Rosh Review #2
Peptic Ulcer Disease
- Most common cause of UGIB - RFs: smoking, H. pylori, NSAIDS, ASA, steroids - Free air under diaphragm on CXR - Duodenal > gastric - Duodenal: pain Decreases food - Gastric: pain Greater with food - Proton pump inhibitors, endoscopy - Complications: perforation, gastric outlet syndrome
Oral Hairy Leukoplakia
- PE will show a white plaque that cannot be scraped off - Most commonly caused by EBV virus in HIV patients - Comments: NOT precancerous - TX: Most cases are self-limited, but antiviral agents like acyclovir, ganciclovir and foscarnet can be considered.
Intusseception
- Patient will be a child five months - three-years-old - Complaining of colicky abdominal pain, vomiting and bloody stools (currant jelly) - Diagnosis is made by ultrasound ("target sign") - Most commonly caused by a tumor or meckel's diverticulum - Treatment is air/contrast enema
Testicular CA
- Patient will be a man 20 - 35 years old - Complaining of a testicular lump - PE will show painless, hard, fixed mass - Labs will show increased beta-hCG, alpha-fetoprotein (AFP), or lactate dehydrogenase (LDH) - Diagnosis starts with ultrasound Comments: Most common risk factor: cryptorchidism, Most common tumor: seminoma
Acoustic Neuroma / Vestibular Schawnnoma
- Patient will be complaining of gradual hearing loss, tinnitus, balance disturbance - Diagnosis is made by MRI with gadolinium - Most commonly caused by CN VIII tumor A typical finding is ipsilateral sensorineural hearing loss in the high tones and a poor word discrimination score (hence the frequent complaint of not being able to use a telephone in that ear).
Anal fissure
- Patient will be complaining of rectal pain and bleeding which occurs with or shortly after defecation PE will show fissure located in the posterior m- idline Diagnosis is made by visual inspection Treatment is stool softeners, protective ointments, sitz baths Comments: If fissures are located laterally, search for pathologic etiologies
MC complication of irrigation of ear for impacted cerumen
traumatic tympanic perforation When this occurs, patients usually experience sudden hearing loss, severe otalgia, or vertigo. Visualizing the tympanic membrane in this scenario is sometimes difficult. Perforation of the tympanic membrane is a clinical diagnosis. In cases of suspected perforation, reassurance, analgesia, and otolaryngology referral in 1 to 2 weeks are indicated.
T/F? In a patient with GCA, aortic involvement can lead to valvular insufficiency, aortic arch syndrome, and dissection.
true
T/F? Rotavirus vaccine doses that are regurgitated, spit out, or vomited do not need to be repeated
true
Is the rotavirus vaccine contraindicated for an infant with a history of intussusception?
yes another contraindication is age: Do not start the series on or after age 15 weeks, 0 days. The maximum age for the final dose is 8 months, 0 days.
Primary Amenorrhea
- Definition: lack of menarche by 15 with normal 2° sexual characteristics or by 13 with no 2° sexual characteristics - Etiologies: Hypothalamic/pituitary Ovarian Uterine Pseudohermaphroditism - Lab workup: FSH, LH, prolactin, TFTs, testosterone, hCG - Rx: treat underlying cause
Wolff-Parkinson-White (WPW) Syndrome
- ECG will show short PR interval, delta wave, wide QRS - Most commonly caused by an accessory pathway (bundle of Kent) connects atria to ventricles, bypassing AV node - Tx: vagal maneuvers --> adenosine --> cardioversion (if unstable or failed previous) - Definitive treatment is radiofrequency ablation
Lyme Disease
- Patient with a history of being in the woods hiking or camping - Complaining of: Stage I: erythema migrans (pathognomonic), viral-like syndrome (fever, fatigue, malaise, myalgia, headache) Stage II: arthritis, myocarditis, bilateral Bell's palsy Stage III: chronic arthritis, chronic encephalopathy - PE will show slightly raised red lesion with central clearing, erythema migrans (bull's-eye) rash Most commonly caused by Borrelia burgdorferi carried by Ixodes tick - Treatment is doxycycline. Children/pregnant - amoxicillin - Comments: Bilateral facial nerve palsy is virtually pathognomonic for Lyme disease
Brown-Séquard syndrome
- Patient with a history of penetrating trauma - PE will show ipsilateral loss of motor, position and vibration and contralateral loss of pain and temperature - Most commonly caused by spinal cord hemisection
Esophageal FB
- Site of obstruction: C6 > T4 > T11 - AP/PA view: flat side of coin appears - Esophageal necrosis → perforation - Most FBs that pass pylorus pass spontaneously - Observe most esophageal FBs for 24 hours - Emergent endoscopy indicated if FB is battery, sharp, or signs of obstruction present
Constipation in Children
-Newborns should pass meconium stool within 48 hours - By age 3, children should have one bowel movement/day - Hirschsprung's disease: absent stool in vault - Fleet enema contraindicated in infants (due to hypocalcemia)
Osborn wave
A positive deflection of the J point is termed an Osborn wave and can be seen in hypothermia
What is the triad of ECG findings in WPW syndrome during sinus rhythm?
A shortened PR interval, a fused QRS complex, and a delta wave at the beginning of the QRS complex
O'Donahue Triad
A.K.A unhappy triad ACL, MCL, medial meniscus
Lisfranc Injuries
Open reduction and internal fixation is indicated for Lisfranc injuries with any evidence of instability or bony fracture. A Lisfranc injury is characterized by a disruption the tarsometatarsal joints, which connect the forefoot to the midfoot. Patients usually present with severe foot pain and an inability to bear weight. Physical exam may reveal midfoot bruising of the plantar surface, generalized swelling, and tenderness of the tarsometatarsal joint.
What is the initial work-up of a patient with primary amenorrhea?
Breast and pelvic examination, pregnancy test, pelvic ultrasound and serum follicle-stimulating hormone
Which incomplete spinal cord syndrome has the best prognosis of full recovery?
Brown-Séquard syndrome
orbital pain, proptosis, and oculomotor palsies
Cavernous sinus thrombosis the cavernous sinus contains CN III, IV, V1, V2, and VI. Resultant facial sensory nerve loss is common.
Why is warm water recommended when irrigating the external auditory canal?
Cold water can induce severe vertigo.
Hookworm versus Ascariasis
hookworm live in small intetsine and feed on host blood which may lead to anemia, where as, ascaris does not lead to anemia
Meniere's disease
is a disorder of endolymphatic hydrops. triad of hearing loss, tinnitus, and vertigo. Some key distinctions from acoustic neuroma include: 1) recurrent bouts of severe and often disabling vertigo (as opposed to ataxia) and 2) hearing loss will come and go and is typically in the low tones (as opposed to the high tones) --> Low frequency hearing loss
STEMI Evolution on EKG
normal 1. hyperacute T waves 2. J point elevtation 3. ST segment elevation 4. Q wave formation and loss of R wave 5. T wave inversion
What chromosomal abnormality is Hirschsprung disease commonly associated with?
Down's Syndrome (Trisomy 21)
How do you definitively diagnose myocarditis?
Endomyocardial biopsy
erythema migrans
pathognomonic for Lyme disease
Tympanic Membrane Perforation
Foreign body, infection, blast, ↑ barometric pressure Pars tensa most commonly perforated Pain, ↓ hearing, bleeding Keep ear dry, analgesics 90% heal in few months
What is the most common cause of lower intestinal obstruction in neonates?
Hirchsprung's Disease
orthodromic versus antidromic narrow tachycardia
In orthodromic AVRT anterograde conduction occurs via the AV node with retrograde conduction occurring via the accessory pathway. This can occur in patients with a concealed pathway. TX: electrocardioversion In antidromic AVRT anterograde conduction occurs via the accessory pathway with retrograde conduction via the AV node. Much less common than orthodromic AVRT occurring in ~5% of patients with WPW. TX: procainimide
CF pt with acute CP and SOB
spontaneous pneumothorax
Brown-Séquard syndrome results
Ipsilateral loss of motor strength, vibratory sensation, and proprioception with contralateral loss of pain and temperature sensation below the level of injury Brown-Séquard syndrome results from hemitransection of the spinal cord with unilateral damage to the corticospinal and spinothalamic tracts. This injury is usually the result of penetrating injuries or a lateral mass fracture of the cervical spine. It is also caused by spinal cord tumors, infections, and ischemia. It is rarely seen in its pure form, typically occurring with incomplete involvement of related tracts. Prognosis is excellent, with most patients recovering. ascending = sensory = senses go up to the brain (contralateral) SenSory = croSS descending = motor = movements go down to the muscles (ipsilateral) Motor = saMe
What is the MC complication is most commonly associated with the Bell's Palsy?
Keratitis Because the orbicularis oculi muscles are involved, this results in incomplete closure of the eyelids on the affected side and leads to corneal exposure keratitis. It is important to prescribe lubricating eye drops, to keep the corneal epithelium from breaking down, and to patch the affected eye at nighttime
Which ligament connects the medial aspect of the cuneiform to the second metatarsal base?
Lisfranc ligament
Bilateral facial nerve palsy
Lyme disease
Bilateral facial nerve paralysis should alert the provider to which potential diagnoses?
Lyme disease, infectious mononucleosis, HIV infection, botulism.
MC site for esophageal impaction
Most impactions occur in the mid to distal 1/3 of the esophagus.
Does an alkaline button battery that passes into the stomach need to be emergently removed endoscopically?
No. If the battery has passed into the stomach, it can be followed radiographically to ensure passage
anterior cord syndrome
Pain, temperature, and complete loss of motor function below the level of injury, but retains proprioception and the ability to sense vibration and deep pressure A = almost all (motor, pain, temp.) Do it all up front
What is the MOST sensitive PE test for CTS?
Phalen's test has a sensitivity of 76% and specificity of 80% for carpal tunnel syndrome. Tinel's sign is less sensitive that Phalen's sign for carpal tunnel syndrome.
Tx for child with CF who gets PNA
Piperacillin/tazobactam (Zosyn) Avoid fluoroquinolones in children d/t risk of tendon rupture
Which anti-parasitic agent is used to treat schistosomiasis?
Praziquantel
posterior cord syndrome
Preservation of motor function with loss of proprioception and vibration below the level of injury is consistent P = Posterior tract = Propioception (+vibratory) Poop from the back, posterior, propioception
Stress-induced cardiomyopathy
Takotsubo cardiomyopathy and "broken heart" syndrome ventricular apical ballooning, usually triggered by intense emotional or physical stress. Common presenting features include electrocardiographic changes (often anterior ST-segment elevations), mildly elevated cardiac biomarkers, sub-sternal chest pain, and dyspnea. Accepted criteria for the diagnosis are (1) ST segment elevation, (2) transient regional wall motion abnormalities of apex and mid ventricle, (3) the absence of coronary artery disease, and (4) absence of other causes of left ventricular dysfunction such as pheochromocytoma or myocarditis. Treatment is largely supportive care with hydration and efforts to alleviate physical or emotional stressor.
How long should a deer tick be attached before prophylactic treatment to prevent Lyme disease is recommended?
Typically, longer than 36 hours.
progressive ipsilateral hearing loss, ataxia, and tinnitus
Vestibular Schwannoma
Change in hearing associated with Bell's Palsy
acute hearing (hyperacusis) increased hearing