to back Dx: cardiac CTA - blood pressure control is important but so is heart rate less than 60 - can occur spontaneously in 3rd trimester

IBD and C-scope

UC involving proximal colitis and Crohn's = 8 years UC left sided = 12 years after diagnosis - C scope typically done annually anyway

What is the investigation of choice for a neck lump?

US guided FNA Result of the FNA will guide further investigation

What are the surgical options for renal stone removal?

Ureteric Stones - Ureteroscopy and laser fragmentation. - ESWL Renal Pelvis Stones (Usually larger) - Flexible ureteroscopy and laser: suitable for smaller stones. - Percutaneous nephrolithotomy: Technique of choice for large calculi and staghorn stones. - ESWL (Not suitable for large calculi)

What is the definition of oliguria?

Urine output <30ml/h

What is the rule of 9s?

Used to calculate %TBSA burns Note: superficial thickness burns not included

What type of LUTS symptoms would you get in a voiding problem?

VOIDING SYMPTOMS: - Hesitancy - Straining - Poor flow - Intermittency - Terminal dribbling - Feeling of incomplete voiding

Neuro ddx:

Vascular: AVM, Aneurysm, HTN Infection: Meningitis, Encephalitis, UTI, PNA Trauma/Toxins Alcohol withdrawal Metabolic: Glucose, Na, Mg, Phos, Medications Idiopathic Neoplasms Stroke

21. Vertigo is the most common cause of dizziness. Name the central and peripheral causes.

Vertigo is the most common cause of dizziness. Name the central and peripheral causes: Central causes include vascular disease such as stroke, mass lesions of the brainstem and cerebellum, multiple sclerosis, migraine and seizures. Peripheral vertigo is caused by benign paroxysmal positional vertigo, vestibular neuronitis and Meniere disease. Other peripheral causes include aminoglycoside toxicity, herpes zoster, otitis media and perilymph fistulas.

What is the typical description of visceral vs somatic pain?

Visceral - Pain associated with stretching of the gut - Poorly localised - Midline (if from gut) - Level helps localisation of pathology: epigastrium (foregut), periumbilical (midgut), hypogastrium (hindgut) Somatic - From irritation of parietal peritoneum - Well localised

Why is PT prolonged in obstructive jaundice?

Vit K is fat soluble and hence in obstructive jaundice PT may be prolonged

multiple sclerosis

Vitamin is standard of care

11. What 2 well proven methods are there for preventing pressure ulcers?

What 2 well proven methods are there for preventing pressure ulcers? Foam mattresses to distribute pressure over larger area and medical grade sheepskin are beneficial in preventing ulcers in hospitalized patients when compared to standard mattresses.

67. What are some interventions that have been shown to successfully prevent falls?

What are some interventions that have been shown to successfully prevent falls? a.Prescribing gait exercise and balance training b.Using anti-slip shoes in icy conditions c.Pacemaker installation for patients with carotid sinus hypersensitivity d.Cataract surgery in the first eye affected e.Medication review and modifying medications, particularly psychotropic medications f.Interestingly although it is done, the U.S. Public Health Service Task Force cannot find data that home hazard modification helps g.U.S. Public Health Service Task Force recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community dwelling elderly 65 and over who are at increased risk

24. What are some of the interventions for people with chronic pulmonary disease that might be effective perioperatively? (5)

What are some of the interventions for people with chronic pulmonary disease that might be effective perioperatively? a.Lung volume expansion through deep breathing or incentive spirometry reduces pulmonary complications b.In patients with poorly controlled asthma, systemic corticosteroids can be used c.In patients with suboptimally controlled COPD, bronchodilators and systemic steroids can be used d.Analgesia can be given postoperatively to minimize atelectasis e.Smoking cessation at least 8 weeks prior to surgery is clearly beneficial but when done for less than 2 months the data are unclear

64. What are some of the major criteria for attention deficit hyperactivity disorder?

What are some of the major criteria for attention deficit hyperactivity disorder? DSM 5 lists 1) inattention and 2)hyperactivity-impulsivity and among these two LIST several criteria that need to be met. In adults, 5 or more symptoms for those 17 years and older need to be present and symptoms of inattention have to be present for at least 6 months and be inappropriate for the developmental level. These include: •Often fails to give close attention to detail or makes careless errors •Often has trouble holding attention on tasks or play •Often does not seem to listen when spoken to directly •Often does not follow through on instruction and fails to finish work •Often has trouble organizing tasks and activities •Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time •Often loses things necessary for tasks and activities •Is often easily distracted •Is often forgetful in daily activities For the next criteria, hyperactivity-impulsivity, there need to be at least 5 present in those 17 years or older. Symptoms of hyperactivity have to be present for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level and these include: •Often fidgets with or taps hands or feet or squirms •Often leaves seat in situations when remaining seated is expected •Often runs about or climbs in situations that are not appropriate •Often unable to take part in leisure activities quietly •Is often "on the go" acting as if "driven by a motor" •Often talks excessively •Often blurts out an answer before the question is completed •Often has trouble waiting for his turn •Often interrupts or intrudes on others In addition, the following must be met: •Several inattentive or hyperactive-impulsive symptoms were present before age 12 •Several symptoms are present in two or more settings which is a new criteria in DSM V. For example, at home or work, with friends or relatives, in other activities •There is a clear evidence the symptoms interfere with or reduce the quality of school or work •The symptoms do not happen only during the course of schizophrenia or other psychotic disorders. The symptoms are not better explained by another mental disorder. Certain individuals can have combined presentation, a predominantly inattentive presentation or a predominantly hyperactive-impulsive presentation.

59. What are some of the mood stabilizing drugs used for bipolar disorder?

What are some of the mood stabilizing drugs used for bipolar disorder? Lithium, valproate, and carbamazepine. Lamotrigine which I think is categorized differently, is also used. Note that MKSAP warns us that anyone with depression must have a good history for any manic symptoms as SSRIs can activate those in individuals with bipolar disorder and these individuals are underdiagnosed.

61. What are some of the physical findings of anorexia nervosa?

What are some of the physical findings of anorexia nervosa? Parotid hyperplasia, dry and brittle hair, lanugo, yellowing skin, and xerosis. Obviously a low BMI and bradycardia, orthostatic hypotension and hypothermia may be seen. Cognitive impairment and depressed mood or an anxious mood are common. Scarring of the dorsum of the hand from repeated abrasions may be found. Dental caries might be seen because of the repeat emesis. There may be a history of amenorrhea from the hypoestrogenic state.

31. What are some of the surgeries that are very high risk for venous thromboembolic disease? (5)

What are some of the surgeries that are very high risk for venous thromboembolic disease? a.Major surgery in individuals older than 40 years old with a history of venous thromboembolic disease, cancer or thrombophilic states b.Hip or knee arthroplasty c.Hip fracture surgery d.Major trauma e.Spinal cord injury

66. What are some of the things to consider when seeing a patient with autism spectrum disorder in your practice?

What are some of the things to consider when seeing a patient with autism spectrum disorder in your practice? a.For those individuals with difficulty with physical contact, physical exam should be limited only to essential maneuvers and performed slowly and explained in detail. b.Efforts should be made to communicate with patients who are unable to speak as they are frequently able to comprehend. c.Alternative methods of communication such as pen and paper, pictures, and assisted device should be considered. d.Repetitive and stereotype behaviors are calming and should not be interrupted unless they are harmful or disruptive. e.An assistance of a caregiver or colleague who is familiar with the patient can be invaluable in suggesting how to best interact with him or her.

35. What are some options available for individuals with qualitative platelet defects such as those with kidney or liver disease preoperatively?

What are some options available for individuals with qualitative platelet defects such as those with kidney or liver disease preoperatively? For low risk procedures desmopressin can be given one hour preoperatively; whereas, platelet transfusions can be given for high risk procedures.

40. What are some systemic medical conditions that could cause chronic sinusitis? (4)

What are some systemic medical conditions that could cause chronic sinusitis? Sarcoidosis, granulomatosis with polyangiitis, cystic fibrosis, and hypothyroidism

44. What are some underlying issues that are associated with poor oral health/dentition?

What are some underlying issues that are associated with poor oral health/dentition? Tobacco, alcohol, and methamphetamine use, bulimia, a xerostomia, Sjögren's syndrome, agents that cause gingival hyperplasia such as anticonvulsants like phenytoin, cyclosporine and nifedipine.

34. What are the 3 core components of decisional capacity for a patient?

What are the 3 core components of decisional capacity for a patient? a.Understanding the situation at hand b.Understanding the risks and benefits of the decision being made c.The ability to communicate a decision Understand that we as physicians can only determine the capacity or incapacity of a patient to make these decisions. Competency is decided by a court, namely a judge.

PHN

def: persistent pain 4 months after rash onset TCAs 1st line (beers) Lyrica or Gabapentin 2nd line no evidence for Tegretol Capsaicin for moderate PHN pain

9. What are the 4 major indications for cholesterol lowing therapy with a statin in the ATP4 guidelines?

What are the 4 major indications for cholesterol lowing therapy with a statin in the ATP4 guidelines? a.Did the patient have a history of heart disease and stroke? b.Is the LDL greater than 190? c.Does the patient have diabetes, age of 40 to 75 and an LDL of greater than 70? d.Does the patient have a global 10 year risk score of greater than 7.5% for primary prevention of risk assessment?

17. What are the 5 criteria for metabolic syndrome?

What are the 5 criteria for metabolic syndrome? a.Abdominal obesity with a waist circumference of greater than 40 inches in men or 35 inches in women b.Triglyceride greater than 150 c.Low HDL (less than 40 in men, less than 50 in women) d.BP of greater than or equal to 130/85 e.Fasting glucose of greater than or equal to 110 Three of the 5 are required to make a diagnosis.

9. What are the 6 A's for careful monitoring of patient on opioid therapy?

What are the 6 A's for careful monitoring of patient on opioid therapy? a.Effectiveness of analgesia b.Benefit on activities of daily living c.Adverse events d.Aberrant behaviors suggesting drug abuse e.Assess mood f.Action or treatment plan

17. What are the 6 factors in the revised cardiac risk index?

What are the 6 factors in the revised cardiac risk index? a.History of ischemic heart disease b.Compensated or prior congestive heart failure c.Diabetes mellitus requiring insulin d.Chronic kidney disease with a creatinine greater than 2 e.History of cerebrovascular disease f.High risk surgery such as intrathoracic, intraperitoneal, suprainguinal vascular The greater the number of risk factors the higher the risk, although it only really goes up to about a 5% risk of death, non-fatal MI or non-fatal cardiac arrest.

41. What are the Centor criteria? (4)

What are the Centor criteria? a.Fever, subjective or measured as greater than 38.1 b.Absence of cough c.Tonsillar exudates d.Tender anterior cervical adenopathy >1cm. Individuals with 0 or 1 are low risk and do not need further testing although some do argue with that guideline. Although the IDSA says the preence of all four is enough to treat I still do rapid detection and if negative a culture as only 57% with all 4 features have Strep.

69. What are the U.S. Public Health Service Task Force recommendations for the following: a.Treatment of depression in older adults who are identified through screening in primary care settings b.Screening for hearing loss in older adults c.Screening for glaucoma d.Screening for visual acuity e.Screening for falls

What are the U.S. Public Health Service Task Force recommendations for the following: a.Treatment of depression in older adults who are identified through screening in primary care settings - Yes as it decreases clinical morbidity and treatment can be antidepressants, psychotherapy or both b.Screening for hearing loss in older adults - The USPHSTF does not recommend it but interestingly the Canadian Task Force does recommend a simple screening using a single question screening, the whisper voice test or audiometry and then of course hearing aids to improve communication c.Screening for glaucoma - The USPHSTF does not find evidence yet to date for this d.Screening for visual acuity - The USPHSTF has not found data for this even though there are early treatments for refractive error cataracts and age-related macular degeneration to prevent visual loss. Of course the American Academy of Ophthalmology recommends comprehensive eye exam every 1-2 years for persons 65 years or older and there are geriatricians who look carefully at patients for multifocal lenses because of the potential higher risk for fall when they look down to the ground and suggest separate reading glasses from their regular eyewear. e.Screening for falls - The U.S. Public Health Service Task Force does not comment on this but the Institute of Medicine has made it a high priority and the American Geriatrics Society recommends that physicians ask adults 75 and older if they have had walking and balance problems and then do a screening test afterwards.

63. What are the advantages and disadvantages of second generation antipsychotics such as clozapine and olanzapine compared to the first generation antipsychotics such as chlorpromazine and haloperidol?

What are the advantages and disadvantages of second generation antipsychotics such as clozapine and olanzapine compared to the first generation antipsychotics such as chlorpromazine and haloperidol? The newer generation drugs have fewer extrapyramidal side effects. However, the newer drugs have higher risk for weight gain, diabetes and hyperlipidemia.

18. What are the causes for uveitis and its presenting features?

What are the causes for uveitis and its presenting features? Syphilis, tuberculosis, autoimmune diseases, sarcoidosis and neoplasia. However, many patients have no underlying cause. These patients will complain of pain, photophobia and blurred vision. They may have the ciliary flush if it is an anterior uveitis or iridocyclitis. The vision is typically normal and the slit lamp may show flare cells if a hypopyon is not seen on your gross examination.

50. What are the causes of anal pain? (6)

What are the causes of anal pain? Foreign body, hemorrhoid, fissure, cancer, inflammatory bowel disease, abscess

19. What are the causes of blepharitis and how might they be treated?

What are the causes of blepharitis and how might they be treated? Staph aureus blepharitis is treated with topical antibiotics and warm compresses with cleansing the eyelid margins with a dilute non-tearing shampoo using a cotton tip applicator or a tiny brush. Rosacea can be treated with oral tetracyclines. Seborrheic dermatitis can be treated with topical antifungals and topical steroids.

36. What are the circumstances in which confidentiality is not absolute? (4)

What are the circumstances in which confidentiality is not absolute? a.The first situation might be in which there is an established risk for a patient harming themselves. b.A second might be when a patient is at risk for harming others and that person deserves to be warned. c.Number 3 would be when there is a public welfare risk for communicable diseases d.Number 4, if a person does not have decisional capacity, then the person that has been delegated the decisional capacity can be fully informed as to all aspects of the patient's condition.

32. What are the clues to cardiac causes of syncope?

What are the clues to cardiac causes of syncope? Relationship to exercise or exertion, sensitivity to volume status and association with medications

47. What are the common causes of bilateral lower extremity edema besides medications?

What are the common causes of bilateral lower extremity edema besides medications? Heart failure, nephrotic syndrome, cirrhosis, hypoproteinemia, constrictive pericarditis, chronic venous insufficiency and lymphedema.

54. What are the contraindications to combination oral contraceptive pills? (6)

What are the contraindications to combination oral contraceptive pills? a.Thrombosis b.Liver disease c.Breast cancer d.Migraine with aura e.Uncontrolled hypertension f.Women greater than 35 years old who smoke should not be prescribed estrogen containing preparations

62. What are the contraindications to postmenopausal hormonal therapy?

What are the contraindications to postmenopausal hormonal therapy? Unexplained vaginal bleeding, history of coronary artery disease, stroke, thromboembolic disease, breast or endometrial cancer, hypertriglyceridemia, recent vascular thrombosis or cardiovascular event and immobilization.

10. When are the high-intensity statins used?

What are the high-intensity statins? Atorvastatin and Rosuvastatin

36. What are the indications for pre- and postoperative transfusion in patients who are anemic around the time of surgery?

What are the indications for pre- and postoperative transfusion in patients who are anemic around the time of surgery? Transfusions are given for patients who •Have symptomatic anemia or •Have a preoperative hemoglobin of less than 6 or •Have a postoperative hemoglobin less than 7 or •Are symptomatic from heart disease and have a hemoglobin between 6 and 10.

52. What are the indications for psychiatric referral for depression?

What are the indications for psychiatric referral for depression? a.Suicidal or homicidal ideation b.Bipolar disorder c.Psychotic symptoms d.Symptoms refractory to at least two medications

38. What are the indications for surgical intervention of a patient with BPH?

What are the indications for surgical intervention of a patient with BPH? Refractory lower urinary symptoms, recurrent urinary retention with or without infection, bladder stones and kidney failure from hydronephrosis.

31. What are the modifiable risk factors for patients with erectile dysfunction?

What are the modifiable risk factors for patients with erectile dysfunction? Obesity, tobacco use, sedentary lifestyle and substance abuse such as alcohol, barbiturates, cocaine, heroin, marijuana and methamphetamines.

1. What are the most common causes of chronic pelvic pain defined as noncyclic pain of at least six months duration that localizes to anatomic pelvic, abdominal wall at or below the umbilicus, lumbosacral back or buttocks? (5)

What are the most common causes of chronic pelvic pain defined as noncyclic pain of at least six months duration that localizes to anatomic pelvic, abdominal wall at or below the umbilicus, lumbosacral back or buttocks? a.Endometriosis b.Pelvic adhesions c.Pelvic varices d.Interstitial cystitis e.Irritable bowel syndrome with many women having more than one problem, particularly concomitant IBS

45. What are the most common causes of unilateral leg edema?

What are the most common causes of unilateral leg edema? DVT, cellulitis and malignant lymphedema

28. What are the nonoperative complications of a Roux-en-Y gastric bypass?

What are the nonoperative complications of a Roux-en-Y gastric bypass? Gallstones, a nutritional deficiency such as B12, other B vitamins, iron, calcium, folic acid, vitamin D and rarely magnesium, copper, zinc, vitamin A and vitamin C.

3. What are the risk factors for Achilles tendinopathy?

What are the risk factors for Achilles tendinopathy? Male sex, increasing age, history of fluoroquinolone use, corticosteroid use and obesity.

62. What are the risk factors for carpal tunnel syndrome?

What are the risk factors for carpal tunnel syndrome? Female gender, obesity, pregnancy, diabetes, hypothyroidism, connective tissue disorders, rheumatoid arthritis, amyloidosis. Whenever a patient has carpal tunnel syndrome in their background, think of these disorders as potentially being the diagnosis for the rest of the syndrome being described.

2. What are the risk factors for chronic pelvic pain? (5)

What are the risk factors for chronic pelvic pain? a.Physical and sexual abuse b.Pelvic inflammatory disease c.A difficult obstetric delivery d.A history of abdominal or pelvic surgery e.Other chronic pain syndromes such as fibromyalgia

4. What are the risk factors for plantar fasciitis?

What are the risk factors for plantar fasciitis? Flat feet, running, occupations requiring prolonged standing and obesity. Note, compared to Achilles tendinopathy, plantar fasciitis has sharp pain in the heel in the first few steps after inactivity such as in the morning.

27. What are the specifications for live attenuated flu vaccine used as an intranasal infusion?

What are the specifications for live attenuated flu vaccine used as an intranasal infusion? For nonpregnant persons age 2 to 49 without any medical conditions that predispose to influenza or its complications such as asthma, pulmonary disease, immune deficiency or cardiovascular disease

43. What are the systemic diseases associated with epistaxis?

What are the systemic diseases associated with epistaxis? Hematologic malignancies such as a plasmacytoma, hemophilia, and acquired bleeding disorders from liver and kidney disease. I was surprised they did not mention hereditary hemorrhagic telangiectasia or Osler-Weber-Rendu.

25. What can be done to evaluate pre-op and manage post-op individuals for whom you might suspect obstructive sleep apnea?

What can be done to evaluate pre-op and manage post-op individuals for whom you might suspect obstructive sleep apnea? You can use the STOP-BANG screening tool and ask questions about snoring, daytime fatigue, people noticing whether you stop breathing while you sleep, hypertension, BMI greater than 35, age over 50, neck circumference greater than 40 cm. and male gender. These individuals can be watched longer in the PACU or in a step-down unit and may need BiPAP or other positive pressure interventions.

39. What is in the differential diagnosis for acute scrotal pain? (4)

What is in the differential diagnosis for acute scrotal pain? a.Testicular torsion b.Epididymitis c.Orchitis d.Referred pain from abdominal aneurysm, inguinal hernia with bowel strangulation, nephrolithiasis, lumbosacral nerve impingement and retroperitoneal inflammation

Botulism

descending paralysis

Tamponade

diastolic pressures are equalized systemic hypotension rapid y descent only (constrictive pericarditis has both)

37. What criteria might you use in the history prior to treating acute sinusitis?

What criteria might you use in the history prior to treating acute sinusitis? There are basically 3 criteria in the guidelines. One is an individual who has severe initial symptoms (purulence, facial pain, H/A) that get worse and worse over 3-4 days to the point of a fever of 39° or higher. The second is a worsening of symptoms on or after day six that had been initially improving after a typical upper respiratory infection (aka "double worsening"). The third is a person with sinusitis symptoms that failed to improve after 10 days. The presence of purulence and facial pain as well as the physical findings of purulence, unilateral predominance, local pain with unilateral predominance, bilateral purulent rhinorrhea and pus in the nasal cavity are all helpful. I would learn the 3 IDSA historical guidelines mentioned above as adults with any of these three presentations have a 60% chance of it being bacterial. No radiology is needed.

66. What diagnoses can an MRI help find in a patient with a normal hip x-ray and hip pain?

What diagnoses can an MRI help find in a patient with a normal hip x-ray and hip pain? Fracture, avascular necrosis, infection and tumor

60. What differentiates malingering from factitious disorders?

What differentiates malingering from factitious disorders? Individual with malingering is trying to develop symptoms for external gain, such as avoiding work or the law. Individuals with factitious disorders feign symptoms in order to remain in the sick role. Note MKSAP still uses DSM IV somatoform disorders. DSM 5 uses Somatic Symptom Disorder, Illness Anxiety Disorder and Conversion Disorder all three worth learning. The pseudoneurologic symptoms are what are also called a conversion disorder. In individuals on the Boards who have somatic disorders, they are going to want you to focus on any new symptom if any new symptom is present and not do tests for all the old symptoms or try to eliminate them, just help the patient function with them. Somatic symptom disorder patients are psychologically dependent on potential illness but unlike malingering or conversion, the symptoms expressed are not consciously fabricated. Reassurance that it is not life threatening and help the pt by understanding that the symptoms are real but not well understood.

51. What does the American Cancer Society recommend for MRI and breast self-exam screening for women at average risk?

What does the American Cancer Society recommend for MRI and breast self-exam screening for women at average risk? The data are insufficient to advise.

14. What does the U.S. Public Health Service Task Force recommend having in place prior to screening for depression?

What does the U.S. Public Health Service Task Force recommend having in place prior to screening for depression? The availability of accurate diagnosis, treatment and follow-up

23. What does the U.S. Public Health Service Task Force recommend with regard to screening for additional illnesses in patients with obesity?

What does the U.S. Public Health Service Task Force recommend with regard to screening for additional illnesses in patients with obesity? They don't recommend a screen for diabetes although the American Diabetes Association does so. Also consider looking for signs and symptoms of hypothyroidism and Cushing syndrome and screening when there are clues for these diagnoses.

55. What drugs might make oral contraceptives less effective?

What drugs might make oral contraceptives less effective? Those that induce the CYP3A enzymes such as barbiturates, carbamazepine, other anti-seizure medications, rifampin and antiretrovirals.

34. What drugs should not be used simultaneously with PDE-5 inhibitors?

What drugs should not be used simultaneously with PDE-5 inhibitors? Phosphodiesterase inhibitors should also not be used with nitrates as they will cause profound hypotension. Drugs that inhibit the P450 3A4 pathway such as protease inhibitors, erythromycin and ketoconazole as levels of the erectile dysfunction drug will increase.

39. What features would you seek to decide if a patient might have aortic dissection in your initial evaluation?

What features would you seek to decide if a patient might have aortic dissection in your initial evaluation? Asymmetric intensity of peripheral pulses has a positive likelihood ratio of 5.7. A second feature would be a widened mediastinum.

7. What general recommendations can be offered to all patients with urinary incontinence?

What general recommendations can be offered to all patients with urinary incontinence? Caffeine restriction, losing weight if overweight or obese, reducing fluid intake especially at nighttime

11. What happens to the negative predictive value of a test when there is decreasing prevalence?

What happens to the negative predictive value of a test when there is decreasing prevalence? The negative predictive value increases as the disease becomes rarer and thus a negative study indicates that it is less likely for the test to be falsely positive. Be prepared to do a 2 x 2 table to calculate sensitivity and specificity. Practice this before the Boards to get one free question.

6. What happens to the positive predictive value of a test when there is increasing prevalence of a disease that is being tested for?

What happens to the positive predictive value of a test when there is increasing prevalence of a disease that is being tested for? The positive predictive value of a test increases when there is an increase in prevalence of disease

16. What history and physical would you take after completing your assessment of a patient for whom you want to start high statins to have as a baseline in the record?

What history and physical would you take after completing your assessment of a patient for whom you want to start high statins to have as a baseline in the record? Baseline creatinine kinase and aminotransferase levels should be obtained before initiating statin therapy as well as a history of liver disease or muscle disease or symptoms.

48. What hormonal laboratory tests should be ordered in a woman with female sexual dysfunction?

What hormonal laboratory tests should be ordered in a woman with female sexual dysfunction? Typically none unless there are signs otherwise of prolactinoma, thyroid abnormality or adrenal disease.

10. What is a contraindication to use of anticholinergic agents for urge incontinence?

What is a contraindication to use of anticholinergic agents for urge incontinence? Patients with angle-closure glaucoma

Vascular Neurocogntiive disorder

coexisting AD found on a lot of autopsies stepwise decline

18. What is the A, B, C, D, E approach to the management of metabolic syndrome?

What is the A, B, C, D, E approach to the management of metabolic syndrome? Assess 10 year risk and if greater than or equal to 6% start aspirin. Control blood pressure but be aware of the guideline in MKSAP 16 and look at Joint 8 Hypertension for an update. Cholesterol management. Diabetes prevention through lifestyle modification, weight loss, low glycemic diet, Mediterranean diet and the last is exercise with a goal of greater than 10,000 steps per day.

18. What is the CDC recommendation for HIV screening?

What is the CDC recommendation for HIV screening? The CDC recommends screening all persons aged 13 to 64 whereas U.S. Public Health Services Task Force recommends only screening persons at risk for infection; however, U.S. Public Health Service Task Force recommends that all pregnant women be screened for HIV.

15. What is the U.S. Public Health Service Task Force recommendations for screening for: a.Coronary artery stenosis b.COPD c.Hereditary hemochromatosis d.Peripheral artery disease

What is the U.S. Public Health Service Task Force recommendations for screening for: a.Coronary artery stenosis b.COPD c.Hereditary hemochromatosis d.Peripheral artery disease Recommendation is against screening for all four of them

20. What is the U.S. Public Health Services Task Force recommendation for aspirin use as a primary prevention?

What is the U.S. Public Health Services Task Force recommendation for aspirin use as a primary prevention? Use for men between 45 and 79 and women between 55 and 79 if the risk for cardiovascular disease (male) and stroke (female) in the respective genders outweighs the risk of bleeding. Note the difference in the risk being prevented in men and women.

3. What is the absolute risk reduction ratio to the event rate among controls?

What is the absolute risk reduction ratio to the event rate among controls? The relative risk reduction

70. What is the best test for assessing the intactness of the menisci?

What is the best test for assessing the intactness of the menisci? The medial-lateral grind test

32. What is the classic triad of Ménière disease?

What is the classic triad of Ménière disease? Sensorineural hearing loss, tinnitus and vertigo although a schwannoma can cause the exact same things and an MRI is often needed to distinguish the two.

42. What is the difference between the pathogens causing epididymitis in an individual over age 55 versus someone younger than age 35?

What is the difference between the pathogens causing epididymitis in an individual over age 55 versus someone younger than age 35? Younger individuals tend to have chlamydia and gonorrhea infections; older individuals and men who practice anal intercourse have E. coli, enterobacteriaceae and pseudomonal infection.

70. What is the difference in depression in older adults compared to younger ones?

What is the difference in depression in older adults compared to younger ones? More somatic and vegetative symptoms rather than dysphoria

57. What is the disadvantage of using a progesterone implant and depot progesterone?

What is the disadvantage of using a progesterone implant and depot progesterone? Although highly effective for up to 3 years, there is a delay in return to ovulation for up to 6-10 months once it is no longer used.

39. What is the frequency of addiction in patients for whom you choose an opioid for cancer-related pain?

What is the frequency of addiction in patients for whom you choose an opioid for cancer-related pain? Rare

47. What is the management of a direct or indirect inguinal hernia or femoral hernia that is asymptomatic?

What is the management of a direct or indirect inguinal hernia or femoral hernia that is asymptomatic? These can be monitored although realize that femoral hernias are more likely to become incarcerated or strangulated.

10. What is the most common cause of a red eye and what are its underlying causes?

What is the most common cause of a red eye and what are its underlying causes? Conjunctivitis is the most common cause and viruses, bacteria, allergies or contact lens wear are the underlying causes.

32. What is the most common source of error leading to an adverse event for patients discharged from the hospital within the first few weeks after that discharge?

What is the most common source of error leading to an adverse event for patients discharged from the hospital within the first few weeks after that discharge? An error related to medication and in the elderly in particular this leads to rehospitalization.

58. What is the most cost-effective birth control method used world-wide?

What is the most cost-effective birth control method used world-wide? The copper IUD.

55. What is the most effective long term intervention for general anxiety disorder and panic disorder?

What is the most effective long term intervention for general anxiety disorder and panic disorder? Cognitive behavioral therapy and randomized trials have been shown it to be equal in efficacy to pharmacologic drugs and have a lower relapse rate. SSRIs and SNRIs are effective. Panic disorder usually requires a combination of CBT and pharmacotherapy.

7. What is the negative predictive value of a test when there is a decreasing prevalence of a disease?

What is the negative predictive value of a test when there is a decreasing prevalence of a disease? The negative predictive value of a test increases with a decreasing prevalence of disease

53. What is the only FDA approved drug for cyclical mastalgia?

What is the only FDA approved drug for cyclical mastalgia? Danazol but menorrhagia and weight gain often limits its use.

18. What is the pulmonary function test abnormality seen in nonasthmatic eosinophilic bronchitis?

What is the pulmonary function test abnormality seen in nonasthmatic eosinophilic bronchitis? PFT's are normal in this patient and the presence of sputum eosinophilia and response to inhaled corticosteroids helps make the diagnosis.

48. What is the role of diuretics in treating chronic venous insufficiency?

What is the role of diuretics in treating chronic venous insufficiency? These drugs typically should be avoided and treatment that can be used includes leg elevation, compressive stockings and sodium restriction.

27. What is the role of elastic grading compression stockings in the postoperative period to prevent venous thromboembolic disease?

What is the role of elastic grading compression stockings in the postoperative period to prevent venous thromboembolic disease? None, as they cause a risk of skin damage in a patient who might not be fully alert to complain about the pressure.

33. What is the sensitivity and specificity (high or low) for a 12 lead EKG in evaluating a patient with syncope?

What is the sensitivity and specificity (high or low) for a 12 lead EKG in evaluating a patient with syncope? Very low sensitivity but very high specificity

23. What is the treatment for benign paroxysmal positional vertigo?

What is the treatment for benign paroxysmal positional vertigo? The Epley maneuver

62. What is the treatment for bulimia nervosa and binge eating disorder?

What is the treatment for bulimia nervosa and binge eating disorder? CBT and SSRI and fluoxetine have been approved by the FDA for bulimia nervosa.

63. What is the treatment of choice for carpal tunnel syndrome?

What is the treatment of choice for carpal tunnel syndrome? Avoidance of repetitive motions to the wrist and hand and nocturnal splinting of the wrist at a neutral angle.

50. What is the treatment of choice for female orgasmic disorder and for female sexual arousal disorder?

What is the treatment of choice for female orgasmic disorder and for female sexual arousal disorder? Cognitive behavioral therapy. In female sexual arousal disorder adequate lubrication, either through the use of topical estrogens in postmenopausal women or vaginal moisturizers can be helpful.

49. What is the treatment of temporomandibular pain disorders after you have ruled out dental, ear, mastoid, salivary, temporal arteritis, trigeminal and herpes zoster disorders?

What is the treatment of temporomandibular pain disorders after you have ruled out dental, ear, mastoid, salivary, temporal arteritis, trigeminal and herpes zoster disorders? Jaw relaxation, heat and therapeutic exercises. Cognitive behavioral therapy may also be used.

25. What medical conditions and medications are associated with dry eyes?

What medical conditions and medications are associated with dry eyes? a.Graves' disease as more of the eye is exposed from endophthalmitis or proptosis b.Bell's palsy can cause an exposure of the eye c.Sjögren's disease and rheumatoid arthritis d.Diabetes mellitus, LASIK surgery, prior herpes zoster infection, contact lens wearing can all lead to a decrease in corneal sensation and thus reduce tear secretion e.Medications include anticholinergics, antihistamines, SSRIs, nicotinic acid and isotretinoin

27. What medical conditions might you consider in someone who has insomnia?

What medical conditions might you consider in someone who has insomnia? Thyroid disease, heart failure, alcohol and caffeine use, other stimulants and the conditions listed in the above question.

4. What medication can be used for fibromyalgia?

What medication can be used for fibromyalgia? Tricyclic antidepressants and milnacipra

59. What method of emergency contraception is not an abortifacieants?

What method of emergency contraception is not an abortifacieants? Hormonal therapy such as levonorgestrel. These hormonal contraceptive methods prevent or delay ovulation. The IUD prevents implantation. This information might be very helpful for women of certain belief systems.

65. What might be an ADHD treatment in adults, particularly for those you wish to avoid stimulants because of substance abuse potential?

What might be an ADHD treatment in adults, particularly for those you wish to avoid stimulants because of substance abuse potential? Atomexetine is a selective norepinephrine reuptake inhibitor approved for ADHD in adults. Bupropion and tricyclics may also be beneficial. Lastly, it is important to reevaluate whether an adult actually needs treatment as the natural history shows gradual improvement with age and drug holidays are warranted in well controlled patients. Cognitive behavioral training may be effective as an adjunct to therapy.

9. What pharmacologic therapy might you use for stress incontinence and urge incontinence?

What pharmacologic therapy might you use for stress incontinence and urge incontinence? For stress incontinence duloxetine is an option. For urge incontinence anticholinergic antimuscarinic medications are first line therapies such as oxybutynin, tolterodine, fesoterodine, darifenacin, solifenacin and trospium.

43. What physical findings might be present for pulmonary hypertension?

What physical findings might be present for pulmonary hypertension? A loud P2, a widely split P2 (remember a fixed split second heart sound is seen with atrial septal defect), a parasternal heave and elevated jugular venous pressure. The exam might just say the S2 is loud, of course indicating that the P2 is loud.

43. What precautions might you take in a preoperative evaluation for a patient with chronic kidney disease?

What precautions might you take in a preoperative evaluation for a patient with chronic kidney disease? The patient might benefit from erythropoietin if they are anemic and there is an expectation of a lot of blood loss on surgery. This will take a while to work. If a patient is on an ACE inhibitor or angiotensin receptor blocker then these drugs might be withheld on the day of surgery to avoid intraoperative hypotension.

33. What precautions prior to prescribing PDE-5 inhibitors must you take?

What precautions prior to prescribing PDE-5 inhibitors must you take? Since erectile dysfunction is an atherosclerotic risk factor similar to that of moderate tobacco use, a patient should be assessed with regard to their cardiac risk. Those with intermediate or high risk should not be prescribed the drug until they are fully evaluated for cardiac disease and have the cardiac disease treated.

47. What presenting symptom do a Zenker's diverticulum and pulmonary bronchiectasis have in common?

What presenting symptom do a Zenker's diverticulum and pulmonary bronchiectasis have in common? Halitosis although poor dentition and gingival disease from lack of flossing are a far more common causes.

16. What should a patient who is fasting on the morning before surgery and has AM medications that have been prescribed in pill form do?

What should a patient who is fasting on the morning before surgery and has AM medications that have been prescribed in pill form do? Take the medications with small amounts of water on the day of surgery.

44. What should be done for patients with liver disease in the following situations preoperatively? a.Elective surgery in a patient with a newly recognized but undiagnosed liver disease b.Elective surgery in a patient with acute hepatitis c.A patient who is preoperative with hemochromatosis d.A patient on antimicrobials for hepatitis B heading towards surgery e.A patient with cirrhosis and a high INR preoperatively

What should be done for patients with liver disease in the following situations preoperatively? a.Elective surgery in a patient with a newly recognized but undiagnosed liver disease - Postpone the surgery until diagnosis is made b.Elective surgery in a patient with acute hepatitis - Postpone the surgery until the diagnosis is made and the hepatitis has improved c.A patient who is preoperative with hemochromatosis - Consider cardiac evaluation for cardiac myopathy d.A patient on antimicrobials for hepatitis B heading towards surgery - Be sure the antiviral is continued to avoid a hepatitis B flare e.A patient with cirrhosis and a high INR preoperatively - Vitamin K, fresh frozen plasma, cryoprecipitate or activated factor VII may be needed

14. What treatable causes of corneal abrasions causing a foreign body sensation in the eye, photophobia, tearing and pain should be ruled out upon initial evaluation?

What treatable causes of corneal abrasions causing a foreign body sensation in the eye, photophobia, tearing and pain should be ruled out upon initial evaluation? Fluorescein dye and a Wood's lamp should rule out the dendritic lesions of herpes simplex and if found treated. If there is evidence of an erosive corneal ulcer or early perforation then the patient may have a bacterial infection and ophthalmologist should be consulted immediately for antimicrobial therapy and consideration of corneal scraping. The upper lid should be looked at to make sure that there isn't a foreign body that is causing the corneal abrasion and the foreign body needs to be removed. Of course contact lens wearers should avoid wearing them during this time.

64. What treatment might you consider in a woman with recurrent urinary tract infections who is menopausal to prevent them?

What treatment might you consider in a woman with recurrent urinary tract infections who is menopausal to prevent them? Low dose vaginal estradiol tablets or an estradiol vaginal ring could be considered as these two are not well absorbed compared to creams. These therapies treat the vaginal atrophy that could be predisposing to recurrent urinary tract infections as shown in one NEJM randomized controlled trial.

22. What type of preoperative evaluation should be done in an individual who requires emergent surgery?

What type of preoperative evaluation should be done in an individual who requires emergent surgery? None, we just have to deal with the potential complications in the postoperative period.

3. What types of analgesics can be used for neuropathic pain?

What types of analgesics can be used for neuropathic pain? Gabapentin, pregabalin, tricyclic antidepressants, duloxetine, venlafaxine, tramadol, opioids, carbamazepine, topical lidocaine 5% patch, topical capsaicin

49. What underlying disorders might be present in a woman with a sexual pain disorder or dyspareunia?

What underlying disorders might be present in a woman with a sexual pain disorder or dyspareunia? Vulvodynia, interstitial cystitis, pelvic adhesions, infections, endometriosis and pelvic venous congestion. Vaginal atrophy and inadequate lubrication may exacerbate the syndrome and can be noted on exam.

27. What will be the key words on the case for central retinal vein occlusion and central retinal artery occlusion?

What will be the key words on the case for central retinal vein occlusion and central retinal artery occlusion? Central retinal vein occlusion will be a sudden unilateral visual loss and the individual will have hypertension, diabetes, smoking, obesity, hypercoagulable states, glaucoma and the onset of vision loss will lead to an ophthalmology exam showing the so-called blood and thunder in the eye with hemorrhage and cotton wool spots. Central retinal artery occlusion will have the characteristic cherry red spot as the pale retina leads to us seeing the cherry red fovea that has preserved vascular supply.

56. What will be the typical features of post-traumatic stress syndrome?

What will be the typical features of post-traumatic stress syndrome? An individual with risk factors such as low socioeconomic status, parental neglect, family and personal history of psychiatric condition, poor social support and initial severity of reaction to a traumatic event. These individuals will have intrusive thoughts about the trauma, nightmares or flashbacks, avoidance of reminders of the event and hypervisual and sleep disturbance.

42. What will be the typical story for Lemierre?

What will be the typical story for Lemierre? It will be a young person, ages 18 to 25 who has lateral neck tenderness in the area of the jugular vein. The strep test will be negative. There might be preceding mononucleosis. There might be pulmonary nodules (septic emboli) that will eventually cavitate.

21. What will the clues be for primary open-angle glaucoma?

What will the clues be for primary open-angle glaucoma? Increased optic cup-to-disc ratio of greater than 0.5, disc hemorrhage, age greater than 40, African-American, positive family history of visual loss, painless and gradual loss of vision in both eyes and the progression can be asymmetric.

20. What would be the components of a typical history for macular degeneration?

What would be the components of a typical history for macular degeneration? An older individual, perhaps prior smoker, with cardiovascular disease and maybe a positive family history of vision loss. They might mention neovascularization near the macula or drusen in the area of the macula. There is no redness of the eye but there is difficulty driving, reading and performing activities and sometimes a history of falls.

15. What would be the key words distinguishing episcleritis from scleritis in the history?

What would be the key words distinguishing episcleritis from scleritis in the history? Individuals with episcleritis have less pain and the vision is not affected. Therefore, the presence of pain, visual impairment and redness in the eye are clues for urgent referral to an ophthalmologist.

22. What would be the typical history for acute-angle closure glaucoma?

What would be the typical history for acute-angle closure glaucoma? Patient now has a red eye, pain and headache which differs it from the open-angle glaucoma. Visual acuity is also reduced. There is a semidilated, nonreactive pupil. It is an ophthalmologic emergency.

libre

discrepancy between log and A1c 72 hours some are real time some are stored data

39. What would be the typical story and treatment for nonallergic rhinitis?

What would be the typical story and treatment for nonallergic rhinitis? It might have triggers such as odors, spicy foods and changes in temperature in the environment such as going outdoors. Treatment also includes intranasal steroids, antihistamines and anticholinergic medications. Oral medications are less effective. Nasal saline irrigation might be helpful.

38. What would be the typical story and treatment of choice for allergic rhinitis?

What would be the typical story and treatment of choice for allergic rhinitis? Sneezing, congestion, rhinorrhea, seasonality, environmental exposure, exposure to cats. There is no need to do in vitro specific IgE testing in routine cases and intranasal steroids work quite well.

5. What would you consider screening for in a patient with chronic non-cancer pain syndrome?

What would you consider screening for in a patient with chronic non-cancer pain syndrome? Depression, anxiety, substance abuse and physical, verbal and sexual abuse

40. What would you do for a patient with an elective hernia repair and a fasting glucose of 250?

What would you do for a patient with an elective hernia repair and a fasting glucose of 250? Control the diabetes and postpone the surgery.

39. What would you do with a patient who is on metformin or other oral hypoglycemic preoperatively?

What would you do with a patient who is on metformin or other oral hypoglycemic preoperatively? Discontinue the metformin the night before surgery and the oral agents on the morning of surgery and monitor the sugars. Short-acting insulin should also be withheld the morning of surgery.

11. When the goal is to reduce LDL by more than 50%.

When are the high-intensity statins used? When the goal is to reduce LDL by more than 50%.

17. When the words ciliary flush is used or the picture shows a red ring around the iris on the white of the eye, what diagnosis are they basically saying?

When the words ciliary flush is used or the picture shows a red ring around the iris on the white of the eye, what diagnosis are they basically saying? Uveitis

71. Which 4 medications are responsible for two-thirds of emergency hospitalizations for adverse drug events?

Which 4 medications are responsible for two-thirds of emergency hospitalizations for adverse drug events? Warfarin, insulin, oral hypoglycemic and antiplatelet agents

57. Which antimicrobial would you prescribe for viral conjunctivitis?

Which antimicrobial would you prescribe for viral conjunctivitis? None unless there is a herpes keratitis present

40. Which cause of chest pain has PR segment depression?

Which cause of chest pain has PR segment depression? Pericarditis

41. Which cause of chest pain has dyspnea on exertion and syncope associated with it?

Which cause of chest pain has dyspnea on exertion and syncope associated with it? Aortic stenosis

44. Which cause of chest pain is worse with bending over or recumbency?

Which cause of chest pain is worse with bending over or recumbency? Esophageal reflux

25. Which drugs are approved by the FDA for short term use in obesity and what is the precaution?

Which drugs are approved by the FDA for short term use in obesity and what is the precaution? The FDA has approved phentermine and diethylpropion. The precaution for these sympathomimetic drugs are for people with hypertension and cardiovascular disease. Lorcaserin is another FDA approved drug and the precaution for this drug is increase in serotonin levels so watch for other drug interactions. It will be interesting to see in the long run if there are any valvular problems with this drug as has occurred with others of this type.

56. Which form of contraception combines the highest contraceptive efficacy with a failure rate of less than 1% with the lowest cost?

Which form of contraception combines the highest contraceptive efficacy with a failure rate of less than 1% with the lowest cost? IUD

31. Which form of hearing loss may be preceded by a history of ear drainage, chronic otitis, odor around the ear often noted by a partner and staining of the pillow case with a white membrane on the tympanic membrane?

Which form of hearing loss may be preceded by a history of ear drainage, chronic otitis, odor around the ear often noted by a partner and staining of the pillow case with a white membrane on the tympanic membrane? This is a cholesteatoma that is treated surgically and often due to chronic otitis media as described above.

19. Which infectious diseases are recommended by U.S. Public Health Services Task Force for pregnant women?

Which infectious diseases are recommended by U.S. Public Health Services Task Force for pregnant women? a.Hepatitis B for all pregnant women in their first prenatal visit b.Screening for a UTI with a urine culture for pregnant women between weeks 12 and 16 of gestation c.Screening for Syphilis in all pregnant women d.HIV screening should be performed on all pregnant women

14. Which of the following are recommended for the common cold? a.Newer generation non-sedating antihistamines b.Centrally and peripherally acting antitussive therapy c.Beta-agonists

Which of the following are recommended for the common cold? a.Newer generation non-sedating antihistamines b.Centrally and peripherally acting antitussive therapy c.Beta-agonists None are recommended. Beta-agonists could be used if wheezing accompanies the cough.

13. Which of the following are true regarding ACE inhibitor induced cough: a.The cough typically begins within 1 week b.The cough generally abates within a month after discontinuation c.A different ACE inhibitor can be used as cough rates vary among them d.An angiotensin receptor blocker can be substituted for an ACE inhibitor

Which of the following are true regarding ACE inhibitor induced cough: a.The cough typically begins within 1 week - True b.The cough generally abates within a month after discontinuation - True c.A different ACE inhibitor can be used as cough rates vary among them - False d.An angiotensin receptor blocker can be substituted for an ACE inhibitor - True

Prolactinoma in Pregnancy

concern they might grow due to estogenic stimulation < 10 mm are low risk > 10 mmg High risk formal visual field testing every trimester don't bother with prolactin level can be elevated from pregnancy

PNES

continuous EEG long duration closed eyes Epilepsy monitoring units 2-7 day stay PNES

49. Which of the following are true regarding the straight leg test for low back pain? a.The crossed straight leg raise test (lifting the unaffected side causes pain in the opposite leg) is more specific than the traditional straight leg test b.The key finding in the straight leg test is that the pain radiates below the knee

Which of the following are true regarding the straight leg test for low back pain? a.The crossed straight leg raise test (lifting the unaffected side causes pain in the opposite leg) is more specific than the traditional straight leg test - True b.The key finding in the straight leg test is that the pain radiates below the knee - True

33. Which of the following are true? a.Timely follow-up with a primary care physician after hospital discharge, particularly within one month leads to lower rates of hospitalization b.Medication reconciliation efforts led by pharmacists compared to controls decreased the rate of adverse events at 30 days

Which of the following are true? a.Timely follow-up with a primary care physician after hospital discharge, particularly within one month leads to lower rates of hospitalization: True b.Medication reconciliation efforts led by pharmacists compared to controls decreased the rate of adverse events at 30 days: True, 1% vs. 11%

54. Which of the following causes of syncope may require hospitalization? a.Neurocardiogenic b.Orthostatic syncope c.Cardiogenic

Which of the following causes of syncope may require hospitalization? a.Neurocardiogenic - No b.Orthostatic syncope - No if the patient could be adequately rehydrated c.Cardiogenic - Yes, we are looking for cardiac syncope and those individuals may need to be hospitalized

53. Which of the following has been shown to be effective in an individual with acute musculoskeletal back pain? a.Bed rest b.Maintenance of daily activity as best as they can c.Spinal manipulation therapy d.Supervise exercise therapy and physical therapy e.Acupuncture for chronic low back pain

Which of the following has been shown to be effective in an individual with acute musculoskeletal back pain? a.Bed rest - No b.Maintenance of daily activity as best as they can - Yes c.Spinal manipulation therapy - Yes d.Supervise exercise therapy and physical therapy - Not in the early phases of low back pain but can be helpful in patients for whom pain persists more than 4 weeks and to prevent occurrences. e.Acupuncture for chronic low back pain - No

37. Which of the following has the highest positive likelihood ratio for acute myocardial infarction? a.Relief of chest pain with nitroglycerin b.Radiation to the left arm c.Radiation to the right arm d.Diaphoresis e.Pain with exertion

Which of the following has the highest positive likelihood ratio for acute myocardial infarction? a.Relief of chest pain with nitroglycerin b.Radiation to the left arm c.Radiation to the right arm d.Diaphoresis e.Pain with exertion Answer is radiation to the right arm with a likelihood ratio of 4.7. There is no predictable association with acute myocardial infarction and relief of chest pain with nitroglycerin. Radiation to the left arm likelihood ratio 2.3, diaphoresis 2.0 and pain with exertion 2.4.

1. Which of the following opioid analgesics are available as a solution, lozenge, transdermal patch or suppository for ease of administration in individuals who cannot take pills or who do not have a means for parenteral access? a.Morphine b.Oxycodone c.Fentanyl d.Codeine e.Hydromorphone f.Hydrocodone

Which of the following opioid analgesics are available as a solution, lozenge, transdermal patch or suppository for ease of administration in individuals who cannot take pills or who do not have a means for parenteral access? a.Morphine - Available as a solution and rectal suppository b.Oxycodone - Available as a solution c.Fentanyl - Available as a transmucosal lozenge or buccal tablet in immediate release and as a patch for extended release d.Codeine - Available in liquid e.Hydromorphone - Available in liquid and as a rectal suppository f.Hydrocodone - Only available in tablet form

11. Which of the following statements are true about acute cough? a.For cough of less than 3 weeks duration, upper respiratory tract infections and acute bronchitis are the most common causes b.Mycoplasma, Chlamydophilia and Bordetella pertussis are non-viral causes c.Bronchial hyperreactivity can persist for up to 8 weeks after a viral bronchitis d.Patient satisfaction with care for acute bronchitis depends on whether the patient receives an antibiotic prescription from the physician

Which of the following statements are true about acute cough? a.For cough of less than 3 weeks duration, upper respiratory tract infections and acute bronchitis are the most common causes - True b.Mycoplasma, Chlamydophilia and Bordetella pertussis are non-viral causes - True c.Bronchial hyperreactivity can persist for up to 8 weeks after a viral bronchitis - True d.Patient satisfaction with care for acute bronchitis depends on whether the patient receives an antibiotic prescription from the physician - False, it is primarily based on physician-patient communication

37. Which opiate has problems with QT prolongation?

Which opiate has problems with QT prolongation? Methadone

8. Which opioid can cause an increase in the QT interval?

Which opioid can cause an increase in the QT interval? Methadone

35. Which patients are high risk following a syncopal episode and require immediate hospitalization? (11)

Which patients are high risk following a syncopal episode and require immediate hospitalization? a.Individuals with exertional or supine syncope b.Palpitations before the event c.A family history of sudden death d.Non-sustained ventricular tachycardia e.An abnormal EKG finding f.Chest pain g.Heart failure h.Syncope without warning signs i.Those who have a bleed j.Those suspected or has known heart disease k.Those with frequent recurrent episodes

13. Which stages of pressure ulcers require surgical or non-surgical wound debridement?

Which stages of pressure ulcers require surgical or non-surgical wound debridement? Stage 3 and stage 4

28. Which type of neurocardiogenic syncope is more common in the young and which one is more common in the elderly?

Which type of neurocardiogenic syncope is more common in the young and which one is more common in the elderly? Vasovagal neurocardiogenic syncope often begins in the young. The story will have a few seconds of palpitations, nausea, warmth, sweating, light-headedness, blurred vision and even some memory of the event. Carotid sinus hypersensitivity is found in the elderly, typically male.

3 good answers

contraindiction question

Pemphigus Foliaceus

corn flake crust superifical

fluctuating INRs

daily low dose Vit K

38. Which type of opiate is better for acute onset of pain: a short-acting opiate or a long-acting opiate?

Which type of opiate is better for acute onset of pain: a short-acting opiate or a long-acting opiate? A short-acting opiate is better as there will be a greater initial onset and then once the patient is loaded a long-acting opiate can be used. Thus, short-acting narcotics are better for breakthrough pain.

29. Which type of orthostatic intolerance is classically seen in young women?

Which type of orthostatic intolerance is classically seen in young women? Postural orthostatic tachycardia syndrome. These women often have light-headedness and palpitations and no syncope. Traditional orthostatic syncope is more common in the elderly.

32. Who is at high risk and needing a full bridging strategy? (4)

Who is at high risk and needing a full bridging strategy? a.Individuals who have had thromboembolic disease less than 3 months ago or a history of thromboembolic disease with thrombophilia b.A stroke less than 6 months ago c.Atrial fibrillation with a CHADS2 score of greater than 4 or prior stroke d.Mechanical heart valve in the mitral position or older aortic prosthesis

50. Who was in the only group of patients that U.S. Preventive Health Services Task Force recommends screening for asymptomatic bacteria?

Who was in the only group of patients that U.S. Preventive Health Services Task Force recommends screening for asymptomatic bacteria? Pregnant women

67. Women with structural or anatomical abnormalities and abnormal uterine bleeding have ovulatory bleeding whereas those with unopposed estrogen have anovulatory bleeding. How will you differentiate these by history?

Women with structural or anatomical abnormalities and abnormal uterine bleeding have ovulatory bleeding whereas those with unopposed estrogen have anovulatory bleeding. How will you differentiate these by history? Women with ovulatory bleeding have cyclical bleeding whereas those with anovulatory bleeding have a very unpredictable cycle and variable flow.

Seizure

abnormal, excessive electrical discharge Seizure is a symptom - OCP and AED interaction

Platypnea-orthodeoxia Syndrome

acquired d/o cyanosis & dyspnea when upright R2L shunt across PFO or atrial septal defect transient increase in RA pressure complication of RV infarction PE Tricuspid regurgitation acute Right HF Tx: Device PFO closure

Acquired Hemophilia

acquired factor VIII def tends to be mucocutaneous & intramuscular bleeding & isolated aPTT prolangation Post partum, Malignancy & AI D/O 50% idiopathic Rx: low inhibitor titer = factor VIII concentratate > 5 Bethesda units = Factor VIIa or PCC LA doesn't cause bleeding

Type IV RTA

actually clinically importent diabetics sensitive to ACE or ARB

Sweet Syndrome

acute febrile neutrophilic dermatosis papillary dermal edema = juicy leukocytosis bands and polys old white womenz paraneoplastic, idiopathic

INO

adduction weakness ipsilateral medial rectus palsy CN III palsy v. higher up accommodation test - if can accommodate CN III intact MS

Migraine with Aura

aggravation with physical activity Aura in 25-35% MC visual aura should last 5-60min can precede, occur at same time or separate

PCSK9

alirocumab & evolocumab serine protease inhibitors PCSK9 responsible for clearance and rapid recycling of LDL receptor 0.95% atheroma volume reduction in 18 months 2/3 experienced plaque reduction

TLS

allopurinol takes 3-4 days to take full effect urine floow of 80-100ml per hour

Vedolizumab

alpha4Beta7-integrin inhibitor

acute limb ischemia

anti-coagulate urgent angioplasty

General Crohn's Management

antibiotics are important in fistula and abscesses no rule in luminal treatment ileocolic disease budesonide

Urinary Dysfunction in MS

anticholinergics oxybutynin tolterodine bladder spasticity from myelopathy urge 2/2 uninhibited detrusor muscle function reduces urgency, frequency and incontinence

Brain Death

apnea test pCO2 > 60 mmHg EEG Cerebral blood flow test no flow

Teriparatide

approved for high risk = - 3 or less who have had a fracture or decreased BMD on Bisphosphonate - also on long term glucocorticoid - 20 mcg SQ daily - only 2 years tops

CPH

at least 5 times a day last 3-20 minutes confirm diagnosis by indomethicin

ICDs

battery 7-10 yrs light to mod exercise permissible shock = contact cards more than 1 shock and/or symptoms ER

Aortic Regurgitation murmur

best at 3rd ICS better end expiration leaning forward Widened Pulse Pressure Austin Flint Murmur

UTI on warfarin

best choice: PCN or Cephalosporin Macrobid Quinolones worried TMP Sulfa...NO!!!!!

OSA and the heart

bradycardia and sinus arrest can last 10 seconds -

chronic long acting opiates

can cause hypogonadotropic hypogonadism hence 2ndary adrenal insuff

Pulmonary Vein Stenosis

catheter ablation for a fib 1-3% risk higher with multiple procedures progressive dyspnea CTA/MRA or VQ less common Phrenic nerve injury but immediately after elevated hemidiaphragm

pharmacologic vasodilators

caution in COPD but contraindicated in active wheezing active wheezing means even regadenoson is contraindicated

Digoxin

check in worsening Cr RF for toxicity: old, low BMI or CKD > 1 ng/mL a/w increased Mortality

Flu outbreak

chemoppx for all residents per USAC and IDSA for 14 days or 10 days after onset of last infected which ever is longer

IPF

clubbing 40-50% do NOT biopsy to make diagnosis 40-60 year old no exposure generally fatal in 4-5 years UIP minimal ground glass you can do surgical lung biopsy

ESS Euthyroid Sick Syndrome

nonthyroidal ilness syndrome low T3 syndrome really just changes in thyroid tests during critical illness changes in HPT axis in 75% of hospitalized patients - Drugs: Calcium, PPI, Fe, Questeran, AlOH, Sucralfate, Psylium - Increased metabolism of levothyroxine: Dilantin, Carbamazepine, Rifampin, Phenobarb and Sertraline - Thyroiditis: amiodarone, Lithium, IFN-alpha, IL-2 and TKI - De novo anti thyroid antibodies: IFN-alpha - inhibition of TSH synthesis/release: Glucocorticoid, Dopamine, Dobutamine, Octreotide

Aldactone

only if CHF is stable NYHA II-IV NYHA II only in prior hospitalization or elevated BNP only in sCr < 2.5

CABG in stable angina

only those who are symptomatic despite OMT & have angiographic findings left main multiveseel with LAD involvement concomitant HFrEF

Apneustic

p for pausa

Subacute thyroiditis

painful neck Beta blocker not thionamides low RAIU thyrotoxic phase

widened S2

persistently split PS RBBB early closer in Severe MR ejection click that disappears with inspiration = PS

Pseudo-Cushing

physiologic stress exercise or emotional stress

SLE Pulm

pleural PE pneumonotis

Describe Takotsubo CMP

post menopausal F in 60s 2/2 myocardial stunning and microvascular dysfxn

tarsal tunnel syndrome

posterior tibial nerve compression medial malleolus MC after fracture or dislocation scar tissue or bone spurs inflammatory and malignancy pain paresthesias radiate up heel or calf worse at night or with standing

Inpt Diabetes Managment

pre meal 140 post prandial 180

LAM

premenopausal women cystic and bullous lung disease chylous pleural effusion PNX Sirolimus transplant

tPA contraindications

previous intracerebral hemorrhage, a known cerebrovascular lesion (such as an arteriovenous malformation), suspected aortic dissection, active bleeding or bleeding diathesis (excluding menses) significant closed head or facial trauma within 3 months, Ischemic stroke within the past 3 months. A relative contraindication for thrombolysis is severe hypertension (defined as a systolic blood pressure >180 mm Hg)

NSAID gastritis prevention

prilosec 20 mg 1/4 chronic NSAID users get PUD 4% will have a bleed or perforation RFs: Hpi, > 65 yo, ASA, anticoagulants, Glucocorticoids, high dose NSAIDs and chronic co-morbidities high dose PPI not superior 2nd line: Misoprostol 200 mcg QID

Systemic lupus erythematosus (SLE)

primary Ab is AntiSMITH Ab or AntiDNA Ab - SLE arthritis is non erosive and creates Jaccoud arthropathy, where there may be pain and deformities but no joint damage or abnormalities on XRAY - if patient has appearance of RA but deformities or reducible and no erosive evidence on XR, then this is a sign of SLE rather than a true RA - Hydroxychloroquine, prednisone. If condition worsens, can add further immunosuppressive therapy with mycophenolate mofetil - Diagnosis of lupus nephritis is suggested by proteinuria (>500 mg/24 h) or cellular casts (erythrocytes or leukocytes), low complement levels with KIDNEY BIOPSY - can cause osteonecrosis of the hip - Dx: MRI - sometimes patients can develop mononeuritis multiplex, or muscle weakness due to vasculitic induced peripheral neuropathy - disease activity can be measured by level of anti-double-standed DNA Ab . Can be used to assess acute flare up - if dsDNA positive and COMPLEMENT LOW, this signifies high disease activity and high risk of lupus nephritis - Tx: Pred and add Myco - hypoxemia, new pulmonary infiltrates on chest radiograph, and decreasing hematocrit is highly predictive of underlying diffuse alveolar hemorrhage associated with systemic lupus erythematosus - Dx: Bronchoscopy and lavage - Tx: Mechanical ventilation and aggressive immunosuppresion Cutaneous Lupus - ANA positive but only have skin rashes but do not fulfill diagnostic criteria - SSA (Ro) postive. Remember inc risk of heart block for baby - annular scaly patches on the upper back and sun-exposed areas or a more psoriasiform eruption that can have less distinctive morphology but also occurs in sun-exposed areas - can be due to hydrochlorothiazide, calcium channel blockers, ACE inhibitors, terbinafine, and the tumor necrosis factor α (TNF-α) inhibitors - if due to a drug, antiHISTONE ab will be present (but can also be present in severe SLE, so review druglist!) - consider hydroxychloroquine first PREGNANCY - miscarriage, stillbirth, preeclampsia and premature delivery more often than patients without the disease - if the patient also has positive for anti-Ro/SSA or anti-La/SSB antibodies, higher risk for CONGENITAL HEART BLOCK DRUG INDUCED LUPUS - primary Ab is AntiHISTONE Ab (but can also be present in severe SLE, so review druglist!) - previously procainamide and methydopa (no longer used) - hydralazine, diltiazem, isoniazid, minocycline, chlorpromazine, propylthiouracil, phenytoin, and certain tumor necrosis factor α inhibitors (such as infliximab and etanercept). - can have pulmonary fibrosis with Interstitial infiltrates in LOWER LOBES

Primary Progressive Aphasia

progressive loss of language function frontotemporal dementia or AD Rx OT and Speech language therapy

diphtheria

pseudomembrane cervical LAD fever cutaneous ulcers

Pill Esophagitis

quinidine, Iron rarely opiates which alter LES tone

Parkinson Plus Syndromes

rapid onset of symptoms 15% of PD symmetric findings absent tremor early autonomic dysfunction (urinary incontinence and orthostatic hypotension) MSA Corticobasal degeneration progressive supranuclear palsy

MCTD

rare GN, psychosis or Sz

Tuberculosis cutis orificialis

rare manifestation of advanced tb impaired CMI oral, nasal and anal genital lesions red yellow nodules

When to re-intubate

rate is 12-15% increase hospital mortality, nosocomial pneumonia, longer ICU stay

Milrinone

really only for symptoms - increased hypotension, arrhythmias and non-statistically significant increase in in-hospital and 60-day mortality

DAPT

regardless of stent 1 year at least Clopidogrel for at least 1 mo waiting for endothelializaiton of stent

T3 Hyperthyroidism

remember T3 goes up first measure T3 in patients suspected of thyrotoxicosis - T3 worthless in Hypothyroidism

Benign by FNA

repeat USG in 6-18 months

goals of Migraine treatment

resolve complex within 1-2 hours of treatment lasts for at least 24 hours opioids and barbital lead to: lower responses to other treatments increased ED utilization increase risk of transformation to chronic migraine last line

acute dystonia

retrocollis (neck extension) anticholinergics (benztropine, trihexyphenidyl, diphenhydramine)

RCVS

reversible cerebral vasoconstriction syndrome - thunderclap HA over days - weeks -- intermittent & recurrent - sometimes focal neuro deficits - a/w sympathetomimetics, ergots and triptans) - pheochromcytoma - 40% meds and illicits - 6:1 w>>>M; premenopausal - blood pressure control - can have confusion, visual loss, cerebral edema - affects occipital and parietal lobes

BMD

scan on same machine not T score 4% change = significant

reverse curvature

septum largest at midportion

VSD

small - increase risk of endocarditis murmur Mod 2 Large: Cx: loud holosystolic murmur that obliterates S2 ECG: RVH or RVH/LVH CXR: LA and LV enlargement increase Pulm markings with PAH 1). perimembranous 80% 2). subpulmonic (outlet or supracristal VSD) 6% but 33% in AZN -spontaneous closure is rare progression to AVR is common owing to aortic cusp distortion 3) muscular 10% single or multiple usu close spontaneously 4) inlet adjacent to TV AV septal defect complex common in downs

PDA

small endocarditis prior endocarditis then maybe closure Cx: moderate = dyspnea or HF close with PCI Px: small: inaudible large continuous murmur enveloping S2 L clavicle bounding pulses widened pulse pressure Large: ECG LAA, LVH; with PAH: RVH CXR: CMG, increase pulm markings; calcification of PDA with PAH: prominent central pulm veins Complications: Endocarditis, HF, PAH, Eisenmenger: clubbing and O2 desat that affects the feet but not the hands