Step 2

cavernous hemangiomas

"cavernous malformation" consist of dilated vascular spaces with thin-walled endothelial cells blue, compressible masses growing up to a few centimeters can apepar on skin, mucosa, deep tissues, visvera if in brain/viscera think von-hippel-lindau disease

delivering bad news is optimally done in face-to-face meeting that allows the physician to better assess the patient's emotional reactions and provide empathy and necessary support

*****

burr cells and spur cells

*Burr cells (echinocytes)* [pictured] spiculated RBC with serrated edges seen in liver disease and end stage renal disease *Spur cells (acanthocyte* RBC with irregualry sized and spaced projections that are seen in liver disease

adverse effects of phosphodiesterase-5 inhibitors

*CV*: hypotension: with nitrates, alpha blockers *ocular*: blue discoloration of vision, nonarteritic anteiror ischemic optic neuropathy *GU*: priapism *other*: flushing, HA, hearing loss

drug-induced acne

*MONOMORPHIC*

solitary pulmonary nodule

*SPN defined as* rounded opacity <3cm compeltely surrounded by pulmonary parenchyma no associated lymph node enlargement

potassium sparing diuretics

*aldosterone atgonists* spironolactone eplereone *bloack ENaC* triamteerne amiloride

guidelines for lithium therapy

*baseline tests needed* BUN, Cr UA Ca pregnancy test Thyroid panel lithium is contraindicated in patients with significant renal or cardiovascular dsiease

heart failure with preserved left ventricular ejection fraction

*causes* *LV diastolic dysfunction* - HTN w/ concetric LVH, resitrictive caridomyopathy, Hypetrophic cardiomyopathy *valvular dz* - aortic stenosis/regurg, mitral stenosis/regurg *pericardial dz* - constrictive pericarditis, cardiac tamponade *systemic dz* (highoutput failure: thyroxicsosi, anemia, large AV fistula *management* control BP and HR address concurrent conidtions: AF, ischemia treat voume overload w/ diuretics exercise trainign / cardiac rehab

clinical features of osteomalacia

*defective mineralization of the organic bone matrix* vitamin D deficiency most commonly causes osteomalacia due various etiologies

cholesterol crystal embolism (atheroembolism)

*eosinophilia* *hypo*complementemia *bx* = biconvex, needle shaped clefts within occluded vessels

common features of sarcoidosis

*epidemiology* young adults, african americans *clinically* constitutional cough, dyspnea, chest pain extrapul: skin lesions, anterior/posterior uveitis Lofgren syndrome *imaging* bilatearl hilar adenopathy pulmonary reticular infilrates *labs* hypercalcemia, hypercalciuria elevated seurm ACE *pathology* biopsy showing *nonceasating granulomas* that stain negative for fungi and acid-fast bacilli

avascular necrosis

*etiologies* steroid use alcohol abuse SLE ALP syndrome hemoglinopathies (eg, sickle cell) infeciton (eg, osteo, HIV) renal transplant decompression sickness *clinical* groin pain on weight bearing pain on hip abduction + internal rotation no erythema, swelling, point tenderness *radiographically* crescent sign in advanced stage MRI most senstive modality - needed to exclude other pathologies as well and to help determine management of disease *labs* normal WBC, ESR, CRP

acute bronchitis

*etiology* preceding respiratory illness (90% viral) *clinical* cough for >5 days to 3 weeks absent systemic findings (eg, fever, chills) wheezing or rhonchi, chest wall tendnerss *diagnosis, treatment* clinical, CXR only when pneumonia suspected symptomatic treatment (eg, NSAID and/or bronchodilators) antibiotics *not* recommended

lithium toxicity

*etioology* overdose volume depletion thiazides NSAIDs (not aspiring0 ACE inhibitors tetracyclines metronidazole

evaluation of chest pain

*low risk* men <40, women <50 w/ atpiycal chest pain no signficant cardiac risk factors *intermediate* atypical angina in men of all ages atypical angina in women >50 typical angina in women age 30-50 *high* typical angina in men >40 typical angina in women >60

hypertensive kidney disease

*nephrosclerosis* - hypertrophy and intimal medial fibrosis progresses into *glomerulosclerosis* - progressive loss of glomerular capillary surface area with glomerular and peritubular fibrosis kindyes generally decrease in size

management of cervical spine trauma

*orotracheal intubation* with rapid-sequence intubation is preferred way to establish an airway unless there is signficant facial trauma

diffuse esophageal spasm

*patho*: uncoordinated, simultaneous contractions of esophageal body *symptoms* intermittent chest pain dysphagia for solids and liquids *diagnosis* manometry - intermittent persitalsis, multiple simultaenous contractions esophgram - corkscrew pattern *treatment* CCB [diltiazem] nitrates tricyclics

pathogenesis of refeeding syndrome

*phosphorus* is primary deficient electrolyte as it is required for ATP deficiencies in K and Mg potentiate *crdiac carryhtmias* in a haert that is already atrophic from prolonged malnutrtion therefore, aggressive intiation of nutrtion without adeqaute electrolyte repletion can quickly precipitate *cardiopulmonary failure*

infections in sickle cell disease

*pneumonia* strep pneumonia - vaccination with conjugate capsular polysaccharide *osteomyeltis/septic arthritis* staph aureus salmonella *bacteremia/sepsis* strep pneumonia (most common) h flu *meningitis* strep pneumonia

HIV screening indications

*preferred screening test* detection of HIV P24 antigen *and* HIV antibodies this combo test can more effectively diagnose acute or early infection patients with positive test should then undergo confirmatory testing with *HIV-1/HIV-2 antibody differentiation immunoassay* *plasma HIV RNA* is recommende din patients with negative serological studies but high clinical suspicion of acute HIV

clinical presentation of uterine fibroids by location

*subserosal* bulk symptoms: pressure, incontinence, constipation irregular uterine contour *intramural* enlarged uterus heavy menstrual bleeding *submucosal* heavy menstrual bleeding infetility/miscarriage abortion myoma

recommended vaccines for chronic liver disease

*tdap/td* - tdap once as subtite for Td booster, then Td q10y *influenza* - annualy *pneumococcal* - PPSV23 once, then revaccination with sequential PCV13 + PPSV23 at age 65 *Hep A* - 2 doses 6m apart with inital negative serologies *Hep B* - 3 doses at 0 months, 1 month and at least 4 months with inital negative serologies

clinical features of trichinellosis

*triad* periorbital edema myositis eosinophilia

what nerves are affected in neurogenic bladder

S2-S4

taxia telangiectasia

T cell deficiency *defect in NDA reapir* immune dysfunction progressive cerebellar degeneraiton skin cancer high risk

clinical features & management of tricyclic antidepressant overdose

TCAs inhibit fast sodium channels in the His-Purkinje system and myocardium This decreases conduction velocity, increases duration of repolarization, and porlongs absolute refractory preriods *results in*: hypotension, QRS prolongation, ventricullar arrhythmias QRS >100ms --> give NaHCO3 --> increases serum Ph and extracellular sodium --> increases electrochemical gradient across cardiac cells and affects the ability of TCAs to bind to fast sodium channels

pt presents with hemopytsis.. next step? evaluation of hemoptysis

chest xray bronchoscopy should be performed in all cases of hemoptysis after a cxr is performed important tool in investigation of non-massive hemoptysis as it allows direct visualization of oral cavity and upper airway massive hemoptysis (>600ml/d or 100ml/h) = bronchoscopy always play patient with *bleedingl ung in dependent position* (lateral position) to avoid blood collection in the airways of opposite lung

smudge cells

chronic lymphocytic leukemia "smudged" lymphocyte from increased fragility

medication nonadherence

chronic, silent illneses have high rates of medication nonadherence strategies to imrpove adherence include targeted patient eduction, choosing simple and inexpensive regiments, and close follow up

iron toxicity

common cause of accidental poisoning in young children whose parents have been prescribed iron supplements inital s/s = GI symptoms (n/v/d - can be green due to disintegrated iron tablets) in severe toxic dose, the vomitus and diarrhea can be *hemorrhagic* because iron is caustic to GI tract fluid losses with v/d can lead to hypovolemic shock late findings = lactic acidosis, hepatotoxicity, organ failure death can result bowel obstruction can occur due to scarring of GI tract

is assisted living considered hospital or community

community

workup for new onset psychosis in ED

complete physical and MSE CMP CBC TSH Urine tox others based on risk factors: syphilis, HIV, B12, neuroimaging

rapid eye movement (REM) sleep behavior disorder

complex motor behaviors that occur during REM sleep dream enactment can occur if the muscle atonia that usually accompanies REM sleep is absent or inompcete occur in latter part of night patient awakens quickly and can become fully alert more likely in adult men can be sign of neurodegeneration in Parkinsons or dementia with Lewy bodies can occur with other prodromal s/s - motor deficits, anosmia, constipation

most common cause of labor protaction

contraction inadequacy they are considered adeqaute when forceful and occur q2-3m most would benefit from oxytocin augmentation

medial mid-pontine infarction

contralateral ataxia hemiparesis of face, trunk and limbs

dominant parietl lobe

contralateral sensory loss contraltearl ifnerior homonoysoud quandratanopsia - superior optic radiations

medications that can cause hyperkalemia

cyclosporine: blocks aldosterone activity heparin: blocks aldosterone proudction succinylcholine: causes extracellular leakage of potassium through acetylcholine receptors tmp/smx: blocks ENaC [similar to K-sparing diuretic amiloride]

symptoms of OSA

daytmine somnlence non-restorative sleep w/ frequent awakenings morning headaches affective and cognitive symptoms

contributing factors to orthostasis in elderly

decreaed baroreceptor sensitivty arterial stiffness decrased NE content of sympathetic nerve endings reduced sensitvity of myocardium to sympathetic stimualtion

spirometry of interstitial lung disease

decreased FEV1, FVC and TLC FEV1/FVC remains nromal or may be icnreased

edema in nephritic glomerulonephritis

decreased GFR and retention of sodium and water by the kidneys

transient hypogammaglobulinemia of infancy

decreased IgG, vairable IgM, normal IgA, normal B cell concentration normal physiologic nadir of maternally dervied antibody is age 3-6 months in term infants increased sinopulmonary and GI infection that are usually mild levels normalize by 9-15 months;

hemodynamic changes in cardiac tamponade

decreased preload decreased stroke volume decreased cardiac output *elevation and equalization of intracardiac diastolic presures* (RA, RV and PCWP) fluid in pericardial cavity icnreases intrapericardial pressure above diastolic vnetricular pressure - resitrcts venous return to heart and lowers right and left ventricualr filling

increased aging sleep changes

decreased total sleep time peak sleepiness earlier nocturnal awakenings reduced sleep during early morning hours daytime napping increased nighttime sleep latency decreased REM latency decreased slow wave sleep

changing lowering cutoff value on predictive value

decreases PPV increases NPV more false positives, less false negatives

hyperthyroidism on blood pressure

decreases SVR but BP (systolic) rsies due to positive inotropic and chronotropic effects hypo-thyroidism causes HTN due to increased SVR

progesterone supplementation for pregnancy

decreases risk of preterm birth in patients with hx of prior spontaenous preterm delivery

prune belly syndrome

defect in abdominal musculature intestinal loops can be seen through thin abominal wall and are covered by skin

spondylolysis spondylitis spondylolisthesis

defect in pars interarticularis common in adolescents who over train and have micro-trauma leading to stress fracture at the pars spondylolisthesis = anterior displacement of vertebral segment relative to segment above *forward slip* causing a *palpable step off* sponylitis = inflammation of vertebrae spondylosis = OA of the spine

what should be next step in vfib or pulseless vtach

defibrillation

angelmann syndrome

deletion of materanl chromosome 15q11-q13 short stature intelletual disability *frequent smiling/laughter* hand flapping ataxia seizures

eosinophilic inclusions of substantia ngira

dementia with lewy bodies - episodic fluctuating cognitive function, visual hallucinations, parkinsonism, REM sleep behavior disorder eosinophilic inlcusions = alpha-synuclein protein; can be seen in substantia nigra, locus ceruleus, dorsal raphe, substantia innominata

anti-histone antibodies

drug induced lupus

most common cause of blood diarrhea in the absence of fever

e coli

gass in gallbladder wall....

emphysematous cholecystitis

adenomysosis

endometrial galnds become trapped within myometrium and continue to cyclically shed in that new location *multiparous women >40 y/o* dysmenorrhea w/ heavy menstrual bleeding that starts later in reproductive years with progression to *chronic pelvic pain* *boggy, tender, uniformly enlarged uterus* dx = pelvis u/s and/or MRI gold standard = histopathologic exam of a hysterectomy specimen tx = hysterectomy if hormonal methods are unsucessful

next step in 62 y/o patient with anemia and iron deficiency

endoscopic evaluation - colonscopy, EGD new iron defiiency anemia in elderly patients should be considred from *GI blood loss* until proven otherwise single negative FOBT is not enough to exclude occult GI bleeding *NSAIDs* are common cause of iron deficiency in adults, thought chronic blood loss in GI tract

evelope shaped calcium oxolate crystals in urine

ethylene glycol

next step when pt has abdominal gaurding and CT shows free air

ex lap

milk-alkali syndrome

excessive intake of calcium and absorbably alkali (eg, calcium carbonate preps for osteoperosis) hypercalcemia --> renal vasoconstriction and decreased Glomerular flow inhibition of Na/K/2Cl transporter (due to CaSR in thick ascending loop) and impaired ADH activity lead to loss of sodium and free water causes hypoveolmiea and increased reabsorption of HCO3 (augmented by increased intake of alkali) *labs* hypophosphatremia hypercalcemia hypomangesemia mebanolic alkalosis AKI decreased PTh

illness anxiety disorder

excessive preoccupation with having serious illness in context of minimal to no symptoms

fetal hydantoin syndrome

exposure to phenytoin and carbamazepine [but can theoretically be any anticonvulsant] midfacial hypoplasia microcephaly cleft lip and palate [lip repair = 3 months; palate repair = 9 months] digital hypoplasia hirsutism developmental delay s

factitious diarrhea

female, health care field watery frequent BM's, voluminous nocturnal Bm and cramps are common metabolic alkalosis is common in laxative abuse (usually diarrhea leads to metabolic acidosis) Profound hypokalemia - impaires Cl reabsorption and results in decreased Cl-HCO3 exchange, icneasing srum HCO3 concetrations dx = positive stool screen for diphenolic (bascodyl) or polyethelene laxatives colonscopy shows melansosi coli - brown discoloration of colon with palte patches of lymph follciles (alligator skin) histo = pigment in amcropahges of lamni propria

what imaging is used to diagnose brain abscess

gadolinum-enhanced brain MRI

yolk sac tumors

germ cell tumors more common in young women secrete AFP grow rapidly --> acute onset pelvic pain

diabetic ketoacidosis in children

gluconeogensis is increased due to increased circulating glucagona, catecholamines and cortisol increase in FFA due to excess of glucagon to insulin ratio

hazard ratio

hazard ratio are the ratio of an event rate occuring in the treatment group vs. the non-treatment group ratio <1 = tx group has lower event rate ratio >1 = tx group had higher event rate

first symptom of hypertensive crsis using MAO-inhibitors

headache --> intra-cranial bleeding, stroke, death

most common mechanism of septic arthritis in children

hematogenous spread of bacteria into synovial fluid

vaccines for traveling to North Africa

hepatitis A hepatitis B typoid polio booster

common variable immunodeficiency

impaired B cell differentiation and hypogammglobulinemia most common primary immunodeficiencies in adults increased susceptibility to bacterial infection *manifestations* recurrent respiratory [pneumonia, sinusitis, otitis] and GI [salmonella, campolyobacter, giardia] infections autoimmune disease [eg, RA, thyroid] chronic lung disease [eg, bronchiectasis] GI disorers [eg, chronic diarrhea, IBD-like conditions] most common infections - strep pneumo, h flu, giardia *diagnosis* severely decreased IgG, decreased IgA, decreased IgM *[quantitative measurement of immunoglobulin levels]* no response to vaccination *management* immunoglobulin replacement therapy increased risk of autoimmune disease and certain malignancies regardless of treatment

patient goes under subtotal gastrectomy. pallor, shiny tongue. Cause?

impaired DNA synthesis - b12 deficency due to loss of intrinsic factor b12 is used for formation of thymidylate and purine molecules for DNA synthesis B12 deficiency causes ineffective erythropoiesis due to delayed nuclear maturaiton, resulting in decreased transition to mature RBC forms and high numbers of immature megaloblasts in bone marrow increased intramedullary hemolysis of these megaloblasts relaeses heme, causing indirect hyperbilirubinemia, which may manifest as jaundice hemolysis relases the intracellular enzyme lactate dehydrogenase (LDH), raising serum levels total RBC and reticulocyte count will be low patients may have thrombocytopenia and leukopenia with hypersegmented polymorphonuclear cells

phimosis

inability to retract the prepuce in an uncircumcised male patient is usually considered physiologic in infants nad young children forced manipulation may result in paraphimosis, the *retraction and entrapment of the prepuce* due to decreased lymphatic and venous blood flow to the distal penis, the presentation of paraphimosis includes *edema* and signficant *tenderness* of glands penis and prepuce without intervention, arterial bloow flow can be compromised, elading to ischemia and penile tissue firmness and darkening management = *emergency reduction* circumcision is a defintive treamtent

dietary recommendations for renal calculi patients

increase fluid intake decrease sodium intake normal dietary calcium intake

signs of complicated small bowel obstruction

increased risk of impending ischemia, strangulation, necrosis fever hemodynamic insability- hypotension, tachycardia guarding leukocytosis metabolic acidosis (low HCO3) *surgery is needed*

the power of a study represents ability to detect a difference between 2 groups when there truly is a difference

increasing sample size increases power of study and narrows confidence interval confidence intervals express statistical signifcance and are interrelated with p-values

most common complication of neutropenia

infection bacteira most common in newly netropenic patients

balanoposthitis

inflammation of glans penis and prepuce presnts with penile pain, erythema, and discharge in uncircumcised male patients

metyrapone

inhibitor of cortisol snythesis used in pt with cushing's waiting definitive surgical tx

adolescents who develop signficant changes in behavior should be assessed for psychosocial stressors, trauma, substance use, and psychiatric dirosdres

initial development of a trusting physician-patient relationship is key to an accurate assessment scehdule individual follow up to obtain additioanl hx and develop relatinoship - when pt is not forthcoming when aprents are around

metabolic syndrome

insulin resistance plays central role in pathogenesis of metabolic syndrome requires 3/5 diagnostic criteria

midbrain stroke

ipsilatearl oculomotor nerve palsy ataxia (superior cerebellar peduncle) contralateral hemiparesis (cerebral peduncle) ventral tegmental area is region in midbrain taht contains high density dopamine-releasing neurons, which project to nucleus accumbens and modulate reward pathways

pinpoint pupils are seen in what stroke pattern?

large pontine hemorrhage - damage to descending sympathetic fibers

apthous stomatitis (ulcer) [canker sore]

localized, shallow, painful ulcers with gray base if bx was done = shallow, fibrin coated ulcerations with underlying mononuclear infiltrate [bx not needed]

tx for agitaiton in elderly

low dose haloperidol do not use typical AP's in patients with lewy body dementia

discocation of which wrist bone can cause median n. compression?

lunate

95% confidence interval of mean is calculated by

mean +/- 1.96(SD)

what does Wilms tumor arise from?

metanephros (embyrologic precursor of renal parenchyma)

most common headache in children

migraines - often bifrontal and shorter duration firs tling tx in children <12 y/o = supportive and acetaminophen of NSAID triptans can be used if these mearues fail based on a clinical diagnosis and the paroxysms of repetitive events

peripheral blood smearl in aplastic anemia

morphologically normal cells

second stage arrest of labor

most common cause of a prolonged or arrested 2nd stage = *fetal malposition* optimal position = OA; deviations frmo this position cna cause cephalopelvis disproprotion and arrest of the second stage

wilms tumor (nephroblastoma)

most common presentation = asymptomatic abdominal mass that is found incidentally proliferation of the *metanpehric blastema* abdominal mass + fever + hematuria abdominal u/s should be first step in diagnosis followed by contrast-enhanced CT of abdomen to evaluate nature/extent and of chest to identify any pulmonary metases

teardrop-shaped red blood cells

myelofibrosis or beta thalassemia (after splenectomy)

major adverse effect of hydroxyurea

myelosuppression - pt will have lwo ANC

preeclampsia

new onset HTN (140/90) at >20 weeks gestation + proteinuria and/or end organ damange

do patients with MVP get bacterial prophylaxis

no

is unviersal screening for TB during pregnancy recommended?

no

does sertaline cause major congenital malformations?

no pt if on sertaline should remain on it to reduce risk of deprssion during pregnancy and postpartum period

is massaging an area that is developing a pressure ulcer a good initial technique?

no - this can increase further breakdown of skin

acute causes of hemiplegia in children

Todd paralysis tx is supportive; self resolves within 36h

preferred method of respiratory support in ptient with acute exacberaiton of COPD that has sx despite medical mangement

noninvasive PPV - decrease in RR and PaCO2, with an increase in TV, MV and PaO2

clinical features of analgesic nephropathy

UA - painless hematuira, sterile pyuria, WBC casts, trace proteinuria

contrast-induced nephropathy

UA = muddy brown granular casts and epithelial cells resolves in 2-5 days

causes of abnormal menstrual bleeding

obesity increases circulating estrogen levels through increased periphearl conversion of androgens to estrogens and aromatization of androsteneione to estrone

treatment of asymptomatic bartholin cyst

observation - spontaenous drainage and resolution can occur

plasma osmolality

2xNa + glucose/18 + BUN/2.8

clinical features of alcoholic hepatitis

AST:ALT is >2:1 [AST is usually <300, almost always <500] elevated gamma-glutamyltransfearse increased ferritin

medial medulalry syndrome

oclusion of vertebral or anterior spinal a. contralateral paralysis of arm and leg tongue deviation toward lesion

DEXA scan

one time DEXA for all women age >65, as well as women <65 who have requivalent risk of osteoporotic fracture Osteoperosis: >2.5 SD's below mean Osteopenis: -1 to -2.4 SD's below mean

medications that can cause gallstones

oral contraceptives ceftriaxone octreotide

prodromal dizziness + blurred vision when quick tranistion from bed to walking suggests....

orthostasis

heberden nodes and brouchard nodes

osteoarthritis *risk factors* age >50 obestiy prior joint injury *hx* chronic, insidous sx minimal/no morning stiffness *PE* knees/hips, DIP, cervical/lumbar spine hard, bony enlargement of joint *crepitus* w/ movement *xray*: narrowed joint sapce, osteophytes, subchrondral sclerosis athrocentesis (not indicated): clear fluid, few inflammatory cells

screening when child comes in hemarthrosis

CBC + coags

leukemoid reaction vs chronic myeloid leukemia

CML is often found on routine blood work in asymptomatic patients but may present with fatigue, weight loss, night sweats, or abdominal fullness (splenomegaly)

oxygen-induced CO2 retention in COPD

COPD causes destruction of temrinal bronchioles and alveoli ausing increaed dead sapce affected areas have limited surface area available for gas exchange --> V/Q mismatch causing loal hypoxia and hypercapnia hypoxia asues vasoconstrciton in these areas o the lung supplemental oxygen causes: -loss of compensatory vasoncsrtion in areas of ienffective gas excahnge -increased oxyhemoglobin reduces uptake of CO2 from tissues -decreased RR acidosis by acute increase in CO2 increases brain GABA and glutamine and decreaes glutamate and aspartate --> decreased lvel onf consciousness hypercapnia causes *cerebral vasodilation* --> seizures oxygen should be kept at *90-93% or PaO2 60-70 mmHg*

modified wells criteria for pretest probability of pulmonary embolism

CT angiography is test of choice in clinically stable patient in whom PE is likely TEE can be used for clinically decompensating patients in whom CTA cannot be obtained

measures of association

Chi-square = compre proprotoins two sample z test, two sample t-test = compare two means ANOVA = means of >3 variables

what is required of all patients with new-onset ascites best long term management of ascites

paracentesis to determine the cause negative sodium balance is important goal in tx of ascites - Na restrictive diet + use of diuretics *spirnolactone* inhibits Na rentetion ability of aldosterone, a key hormone in ascites, while sparing potassium levels [*first choice diuretic in ascites*]

dermatomysotisi

paraneopalstic syndrome - muscle fiber injury: symmetrical and more proximal muscle weakness interstitial lung dz, esophagel dysmotility, raynaud phenomenon polyarthrtiis esophageal dysmotility skin findings: gottron papules, heliotrape rash

clinical features of VIPoma

VIP binds to intestinal epithelial cells to increase fluid and electrolyte secretion in the intestinal lumen patients may also have coexisting hyperparathyroidism as part of MEN syndrome *VIP >75pg/mL* confirms VIPoma diagnosis CT localizes tumor in pancreas *treatment* IVF octreotide to decrease diarrhea possible hepatic resection in pt with liver metastases

genito-pelvic pain/penetration disorder [vulvodynia in ddx]

Vaginismus exam differentiates ir from other pathologies (eg, infectious vaginitis, vulvodynia) but may be limited as patients often cannot tolerate speculum insertion no tenderness on external exam tx is aimed at relaxing vaginal muscles *DDX: vulvodynua* - pain to superficial touch on vesitbule

acute tx of migraines and when to give additional dose

patient who have received a triptan or an ergot derivative within past 24h should not receive another triptan as this combination can cause severe, prolonged vasoconstriction due to overaction of serotonin receptors --> resulting in elevated blood pressure, myocardial infarction, or stroke

when ampicillin suggested in meningitis coverage

patients >50 y/o or immunocomrpoised coverage for listeria

annual low dose CT

patients age 55-80 with >30 pack year history (current smoking or quit within last 15 years) *stop when:* >15 since quit >80 y/o pt has other medical conditions that severely limit life span

guidelines for lipid-lowering therapy

patients age >40 w/ diabetes have been shown to benefit from lipid lowering thearpy with statin drugs + appropriate dietary and exercise lifestyle modifactions

approach to pharyngitis in children

patients are considered to be contagious with GAS until they have been on antibiotics for 24-48 hours stay home until they have been on abx for >1d

chronic prostatitis/chronic pelvic pain syndrome

patients are generally afebrile and have little/no prostate tenderness; normal UA, *negative culture* on urine PSA is normal *noninfectious chronic prostate inflammation*

fibrous thickening of the tunica albuginea

peyronie disease - excess collagen formaiton within tunica albuginea painful erections with curvature of penis

major drug interactions of levothyroxine

phenytoin, rifampin, carbamzepine increase metbaolism of thyroid --> decrease circulating thyroid hormone

symmetrical proximal *weakness* + elevated creakine kinase

polymyositis

what needs to be done in a women of childbearing age before perfomring any abdominal diagnostic tests such as xray or CT?

pregnancy test if + --> u/s for intrauterine or ectopic pregnancy if negative --> CT for appendicitis, kidney stones, etc; xray for obstruction

reactive arthritis

presents 1-4 weeks after an enteric or chalmydial infection arthritis, conjuctivitis, uveitis

vitreous hemorrhage

presents as sudden loss of vision and onset of floaters most common cause is diabetic retinopathy dx clue is taht fundus is hard ti visualize immediate opthalmologic consultaiton is required

63 y/o w/ abdominal pain, microcytic anemia, +FOBT, hepatomegly with hard edge on palpation Suggests?

GI malignancy, likely colon acncer, metastatic to liver pt should have CT of abdomen w/ IV contrast to evaluate for malignancy

diagnostic tests for acute hepatitis B infection

HBsAg - appears 4-8w after infection anti-HBc time lag between disapperance of HBsAg and apeprance of anti-HBs = *window period* IgM anti-HBc may be only detectable marker during this period HBcAg is not detectable in serum so not useful HBeAg is measure of ifnectivity for poor for acute ifnection

hyperemesis gravidarum

HG is differentiated from typical n/v of pregnacny by presnce of *ketones on UA*, labs and volume status ketonuria occurs in prolonged hypoglycemia and resultant ketocadiosis suggests svevere disease

roseola infantum

HHV-6 age <2 3-5d of high fever (>104) followed by blanching maculopapular rash tx = supportive

complications of bacterial meningitis

Hearing loss (*most common*) intellectual disability cerebral palsy about 15% will have some long term complication

treatment of borderline personality disorder

primarily psychotherapy - dialectical behavior therapy adjuctive pharmcotherapy to target mood insability + transient psychosis (2nd gen AP's, mood stabilizers) antideprssants if comorbid mood or anxiety disorder

evaluation of secondary amenorrhea

primary hypothyroidism ---> hyperproalcintemia due to TRH stimualtion of lactotrophs

pH<7.4, low PaCO2 suggests

primary metbaolic acidosis

legionella pneumonia

primary source is water (lives inside of protozoa) intracellular gram-negative rod --> not seen on sputum *clinical* fever >101.8 relative bradycardia GI: diarrhea, vomiting, cramps pulmonary symptoms delayed *diagnostic* hyponatremia cxr: lobar infilitrate suputum stain - PMNs, few/no organisms *urine legionella antigen* *treatment* respiratory fluoroquinolone or newer macrolide

most important risk factor for small bowel obstruction

prior abdominal or pelvic surgery due to adhesion development

dupuytren contracture

progressive fibrosis of palmar fascia and presents with palmar nodule or thickening usually at 4th and 5th digits possible nodules formation along flexor tendons near distal palmar crease progressive dz leads to decreased extension of digits

treatment of SVT in hyperthyroidism

propanolol - controls HR and decreases conversion of T4 to T3 in peripheral tissues beta blockers should be intiated as soon as hyperthyroidism is diagnose dand be continued until hyperthyroidism is treated with thionamides, radioiodine and/or surgery

antibiotic prophylaxis for patient undergoing joint replacement leukocyte count in prostethic joint infection

prophylactic antibitoc for joint replacement = IV cefoxtamine >1000 (but lower than spetic native joints which is usually >50k)

reasoning for microscopic hematuria in acute appendicitis

proximity of right ureter to appendiceal inflammation

clinical features of cocaine use / long term treatment of cocaine use disorder

psychosocial itnernvetions - psychotherapy + 12 step groups (cocaine anonymous, narcotics anonymous) no medication shows consistent efficacy for cocaine use disorder

comparison of benign prostatic hyperplasia & prostate cancer

pt with lower urinary tract symptoms should have UA to evaluate for hematuria and infection PSA should be obtained in *symptomatic* patients to assess risk for prostate cancer unless predicted lfie expectance is <10years

what nerve injury could cause anal incontinence

pudendal n. injury (can be seen after giving nerve block in obstetrics)

respiratory distress syndrome

pulmonary condition caused by immature lungs and surfactant deficeincy incidence is ivnersely proportional to gestational age most important risk factor = prematuriy; others = male sex, perinatal asyphxia, maternal diabetes, C-section low lung compliance low FRV R-->L shunting through ductus arteriosus and foramen ovale

infective endocarditis (IE) in intravenous drug users (IVDU)

pulmonary septic emboli show as pulmonary infilitrates, abscesses, infarciton, gangrene or cavities usualy located in lung periphery

what neurovascular structure can be affected with a mid shaft humeral fracture

radial nerve - travels in spiral groove innervates extensor muscles of wrist and digits sensory to posterior arm, forearm, dorsolateral hand

parallel study

randomizes one treatment to one group and a different treatment to other group no other varaibles measured

acute organ rejection is best treated with

IV steroids

peripartum cardiomyopathy

rapid-onset systolic heart failure = fatigue, dyspnea, cough, pedal edema seen at >36 weeks gestation or early puerperium

ludwig angina

rapidly progressive cellulitis of submandibular space most cases arise frmo *dental infections* in amndibular molars that spread continguously down the root into submylohyoid (and then sublingual) space infection is *polymicrobial* rapid systemic sympoms and local compressive (mouth pain, drooling, dysphagia, muffled voice, airway comrpomise) PE = *massive edema*; submandibular area is tender and indurated; floor of mouth is elevated, displacing tongue anareobic gas may caue crepitus *CT confirms diagnosis*, rules out abscess *IV ABX* are needed and removal of inciting tooth

creutzfeld-jakob disease

rapidly progressive dementia myoclonus sharp, triphasic synchronus disrachges on EEG spongiform encephalopathy caused by a prior most die within 1 year of symptom onset *presence of 14-3-3 protein in CSF*

inflammatory breast cancer

rare, aggressive cancer presnts as rapid onset edematous cutaenous thickening with *peau d'orange* (superfiical dimpling, fine pitting) affected breast is *edematous, erythematous* and *painful* patients commonly have axillary LAD (suggests metastatic disease)

fascial dehisence

re-opening of fascial icnision presents with 'popping' sensation feollowed by copious serosanguineous drainage and an incisional bulge

nasopharyngeal carcinoma

reactivation of EBV (endemic in southern China) obstruct nasopharynx and invade adjacent tissues results in nasasl congestion with epistaxis, headache, cranial nerve palsies, and/or serious otitis media early metasttic spread to cervical lymph nodes can cause nontender neck mass

when to give NaHCO3 in acidemia

recommended for severe acute metabolic acidosis with *pH<7.1* with pH.7.1, small beneits of HCO3 do not typically otuweigh risks

Job syndrome (hyper-IgE syndrome)

recurrent skin and lung infnections pruritic rash similar to eczema

which vessels are most often affected in fibromuscular dysplasia

renal - abdominal bruit internal carotids - subauricular bruit

renal & urinary changes in normal pregnancy

renal function increases gradually in 1st trimester and reaches 40-50% above nonpregnant state by midpregnancy, after which it remains unchanged until term pt's on medications that are renally excreted, require close monitoring and dose adjustments >300mg protein is considered abnormal [trace and 1+ protein on dipstick is nromal since normally, >150mg is considered abnromal in nonpregnancy]

pseudogout crystals

rhomboid shaped positive birefringent

calcium pyrophosphate dihydrate

rhomboid shaped weakly positive birefringent

peripheral edema ascites elevated JVP clear lung fields

right heart failure common causes for acute conditions are constrictive pericarditis

major depression during pregnancy treatment

risks of antidepressants during pregnancy are generally low and are outweighed by risks of untreated depression SSRIs are commonly used as inital treatment for modoerate to severe depression with the *exception* of paroxetine [inc. cardiac malforamtions], *SSRIs do not cause congenital malformations*

penile fracture

rupture of corpus cavernosum due to tramatic tear in tunica albuginea most frequently encountered when penis is in erect state audible snapping sensation, detumescence, and minimal to severe pain hematoma forms rapidly, causing bending of shaft at fracture site diagnosis is usually clinical; surgical management (urological emergency) only test used in evaluation retrograde urethrogram, inicdcated when: blood at meatus, hematuria, dysuria, urinary retention

ogilvie syndrome

s/s of bowel obstrutionw ithout any actual mechanical obstruction

what medications can displace T4? what does this cause?

salicylates furosemide heparin this causes T4 to feedback on hypothalamic-pitutairy, causing a decrease in thyroid production

sonohysterography

saline infusion ultrasound improves sensitvity of diagnosing submucous firboids on u/s

anti-scl-70 (anti-topoisomerase) is associated with limited or diffuse? systemic sclerosis subtype characteristics

scleroderma - systemic sclerosis

modified wells for DVT

score >2 --> *compression u/s* is initial test as it can be perfomed quickly score <1 --> D dimer patient with evidence of PE should be started on anticoagulation if no contraindciations while undergoing diagnostic eval

pt with COPD + acute onset of SOB, hypoxia, unilaterally decreased breath sounds....

secondary spontaenous pneumothorax chronic destruction of alveolar sacs leads to formation of large alveolar bleds, which can eventually rupture and leak air into pleural spce tracheal deviation is rare

post-strep GN

seen 10-20d after strep throat or skin infection presenting s/s = periorbital swelling, hematuria, oliguria hypertension UA = hematuria, RBC casts, proteinuria C3 levels are low

patients in whom a treatment plan is selected based on the severity of their condition what bias?

seleciton bias

what type of hearing loss do ototoxic antibiotics cause?

sensorineural

retinal detachment

separation of layers of the retina occurs in ppl aged 40-70 complaints of photopsia (flahses) and flaoters "curtain coming down over my eye" myopia or trauma can cause retinal breaks, through which fluid seeps in and separates the retinal layers opthalmo exam = grey, elevated retina tx - laser therapy and cryotherapy are done to create permanent adhesions between neurosensory retina, retinal pigment epithelium, choroid

retinal hemorrhages in infant....

shaken baby sydrome - subdural bleeding

small vs large fiber neuropathy in diabetes mellituz

small fiber = positive symptoms (pain, paresthesias, allydnia) large fiber = negative symptoms (numbness, loss of proprioception and vibration sense, diminished ankle reflexes)

transferrin saturation

Iron / TIBC

Kleihauer-Betke test Rossette test

Kleihauser-Betke = determines *dose* of Rh(D) anti-D Ig to be given to Rh-negative methoer Rossette = was there blood mixing

atrial septal defect

L->R shunt often remain asymptomatic until adulthood (develp dec. exercise tolerance, atrial arryhtmias, stroke from paraodixcal embolizaiton, pulm HTN, RHF, cerebral abscess) *auscultation* wide and fixed split S2 mid systolic or ejeciton murmur over left upper sternal border: increased flow across pulmonic valve mid diastolic rumble: increased flow across tricuspid

treatment of brain abscess

spinal drainage or aspiration prolonged antibiotic therapy

clinical features of splenic abscess

splenectomy is recommended for all patients

skeletal TB presentation

spondlytis - back pain, fractures arthritis ostoemyelitis

which lung cancer makes PTHrP what makes ACTh, SIADH

squamous cell = PTHrP PTHrP funcntions on kidney like PTH; however, PTHrP cannot form active vitamin D like normal PTH can therefore *vitamin D levels are low* in PTHrP of malignancy small cell = ACTH, SIADH

lymphadeneitis in children

staph aureus is most commonly isolated affected LN is tender, warm, eryhteamous and usually 3-6cm in size

nasal furunculosis

staphylococcus folliculitis following nsoe picking or nasal hair plucking potenitally life threatening as it can spread to cavernous sinus pain, tenderness and erythema in nasal vestibule

gram positive cocci

strep pneumo

location of fibroids contributing to pregnancy loss

submucosal intracavitary

erythrasma

superfiical skin infection in intertriginal areas caused by *corynebacterium minitissimum* well-demarcated, thin, red-borwn plaques with wrinkling and fien scale *coral-red* under Wood's lamp

eczema herpeticum

superimposed HSV infection open area exposed to HSV1 --> painful vesicles with erythematous base that evolve to punced out erosions with hemorrhaic cursting acyclovir asap as infeciton can be life thretening to infants and can disseminate quickly

cerclage placement

suture or synthetic tape to reinforce cerfect used in pt with hx of 2nd trimester delviery or short (<2.5cm) cervical length

what should be given when pt has torasdes de pointe

Magnesium sulfate

KOH prep: Septate hyphae

tinea

generalized seizure vs vasovagal syncope vs cardiogenic syncope

tongue biting, urinary incontinence, and perioral cyanosis can be seen during or after seizures, but can also be seen in syncopal or nonepileptiform events

maternal cardiopulmonary adaptations to pregnancy

trace protein is normal plasma volume expansion --> edema

most common cause of proteinuria in kid

transient - fever, exercise, seizure, stress, volume depltion orthostatic - icnreased protein when upright and reutrns to normal when rcumebant benign, dont require further evulation check urine dipstick on >2 occasions to r/o biological disease

biophsyical profile

NST + u/s of amniotic fluid volume and fetal tone, breathing, general body movements

most common cause of septic arthritis in young, sexually active patients?

Neisseria gonorrhoeae

livedo reticularis

transient red or purplish, blotchy or latticlelike rash that primarily affects the lower extremities caused by obstruction, vasospasm, or sluggsih flow in superficial venules often benign finding, frequently seen in healthy women during cold weather however, it can also be a sign of *vasculitis* (eg, polyarteritis nodosa, SLE) or *vasoocclusive* (eg, cholesterol embolization, anti-phospholipid syndrome, cyroglobulinemia) disorders

drugs with anticholinergic properties can cause acute urianry retention by preventing detrusor muscle contraction and urinary sphincter relaxation

treatment involves urianry cath and discotninuing the medicaiton

differential diagnosis of depressed mood

treatment of choice for adjustment disorder = CBT

comparing means

two sample t test: means of two groups of subjects two sample z test: two means of population variances ANOVA: compare >3 means chi squared: categorical data and proportions

milk- or soy-protein-induced colitis

tx = siwtch to *hydrolzyed forula* prognosis is excellent and almost all affected infants can tolerate dairy and soy products by age 1 year

staging of gastric adenocarcinoma

tx and prognosis are determined primarily by disease stage at time of diagnosis surgical tx is mainstay of management, therefore, early detection of gastric cancer improves chances of successful managment

monoclonal antidbodies against EGF receptors

tx of colorectal, head and nack, certain lung cancers

IL-1 receptor antagonsits used in?

tx of rheumatoid arthritis

clozapine treatment guidelines

tx resistant means failed at least 2 prior antipsychotic trials must participate in *regular monitring of ANC* before dispening of drug

crigler-najjar syndrome

type 1 = absence of UGT early on with unconjugated hyperbilirubenemia (up to 50mg/dL0 develop kernicterus if not promptly treated with exchange transfuion and long term phototherapy type 2 = mild deficiency of UGT enzyme develop unconjugated hyperbili (20 mg/dL0 responsive to treatement with phenobarbital unlike type I phenobarbital induces expression of UGT in these patients *kernicterus* = hypotonia, deafness, lethargy, oculomotor palsy

embyronal carcinoma

type of ovarian germ ell tumor in young women secretes AFP and hCG

patient has long term cough. Started after a URI, occurs primarily at night. Without expectoration

upper irway cough syndrome (postnsal drip) tx = oral first general anithistamine or combined antihistamine-decongestant pt who doesnt respond after 2-3 weeks may require further ivnestation

hepatojugular reflux

useful tool that can differenitate between cardiac- and liver disease-realted causes of lower-extremity edema peripheral edema from heart failure = elevated JVP and positive hepatojugular reflux peripheral edema from primary hepatic disease and cirrhosis = normal JVP and negative hepatojgular reflux

psoas abscess

PA occurs from recent skin infection near psoas, hematologic seeding or direct extnesion of intrabdominal infection (diverticulosis, vertebral osteomyelitis) risk factors - HIV, IVDU, diabetes, Crohns *clinical* subacute fever, abdominal/flank pain radiating to groin anorexia, weight loss abdominal pain with hip extension (psoas sign) *diagnosis* CT of abdomen and pelvis leukocytosis, elevated inflammatory markers blood an abscess cultures *treatment* drainage broad spectrum antibiotics

patho of cough from ACE-I

usually within week of drug initaition or dose increase increase in circulating inflammatory mediators: bradykinin, substance P, thromboxane, prostaglandins these cause bronchoconstriction and bronchial irritation

CHADS-VASC score

utilized to identify patients who are at greatest risk fo thromboembolic complications and would benefit from antithrombotic therapy 0-1 = aspirin >2 = full anticoagulation (warfarin or newer oral anticoagulants)

what is the quickest way to decrease anginal pain?

venous dilation - nitroglycerin systemic venodilation *lowers preload and LV-EDV* and reudces myocardial oxygen demand by *reducing wall stress* nitrates act on coronary vasodilators, but this benefit is ucnertain. Main mechanism of reducing anginal pain is a reduction in preload, and a reduction in LV wall stress reflex tachycardia may ensure; best to avoid this by using concomitant beta blockers

ethics

vicarious liability - being liable for someone else's actions standard of care - level at which average, prudent physician would practice conservatorship - guardianship where a preson may control the finances of an incompetent person non-maleficience - do no harm It is a physicians duty to take responsibility towards warning those people they know to be at risk of genitc condition (Safter v. Pack) forgiving co-payments and deductibles may constitute fraud EMTALA applies to stiuations where a patient requests an examination or where the patient appears to have an emergency medication conditions. Where no exam is requested or where there is no emergency medical condition, EMTALA likely does not apply. Ex: pt in ER requests immunization or blood alochol test - ER is not required to provide these services brain death refers to total loss of brain function and is a legally acceptable definition of death physician has moral responsibility to act in patient's best interests when a physician's mistake is discovered, the facts should be calrified and the truth be told to the patient patients who are an acute threat to themselves should be hospitalized (involuntrily, if necessary) for treatment and stabilization this principle applies to minor, even without paretnal consent patients have the right to request to not be told about their diagnosis; physician should avise pt to give thought to the implications of such medical records must be made available within 5 working days after a written request is made a physician can only withdraw care after providing sufficient notice of withdrawal - typically 30 days when optimal treatment requires immediate intervention on a minor, treatment should not be delayed even if explicit consent has not been obtained confidential patient information should be disclosed only to fellow health care workers who are directly involved in the patient's care physicians should avoid discussing a patient's medical condition in public areas where comments might be overheard inappropriate inquiries from colleagues curious about a patient's medical condition should be politely but firmly rebuffed accepting fits from interested third parties can influence a physician's practice in subtle or subconscious ways only nonmonetary gifts that are of minimal value and that directly benefit the patient, such as unbiased educaitonal material or drug samples, should be considered according to ethical guidelines, permission must be obtained frmo family (or from patient prior to death) before procedures can be performed on a newly deceased patient for training purposes when a patient refuses potenitally life-saving treatment, it is important to explore why and discuss reasons befor honoring it physicians should respond politeraly but firmly to inappropriate patient requests maintaining professional boundaries is an important component of physician-patient relatinoship

amblyopia

vision loss from diuse of deviated eye in strabismus

anticoagulation for atrial fibrillation causing TIA

warfarin or NOAC's Patients with CHADSVASC >2 should be managed with oral anticoagulation to reduce long term risk of systemic embolization NOACs: dabigatran, rivaroxabn, apixaban, edoxaban

injury to long thoracic n.........

weakness of serratus anterior impiarment at extreme abduction (>90d) due to inability to rotate scapula upward cause by penetrating trauma or medical/surgical procedures

definition of macrosmic infant

weight >4kg (8lb 14oz)

brushfield spots

whitest-grey spots on periphery of the iris associated with: Down syndrome, ALL

management of preeclampsia

without severe featuers: delivery at >37 weeks with severe features: delivery at >34 weeks MgSo4 (seizure prophylaxis) antihypertensives

inheritance of hemophilia

x linked recessive A = factor VIII B = factor IX

key features of DSM-5 personality disorders

a diagnosis of Antisocial requires a prior diagnose of conduct disorder [can be made retrospectively]

ruptured abdominal aorta

abaominal aortic anuresym rupture into peritoneal cavity or into retroperitoneum - signifcant abdominal pain and hypotension require urgent surgery CT is only done in stable patients; if unstable use u/s --> surgery all hypotensive patients with pulsatile abdominal mass should be evaluated in operating room

steps when neonate presents with bilious emesis and failure to pass meconium

abdominal xray to r/o pneumoperitnoeum from perforated bowel that would require emergent surgery after penumoperitoneum excluses, water soluble *contrast enema* is next step appearence of microcolon = meconium ileus; workup should be geared towards CF transition point = hirsprung disease; should have rectal biopsy (absence of ganglion cells would confirm diagnosis)

hypotension + tachycardia + elevated JVP + blunt trauma

acute cardiac tamponade bleeding into stiff pericardium that has no elasticity 100-200mL of blood needed to cause sudden rise in intrapericardial pressue that compresses the cardiac chambers and compromise venous return and cardaic output cxr = normal tx of the cardiogenic shock = pericardiocentesis or surgical pericardiotomy

characterization of korsakoff syndrome

amnesia confabulation *acute onset* of severe memory impariment in setting of thiamine deficiency commonly seen in alcoholics KS can occur concurrently with or following the development of Wernicke encephalopathy (late phase) [ocular distburances, alteration of consciousness, ataxia]

giant cell arteritis - clinical manifestations

anterior ischemic optic neuropathy [most common ocular manifesattion] = swollen and pale disc with blurred margins

strawberry hemangioma (infantile hemangioma)

appear during first weeks of life grow rapidly and then frequenyl regress spontaenously by age5-8 growths: Age 0-1 Involuation: age 1-9 [become deeper red/violet as they regress in size] bright red when near epidermis more violaceous when deeper benign vascular tumors that grow the fatest during first 4-6 months of life, and then proliferate more slowly, stabilize and involute intervention is needed when airway, vision or other organs are compromised corticosteroids - used when hemangioma is compressing airway *propranolol* is used for life-threatening hemangioma or: [ulcerated or sometically senstivie areas]

choriocarcinoma

arises from placental trophoblastic tissue, secretes bhcg most commonly follows hydatidiform mole, but can occur after a normal gestation or spontaenous abortion presents <6 months after pregnancy *risks* advanced maternal age prior complete hydatidiform mole *presentation* amenorrhea or abnormal uterine bleeding pelvic pain/pressure symptoms from metastases (lung, vagina) uterine mass elevated bhcg level friable vascular lesion [placental tissue] *treatment* chemotherapy

exposed to antique wood polyneuropathy pnacytoepnia hyperkeratoses on palms

arsenic toxicity

hypertensive retinopathy

arteriolar narrowing hard exudates cotton wool spots

anomalous R coronary a agina

artery that courses through aortic root and main pulmonary trunk can become depressed during exercsing --> agina no murmur no thrill

evaluate delayed verbal milestones with...

audiological evaluation

pernicious anemia

autoantibodies against gastric instrinic factor, which is required for b12 absorption most common cause of b12 deficiency in whites of northern european ancestory megalobaslastic nameia atrophic glossitis other autoimmune disorders *long term complications* gastric cancer - weight loss, epigastric pain; dysphagia, early staiety, anroexia, n/v blood type A increases risk for gastric cancer atrophic gastritis increases risk of intestinal-type gastric cancer and gastric caricnoid tumors by 2-3x over general population

clinical features of primary adrenal insufficiency

autoimmune = 90% of cases in developed countries; autoantibodies against adrenal enzymes responsible for corticosteroid synthesis

anti-smooth muscle antibodies

autoimmune hepatitis fluctuating hepatocellar injury tx = po glucocorticoids

inheritance of von willebrand disease

autosomal dominant

piebaldism

autosomal dominant patchy absence of melanocytes noticed and birth confined to head and trunk

noonan syndrome

autosomal dominant M=F low set ears webbed neck down turned eyes short stature normal puberty normal fertility

Chediak-higashi syndrome

autosomal recessive partial oculocutenous albinism recurreunt cutaenous infections peripheral neuropathy staph aureus and strep pyogenes are common

clinical features of esophageal perforation

avoid endoscopy for diagnosis as the air at distal tip of endoscope could extend the rupture

thrombocytosis after splenetomy

because spleen removes senscent platlets, patients often have dramatic thrombocyotisis (as high as 1,000,000) following splenectomy in most, plt elevations resovle within weeks or months however, a minority will have persistent thrombocytosis for years (driven by cytokines)

stranger anxiety

begins as easly as *6 months*; lasts until age 18-24 months

osteod osteoma

benign bone-forming tumor that occurs most often i adolescence and early adulthood males most commonly affects proximal femur but can occur in any long bone and the spine scleortic, cortical lesion on imaging with central nidus of lucency pain worse at night and unrelated to activity pain relieved by NSAIDs tx = NSAID, serial exams 14-5months surgical resection is reserved for patients with refractory symptoms

brenner tumor

benign subtype of epithelial ovarian tumor typically found incidentally in asymptoamtic patients

physiologic tremor

benign tremor with low amplitude, high frequency not visible under ordinary conidtions postural tremor (eg, holding arms outstretched) and infrequently occur with action worsened with emotion or physical stress, toxic/metabolic derangements, caffeine, or drug withdrawal

sialadenosis

benign, noninflammatory swelling of salivary glands associated with abnormal autonomic innervation of the glands, with accumulation of secretory granules in acinar cells commonly found in patients with advanced liver dsiease (eg, acloholic and non-alcoholic cirrhosis) also seen in pt with altered dietary patterns or malnutrition (eg, diabetes, bulimia)

iron deficiency anemia & thalassemias

beta thalassemia has increased HgA2 both alpha and beta thalassemia ahve target cells thalassemia shows no response to iron supplementation *plummer vinson syndrome*: iron deficiency, pica, kolinychia, esophageal webs

treatment of aktathisia

betablockers - propranolol benzos - lorazepam

rickets xray

bow legs

small-bowel obstruction management

bowel rest, NG tube suction, IVF surgical exploration for signs of complication

most common intracranial tumor in adults

brain metastses contrast enhaced MRI shows multiple, well circumscribed, enhancing lesions at *grey-white junciton* typically these lesions are surrounded by large amounts of edema leading causes of metastases = lung, breast, melanoma, renal cell *single brain metastases* = surgical resection *multiple brain metastases* = whole brain irridation

electrical alternans

QRS compelxes whose amplitudes vary from beat to beat on EKG results from heart swinging back and forth within an increased quantity of pericardial fluid JVP+muffledsounds+hypontesion = cardiac tamponade echo confirms dx

myocardial infarction location based on coronary vessel involvement

RCA supplies AV node through AV nodal artery - RCA occlusion can cause AV block most commonly involved vessel in an aterior MI is LAD

prevention of recurrent nephrolithiasis

calcium stones are most common most patients have hypercalciuria (24h urinary calcium >4mg/kg)

anomalous vascular branches of aortic arch

can cause stridor and dysphagia dur to compression of trachea and esophagus

features of constrictive pericarditis

cardiac surgery- CABG, valve surgery example in uworld was 10-20years after hodgkin radiation --> fibrosis and scarring of. pericardial sac edemic areas for TB pericarditis: AFrica, india, china in US most common causes: idiopathic/viral > radiation > cardiac surgery > CTD cxr = ring of calcification around heart *prominent x and y descent* - repeatedly in uworld questions *echo confirms dx* = icnreaesd pericardial thickness, abnormal septal motion, biatrial enlargement diuretics can provide temporary relief pericardiectomy is definitive tx for patients with refractory symptoms

ovarian hyperthecosis

cause of virlization in postmenopausal women signs of insulin resistance - hypergylcemia, acanthosis nigricans low/normal LH and FSH u/s - solid appearing, enlarged ovaries

considerations in accepting gifts from patients include cost, type, timing, and intenion. gifts given by patients with an unstable mental illness that could be affecting their judgement should *not* be accepted

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coxasckie virus is bilateral macular, maculopapular, or vesicular rash of hands and feet

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physicians should explore nonadherence in an empathetic and nonjudgemental manner and try to understand behvaior from the patient's perspective this will help build rapport and facilitate development of a united plan

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up to 70% of patients with mitral stenosis develop atrial fibrilattion because of signifcant left atrial dilatation

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counfounder is a extraneous factor which has properties linking it with the exposure and outcome of interest

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selective estrogen receptor modulators

*hot flahses* are seen in 80% of those who take *tamoxifen* anti-estrogen effects in CNS and causes thermoregulatory dysfunction in anterior hypothalmus via mechanism similar to pathophysiology of menopausal hot flashes current or prior VTE is contraindcation to both raloxifene and tamoxifen

etiologies of SIADH

CNS disturbance - storke, hemorrahge, trauma meds - carbamazepine, SSRI, NSAIDs, cyclophosphamide, chlorpropamide, desmopression lung disease - pneumonia ectopic ADH secreiton - small cell cancer pain/nausea

what is next step when an xray shows evidence of diaphragmatic hernia in stable patient congenital diaphragmatic hernia

CT of chest+abdomen - more senstivie and definitive diagnostic modality *congenital diaphragmatic hernia* defect in diaphragm that allows abdominal viscera to herniate into chest, resulting in *pulm hypopalsia* and *pulm HTN* most are diagnosed in utero by prenatal utlrasound polyhydramnios can occur as a result of esophageal compression deviation of abominal viscera into thorax results in *concave abdomen* and *barrel-shaped chest* on PE *ABC then diagnostic studies* nasal or orogastric tube placed

number needed to treat

1/ARR

factorial study design

2 or more experinemntal interventions, each with 2 or mor variables that are studied indepednetly ex: 3 different BP drugs with 2 different BP endopoints

2-step approach for screening & diagnosing gestational diabetes mellitus

24-28 weeks gestation step 1 - 50g oral glucose load; check 1hr later <140 = diabetes unlileky >140 = step 2 step 2 - 100g load checking at 1h intervals fasting = >95 1hr = >180 2hr >155 3hr >140

which medication is indicated for depressed phase of bipolar illness

2nd generation antipsychotics (eg, quetiapine, lurasidone)

first line drugs for HTN crisis in pregnancy

Hydralazine - vasodilator labetalol - beta blocker with alpha blocking; dont give if patient is bradycardic nifedipin - CCB, given po so dont give to nauseus patient

in emergent pediatric case, and IV access cannot be obtained. What should be done?

IO access should be attmepted most common site = proximal tibia contraindication to IO = infection overlying access site, fracture or previous IO attempts in chosen extremity, bone fragility

first stage of labor time xperiods

Latent: 0-6cm active: 6-10cm

digoxin toxicity

acute sx = GI [anorexia, n/v, pain] + weakness, confusin chronic = neurologic [lethargy, fatigue, confusion, disorenitation] and visual [changes in color vision, scotomas, blindess] *most specific arrhythmia of digoxin toxicity = atrial tachycardia with AV block* dixogin dose should be decreased by 25-50% when initating amiodarane therapy

clinical features of acute urticaria

acute urticaria <6 weeks chronic urticaria >6weeks tx of urticaria+pruritis w/o systemic s/s = antihistamines and d/c offending agnet

disorders of active phase of labor

adequate contractions: contactiosn generating >200MVUs in 10m

diagnosis of parvovirus b19 infection

adults have polyarticualr, symmetric arthritis of peripheral joints Children have slapped cheek rash diangsis via anti-b19 IgM antibodies (develop within 10-15d of ifnection; remain positive for 1-6months) symtpoms resolve in 2-3 weeks without need for specific treatmnet

dominant temporal lobe

affect comprehension, ability to speak nouns, reptition - arcuate fasciculation

presbyopia

common age-related disroder resulting frmo *loss of elasticity in the lens* - prohibits accommodation of lens (needed to focus on near objects) pt has tendence to hold reading material further distance is classic

distinguishing features of common upper respiratory illnesses

do *not* given influenza vaccine to people who are moderately or severely ill *oseltamivr indications* >65 y/o chronic medical problems pregnancy pt presenting within *48h*

cigarette cessation effec ton BP

does not signifcantly reduce BP as cigarette msoking causes transient elevations in BP smoking cessation should be reocmmended due to decraese in CV complications

drug induced liver injury

dose depedent direct toxins: CCl4, acetminphen, tetracycline, Amanita phalloides mushrrom idiosyncratic, non dose depedent, variable latent period: isoniazid, chlropromazine, halothane, antiretroviral therapy choletasis: chlorpramize, nitrofurantoin, eryhromycin, anabolic steoids fatty liver: tetracycline, valproate, anti-retrovirals hepaitis: halothane, phenytoin, isonizid, a-methyldopa toxic, fluminalt liver: CCl4, acetamniophen granulomatous: allopurinol, phenylbutazone

why does TB go to lung apices

higher O2 tensions slower lymphatic outflow (allows for greater accumualation of organisms) *substance abuse* is most common behavioral risk factor for TB

acquired cases of aplastic anemia

drugs: NSAID

cryptogenic organizing pneumonia

dry cough systemic symptoms that last for months ground glass infiltrates bilatearlly

hodgkin lymphoma peripheral smeer / complitions of treatment of disease

hodgkin lymphoma is a curable lymphoma ffecting young patients; howevre secondary malignacies from chemo and/or radiation are high most common secondary solid tumor malignancies are: lung, breast, thyroid, bone, GI increased risk of acute leukemia and non-hodgkin lymphoma

criteria for thrombolytics in stroke

hold aspirin for 24h after giving thrombolytics IV heparin is not recommended in early acute ischemic stroke due to limited efficacy and increased risk of bleeding Labetalol is a alpha1+betablocker that can be used to lower BP to <185/110

first line therapy for chemotherapy induced nausea

serotonin receptor antagonists (eg, ondansetron) target the 5HT3 receptor - can be used for acute emsis but also used as prophylaxis

diagnostic tests in urinary tract infections

serum bun + Cr = estimate renal function urine dipstick = qualitative measurement of urine properties urinalysis = quantiative measurement of urine properties urine culture = identiation, quantifcaiton and susceptibility testing of bacterial colonies

hypovolemic hyponatremia

serum sodium <135 *extrarenal losses: urine sodium <20* diarrhea, vomiting burns pancreaitis *renal losses: urine sodium >20* diuretics mineralocorticoid deficiency *decreased effective ciruclating volume* CHF cirrhosis

lung cancer types, incidence, location, clinical associations

small cell lung cancer: secretes ACTH (polypeptide hormone) adenocarcinoma is *most common type of primary lung cance rin both smoekrs and nonsmoekrs* and is the *predominant type seen in nonsmokers* peripheral, solitary nodule

heinz bodies

small inclusions within an RBC - aggregates of denatured hemoglobin and commonly seen in *G6PD* and *thalassemia* when phagocytse extract this rigid precipitate they form *bite cells*

management of cirrhosis

small to medium varices = beta blocker prophylaxis (propranolol nadolol) actively bleeding varices = endoscopic sclerotherapy [can be used as prophylaxis in beta blocker contraindcated] octreotide - splanchnic vasoconstriction

anticoagulation in DVT + end stage renal disease

unfractioned IV heparin followed by warfarin heparin contiued for 4-5d until INR is 2-3 LMWH and rivorxabn are not reommedned in ESRD

hemiballismus

unilateral, violent arm flinging caused by damage to *contralateral subthaamic nucleus* very disruptive but is *self-limited*

where is the msot common ectopic foci for atrial fibrillation

within *pulmonary veins*

wiskott-aldrich syndrome

x-linked recessive defect in *WS* protien gene impaired cytoskeleton changes in leukocytes, platelets eczema thrombocytoepnia [small plts, low plt count] reccurrent infections [bacterial, viral and fungal] tx = stem cell transplant

do PPI's increase risk of pneumonia?

yes

is pregnant patient with acute chest pain and dyspnea high probability of PE?

yes

patient comes in with URI. Takes PTU. Next step?

stop PTU PTU is associated with agrnulocytosis routine monitoring of the granulocyte count is *not* cost effective current reommendations state that once patient complains of fever + sore throat, the antithyroid drug should be discontinued promptly and the WBC count emasured WBC <1000 = disconitnue drug if WBC >1500 - drug is most likely not cause of sore throat and fever

most common cause of CAP

strep pneumo

biopsy of polymyositis

inflammation, patchy necroris, regeneration and fibrosis of muscle fibers inflammation of endomysium by macropahges and CD8 lymphocytes is typical

causes of recurrent pneumonia

lung malignancy is a potential cause of localized airway obstruction and may present with episodes of recurrent pneumonia CT scan of chest should be used to evaluate patients in whom there is suspicion for lung malignancy

pressures measured on ventilator

peak airway pressure - max pressure measured as the TV is being delivered (resistive pressure + plateua pressure) pleatue pressure - measured during and inspiratory hold manvuer (when pulmonary airflow and thus resistive pressure are 0) [elastic pressure +PEEP] elastic pressure - product of lung's elastance and volume of gas deliviered decreased compliance --> stiffer lungs, higher elastic pressure expiroatry muscle strength - measuring patients forced vital capcity and max expiratory pressure PEEP is calculated with the end expiratory hold maneuver

treatment of symptomatic severe waldenstrom macroglobulinemia

plasma exchange

most common cause of abnormal hemostasis in pateints with chronic renal failure

platelet dysfunction - defect in platelet-vessel wall and platelet-plaetelt interaction several uremic toxins have been implicated (*guanidinosuccinic acid*) PT, PTT, plt count are normal *BT is prolonged* DDAVP is tx of choice if needed

clinical clues to renovascular disease

resistant HTN - unctrolled with 3 drugs malignant HTN - end organ damage onset of evere HTN (>180/120) after age 55 severe HTN w/ diffuse atheroscleorsis recurrent flash pulmonary edema w/ severe HTN *PE*: asymmetric renal size, abdominal bruit *labs*: unexplained rise in createinine (>30%) after starting ACE *imaging*: unexplained atrophic kidney

management of septic shock

restore adeqaute tissue perfusion = IV 0.9% saline treating underlying infection goal SBP >90

inflammatory diarrhea predominant

salmonella camplybacter shiga toxin producing e coli shigella enterbacter vibirio yersinia

apgar

scores of 7-9 = no intevention scores <7 = further evaluation and resuscitation if neonate has bradycardia and irregular breathing - begin O2 monitrs and PPV if HR <60 --> *chest compression* APGAR scores do not correlate with prognosis

tx of intrauterine fetal demise by weeks

20-23 = d&e >24 = vaginal

opportunistic infections in HIV

*P. jiroveci* CD4<200 TMP/SMX *Toxoplasma* CD4<100 TMP/SMX *Mycobacteirum avium complex* CD4<50 azithromycin *Histoplasma capsulatum* CD4<150; endmic areas (Ohio, Mississippi) Itraconazole

exercise-induced hypothalamic amenorrhea

*atheletes triad* amenorrhea osteoporosis eating disorder

splenic sequestration crisis asplastic crises seen in sickle cell patients

*splenic sequestation* increased reitculocytis decreased plateltes splenic vaso-occlusion --> rapidly enlarging spleen occurs in children prior to autosplenectomy *aplastic crisis* decreased reticulocytes transient arrest of erythropoiesis secondary to infection (eg, Parvovirus b19) no splenomegaly

pregnancy & exercise

20-30 minutes of moderate-intesnity exercise on most or all days is recommended 'be able to engage in moderate conversation throughout activity'

tx for vasospasm associated with rayanaud

1. avoid cold 2. CCB: nifedipine

treatment of variable decelerations on fetal heart monitoring

1. materanl repositioning 2. amnioinfusion is 1 fails

treatment for active pulmonary TB

8 weeks = isoniazid + rifampin + ethambutol + pyraizamide followed by isoniazid + rifampin for additional 4 mtonhs total of 6 months of therapy

muscular dystrophies

Duchenne = *gene deletion* - disrupts amino coding seqeunce for dystrophin; protein found on plasma membrane of muscle fibers Becker = *decreased gene*; but not absent

clinical features of type 2 heparin-induced thrombocytopenia

HIT can occur even on LWMH (enoxaparin) heparin induces conformational change to platelet surface protein (PF4), which creates a neonangiten in patients with HIT, immune system responds by forming and IgG autoantibody (HIT antibody) - HIT antibodies coat surface of platlets causing: *thrombocytoepnia* *thrombus* - arterial and venous plt counts normalize in 2-7 days after stopping heparin tranfusiosn are *not* required unless patient is overtly bleeding (which is *uncommon* in HIT)

tetrad of henoch schonlein purpura

IgA mediated vasculitis *tetrad* lower extremity palpable purpura lower extremity arthalgia/arthritis abdominal pain/intussusception renal disease - hematuria, mild proteinuria nephrotic syndrome, HTN, elecated creatienine are less commonly seen

red cell distribution width

Iron deficiency = high RDW thalaseemia = normal RDW

tx for reactive arthritis

NSAIDs triad: nongonoccal urethrtiis, asymmetric oligoarthritis, conjuctivitis; mucocutenous lesions, enthesitis is also common

what blood type of mom gets Rho(D) immune globulin

Rh(d) *negative* mothers

most common kidney stone? which stones dont show up on xray?

calcium oxolate remember - uric acid and cystine stones are radioLUcent = dont show up on xray *treatment of uric acid stones* hydration *alkalanize urine*: po K-citrate low-purine diet

treatment of major depressive disorder *with* psychotic features

combo therapy: antidepressant + antipsychotic OR ECT

pediatric constipation

UTI from urinary stasis

silver staining inclusions in neurons of hippocampus

frontotemporal dementia - early personality change and later memory imapirment and compulsive behavior

treatment for suspected pneumonoccocal sepsis

ceftraixone vancomycin if concern for meningitis or osteoarticular ifnection

tick borne paralysis

characterized by *rapidly* (hours) progressive ascending paralysis (can be asymmetrical) absence of fever and sensory abnoramlities normal CSF exam ticks must feed for 4-7d for release of neurotoxin meticulous search for tick, and with removal results in improvement within an hour and complete recovery after several days

what test has the highest *sensitivity* for CHF diagnosis

elevated *BNP*

evaluation of fetal demise

however, often no etiology is found

where is renin released from

juxtaglomerular cells

CT of abdomen: segmental bowel wall thickening, small bowel dilation, mesenteric stranding

mesenteric ischemia *non-occlusive* commonly occurs in cirtically ill patientsin ICU; other risks - PAD< AI, arrhyhtmias, dialysis epinephrine in tx of shock can worsen ischemia further hemoydynamic compromise [dobutmaine or milrinone are preferred intropic meds in ICU] tx of nonocclusive mesenteric ischemia is with emergent laparatomy for resection of non-viable bowel

mood shifts in BPD duration

minutes to hours - happen in response to situational stressors

tx of urge incontinence

muscarinic antagnosits beta agonist (mirabegron)

myelofibrosis

myeloproliferative disorder occsaionally has pancytoepnia *always* has massive splenomegaly due to extramedullary hematopoiesis

internal podalic version

perfomred in twin delivery conver 2nd twin from tranverse/oblique presentation to a breech presentation for subsequent dlievery

pulmonary auscultation examination findings

remember that pleural effusion causes *decreased* tactile fremitus as it insulates sounds and vibrations originating from lung pneumonia has *increased* breath sounds

basophilic stippling

seen in thalassemias, heavy metal poisning

weakness, leg cramps after initiation of thiazide diuertic

signficant hypokalemia - suggest hyperaldosteronism

hypochleremia hypokalemia elevated bicarb

vomiting HCl lost in vomit volume contraction --> RAAS activated --> K+ excreted, H+ excreted --> increased bicarb

drugs for alcohol use disorder to decrease cravings

*acamprosate* glutamte modulator do not use in *renal disease* *naltrexone* mu-opioid receptor antagonist do not use in *liver disease*

acute drug intoxication

*benzodiazepine paradoxical agitation* confusion, agitation, aggression, dishinitbion after taking benzo uncommon taper and discontinue benzo *teratment of PCP intoxication* = duration is <8h benzodiazpines used for PCP-associated agitations [lorazepam, diazepam] Haloperidol is 2nd line treatment propofol in severe cases

acute limb ischemia

*etiology* cardiac/arterial embolus: AF, LV thrombus, IE arterial thrombus: PVD iatrogenic/blunt trauma *clinical: 6Ps* pain pallor parasthesias pulselessness poikilothermia (cool extremity) paralysis (late) *management* anticogulation (eg, heparin) thrombolysis vs. surgery

hepatic encephalopathy triggered by diuretics

*hypokalemia* exacerbate HE as the resultant itnracellular acidosis (excrete intracellular potassium repalced by hydrogen ions to maintain electroneutrality) causes increased NH3 production *glutamine conversion) in renal tubular cells *metabolic alkalosis* (eelvated HCO3) which can exacerbate HE as it promotes conversion of NH4, which cannot enter CNS, to NH3, which can enter CNS patients with HE and hypokalemia require *prompt potassium repletion* in addition to intravascular *volume repltion* dissacharides (eg, lactulose, lacitol) are also administered to lower NH3 levels

treatment of rhinitis

*mild nonallergic rhinitis* intranasal antihistamine or glucocirtcoids *moderate/sever nonallergic rhinitis* combo therapy *allergic rhinitis* intranasal glucocorticoids antihistamines

opioid intoxication... respiratory rate tidal volume temperature bowel sounds clinical features of opioid withdrawal

*opioid intoxication* resiratpory rate = decreased tidal volume = decreased tmepreature = hypothermic bowel sounds = decreased

indications for imaging in low back pain

*red flags* age >50 hx of cancer constituinoal sx nocturnal pain no response to tx signifcant or progressive neurologic deficits

stress fracture ddx = shint splint

*risk factors* repetitive activitings (eg, running, gymnastics) abrupt increase in activity inadewate calcium and vitamin D decreased caloric intake female athelete triad - low caloric, amenorrhea, low bone desnity *clinically* insidous onset of localized pain *point tenderness at fractured sit* possible negative xray in first 6 weeks common in foot - 2nd,3rd,4th metatarsals *2nd metatarsal* is most commonly involved due to extremes of loading during gait *management* reduced weight bearing for 4-8 weeks referall to orthopedic surgeon for fracture at high risk for maunion - anterior ttibial cortex, 5th metatarsal *ddx* - shin splint = overuse injury of connective tissue of posterior comaprtment of leg; will have diffuse tenderness over the anterior tibia

clostridium difficile infection in children

*risk factors* - recent abx, hospitilizaiton, PPI *clinical* - profuse diarrhea (most common); fulminant colitis or toxic megacolol *diagnosis* - stool PCR *treatment* - po flagyl or vanc *infection control* - hand hygeine, contact isolation, sporicidal disinfectants (bleach)

clinical features of aortic dissection / treatment of acute aortic dissection

*systemic hypertension is most important predisposing risk factor for aortic dissection* pain control (eg, morphine) IV beta blockers (eg, esmolol, labetolol) +/- Sodium nitroprusside (if SBP >120) urgent surgical repair for ascending dissection if pt has effusion on xray, and is stable --> CT angio for diagnosis of aortic dissection if pt has effusion on xray, and is unstable --> percardiocentesis + TEE for diagnosis of AD *goals* adeqaute pain control reduction of SBP to goal of 100-120mmHg decrease in LV contractility to reduce aortic wall stress

how long must SSRI be d/c before initating MAOI

2 weeks fluoxetine = 5 weeks due to long half life

routine GBS screening in pregnacny time

35-37 weeks gestation results are valid for 5 weeks *inidcations for tx* prior to delivery complicated by neonatal GBS ifnection GBS bacteriuria or GBS UTI during current pregnancy (regardless of tx) GBS-positive rectovaginal culture unknown GBS status plus any of the following: <37w gestation, intrapartum fever, ROM>18h *penicllin*

cri-du-chat

5p deletion cat like cry protruding metopic suture hypotonia short stature hypertelorism wide, flat nasal bridge intellectual disability

cardiac myxoma

80% are in the LA most common benign primary cardiac tumors *clinical* constituitional [*overproduce IL-6*] - fever, weight loss, raynaud phenomenon *cardiovascular* valvular abnormalities (eg, mitral disease) heart fialure due to anatomic obstruction myocardial invasion causing arrhyhtmias, heart block or pericardial effusion *embolization* - TIA, stroke, splenic infarct lung invasion causing respiratory symptoms, mimicking bronchogenic carcinoma *diagnosis/management* TEE prompt surgical resection

infection after transplant

<1 month: bacteiral casues from opeartive complications or hospitlization 1-6m: opporunistic pathogens in setting of high dose immunosupression >6 months: immunosuprpessants at maintenace lvels; patients at risk for typical ommunistty aquire dpathogens

when should women begin folic acid supplementation

>1 month before conception as neural tube closes very early in pregnancy [3-4 weeks after conception]

frequency of feeds for exclusively breastfed newborns

>10-20m q2-3h

postvoid residural urine in overflow incontinence

>150 mL in women >50 mL in men

medications that imrpove long term survival in patients with LV systolic dysfunction

ACE inhibitors angiotensin II receptor blockers beta blockers aldosterone antagonists - spironolactone and eplerenone

initial evaluation of patient with acute vaginal bleeding

CBC, pregnancy test, coags hemodynamically stable - medically managed first line - IV estrogen or high dose oral estrogen/prgoestin high dose estrogen stabilizes the denuded endometrium and stops menstrual bleeding high dose progestins may be given to patients with contraindications to estrogen hemodynamically unstable (anemic - tachycardia, hypotension) - D&C and/or PRBC may be indicated

treatment of pneumonia

CURB-65 score <2 = outpatient with macrolide or doxy 2 = inpatient with respiratory flouqrowuinoline (moxifloxacin or levofloxacin) or a combo of macrolide+betalactam >3 = ICU with batalactam/flurowuinoline or beta-lactacam/macrolide

dumping syndrome

DS is common *postgastrectomy* - occurs in 50% of patients caused by loss of normal action of pyloric sphincter due to injury or surgical bypass and leads to rapid empyting of hypertonic gastric contents into duodneum and small intestine this causes fluid shifts from intravascular sapce into small intestine, leading to hypotension, stimulation of autonomic reflexes and realse of intesinal Vasocative peptides *symptoms* abdominal pain, diarrhea, nausea hypotension/tachycardia dizziness/confusion, fatigue, diaphoresis *timing*: 15-30 minutes after meals *pathogenesis*: rapid empyting of hypertonic gastric contents *management* small/frequent meals replace simple sugars with complex carbs incorporate high fiber and protein rich foods drink fluids between meals and not with them

contraindications to external cephalic version normal indications for cesarean section

ECV can be performed between *37 weeks gestation and onset of labor* fetal well being must be document by NST and there be no contraidnications to a vaginal delivery backup emergency delivery must be a possibility *indications for cesarean section* placenta previa [placenta <2cm from cervical os] vasa previa placenta accreta active or symptomatic herpes lesions HIV viral load >1000 copies/ml irreversible fetal distress malpresentation

pathophysiology of polycystic ovary syndrome

Increased testosterone levels increased estrogen levels LH/FSH imbalance peristently elvated estrone levels due to periphearl androgen conversion in adipose tissue and decrased levels of SHBG Such high estrogen affet GnRH pulses, resulting in high freqency, short interval GnRH pulses These high frequency pulses preferntially produce LH --> causing LH/FSH imbalance ---> results in lack of LH surge --> failure of follicle maturation (anovulation)

do you need to test male partner when female has trichomonas

NO - just empirically treat since high rate of conrurerent carraige, difficulty of diagnosis in men, low cost of therapy

is thrombocytoepnia found in henoch-schonlein purpura

NOOOOOOO normal platelet count and coagulation studies

HIV in infancy

PCR is used to detect HIV in newborns

pneumo vaccination sequence for adults

PCV13 for all adults age >65 PPSV-23 given 6-12 months later

pt has asthma with comorbid GERD tx?

PPI - shown to improve BOTH asthma symptomas and peak expiratory flow rate in sathma patients with evidence of comorbid GERD

diagnostic approach for suspected aortic dissection

TEE is preferred in renal insufficiency or hemodynamically unstable CT angio is *preferred overall* in hemodynamcially stable patients

next step in patient who is hemodynamically stable with cxr showing widened mediastinum after blunt trauma

TEE or CT ex thoractomy is used in *unstable* patients with hemodnyamic shock

TIA vs MS attack

TIA = sudden onset neurologic findings that resolve within 30 minutes MS = acute demylinating plaque lesions lasting for days to weeks

69 y/o with irregular rhytmn + weight loss initial screening test?

TSH, T4 - hyperthyroidism testing for hyperthyroidism is advisable in all patients with afib, particarulry if they have additional symptoms of thyroid dysfunction

which vaccine should all women receive every single pregnancy?

Tdap preferred in *3rd trimester* - facilitates both maternal antibody response and transfer of amternal antibodies through palcenta, providing passive immunity Tdap is also recommended for fmaily membres who have not been recently vaccinatied and will be in close contact with newborn

interstitial cystitis (bladder pain syndrome)

UA should be obtained to exclude other causes of bladder pain; results will be normal in interstitial cystitis

current guidelines for screening for diabetes in asymptomatic patients

USPTF: all pts with BP >125/80 ADA: all pts >45 y/o as well as those at any age with risk factors

wolff-parkinson-white syndrome

WPW can be associated with cardiac arrhthmias if there is a retrogrde conduction from ventricles to atria, a re-entrant SVT may occur tx = procainamide or ibutilide radial ablation is long term choice if unstable - electrical cardioversion

modification on blood pressure

Weight loss is *most effective* intervention in obese patients DASH diet, exercise, limiting alochol, limiting falt

clinical presentation of hyrdatiform mole

abnormal vaginal bleeding +/- hydropic tissue uterine enlargement > gestaionl age abnormally elevated bchg theca luteun ovarian cysts hyperemesis gravidarum preeclampsia w/ severe features (*preclampsia prior to 20 weeks is big sign*) hyperthyroidism *diagnosis* snowstorm on u/s quantitative serum bhcg histo of uterine contents

contraction stress test

administering oxytocin until 3 contrations occur in 10 minutes and osberving FHR

what do dysgerminomas secrete

adolsecents - lactate dehydrogenase germ cell tumors that contain cells that differentiate into syncytiotrophoblast cells of placenta

pathogenesis /clinical of brain abscess

bacterial invasion due to: direct extnesion from contiguous infection (sinusitis, mastoditis, otitis media) [*single abscess*] *or* hematogenous spread from distant infection (endocarditis, osteomylitis) [*multiple abscess*] *manifestations* headache fever focual neurologic deficits, seizure brain iamging (CT scan, MRI) : >1 ring enhancing lesion with central necrosis

ADH-related causes of polyuria and polydipsia

central DI usually has high Na due to impaired third mechanism nephrogenic DI has intact third mechanism --> noraml Na lvel

what type of vision is lost in macular degeneration

central vision

patient has asthma attack. Treated with albuterol and methylprednisolone. Next morning, has muscle weakness. Next step?

check electrolytes - patient is *hypokalemic* patients on high dose b2 agonists can develop hypokalemia = weakness, arrhythmias and EKG abonormalities

separation anxiety development

commonly develops at age *9-18 months* tends to improve with time can recur during times of transition that require separation, such as attending school

calcinosis cutis

deposition of calcium and phosphorus in the skin

most common underlying cause of diabetic foot ulcer

diabetic neuroapthy - test with monofilament monofilament testing predicts risk of future ulcers

follow up of an abnormal prenatal screenign test...

diagnostic testing with either amniocentesis or CVS depending gesational age

beta-2 microglobulin

elevated in lymphoproliferative disorders (eg, multiple myeloma) conditions with *increased* cell turnover

treatment of OA

exercise, weight loss meds = acetaminophen or NSAIDs

most common cause of nephrotic syndrome in adults

focal segmental glomerulocslerosis

type of hematuria in glomerular vs nongloemrular

glomerular = microscopic nonglomerular = gross

toxoplasma encephalitis

headache, confusion, fever, focal deficits *diagnostic* CD4<100 positive toxoplasma gondii IgG multiple *ring-enahcing* brain lesions *tx* sulfadiazine and pyrimethaine + leucovorin antiretroviral intiation prophyalxis - TMP/SMX when CD4<100

minimal change disease is asociated with what cancer? staging of hodgkin lymphoma

hodgkin lymphoma

most common etiology for sudden cardiac death in young adult

hypetrophic cardiomyopathy 50% of patients who die suddenly from HCM have no prior symptoms Long QT syndrome is also a cause but less prevalent than HCM

cystinuria

impaired transport of cystine and dibasic amino acids (ornithine, lysine, arginine) by brush borders of renal tubular and intestinal epithelial cells decreased reabsoprtion of cysteine - which is poorly soluble in water --> cystine stones (hard and radiolucent) *cyanide-nitroprusside test* can detect elevated cystine levels in urine *heaxagonal crystals*

human rabies

incubation period = 1-3 months if in US = *bats*

management of suspected ectopic pregnancy

intrauterine pregnancy should be seen with TVUS at a bhcg of 1500-2000IU/L

myoclonus

involuntary jerking of muscle or muscle group can be rhytmnic or patterend usually initaited by contraction or relaxation

hypertensive vasculopathy

involving small pentrating branches of major cerebral arteries is msot common cause of *spontaenous deep intracerebral hemorrhage* chornic HTn leads to formation of Charcot-brouchard aneurysms, which may reupture and bleed within deep brain structures most frequently affected locations: basal ganglia, cerebellar nuclei, thalamus, pons

serous otitis media

most common middle ear pathology in pt with *AIDS* due to auditory tube dysfunction arising from HIV-lymphadenoapthy or obstructing lymphoma characterized by presnce of middle ear effusion w/o evidence of acute infection conductive hearing loss is most common symptom exam = dull tympanic membrane that is hypomobile on pneumatic otoscopy

nail melanoma

nail melanomas form longitudinal bands in nail plate (longitudinal melanonychia) due to presence of pigment in nail as it grows outward unpigmented melanomas can also occur and present as nodules or irregularities in nail plate

pyoderma gangrenosum

neutrophilic ulcerative skin disease 30% are triggered by local trauma (pathergy) 50% have systemic disorder - IBD, arthropathies, hematologic conidtions diagnoes with *skin biopsy* treatment = *local or systemic corticosteroids*

heart conditions preventing pt from sexual activity

ongoing stable or unstable angina incomplete revascularization LV dysfunction or symptomatic HF high irsk arrhythmia very recent (<2w) MI *PDE5 inhibitors* CAN be used in heart conditions; just be weary of nitrates and alpha blockers

Meigs syndrome

ovarian fibroma ascietes pleural effusion

patients who have decision making capcity have the right to refuse procedures and treatment

physician should address any modifiable obstacles to treatment if patient still refuses, services should be offered if patient reconsiders

bacterial pharngotonsilitis + proteinuria + hematuria + dysmorphic RBC

poststrep glomerulonephritis

hospice services provide interdiscplinary palliative care for with with...

prognosis <6 months

false positives for amphetamines on urine tox

pseudophedrine buproprion selegilline *bath salts are not found on urine tox*

rouleaux fomration

seen with elevated serum protein

sudden loss of consciusness + loss of postural tone + delayed return to baseline....

seizure in contrast, syncope has immediate spontaenous return to basleine neurologic function

Positive leukocyte esterase on UA

significant pyuria

in patient with osteoporsis, the risk for fargility fracture is highest in those...

with prior history of ragility fracture

a living will communicates the patient's own wishes if he or she becomes incapcitated, and it overrules the wishes of the family

***

endometrial biopsy is indicated in all premnopausal patients >45 with AUB

****

in nonemergency situation in which parent refuses potenitally life saving treatment for their child, the physician should seek a court order mandating treatment

****

microbiology & clinical associations of infective endocarditis complications of infective endcoarditis

*cardiac* valvular insufficiency - common cause of death perivalvular abcess conduction abnormalities mycotic aneurysm *neurologic* embolic stroke cerebral hemorrhage brain abscess acute encephalopathy or meningoencpehalitis *renal* renal infarction glomerulonephritis drug induced acute interstital nephritis from therapy *MSK* vertebral osteomyelitis septic arthritis musculoskeletal abscess

viral pleuritis (viral pleurisy)

*clinical* viral prodrome: feevr, cough, rhinorrhea pleuritic chest pain dyspnea pleural friction rub on lung auscultation absence of pleural effusion *treatment* supportive care analgesia with NSAIDs

differential diagnosis of marfanoid body habitus

*diagnosis of homocystinuria* = elevated homocystine and methionine levels *treatment* = b6, folate, b12; antiplatelets or anticoagulation to prevent stroke, CAD, VTE

bacterial endocarditis prophylaxis

*high risk conditions* prosthetic valves previous endocarditis structural abrnomality in transplanted herat unrepained cyanotic congenital heart dz repaired congenital heart disease with residual defect

what should be the endometrial stripe in postmenopausal women?

*less than 4mm* thickened endometrial stripe requres endometrial biopsy

estimating central venous pressure (CVP)

*normal CVP*: 6-8 cm H2O *elevated CVP*: >8cm H2O

digeorge syndrome / velocardiofacial syndrome

*patho* chromosome 22q11.2 deletion defective development of pharyngeal pouches *clinical* conotruncal cardiac defects (TOF, truncus arteriosus, interrupted aortic arch) abnormal facies thymic hypoplasia (T cell deficiency) craniofacial deformities (cleft palate) hypocalcemia/hypoparathyroidism

endometrosis

*patho*: ectopic implantation of endometrial glands *clinical* dyspareunia dysmenorrhea chronic pelvic pain infertility dyschezia *pain occurs 1-2 weeks prior to menses and peaks just before menstruation* *physical exam* immobile uterus cervical motion tenderness adnexal mass recto-vaginal septum, posterior cul de sac, uterosacral ligament nodules *diagnosis* direct visualization and surgical biopsy *treatment* Medical: oral contraceptives, NSAIDs surgical resenction

adenocarcinoma xray

*peripheral* nodule

periorbital (preseptal) cellulitis vs orbital cellulitis

*preseptal cellulitis tx* oral antibiotics *orbital cellulitis tx* IV abx +/- surgery

inidcations for statin therapy

*primary prevention* estimated 10year risk of ASCVD >7.5% *secondary prevention* known ASCVD (eg, MI, stroke) LDL >190 LDL levels are used for compliance on statin; they are not used as indicators for starting therapy

electroconvulsive therapy for depression

*side effects* amnesia - anterograde and retrograde anterograde resolves within 2 weeks; retrograde may persist longer

clinical features of multiple sclerosis

*treatment* acute MS exacberation = IV methylprednisolone chronic MS = IFN-beta, glatiramer acetate

pt has hypovolemic hypernatremia with AMS. What fluid should be given as initatal bolus?

0.9%NS when pt is hypovolemic - restore the fluids with NS once they are euvolemic you can use 5% dextrose should only give isotnic solutiosn (NS, LR) - slowly return sodium back to normal 1/2NS and 5%dex are hypotonic and can lower sodium too rapidly --> *cerebral edema* mild cases can be treated with 5%d extrose in 0.45% saline

ongoing management of hypovolemic shock due to massive hemorrhage transfuion of RBC, platelets, coags in what roatio?

1 : 1 : 1 transfusion of *O negative* RBC is best as it resotres blood volume and oxygen carrying capcity while minimizing risk of hemolytic transfusion reaction

how long do bioprosthetic valves last? mechanical valves?

10-15 years mechanical valves are more durable and rarely affected

when should a child be able to scribble

18 months running, kicking at this point, should have 10-25 words run and kick a ball remove clothing pretend play

how much does serum sodium concentration drop for ever 100mg/dL increase in glucose over the normal value (eg, 100mg/dl)

2 mEq/L for every 100mg/dL

ideal location of distal tip of endotracheal tube

2-6cm above the carina ETT advanced too far will preferentially enter right main bronchus --> overinflation of right lung, underventilation of left lung, asymmetric chest expanion

digeorge syndrome

22q11.2 deletion defective development of pharyngeal pouches *CATCH* Conotruncal cardiac defects - *truncus arteriosus* - neonatal cyanosis, heart failure, systolic ejection murmur with loud ejection click at left sternal border abnormal facies thymic aplasia/hypoplasia - *T cell lymhopenia*: increased risk of viral/fungal infections; decreased B cella ctivation --> inc. bacterial infections cleft palate hypocalcemia serum Ca and echo must be ordered immediately neonates are at high risk for life threatening *tetany, seizures, arrhytimias* that can further exacebrate co-existing heart conditions and may require aggressive Ca repletion *defeinitively diagnosed by FISH*

medulloblastoma

2nd most common psterior fossa tumor in children after cerebellar astrocytoma most occur in *cerebellar vermis* - important for balance and gait coorindation less commonly occur in cerebellar hemispheres - dysmetria, intention termor, dysdiadoschokinesia medulloblastoma cause osbtructive hydrocephlus by comrpessing 4th ventricle hvae potential for leptomeningeal spread tx - combo of surgery, craniospinal radiation, chemo

gallstones after bypass surgery

30-40% get symptomatic gallstones resulting rapid weight loss --> gallstones from increased bile concetrations of mucin and calcium prophylatctic ursodeoxtcholic acid is given for 6 months postop to reduce risk of gallstone development

perivalvular abscess

30-40% of patients with infective endocarditis typically the new conduction abnormality = AV block Aortic valve infection and IV drug use are msot common implicators development of new condution abnoramaity in patient with infective endocarditis should raise suspicion for perivalvular abscess extending into adjacent conduction pathways

transferring obejcts from one hand to another....

6 months

sit on propped hands transfer objects respond to name stranger anxiety disappernce of primitve reflexes

6 months old

how much does infant have to weight to receive HBV vaccine at birth

>2kg (4lb 6oz)

prolonged postop ileus

>3-5d postop contirbutors to PPI are increased splanchnic nerve sympathetic tone following peritoneal instrumentaiton, lcoal reelase of inflammatory mediators, and pstop opiate analgesics techniques to prvent PPI: -epidural anesthesia minimally invasive surgery judicious perioperative use of IV fluids (minimize GI edema)

adrenal production of DHEAS isc ontrolled by?

ACTH thus if there is a cortisol producing adrenal tumor, DHEAS levels will be low secondarily to low ACTH

what is first order test in suspected SLE?

ANA - sensitive if ANA is positive, order a anti-DsDNA and anti-Smith - these antibodies are more specific, but less sensitive; therefore, less useful for inital testing

what should be checked in all patients with suspected granulmatois with polyangiitis

ANCA - qualitative serum antibodies c-ANCA (proteinase 3-ANCA) is associated with GPA

anterior spinal cord syndrome

ASA supplies anterior 2/3 of spinal cord, including ACST and LSTT *main findings* bilateral hemiparesis - LSCT; at level of injury + below diminished bilatearl pain and temp: LST; 1-2 below cord injury intact bilateal proprio, vib sensation, light touch: dorsal coulmns supplied by posterior spinal a. ASA is particuarly dependent on blood supply from radicular arteries that originate from thoracic aorta, such as a. of Adamkiewicz. Thoracic aortic surgery can resutl in reduced blood flow through radicular arteries and laed to anterior spinal cord infarction patients have abrupt onset of bilateral flaccid paralysis and loss of pain/temp below level of injury flaccid paralysis is due to spinal shock UMN signs such as spasticity and hyperreflexia develop over days to weeks bowel/bladder ysfunction can occur from autonomic dysfunction from involvement of intermedioaltearl cell clumb vibration/2pt are preserved

respiratory syncytial virus (RSV) and prophylaxis bronchiolitis

Age <2 years RSV most common cause of bronchiolities common pediatric respiratory infection present with productive cough and rhinorrhea babies may have refusal toe at --> dehydration highly contagious illness that is generally self limited pneumonia can complicate the picture in those are are at risk (chronic lung disease, congenital heart defect, prematurity) main treatment = *supportive* treatment with *ribavarin* only used in immunocompromised pediatric patients with a severe life-threatening RSV infection prophylaxis in these high risk patients is important *best method of prevention* = passive prophyalxis with *palivizumab* - monoclonal antibody against RSV one IM dose per month for entirety of RSV season *those who quality*: preterm birth <29 weeks gestation chronic lung dsiease of prematuiry hemodynamically singnficant congenital heart disease *complications* apnea (infants <2 months) respiratory failure

water-soluble vitamins

B2 is involved in oxidation-reduction reactions for energy

bipolar & related disorders

Bipolar one requires 3 of the following of symptoms (DIGFAST) distractibility impulsivity grandiosity flight of ideas/racing thoughts activity (goal directed / psychomotor) sleep (decreased need) talkativeness/pressured speech cyclothymic = 2 years of periods of *hypomanic sx* and *depressive sx* w/o meeting full criteria for hypomaic or MDD

management of shoulder dystocia (BE CALM)

Breathe; do not push Elevate legs and flex hips, thighs against abdomen (mcroberts) Call for help Apply suprapubic pressure EnLarge vaginal opening with episiotomy Maneuves: -deliver posterior arm -rotate posterior shoulder (woods screw): pressure to anterior of posterior shoulder -addult posterior fetal shoulder (rubin): pressure to posterior of posterior shoulder -mother on hands and knees (Gaskin) -replace fetal head for C-section (Zvanelli) shoulder dystocia is due to anterior shoulder behin pubic symphysis

ovarian mass found in postmenopausal women workup

CA-125 + pelvic u/z elevated CA125 raises chances of malignancy if u/s is normal, and CA125 is nromal --> follow up with periodic u/s if suspcious u/s (large, solid components, septations) and/or CA125 is elevated - further imaging (eg, MRI, CT)

treatment of trichotillomania

CBT - habit reversal training .

tx of atrial fibrilation with RVR

CCB or BB unstable - synchronized cardioversion

Fragile X syndrome

CGG repeat on FMR1 gene on X chromosome *x-linked dominant* hypermethylation of gene causes impaired transcirption of FMRP - important in brain development more common in males *most common inherited form of intellectual disability* - most exhibit autisitc behavior delayed milestones, seiures, macrocephaly, hypotonia increased prevalence of ADHD and autism elongated face, large ears, enlarged testes (seen in adolsecne)

most common congenital infection and how does is typically present?

CMV HSM, jaundice, petechiae severe cases have periventricular calcifcations and microcephaly

risk for postop pulmonary complications

COPD, active smoking obestiy OSA age >65 open thoracic surgery *preopertive physical therapy* signifcantly reduces the postoperative invidence of atelectasis and pneumonia and shrotens the length of postop hospital say in patients undergoing elective cardiac surgery CPAP is strongly advised *postoperative period* in pt with OSA

clinical features of compartment syndrome

CS can be caused by direct trauma or porlonged compression of an extremity or after revascularization of acutely ischemic limb (ischemia-reperfusion syndrome) *eschar* frmo a *circumferential, third degree burn* can often lead to constriction of venous and lymphatic drainage, fluid accumulation, and resulting distal ACS patient oftne has *excruciating pain* worsened on pasive ROM that doesnt respond to narcotic paresethsia is early finding arterial pulses are present in most, espeically early on diagnosis is confirmed with *compartment pressures* in affected extremity Compartment pressure >30 *time to fasciotomy* is most critical prognostic indicator

syringomyelia

CSF drainage from central canal of spinal cord is disrupted, leaing to a fluid filled cavity that compresses surrounding neural tissue dmage involes crossing fibers of spinothealmic tract and upper extremity motor fibers due to medial locations within CST most common causes of syringomyelia = Arnold Chiari type 1 and prior spinal cord injuries *characteristic findings* decreased strength and diminished pain and temp affected arms/hands *cape like* distrubtion preservation of dorsal columns *diagnosis* made with *MRI*

is CT or MRI better for depicting bone?

CT MRI is ebtter for soft tissue details

brain imaging for new onset seizure

CT without contrast should be used if there was associated trauma with fall after the seizure to r/o intracranial bleed however, MRI is the neuroimaging modality of choice in new onset seizure; it has more sensitivity to identify structural causes of epilepsy - tremporal sclerosis, cortical dysplasia, vascular malofrations, traumatic brain injury, cerebral infarction, CNS tumors, infections

hepatorenal syndrome

Classic case: severe lvier dsiease with progressively rising serum createinine with minimal proteinuria (<500mg/d) *any factor that may further reduce glomerular capillry pressure (eg, hypotension for GI bleed) can cause an acute decline in GFR and precipitate hepatoernal syndrome* due to splanchnic and systemic vasodilation [incnreased production of nitrix oxide] that occurs in cirrhosis and portal HTN leads to increased cardiac output and decreased SVR SNS, RAAS and vasopressin activated to counteract, leading to renal vasoconstriction and eventually decreased GFR/renal failure *labs resemble prerenal azotemia* - elevated serum createinine, and ver ylow urine sodium tx = liver transplant

32 y/o has estrogen+ breast cancer. Scheduled to begin chemo. Advised to avoid pregnancy. Best contraceptive to use?

Copper intrauterine device - safe, long term, hormone free method of contraception it is 99% effective and prevents pregnancy by creating chronic cytotoxic inflammatory response all hormone containing contraception is absolutely contraindiaed condoms are only 80% effective

65 y/o woman with pain + swelling over inner aspect of right eye for 2 days. Eye is tender, edematous, redness over medial canthus. Slight pressure over area causes expression of purulent material. Visal acuity = normal. Dx?

Dacryosytitis - infection of lacrimal sac characterized by sudden onset of pain and redness in medial canthal region can have purulent discharge staph aureus and beta hemolytic strep are organisms tx = abx

medical therapy shown to imrpove morbidity and motrality in patients with known coroanry herat disease

Dual antiplatelet therapy: aspirin + P2y12 receptor blocker beta-blockers ACE-I or ARB Statins Aldosterone antagonists [LV EF<40% w/ CHF or DM]

infectious mononucleosis

EBV is most common; CMV causes an IM syndrome (less likely to have pharyngitis) *clinically* fever tonsilitis/pharyngitis +/- exudates posterior or diffuse cervical LAD - *tender* signifcant fatigue hepatosplenomegaly rash after amoxicillin (polymorphous and maculopapular) *diagnostic* positive heterophile antibody (monospot) - 25% false neg during 1st week testing for anti-EBV antibodies is another way atypical lymphocytosis - variant lymphocytes with large vacuolated cytoplasm transient hepatitis *management* avoid sports for >3 weeks due to risk of splenic rupture >4 weeks for contact sports *rare complications* splenic rupture airway compromise autoimmune hemolytic anemia [coombs test positive, elevated reticulocyte count] thrombocytoepnia

primary sclerosing cholangitis

ERCP or MRCP confirms diangosis = multifocal narrowing with intraheptic and extrahepatic duct dilation liver bx is no necessary but shows intrahepatic ductual obliteraly with lymphocytic infiltration and periductual onion skin fibosis

which anti-retroviral drug can cause serious psychaitric side effects

Efavirenzr (NNRTI) can cause dizziness, insomnia with vivid or bizarre dreams, depression, anxiety, confused thinking, aggression symptoms resolve within first few weeks of treatment

most common brachial plexus injury from fetal macrosomia

Erb-Duchenne palsy - C5, C6, sometimes C7 application of excessive traction on head/neck in attempt to extra trapped infant weakness of deltoid and infraspinatus muscles, biceps, and wirst/finger extensors *waiters tip* tx = gentle massage and PT to prevent contractures 80% have spontaneously reocvery within 3 months

management of blunt abdominal trauma in hemodynamically unstable patients

FAST exam if free intrapertineal fluid found --> uregent laparotomy if negative look for signs of extra-abdominal hemorrahge and stabilize

antidepressant classification & major drugs

First line = SSRI If pt fails treatment with one class of drug, its preferable to switch to antidepressant with a different mechanism of action

most accurate method of determining gestational age

First trimester ultrasound with crown-rump length accuracy varies from +/- 3-5d b/w 7-14w gsestation fundal height - after 20w fundal height measured in cm - pubic symphysis to top of fundus; correlates with gestational age by +/- 3 weeks LMP is not used because many women do not have regular 28d cycle and fertilization can occur before or after day 14 If EGA varies by >7d in 1st trimester and >10d in 2nd trimester, then u/s EGA is used rather than LMP

how long does anxiety need to be present for generalized anxiety disorder? Major dperssive disorder?

GAD: >6 months MDD: >2 weeks often these two disordershave overlaping symptoms (eg, fatigue, insomnia, impaired concentration) GAD patients often have lifelong chronic anxiety

pharyngitis + lower abdominal pain in young, sexually active patient

Gonococcal pharyngitis with pelvic inflammatory disease pharngitis occurs due to incoulation of pharynx during orogenital contact usually asymptomatic; can present with pharyngeal edema and nontender cerical lymphadenopathy

disseminated mycobacterium avium complex

HIV, CD4<50 nonspecific symptoms: fever, cough, abdominal pain, diarrhea, night sweats, weight loss splenomegaly elevated alk phos (MAC hepatosplenic involvement) dx = blood cultures (lymph node or bone marrow biopsy) tx = azithromycin or clarithromycin if CD4<50 = prophyalxis with azithromycin is recommended

condylomata acuminata

HPV6 and 11 *clinically* multiple pink or skin colored lesions lesions ranging from smooth, flattened papules to exophytic/cauliflower like grwoths *tx* chemical: podophyllin resin, trichloracetic acid immunologic: imiquimod surgical: cryotherapy, laser therapy, excision *prevention* vaccination barrier contraception recurrence rates are high regardless of treatment modality

eclampsia = severe preeclampsia + seizures

HTN, proteinuria severe headaches, visual distubrances [prodromal sx] RUQ or epigastric pain 3-4 mintues of tonic clonic seizure *management* MgSO4 [if mag doesnt control seizure, give diazepam or phenytoin] anti-HTN agent deliver fetus *MRI* = reversible posterior leukoecephalopathy syndrome [patchy hyperintesnities in subcortical white matter and adjacent gray matter of parietal and occipital lobes]

infectious epiglottitis

Haemophilis influenzae (Reduced risk with vaccination) - but can still occur in vaccinated children *clinical* - rapidly progressive, life threatening fever, sore throat, drooling, muffled voice airway obstruction: stridor, dyspnea pooled oropharynx secretions/laryngotracheal tenderness pt may *hypextend neck* and maintain *tripod* psoition to maxmize airway diameter *diagnosis* direct visualization imaging - *thumbprint sign* *treatment* early artifical ariway (if needed) IV abx: ceftriaxone + vancomycin *prevention = immunizaiton*

next step when pt presents with severe acute arterial occlusion (sensory loss, rest pain, muscle wekaness)

IV heparin - prevents further thrombus propagation and thrombosis in distal arterial and venous circulation emboli most commonly lodge in femoral a. 6Ps: pain, parasthesias, pulselnessness, pallor, paralysis, poikilothermia *arteriography of extremity used for diagnosis*

treatment of Kawasaki disease

IV-IG given within 10 days of fever onset has been shown to decrease incidence of coronary artery aneursyms aspirin is given to prevent coronary a. thrombosis

when does IgA nephropathy occur? PSGN?

IgA = within 5 days of viral URI (gross hematuria) PSGN = >10d GAS infection (microscopic hmeaturia)f

commonly tested renal conditions

IgA nepropathy - follows viral illness, IgA and C3 on staining; normal C3 PSGN: occurs >1w after strep throat or skin infection; High ASO, low C3. Lumpy bumpy deposition Granulomatosis w/ polyangiits: damges lungs, kidneys. C-ANCA. Involves upeprairway: sinusitis, otitis medial, naasal ulceration Goodpasture: damages lungs + kidneys. Linear deposit of anti-GBM antibodies; does not affect upper airway MCD: fusion of podocyte foot proceses; asymptoatic child w/ puffy and edematous alport: deafness + heamturia membranous nephropathy: adult w/ proteinuira and thick GM. Spike and Dome Diabetic nepropathy: Kimmelsteil-wilson nodules FSGS: IV drug abuse, HIV. Sclerosis on biopsy Lupus nephritis: multiple types so bx is essential to determine tx amyloidosis: apple green birefringence w/ congo red staining membranoproliferative nephropathy: tram track appearnce of absememnet membrane

features of leukocyte adhesion deficiency

LAD is caused by defective integrins on the leukocyte surface, which normally allow neutrophils to adhere to vascular endothelium, exit the vasculature, and migrate to areas of infection or inflammation inflammation with *lack of purulence* - biopsy is devoid of neutrophils and often growth staph aureus or gram-negative bacilli delayed cord + recurrent skin and mucosal infections w/o purulence + severe periodontal disease serum studies = marked leukocytosis and *neutrophilia* first presenting sign: *delayed umbilical cord separation (>3 weeks)*

leukemoid reaction

LAP = high WBC = >50k cause: severe infection mature neutrophils no basophilia

musculoskeletal test - indiction

Lachman - ACL, PCL [depending on vector] Drawer test - ACL, PCL [depending on vector] Trendelenberg - gluteus medius Lasegue's (straight legg raise) - nerve impingement Thomas - iliopsoas contracture Patricks (FABERE) - hip pathology [OA] phalens - carpal tunnel adsons - thoracic outlet [extent pt elbow and shoulder, while abduction and ext rotating upper extremity] wallenberg - vertebral a. insufficiency [hold head in 6 different planes of motion for 10s periods of time - eliciting neurologic s/s drop arm test - supraspinatus m. apley scratch - ROM of GH joint spurlings - cervical radiculopathy speeds - bicipital tenditis

clinical features of metabolic alkalosis

MA is due to disorder producing excess bicarb (generation phase) combined with a process prevneting renal bicarb excreiton (maintenance phase) generation phase in saline-responsive MA can be due to urianry or GI hydrogen loss or decreased oral intake The maitnence phase (eg, hypoveolmia) prevents normal kidney frome xcreting excess bicarb kidneys perceve decreased effective blood volume and increases RAAS --> Na rabsoprtion, K/H excretion *Saline-resistant* has *excess minerloscorticoid* causing hydrogen and poatssium loss and increased sodium retention leading to increased extracellular volume Kidneys respond be excreting both sodium and chloride to result in *high urine chloride* *saline-responsive* has *low urine chloride* due to hypovoelmia and hypochloremia Saline administraiotn restores arterial volume, corrects hypochlremia and increses urianry bicarb excretion

multiple endocrine neoplasia

MET 2A and 2B are caused by *RET* mutations - if one of the cancers is found, patient shoudl undergo RET mutation testing and plasma metanehrine because surgery can cause a HTN crisis if pt has underlying pheochromocytoma *treatment of pheochromocytoma* placed on phenoxybenzamine for one week prior to surgery then before surgery, propranolol should be added adrenalectomy is tx of choice - must ligate all venous drainage from tumor before resection to avoid release of catehcolamines must recheck urine after surgery for catacholamines *pheochromocytoma* = chromaffin cells of adrenal medulla *paraganglioma* = extra-adrenal paraganglia

maternal serum alpha-fetoprotein screening

MSAFP primarily used for open NTD elevated MSAFP warrants u/s multiple gestation = uterus will be larger than gestational age MSAFP elevation warrants to double check gestational age

morbilliform rash following prodrome of cough, conjcuvitivtis and coryza

Measles (rubeola) rash spreads cephalocaudally *transmission*: airbone *clinical* prodrome - cough, coryza, conjuctivitis, fever, Koplik spots Maculopapular exanthem - caphlocaudal and cnetrifual spread; spares palsm soles *prevention*: live attenatuad measles vaccine airborne precautions (negative pressure room, N95 face mask) *tx*: supportive, vitamin A for hospitlized patients - promotes anti-body producing cells and regneration of epithelial cells *can return to school 5 days after onset of rash* [contagious for 4 days] *prevention* MMR vaccine - age 1 and age 4 precaution - can cause fever and maculopapualr rash as it is a live virus [this is self limiting, but avoid immmunocompromised individuals until rash has resolved]

neurofibromatosis type 1

NFI gene - nerufirbomin - autosomal dominant cafe-au lait macules - flat, uniformly hyperpigemtned skin lesions clustered freckles - particularly in axillary and finguinal regions lisch nodules - raised, tan-colored hamartomas of iris neurofibromas optic glioma - *most common type of intracranial lesion* - manifests during toddlerhood: decreased visual acuity, optic n. atrophy, alterations in color vision, proptosis child presents with: cafe-au-lait, macrocephaly, feeding issues, short stature, learning disability *MRI of brain and orbits* shuld be ordered when pt is symptoamtic to thoroughly evaluate intracranial structures

obstructive sleep apnea / obesity hypovenilation syndrome

OSA can exist alone or in combo with obesitry hypoventilation syndrome patients with OSA in absence of OHS experience hypoventilation only at night with transient hypoxia and hypercpania that resolve while awake Obesity hypoventilation, physical restriction of thoracic cavity cause dby excess thoracic tissue continues during day, resutling in chronic hypoxia and hypercapnia Patient has to retain bicarb and decrease Cl reabsortion (via HCO3-Cl exchanges in intercalated cells of distal nephron) to compensate for the respiratory acidosis OHS patients can develop pulm HTN (due to hypoxic vasoconstriction) with eventrual cor pulmonale systemic HTN is common with both isolated OSA and comorbid OSA/OHS, due to hypoxic triggers of symtphaetic nervous system --> increased catecholamines >5 = high risk 304 = intermediate 0-2 = low

clinical features of pulmonary hypertension

PAH is common in *limited cutenous subtype of systemic sclerosis* - results from intimal hyperplasia of pulmonary arteris and presents with progressive dyspnea pt may have exertional syncope or presyncope due to RV failure and inadeqaute venous return to LA PE = *RV HEAVE* which is an impulse palpated immediately to left o sternum that suggets *RV enlargement* *biopsy of SS induced pulmoanry artery hypertension* = hyperplasia of intimal smooth muscle layer of pulmoanry arteries leading to increased pulmonary vascular resistance alveolar spaces filled with fibroblasts can be seen in interstitial lung disease - common cause of secondary pulm HTN in patients with SS; however, you need a resitrctive lung PFT's w/ reticular opacities on cxr *PFT in pulmonary hypertension* - reduciton in DLCO w/o affecting TLC or FEV1/FVC ratio

occupational HIV postexposure prophylaxis

PEP started urgently - triple drug therapy Tenofovir-emtricitabine + raltgrvir continue PEP for 4 weeks

management of preterm prelabor ROM

PPROM refers to rupture of membranes at <37weeks gestation prior to onset of labor management of PPROM is expectant until 34 weeks gestation, follwed by delivery at 33 weeks or ealier, patient administered corticosteroids for fetal lung maturity and course of prophylactic braod spectrum antibiotics latency abx prevent intraamniotic infection, prolong pregnancy, and reduce risk of maternal and neonatal complcations to prevent neonatal GBS, intrapartum IV-pencillin should be administered to patients with PPROM who are delivere and have either an unknown or positive GBS status

recommended vaccines for adults

PPSV23 alone = diabetics, smokers, alcoholics heart, lung liver dz *Tdap* once in place of Td for immunicty to *pertussis* then once 65 - PCV13 --> PPSV23

mobitz type I

PR interval that gradually increases with successive beats utnil a P wave fails to conduct to ventricles, resulting in absence of a QRS complex

recommendations on PSA screening

PSA screening should be determined on a case-by-case basis by physician and patient

hypercalcemia of malignancy

PTHr-P realted hypercalcemia is characterized by *severe8 (eg, >14 mg/dl) and *rapid-onset* hypercalcemia

anisocytosis

RBC of unequal size often first finding on smear of *iron defiency anemia* Increased RBC distrubtion width (RDW) is quantifcation of this

ROC curve

ROC curves emphasize importance of choosing appropriate cutoff value when designing a diagnostic test based on continuous values at any particular cutoff point, there is a trade-off between sensitivty and specificty changing cutoff to increase true-positive rate (directly proportional to sensitivity) will also increase false-positive rate (inversely proprotional to specificity)

renal tubular acidosis

RTA is group of disorder characterized by *non anion gap metabolic acidosis* with *preserved kidney function* impaired function of cortical collecting tubule due to aldosterone deficiency or resistance will cause retention of H+/K+ = hyperkalemic RTA (type 4 RTA) commonly seen in poorly controlled diabetics who have damage to juxtaglomerular apparatus

isolated systolic hypertension

SBP >140 w/ DBP <90 very high risk of CV morbidity and mortality patho - increased stiffness or decreased elasticity of aortic and arterial walls in elderly patients reduces ability of the arteries to dampen the systolic pressure and leads to increased pulse wave velocity and pulse wave reflection in systole *increased pulse pressure* tx - lifestyle and pharmacologic similar to regular hyperntesion

severe featuers of peeclampsia

SBP >160 or DBP >110 thrombocytoepnia inc. creatinine inc. LFT's pulmonary edema visual or cerebral symptoms

differentiating SLE flare in pregnacny from preeclampsia

SLE has associated signs = joint pain, malar rash, RBC casts, decraesed complement levels, increasing ANA

septic pelvic thrombophlebitis

SPT is a thrombosis of deep pelvic or ovarian veins that becomes infected severeal factors predisopse postpartum patients to thrombosis: -hypercoaguable state of pregnancy -pelvic venous stassi and dilation -endothelial damage from infection and/or trauma during delivery most common etiology for pueperal fever is endometritis; thus pt's intially get abx *persistent fever* unresponsive to broad spectrum abx therapy and negative ifnectious eval --> *suggest SPT* *risk factors* = csection, chorioamniotic/endometritis *treatment* = anticoagulation and broad spectrum abx

treatment of OCD

SSRI + CBT (exposure and response prevention)

treatment for major depression in medically ill patients

SSRI - have a low threshold for initating treatment for depression; given the potenital to provide relief and imrpove quality of life

antidotes to remember

TCA - NaHCO3 Beta blockers - glucagon acetaminophen - NAC methanol, ethylene glycol - fomepizole, ethanol organophosphate - pralidoxime + atropine opioids - naltrexone, naloxone warfarin - vit K, FFP tPA - aminocaproic acid heparin - protamine CO - 100% O2 methemoglobin - methylene blue

most important prognostic consideration in treatment of pt with breast cancer

TMN staging is most important ER+, PR+ = good HER2/neu = bad poorly differeniated = bad

tuberous sclerosis

TSC1, TSC2 genes associated with: Intracranial tumors - cortical tubers or hamartomas, subepednymal giant cell astromcytomas, subepedynaml nodules Ash leaf spots facial angiofibromas cardiac rhabdomyomas renal angioleiomyomas mental retardation seizures

clinical features of toxic shock syndrome

TSS is caused by toxic shock syndrome toxin-1, which acts as superantigen cand causes T cell activation and release of large amount of cytokiens *risks* tampon use nasal packing surgical/postpartum wound infection *patho*: staph aureus exotoxin release acting as superantigen *clinical* Fever >102 hypotension diffuse macular rash involving palms and soles desquamation 1-3w after disease onset vomiting, diarrhea altered mentation w/o focal neurologic signs *treatment* supportive - IVF removal of foreigh body (eg, tampon) abx: clinda + vanc

thrombotic thrombocytopenia purpura

TTP is disease of young adults, often idiopathic but can be triggered by: HIV, malignancy, medications in absence of ADAMTS13, long chains of vWF accumulate on endothelial wall, trapping platelets and genrating thrombi in areas of high shearing force (eg, arterioles, capillaries) dx is primarily clinical and labs *peripheral blood smear* is curcical to show intravascular hemolysis (schitocytes, helmet cells, triangle cells) plasmas excahnge - replnishes ADMTS13 and removes autoantbidoes

short stature + aortic coarctation (BP diff) + absent menarche

Turner syndrome

recommendations for breast cancer screening

USPTF: mammogram every 2 years for women 50-74 y/o ACOG: mammogram every 2 years for women starting age 40 genetic counseling and testing for women with high risk family history: -two 1st degree realitves with breast cncer, 1 relative <50 -three or more 1st or 2nd degree realtives with rbest cancer -1st or 2nd degree realtive with breast and ovarian -1st degree with bilatearl breast -breast in male realtive -ashkenazi jew women with any 1st or 2nd degree realtive with breast or ovarian

alport syndrome

X linked defect in collagen-IV formation hearing loss ocular abnormalities hematuria progressive renal insuffiency bx = thinning of glomerular basement membrane

hyper-IgM syndrome

X-linked genetic defect in CD40 ligand CD40L is present on T cells and binds to CD40 on B cells idnucing class swtiching elevated IgM levels and deficiency of all other immunoglobulin types CD40L deficiency also inhibits plasma cell formation --> poor response to infection and immunization recurrent sinopulmonary infection with encapsulated bacteria more frequent viral infections increased risk of opportunistic (Pneumocytis pneumonia) tx = abx prophylaxis and interval administration of IVIG

non-dominant temporal lobe

ability to comprehend emotional gestures - sensroy aprosodia contralateral homonymous quandrantanopsia - inferior optic radiations invoelment

hordeolum

abscess located over upper or lower eyelid caused by staph aureus but can be sterile in many cases within a few days, a minute pustule may appear at the lid margin (pointing), which will then rupture with discharge of pus and relief of pain *warm compresses* are advised to accelerate the process some hae residual chalazino that regresses slowly over months

central retinal vein occlusion

acute, unilateral, *painless* loss of fision *fundoscopy* venous dilation + tortuosity due to venous occlusion scattered + diffuse demorrahge sdue to backup of blood and increased resistance, leading to ischemic damage Blood and thunder appearnce due to diffsue hemorrhages cotton wool spots disk swelling CRVO is caused by *thrombosis* of centrla retinal vein and is most common in patients w/ coagulopathy, hypervisocistiy, chronic glaucoma and atherosclerotic risk factors (eg, age, diabetes, HTN) *diagnosis confirmed with*: fluorescein angiography *treatment* no signficant macular edema or neovasculirzation = conservative, observation significant macualr edema = itnravitreal injection of VEGF inhibitors

next step in patient with high pretest probablity of PE, low probability V/Q

additional testing: CTA

conditions / treatment of atrial fibrilattion

addresses 3 issues: rate control, rhythm control, anticoagulation rate control (anything that slows AV conduction) - beta antagonists [metropolol, esmolol], non-dihydropyridine CCBs [dilitizam, verapamil]

which lung cancer is associated with hypertrophic pulmonary osteoarthropathy

adenocarcinoma

risk factors prescription opioid misuse

age <45 y/o psychiatric disorder presonal or family hx of substance disorder presnce of legal history *mechanisms to decrease misuse* review of states prescription drug-monitoring program data random urine drug screens regular follow up

gestational diabetes mellitus

all pregnant women are screened at 24-28 weeks gestation physiologic adapatations of pregnancy include *pancreatic B cell hyperplasia*, inuslin secretion and increased *peripheral inuslin resistance* Human palcental lactogen (placental somatomammotropin) has increased proudction in 3rd timester resulting in pancreatic B cell hyperplasia and increased insulin resistance GDM occurs when peripheral inuslin resistance exceeds pancreatic insulin secreiton, resulting in pathologic maternal hyperglycemia *target blood glucose levels* fasting <95 1h postprandial <140 2h postprandial 120 *treatment* 1. dietary 2. insulin, metofrmin

treatment acute promyelocytic leukemia

all trans retinoic acid

missed abortion

an intrauterine pregnancy demise at <20 weeks gestation prior to expulsion of products of coeneption patient may be asympatomtic or have ecreased pregnancy sx (nausea, breast tenderness) PE = closed cervix u/s = embyro w/o cardiac activity or an empty gestational sac without a fetal pole viability is determined with repeat u/s and serial bhcg (increase until end of 1st trimester, decreaseing Bhcg indicated demise)

micro of brain abscess

anerobic (virdans) staph aureus gram negative

euthyroid sick snydrome

any patient with acute, severe illness may have abnromal thyroid function tests most common apttern is *fall in total and free T3 levels, with normal T4 and TSH* -euthyroid sick syndrome thought to be a result of decreased peripheral 5-deiodination of T4 due to caloric deprivation, elevated glucocrticoid and inflammtory cytokine levels, and inhibitors of 5'monodeiodinase (eg, FFA, certain meds) since thyroid hormone supplementation ahs not been shown to imrpove clinical outcomes; thyroid function tests are *not* recommended in acutely ill patients many patients when recovering from illness (non-thyroidal illness), have modest transient increase in serum TSH - often misinterpreted as subclnical hypothyroidism delay testing until patient has returned to baseline health

Leriche syndrome

arterial occlusion at bifurcation of aorta into common iliac arteries - aortoilliac occlusion high risk in atherosclerosis - smokers are greatest risk 1. bilatearl hip, thigh and buttock caludication 2. absent or dminished femoral pulses: from groin distally, often with symmetric atrophy of bilatearl lower extremities dueo chronic ischemia 3. impotence: almost always present in this conidtion

interventions for lowering ICP

as cerebral paCO2 rsies, so does blood flow; hypernveitlation --> rapid vasoconstriction CO2 has much greater affect than pO2

cross sectional studies

assess exposure and outcome at single point in time can show an association exists; but cannot establish causation used to estimate *prevalence* or examine *associations* between risk factors and disease as they exist in a well-defined population at *one particular time*

diffuse alveolar hemorrhage

associated with SLE abrupt cough, fever, hemoptysis, dyspnea cxr = interstitial inflitrated

mixed cryoglobulinemia

associated with chronic HCV arhlagias palpable purpura lymphadenopathy nephropathy neuropathy

seborrheic dermatitis

associated with colonization by Malessezia species common inflammatory disease that affects: scalp: dandruff face: eyebrowns, nsolabial folds, external canal/posterior ear chest intertriginous areas most common in first year of life and again at age 30-60 assocaited with Parkinsons and HIV *craddle cap* in infants; other s/s in infants: eyelides, nasolbial folds, postauricular area, umbilicus *yellow, oily scales*, erythematous patches and plaques, mild pruritis pruritic eryhteamous plaques with fine, loose, yellow and *greasy looking scales* affects areas with *numerous sebaceous glands* - sebum production is *normal* *treatment* first line: emollients, nonmedicated shampoos scond line: topical glucocorticoids topical antifungals: ketoconazole, selenium sulfide

myotonic dystrophy

autosomal dominant expansion of CTG in DMPK gene on 19q13.3 affects skeletal, smooth and cardiac muscles distal muscle s/s slowed relaxation phase of muscle contraction familial inheritence pattern *delayed muscle relaxation (myotonia)* - most notible when patient is unable to release the hand after a handhsake skeletal muscle weakness i rpominent in face, forearms, hands and ankle dosifleexors (eg, bilateral foot drop) dysphagia, the most dangerous smooth muscle manfiestation, increases risk of aspiration cardiac involvement --> conduction issues, arrhythmias myotonia, testicular atrophy, baldness, cataracts, insulin resistance

Fanconi anemias

autosomal recessive or X-linked disorder most diagnosed by age 16 predisposition for developing cancers numerous genes, all involved in DNA repair, have been implicated *diagnosis of FA* is made by chromsomal breaks on genetic analysis combined with clinical findings pancytopnia (begins b/w 4-12 y/o) hyperpigemtnation of trunk, neck and intertriginous areas cafe au lait spots short stature upper limb abnormalities hypogandism skeletal anomlies eye/eyelid changes renal malformations bone marrow: aplastic anemia and progressive bone marrow failure appearance: short status, microcephaly, abnormal thumbs, hypogonadism skin: hypopigmented/hyperpigemnted areas, cafe au lait, large freckles eyes/ears: stabismus, low-set ears, middle ear abnorlities (hemorrhage, incomplete development, chronic infeciton, deafness, etc.)

first line empiric treatment for acute cervicitis

azithromycin + ceftriaxone azithromycin is for chlamydial cervicitis ceftriaxone is for gonococcal cervicitis

*renal biopsy and disease* basement membrane thickening without proliferation: fusion of foot processes of podocytes: positivity for IgA and C3 on immunohistochemical staining: immune deposits with a lumpy bumpy appearnce: linear depsoit along basement membrane:

basement membrane thickening without proliferation: membranous nephropathy [spike and dome] on microscopy - IgG and C3 deposits along basement membrane fusion of foot processes of podocytes: minimal change disease positivity for IgA and C3 on immunohistochemical staining: IgA nephropathy immune deposits with a lumpy bumpy appearnce: post strep glomerulonephritis - elevated ASO titers, low serum C3 linear depsoit along basement membrane: Goodpastures

patient with negative screening serology but strong clinical evidence of primary syphilis (eg, chacnre) shoud....

be treated *empirically* with *IM bezthine pencillin G* repeat nontreponemal serology should be done in 2-4 weeks to establish titers 4-fold titer decrease at 6-12 months confirms treatment

at what age is bedwetting normal?

before the age of 5 once developmentally ready, most children master daytime continece within months; nighttime contnence can sometimes take years to accomplish parents should be *reassured that bedwetting is normal before age 5*; most cases even ebyond age 5 resolve spontaenously when incontinece persists beyound age 4, a UA should be performed to screen for UTI, diabetes mellitus, diabetes insipidus

pityriasis rosea

begins with single salmon colored macule (herald patch) followed by development of multiple lesions on trunk and extremities in christmas-tree distribution center of the patch clears leaving an oval, cigarette-paper like lesion followed by multiple oval-shaped rashes along lines of cleave of skin lesions are eryhematous and eventualyl desquamte, causing itching KOH should be done to r/o tinea corporis no treatment needed; leasions heal without post inflammatory scarring can treat the pruritis (eg, antihistamines)

pyogenic granuloma

benign vascular skin tumor that presents as a small red papule that grows rapidly over weeks or months to a pedunculated or sessile shiny mass lip or oral mucosa bleed w/ minor trauma

crohns vs ulcerative colitis

bimodal age for UC: 15-40, 55-80 *treatment of UC* 5-ASA/mesalamine or sulfasalazine colectomy for toxic megacolon or cases non-responsive to medical management *treatment of Crohns* 5-ASA drugs, corticosteroids, abx Azathiprine anti-TNF therapies *radiography of crohns* = strictures, bowel wall thickening

first line pharmacologic tx for smoking cessation

buproprion (NE/DA reuptake inhibitor; contraindicated in pt with bulimia or seizures) can be used in pt with comorbid depression; it has stimulating effects (monitor pt for side effects of anxiety, insomnia - but these are not conntraindications to its use) *cannot use buproprion in GAD + smoking* - will increase anxiety in patient varenicline (a4b2 partial agonist; associated with mood changes and suicidality, CV risks in prediposing conditiosn) nicotine replacement therapy

purpose of ACTH stimulation test

can clarify diagnosis in patients with suspected primary adrenal insufficiency who have low-normal cortisol levels (5-15 ug/dL) ACTH will not cause rise in cortisol if disease is primary

sjogren syndrome / age related sicca syndrome

can occur as isolated dz or manfiestation of another autoimmune dz (eg, RA) impaired salivary and other exocrine glands can produce *sicca syndrome* - dryness of mucous membranes cause dry mouth with dental caries, irrtated/itchy eyes, cough dryness of vaginal mucosa --> dyspareunia use biopsy of salivary gland to confirm diagnosis if other evaluations are nondiagnostic sample are taken from minor glands of lip *age related sicca syndrome* exocrine output from lacrimal and salivary glands declines with age, associated w/ atrophy, fibrosis and ductal dilation of glands dec. blink rate, oxidative damage, excessive evapoation of tears, and use of anti-cholinergic meds constributes ocular discomfort --> corneal epithelial erosions --> impaired vision *tx* = artifical tears or other lubricants

treatment of trigeminal neuralgia

carbamazepine -side effects: n/v, leukopenia and aplastic anemia - CBC is included in monitroing failure of medications --> surgical decompression of trigeminal n.

episodic pounding sensation chronic diarrhea weight loss tricuspid regurgitation

carcinoid syndrome - tumor secreting

cauda equina syndrome vs conus medullaris

cauda equina = compression of *spinal nerve roots* in adults spinal cord ends at L1-L2 and the lumbosacral nerve roots below this levelf orm the cauda equina, which floats in CSF cauda equina provides sensory innervation to saddle area, motor innervation to sphincters (anal and urethral), and parasympthetic to bladder and lower bowel

superior vena cava syndrome

caused by compression of SVC s/s - headache worse when leaning fowared due to decreased graviation pull; JVD, but lack of periphearl edema (suggesting other cuse than cardiac) facial and upper extremity swelling is prominent from obstruction of venous flow prominent collateral veins may be present on skin exam most common cause is *malignancy* either lung (small cell) or lymphoma malignancy related SVC especially when causing respiratory compromise, may require endovenous stenting followed by radiation theraoy, althought this is primarily palliative depending on type of malignancy and prior treatment course, some patients may benefit from chemotherapy

scarlet fever

caused by erythrogenic toxin-producing straings of group A strep fine, pink, sandpaper like rash following episode of pharyngitis tonsillary erythema and exudate strawberry tongue tender anterior cervical nodes rash is in flexural areas desquamtates *no* blisters *diagnosis* rapid strep antigen test throat culture *treatment*: pencillin (eg, amoxicillin)

chloracne

caused by exposure to halogenated hydrocarbons (occupational exposure to the pollutant dioxin) inflammatory nodules and large comedones affecting head, neck, axillae

pathophys of DKA

caused by insulin deficiency leads to increased lipolysis of peripheral fat stores secondary to high catecholamine levels these fatty acids are delivered to lvier and broken down into ketons (eg, beta-hydroxybutyrate, acetoacetate) acidosis from ketone accumulation is responsible for many of clinical manifestations of DKA (eg, vomiting, abdominal pain, kussmaul respirations) and contibues to anion gap polyuria and polydipsia result from hyperglycemia-induced omsotic diuresis

testicular torsion

caused by twisting of the spermatic cord due to *inadeqaute fixation* of the lower pole of the testis to the tunica vaginalis leads to comrpession of the pampiniform plexus of the testicular vein and reduced venous outflow causes testis to ride high in scotrum with long axis oriented ohorizontally - *bell ckapper defomirty* cremasteric reflex is *absent* in most in dx uncertain, confirm with dppler

GI perforation

caused most frequently from penetrating abdominal trauma (can also occur from blunt due to damage mesenteric blood supply --> GI necrosis --> perforation) pentrating trauma presents acutely; blunt trauma can present days later

tx of pyelonephritis in pregnancy

ceftrixone - covers e coli

small cell carcinoma xray

central (hilar, perihilar) mass mediastinal lymphadenopathy

newborn with bluish discloration of nail beds, lips and tongue extremities are warm diaphoretic when breastfeeding

central cyanosis - indicates low arterial oxygen saturation congenital heart dz is highly suggested by presentation warm extremities = blood getting to them, so just low O2 sat cold would indicated a peripheral cyanosis

features / diagnosis of cushing syndromere

central obestiy - fat accumulation in cheeks, dorsocervical, supraclavicular fat pads skin atrophy and wide, purplish striae[catabolic effects of cortisol on connective tissue] proximal muscle weakness HTN easy brusability, dermal atrophy glucose intoelrance [peripheral insulin resistance, hypercortisolism-induced gluconerogenesis] skin hyperpigmentation (if ACTH excess) women can have hyperandrogenism due to co-secretion of adrenal androgens with cortisol *diagnosis* 24h urinary cortisol excretion or low dose dexamethasone suppression once hypercotlism is establihed, an ACTH level can determine whther it is ACTh depdnent or ACTH indepdnent elevated ACTH shuold have high dose dexamethasome suppression test to determine whether ACTh is pituiatry (suppressed production from test) or ectopic (does not suppress) *cushing disease* = ACTH pituitary tumor; low dose dexmethasone will show cortisol >1.8 High dose dexamethaseon suppression will reduce cortisol by at least >50%

gait characteristics

cerebellar ataxia - ipsilateral, patient falls towards lesion [accmoapnied by nystagmus, hypotnia, dysathria, loss of corindaiton, dysdiadokinesia] hypokinetic - parkinsons waddling - muscular dystrophy from weak gluteals spastic - UMN lesions gait disequlibrium - disorder of fontrol lobe and multiple sensory system sensory ataxia - lseions of periphearl nerves, dorsal roots, posterior colums [loss of proprio - wide based, high steppage gait] vestibular ataxia - en-bloc gait, with minimal movements of head during walking [accomapneid by vertigo and nystagmus] wide based gait - multiple system atrophy, spinocerebellar atrophies, multi-infarct, sensory ataxia dystonic gait - involuntary, sustained, twisting mvoements of limbs and turnk

most common cause of spontaenous lobar hemorrahge

cerebral amyloid angiopathy particuarly in adults >60 y/o occurs as conseuqnce of b-amyloid deposition in walls of small- to medium-size cerebral arteries, resulting in vessel wall weakening and predispotion to rupture same amyloid proteins of *alzheimer dementia* hemorrhage occurs during routine activity and most often involves occipital and parietal lobes

cervical cancer

cervical caner is caused by persistent infection with high risk HPV tobacco is another HIGH risk factor - exerting ocngenic effects on cervix via impaired immunity pt with lower back pain + lower uterine segment mass + hydronephrosis = advanced stage cervical cancer as tumor extends laterally through parametrium and pelvis (low back pain), it can lead to obstruction of surrounding blood vessels and lymphatics (lymphedema) and ureters (hydronephrosis) cervical cancer is an *AIDS defining illness*

prevention of malaria

chloroquine resistant [Africa, Asia, Oceaniea] = atovaquone-proguanil, doxycyline, mefloquine chloroquine sensitive [Central America, Caribbean] = chloroquine chemoprophylaxis should begin 2 weeks prior to travel and continued until 4 weeks fater returning mosquito bite prevention (eg, isecticide, bed nets) are used adjunctively in endemic areas these measures can be used alone in places with sporadiac cases of malaria

patient tets positive for gonorrhoeae. what other organisms to test for?

chlymadia HIV treponema pallidum (syphilis) hepatitis B virus

tx of overflow incontinence

cholinergic agents (bethanechol) - aids in contraction and urethral realaxation severe cases = intermittent self cath

testicular tumor markers

choriocarcinoma - bhcg teratoma - AFP, beta-hcg seminoma - normal; bhcg can be somewhat elevated; AFP is always normal yolk sac - AFP

congenital cytomegalovirus

chorioretinitis *periventicular* calcfications

juvenile idiopathic arthritis

chronic *symmetric* oligoarthritis, daily fever, rash >2 weeks of fever occuring once a day, arthritis of >1 joint, pink macular rash worsening during fever leukocytosis, thrombocytosis, increased inflammatory makrers, *anemia* [chronic inflammation, iron deficiency] hyperferritinemia hypergammaglobulinemia dx clinically tx = NSADIs, glucocorticoids, biologics

otosclerosis

chronic conductive hearing loss - found in middle aged individuals associated with bony overgrowth of the stapes begins with low frequency hearing loss tx = hearing amplification or surgical stapedectomy

most effective measure to reduce risk of catheter associated UTI in patient with neurogenic bladder

clean intermittent cath

hepatic encephalopathy

colonic bacteria metabolize lactulose to short chain FA's; this acidifies colon to stimulate conversion of absorbable ammonia to nonabsorbable ammonium (*ammonia trap*) and causes bowel moves (facilitates fecal nitrogen excretion)

seborrheic keratosis

common epidermal tumor seen in middle-aged or elderly individuals brown palques or nodules with greasy surface and stuck on appearnce benign lesions, though sudden onset of multiple may indicate an occult itnernal malignacy - Leser-Trelat sign bx not necessarily but would show: small cells resembling basal cells, with variable pigmentaiton, hyperkeratosis, and *keratin containing cysts*

tubo-ovarian abscess

complication of PID - fever, abdominal pain u/s *complex multilocualted adnexal mass with thick walls and internal dberis* typically *polymicrobial* of upper genital tract, a normally sterile envionrment labs = increased in nonspecific indices (leukocytosis, CRP, CA125); which along with *fever* suggest infection > malignancy diagnosis = u/s, CT tx = broad spectrum parenteral abx

hemorrhagic trasnformation of ischemic stroke

complication of ischemic stroke, especially when stroke affects large area, due to an embolic cuse, or has been treated with thrombolytics manfiestations arise *<48 hours* after initial even and are characterized by deterioration in patient's neurologic status emergent *noncontrast CT scan of head* is required to evaluate for HT as urgent surgical decompression is often needed

patients age <18 may be treated for STI without parental consent

confidentiality should be maintained, and details of visit cannot be share dwith others without patient's permission

emergency contraception options

containdications to copper IUD = acute cervicitis, PID must be inerted within 5 days of intercourse

major causes of sudden cardiac death

coronary artery disease cardiomyopathy arryhtmia congenital heart defect

tricuspid valve atresia

cyanotic infant with left axis deviation and absent R waves in precaordial leads hypoplastic RV and dminished right ventricular forces on EKG lack of blood flow to RV and pulmonary outflow tract causes underdevelopment of pulmonary valve and/or artery pulmoanry undercirculation --> decreased pulmoanry markings on cxr associated atrial and ventricualr septal defects are necssary for surcical to allow mixing of oxygenated and deoxygenated blood right atrial enarlgement will show with tall, peaked P waves

pyromania

delibrate fire setting on >1 occasion tension, arousal prior to act; pleasure/relief when setting/witnessing fires no external gain, revenge, or political motivaiton; not done to attract attention not better explained by another disorder

malignant catatonia

delirium, autonomic instability, rigidity develops in assocition with concurrent psychatric or medical illness

dementia with lewy bodies

demetion plus >e2 of following: visual hallucinations, parkinsonism, fluctuating cognition, REM sleep behavior disorder *tx* carbidopa-levodopa for parkinsomism cholinesterase inhibitors for cognitive impairment melatonin for REM sleep behvaior trial AP-meds (eg, respiderione) may be indicated for funcitonally imapried hallucations; be beware can cause worsening of confusion, parkinsonism, autonomic dysfunction

management of hot flahses

depends on symptom severity mild hot flahses (not intereference with life) - lifestyle modifcations severe hot flahses - hormone replacement therapy only indication for HRT is vasomotor symptoms in women age <60 who have undergone menopause within past 10 years if patient has contraindication to HRT, patient can receive SSRI

bronchiectasis

development requries an *infectious insult* in combination with *impaired bacterial clearance* (eg, impaired immune defense, structural defect) *typical symptoms* large amounts of mucopurlent sputum (>100ml/d) dyspnea sinus congestion fatigue weight loss hemoptysis patients cna hve ferquent exacerbations (typically bacteria) cxr cannot not diagnose bronchiectasis but can show *linear atelectasis, dilated and thickened airways* *high res CT* is best diagnostic test for bronchiectasis --> bronchial dilation,lack of airway tapering, bronchial wall thickening

polyarthalgia + tenosynovitis + painless vesiculousutal skin lesion

disseminated gonococcal infection

cholesteatoma

dx susepcte din any patient with continued ear drainage for several weeks despite appropraite abx therapy chronic middle ear dz leads to formation of a retraction pocket in tympanic membrane, which can fill with granultion tissue and skin debris otoscopic = discrete white plaque on typicamic membrane with or without perforation or retraction complications - hearing loss, CN palsies, vertigo, life threatening brain abscess or meningitis

clinical features of thyroid storm

dx suspected clinically, and confirmed by thyroid function studies documenting hyperthyroidism

intermenstrual spotting without uterine enlargement

endometrial polyp

patient has chronic pelvic pain. u/s shows adnexal mass: homogenous cystic ovarian mass

endometrioma

which ovarian mass presents with "ground glass" on u/s

endometrioma

trichomonads

eryhteamtous cervix with punctate lesions frothy, green discharge

treatment for severe hypertriglyceridemia (secondary to familial dysbetalipoproteinemia)

fenofibrate

which condition is asociated with fetal heart rate sinusoidal

fetal anemia

most common side effect for infant exposed to preeclampsia

fetal growth restriction/low birth weight uteroplacental insufficiency puts fetus at risk oligohydramnios

viral (herpes simplex virus) ecephalitis

fever, AMS, risk of seizure and coma *exam* hemiparesis, CN palsies hyperreflexia *labs/imaging* CSF: inc. WBC (lymphocytes), normal glucose, inc. protein MRI: temporal lobe abnoraities diagnosis: CSF shows presnce of viral DNA on PCR *treatment* IV acyclvoir - start immediately after getting CSF fluid

peritonsillar abscess

fever, chills, sore throat deviation of uvula priminent unilateral lymphadenoapthy trismus muffled 'hot potato' voice pooling of saliva can cause airway obstruction or spread into pharyngea space (into cartoid sheath) tx - aspiration of abscess and IV abx

most common cause of breast mass in adolescent

fibroadenoma

rheumatoid nodules

firm, flesh colored, nontedner occur over pressure points - elbow and extensor surface of proximal ulna

myasthenia gravis

flucutating, fatgiable muscle weakness that worsens with repetive motions of same muscle groups and impoves with rest women: 2nd-3rd decade men: 6th to 8th decade ocular symptoms (ptosis, diplopia) and Bublbar dysfunctiona re most common manfiestations - can cause fatigable chewing, dysphagia, dysarthria autoantibodies (originating in thymus) directed against N-ACh receptors at NMJ [motor end plate] *causes of exacrbations* antibitoics - flouroqinolones, amniglycosdies anesthetics - NM blocking agents cardiac meds - beta blockers, procainamide other - MgSO4, pencillamine tappering of immunosupression meds pregnancy/childbirth surgery (especially thymectomy) infection *diagnosis* bedside: edrophonium test, ice pack test [low specificity] ACh receptor antibodies (*highly specific*) patients with MG receive CT looking for thymoma as thymectomy can result in long term disease remission *treatment* acetylcholinesterase inhibitors (pyridostigmine) thymectomy +/- immunotherapy

management of SIADH

fluid resitrction +/- salt tablets [<800mL fluids /d ] Hypertonic (3%) saline for severe hyponatremia (seizures, coma) often given with furosemide NS + furosemide: asymptomatic, but Na <120 rapid correction (>8mEq/L in first 24h) can cause *osmotic demyelination syndrome*- dysarthria, quadriparesis, coma other name = central pontine myelinolysis

epithelial ovarian carcinoma

for an average risk patient (eg, no hereditary cancer syndromes), *no screening* tests exist to detect ovarian cancer in its early, more treatable stage pelvis u/s and CA125 are not useful in asymptoamtic patients epithelial ovarian carcinoma = malignacny involving ovary, fallopian tube, and peritoneum EOC commonly presents with advanced disease firm, non-mobile pelvic mass with nodulairty in a postmenopausal pt is concerning for EOC that has extended beyond adenxa

which dementia subtype are primitive reflexes found in?

fronto-temporal dementia rooting, suckling, glabellar are frontal release signs that are more prevalent in frontally based dementia

dysmoprhic RBC, Red cell casts suggets lesion is where?

glomerulus

management of hypercalcemia

glucocorticoids inhibit formation of 1,25-vitamin D in lungs, lymph nodes; can be used to treat hypcalcemia due to excessive vitamin D intake, granulatous dsiease (eg, sarcoid), certain lymphomas effects take 2-5d

55 y/o white woman. CC: nonhealing painful leg ulcer. Two months ago - right ear otalgia, hearing loss. T101F. Cr = 1.9, +2 protein, trace blood, no bacteria

granulomatosis with polyangiitis

cluster analysis

grouping of different data point into similar categories randominziation at level of groups rather than at level of individuals

clinical features of untreated acromegaly

growth hormone increases hepatic production of insulin-like growth factor 1 (IGF-1) this causes excessive growth of bones and soft tissues, leading to clinical manifestations of the disease *diagnosis* = increased IGF1 level if elevated --> oral glucose suppression test indeqaute suppression --> MRI in the heart, *concentric myocardial hypertrophy* leading to diastolic dysfunction, along with LV dilation and global hypokineisis complications = *heart failure, arrhythmias* *cardiovascular disease is leading cause of death in patients with acromegaly* normalization of growth hormone following successful treatment markedly reduces CV mortality

congenital varicella syndrome

growth restriction skin lesions ocular defects limb abnoramlities seizures cortical atrophy

hypertensive retinopathy

hard exudates, AV nicking, silver wiring of aterioles flame hemorrahge sin severe disease headache, eye pain, visual field defects

miliary tuberculosis

hematogenous spread of myobacterium tuberculosis can arise during primary infection or with reactivation chest xray = diffuse reticulonodular pattern (millet seed) subacute symptoms - fatigue, fever, weight loss, cough hx of IVDU, incarceration, international travel, group living extrapulmonay disease: lymph nodes, liver, bones, CNS

spider angioma + palmar eryhema in cirrohsis is due to

hypeestrnism - impaired hepatic metbaolism of circulating estrogens estrogens affect vascualr wall dilation spider angioma - central, dilated arteriole surrounded by small radiating vessels palmar eryhtema - increased normal speckling of plam due to increased vasodilation

nephrogenic DI etiologies

hypercalcemia severe hypokalemia tubulointerstitial renal disease medications ltihium demeclocycline - abx foscarnet cidofvoir amphotericin

post srugical thyroidectomy and you see QT-prolongation.. what you thinking?

hypocalcemia - parathyroid hormone deficiency

treatment of CML

imatinib - tyrosine kinase inibitor of BCR-ABL (translocation b/w 9, 22)

timeline of cause of postoperative fever

immediate postop fever = think transfusion reaction [febrile nonhemolytic tranfusion reaction - stop the tranfusion, r/o other causes, and give antipytrics] avoid aspirin in thrombocytoepnia patients

characteristic findings of cor pulmonale

impaired function of RV caused by *pulmonary hypertension* that occurs due to underlying disease of lungs (COPD, interstitial lung disease), pulm vasculature (idiopathic pulm a. HTN), or obstructive sleep apnea *defintive diagnosis* (if necessary): right heart cath showing *elevated pulmonary artery systolic pressure >25mmHg* treatment: optimizing RV dynamics with supplemental oxygen, diuretics, tx of etiology, IV inotropes (severe decompensation) *cor pulmonale is due to constriction of the vessels of the lungs - this causes increased work for the right ventricle*

type II renal tubular acidosis

impaired renal bicarbonate reabsorption associated with hypoalemia, non-anion gap metabolic acidosis

treatment of acute cystitis & pyelonephritis in nonpregnant women

in patients with suggestive clinical findings, diagnosis can be made with UA culture is reserved for those who fail initial therapy *uncomplicated*: healthy pt with low risk of tx failure *complicated*: diabetic, CKD, pregnancy, immunocomrpmised, urinary tract obsturciton, hospital acquired, associated with procedure or catheter, male *pyeloneprhitis*: UTI w/ fever and flank pain; stable = po abx; unstable = IV abx after 48h of symptoatmic improvement, most hospitilized patients can be transition to culture-guided PO abx

asymptomatic bacteriuria

in pregnancy, icnreased progesterone levels cause smooth muscle relaxation and ureteral dilation - increased risk of acute pyelonephritis, preterm delveiry, low birth weight most common pathogen = E coli 1st line tx = cephalexia, axmocillin-clavulante, nitrofurantoin as a *test of cure*, a repeat urine culture is performed after antibiotic treatment is completed

advanced sleep wake phase disorder

inability to stay awake in evening, early morning insomnia

hepatitis C in pregnancy

inactivated HAV and HBV vaccines are *safe* to give during prenancy

hemodynamics in heart failure

increased SVR increased preload increased LVEDV decreaed CO pulmonry congestion peripehral edema (secondary RHF) cardiac index (CO/BSA) is decreased

panic disorder

increased sensitvity to lactate infusion = panic attacks first step when patient has increased respiratory rate and feeling dizzy - instruct them to breathe into a paper bag this will incrase PaCO2 *treatment* immediate = benzos long term = SSRI/SNRI and/or CBT

incubation period and diagnostic test for giardia

incubation period = 1-2weeks --> diarrhea, abdominal cramps, fould smelling stools, bloating, benign abdominal exm diagnosis = stool antigen assay; oocytes and trophozoites can also identify organism and are useful in resource poor settings tx = metronidazole

etomidate

induciton agent used in rapid sequence induction as sedative prior to itubtation suprpeses corticosteroida ctivity and is known to cause adrenal suppression - anorexia, n/v, abdominal pain, confusion lacks cardio-depressant effects that similar meds have

imatibin

inhibits BCR-ABL tyrosinase kinase funciton in CML

treatment of myasthenic risis

intubation for deteriorating respiratory status plasmapheresis of IVIG + corticosteroids

complex partial seizures

involve loss of consciousness with seizure activity with focal origin within brain patients with CPS often stare blankly for several minutes and egage in atuomatisms such as lip smacking or chewing confusion after episode = postictal state todd paralysis = post seizure neurologic symptoms temporal lobe epilpesy is common cause of complex partial seizures

dermatitis herpetiformis

involves extensor surfaces of extremities *intensely pruritic* erythematous papules, vesicles and bullae that occur symmetrically in *grouped* (herpetiform) clusters on extensors of elbows, knees, back and buttocks bx = microabscesses at tips of dermal papillae immuno = deposits of anti-epidermal tanslgutaminse IgA in dermis *tx* = dapsone = anti-inflammatory and immunomodulatory, provides rapid relief long term = gluten free diet

most common nutritional deficiency in children

iron deficiency after 6 months, inadeqaute dieatry intake becomes most important cause of deficiency early introduction of excessive intake of cows milk (>24oz; or having any before <1y/o) - low iron content

differential for microcytic/hypochromic anemia

iron deficiency (decreased intake or increased loss) - depressed serum iron level, increased TIBC, decreased ferritin anemia of chronic disease (defective utilization of irone) - below normal TIBC, normal/increased ferritin thalassema (reduced globin production) - normal to high serum iron and ferritin levels lead poisoning, sideroblastic anemia (reduced heme synthesis) - normal to high serum iron and high ferritin, decreased TIBC

treatment of latent TB

isoniazid + pyrdixoine for 6-9 months pyridoxine is added to prevent isoniazid-induced peripheral neuropathy [numbness and tingling in stocking-glove distribution] *alternative options* rifampin for 4 months isonizaid + rifapentin weekly for 3 months under direct observation

common pathological causes of gynecomastia

it can occur in up to 2/3 *pubertal boys* - unilateral or bilatearl firm subareolar nodules transiently increased tesicular production of estrogen over testosterone and peripheral conversion of prorhomones to estrogen *resolves in most within few months to 2 years* give paitent reassurance

what type of feeding can reduce risk of aspiration

jejunal (postpyloric) feeding simple NG or endoscipic G tubes - predispose to aspiration pneumonia

treatment of stress incontinence

kegel exercises unresponsive --> urethral sling

hemophilic arthropathy

late complication in both types of hemophilia caused by *iron/hemosiderin deposition* --> *synovitis, fibrosis* within the joint chronic worsening joint pain and swelling resulting in contractures of joint and limited ROM MRI allows for earlier detection and characterization early prophylactic tx with factor concentrates can reduce risk of developing arthropathy

late-term and postterm pregnancy complications

late term: 41 weeks to 41 weeks and 6 days postterm: >42 weeks risks = nullipairty, hx of prior postterm, obesity, fetal anomalies (*ancephaly*) aging placenta can have decreased perfusion, resulting in decreaed renal perfusion and decreased urianry output from fetus ---> oligohydramnios

false labor versus latent labor

latenet labor = regular contractions with incraesing frequency and intesnity that cause gradual cervical change

CT scan of schizophrenia shows....

lateral ventricular enlargement remember - routine imaging is not recommended in medically stable patient with known psychotic disorder CT, MRI may be used as part of diagnostic workup for new-osnet psychosis to rule out non-psychiatric disorders

bullous impetigo

localized form of Staph scalded skin caused by exfoliative toxin producing S. aureus patients appear well, with blister confied to rpiamry area of infection when blisters rupture, they leave distinct honey-colored crust rapidly enlarging flaccid bullae w/ yellow fluid collarette of scale at peripheray of rupture lesions limited involvement: topical mupirocin extensive: oral cephaexin, dicloxacillin, clindamycin

next step after new chest nodule found on xray

look at previous xray if no previous imaging --> chest CT

what is LAP in CML?

low leukocyte alkaline phosphatase in chronic myeloid leuekmia WBC >100k less mature neutrophils (myelocytes > metamyelocytes) basophilia present

mechanism of congenital lymphedema (seen in turner syndrome most commonly)

lymphatic network dysgensis - causes accumulation of protein-rich itnerstitial fluid in hands, feet, neck edema is generally *nonpitting* due to high protein content in interstitial fluid

extraperitoneal baldder injury

may consist of contusion or rupture of *neck, anterior wall or anterolateral wall* of bladder extravasation of urine into adjacent tissues causes localized pain in lower abdomen and pelvic pelvic fracture is almost always present gross hematuria i common urianry retnetion may occur

if patient is acutely agitated and poses danger to themself or others plan of action

may require physical restrains + sedating IM meds

parenteral nutrition

means of providing total nutrition including cabs, amino acids, lipis, electrolytes, vitamins and minerals, to patenrs who are unable to receive enteral nutirtion due to high osmotic load - must be given through central venous catheter when given for >48h greatest risk realted to PN = central line associated blood stream infection factors that increase risk = hygeine, severeity of patient illness, duration of therapy common organisms = coagulase negative staph, staph aureus, and gram negative organisms; candida is also common hyperglycemia is a potential complication *gallstone formation* - decreased CCK stimulation [no proteins and FA in duodenum] thus gallbaldder doesnt contract --> stasis --> stone formation

what does the Tc-pertechnetate scan look for

meckel scan - picks up on ectopic *gastric mucosa* which is present in 50% of cases of Meckel diverticulum

neuorimaging of alzheimers disease

medial temporal lobe atrophy [classic association] early in disease no changes may be seen

what neurovascular structure can be affected with fracture of supracondylar region of humerus

median nerve

what to use for bacterial vaginosis in pregnancy?

metronidazole 500mg bid for 7 days

overview of prostatitis

mid-stream urine sample is approrpiate in order to direct antibiotic therapy empiric TMP/SMX or fluroquinoline started while awaiting culture rueslts tx is 4-6 weeks

euthyroid conditions that alter TBG concentration

more than 99% of circulating thyroid hormone pool is bound to 3 major transport proteins - TBG, transthyretin, and albumin only free (ie, unbound) thyroid hormonens are biologically active estrogen decreaes TBG catabolism and increases its synthesis in the liver TBG binds more thyroid hormone, thyroid hormone production increases to maintain euthyroid state elevation of TOTAL t4, without elevation in free T4

focal nodular hyperplasia

most common benign non-vascular liver lesion normally asymptomatic, and most are discovered incidentally during evaluations for other intraadbominal pathology (eg, gallstone disease) FNH is most commonly small (<5cm), *solitary* lesion and due to hyperplastic response to hyperperfusion that i caused by inappropriately large artery at cente rof lesion CT or MRI demonstrating hypodense lesion with *arterial enhancement* and a *central stellate scar* may be estrogen sensitive; more common in women management is *conservative* if >8cm, discontinue oral contraceptives surgery can be considered if symptomatic

approach to odynophagia & dysphagia in patients with HIV

most common cause = candida (mild pain, oral thrush) empiric tx = flucanozle for esophagitis in HIV if symptoms are worse - endoscopy with biopsy is done

diabetic ophthalmoplegia

most common cause of CNIII palsy is *ischemic neuropathy* due to poorly controlled *diabetes mellitus* inner somatic fibers - innervate levator muscle, and 4 EOM superficial parasympathetic fibers - innervate sphincter of iris and ciliary muscles pt with ischemic CNIII palsy --> paralysis of levator muscle [*ptosis*] and 4EOM [*down and out gaze*] with *preserved pupillary response*

intraductal papilloma

most common cause of unilateral bloody discharge w/o coexisting breast mass *clinical* unilatearl bloody nipple dsicharge no mass or lymphadenopathy *management* mammography + u/s biopsy +/- excision

retinoblastoma

most common intraocular tumor of childood - inactivation of RB1 presents with leukocoria (white pupillary reflex); stabismus, nystagmus, vision impairment and ocular inflammation dx = MRI of brain and orbits do not do biopsy due to risk of tumor seeding

gliomas

most common primary CNS tumor in adults tumor from glial cells MRI shows = solitary lesion with irregular borders

parapneumonic effusions

most pneumonias have an associated plerual effusion - most are small, free flowing, sterile and resolve w/ antibiotics (ie, *uncomplicated* parapneumonic effusion) complicated parapnemonia effusion (bacteiral invasion of pleural sapce) gram stain can be falsely negative due to low baterial count glucose is low in empyema due to *high metabolic activity* of leukocytes (and/or bacteria) in the fluid *high protein* due to increased microvascular permeability and cellular destriction pleural glucose <30 mg/dL suggests an empyema or rheumatic effusion *empyema* have gross pus or bacteria on gram stain *management* Small + no distres/hpyoxia - PO abx, close monitoring moderate/arge euffsion [empyema] *or* distress *or * hypoxia - u/s, IV abx, drainage

manifestations of systemic lupus erythematosus

most sensitive = ANA most specific = anti-Sm, anti-ds DNA infants born to mothers with lupus = *third degree heart block* renal involvement = proteinuria *clinical* constitutional: fever, fatigue, weight loss symmetric, migratory arthritis skin: butterfly rash and photosensitvity serositis: pleursiy, pericarditis, peritonitis thrombomebolic evets (vasculitis, APLS) neurologic: congitive dysfunction, seizures *labs* hemolytic anemia, thrombocytoepnia, leukopenia hypocoplementemia (C3, C4) ANA = sensistive anti-dsDNA, anti-Sm = specficic renal involvement = proteinuria, elevated creatinine

lateral mid-pontine lesion

motor and sensory nuclei of ipsilateral trigeminal - weakness of mastication, diminished jaw jerk reflex, impaired prioception of face

syncope differential

neurocardiogenic is most common cause of syncope; tilt table test is positive in these patients carotid sinus hypersensitvity = syncope with pressure over carotid (shaving, tight collar, etc) prolonged PR, prolonged QRS complex duration on an EKG = AV block with asociated bradyarrhytmia can be *intermittent* and can cause the lighteheaddedness and syncope *situational (postmicturition) syncope* - alteration in autonomic response can lead to a *cardioinhibitory, vasodepressor* response

is there any specific treatment for b thalasemia trait or b thalssemia minor

no

is levothyroxine teratogenic?

no - pt should remain on medicine

henoch-schonlein purpura

nonblanching, PALPABLE purpura arthalgia/arthritis abdominal pain [due to bowel edema and/or hemorrhage from mesenteric vessel vasculitis] nephritis dx is based on clinical findings and confimred with *skin biopsy* or purpuric lesions

persistence of nocturnal and early morning penile erectiosn helps differeniate psychogenic from organic causes of male erectile dysfunction

normal nocturnal erection = intact vascular and nerve function in penis

obesity hypoventilation syndrome

obesity reduces chest wall and lung compliance --> decreased TV and TLC, and increased airway resistance as a result, higher levels of ventiltaory drive are required to maintain normocapnia, but there is an inability to exhale excess CO2 during the day (due to persistent restrictionn) this causes CO2 *accumulation overnight*, with chronic respiratory acidosis renal HCO3 excretion is decreased as a compensatory mechanism patients cant breathe (excess weight) and wont breath (decreased chemosensitivity to hypercpania from persistent nocturnal hypoventilation)

CT shows structural abnormalities in orbitofrontal cortex and basal ganglia Associated with which psychiatric condition? diagnostic criteria treatment

obsessive-compulsive disorder SSRI + CBT

initial approach in a patient engaging in nonsuicidal self-injury

obtain comprehensive psychaitric evlauation to identify any underlying conidtions can be perofrmed on *outpatient* basis unelss there is risk for suicide should respect adolscents specific request for condifentiality in regarding to *cutting behaviors* as patient is interested in pursuing psychiatric treatment and is not at risk of immediate harm

beckwith-wiedmanns yndrome

omphalocele macrosomia macroglossia hemihyperplasia *imprinted expression 11p15*

diabetic neuropathy affects upper or lower motor neurons?

only *lower* if pt presents with an UMN signs, another pathology should be considered - get an MRI motor signs are a late manifestation of diabetic neuropathy *typically neuropathy in diabetes is only sensation and proprioception*

Panner disease

osteochondrosis of capitellum adolscent who is actively engaged in sports that involve throwing commonly = dull pain, crepitation, loss of pronation and supination

jaundice weight loss abdominal discomfort fullness in RUQ

pancreatic cancer

initial fibromyalgia treatment

patient education regular low impact aerobic exercise (fast walking, swimming, water areobics) good sleep hygeine --next phase-- TCA (amitriptyline) are first line drugs Alternatives; SSRI, SNRI, pregalain milnacipran (SNRI)

lipid profile screening

patients with <7.5% risk can be monitered every 5 years

vaccines for adults with HIV

patients with HIV are more susceptible to common pathogens such as strep pneumoniae prophylactic abx not given unless CD4<200 immunization should be given soon after dx of HIV when CD4 count is high enough to mount an appropriate antibody response

which conditions is the copper IUD contraindicated in

patients with heavy mesntraul bleeding (hypermenorrhea, anemia) - the copper IUD can exacerbate these conidtions

mccune-albright syndrome

peripheral precocious puberty irregular cafe-au-lair macules (on 1/2 of body) fibrous dysplasia of bone mutation in *GNAS* gene, which results in constant G protein activation and over production of pitutiary hormones therefore, in addition to *GnRH-independent (ie, periphearl* precocious puberty (FSH, LH), MAS can lead to thyrotoxicosis (TSH), acromegaly (GH), and cushing syndrome (ACTH)

breast abscess

persistent or severe mastitis can cause focal pus collection mst commonly caused by staph aureus which enters breast through nipple trauma localized pain erythema/pain, fever, malaise + flucutant tender, palpable mass tx = needle aspiration + abx (dicloxacillin, cephalexin) continued breastfeeding is reocmmended for continued milk drainage

what drugs cause vitamin D deficiency

phenytoin carbamazepine rifampin induce CYP450 in liver - degrades vitamin D into inactive metabolites

acute onset of severe back pain, syncope, hypotension

posible AAA rupture typically in ppl >60y/o - higher rate in smokers, men, CAD hx PE - pulsatile mass at or above umbilicus AAA can rupture into retroperinteum and creat an aortocaval fistula with the inferior vena cava, leading to venous congestion in retropertioenal structures (eg, bladder) - fragie, distened veins in bladder can rupture and cause gross hematuria mortality is 50% early recognition and operation is essential

patient wwith DM who has elevated A1c depsite good control of fasting glucose...

postprandial hyperglycemia combined regimen of long acting basal inuslin (controls baseline/fasting glucose) and a rapid acting mealtime insulin (to control postprandial glucose) may be needed to provide optimal control

treatment for idiopathic intracranial hypertension

prevent vision loss, reduce itnracranial pressure, symptoamtic relief of headaches avoid exacerbating meds (tetracyclines, isotretinoin) weight loss aceztolamide - inhibits chorid plexus carbonic anhydrase lumbar peritoneal shunting *complications if treatment fails* visual field defects are progressive, shunting or optic nerve sheath fenestration is done to *prevent blindness* - most signifcant complication of this disorder

ezetimibe

prevents absorption of dietary cholesterol from the gut works best at reducing LDL when combined with a statin

evaluation of hyponatremia

primary polydipsia - more common in those with psychiatric conditions [central defect in third regulation] continue to drink despite decreased serum osmolality; kidney does increase water ecretion, but if pt is drinking faster than kidney can excrete, than hyponatremia can result

negative predictive value

probability of being free of disease if test result is negative NPV will vary with pretest probability of disease

ecthyma gangrenosum

pseudomonas lesions progress very rapidly frmo small eryhematous macule to larger, nontender nodules with necrosis caused by bacterial invasion through media and aventitia of blood vessels tx = abx against p. aeruginosa

pap tests for cervical cancer

q3 years in women age 21-65 (or q5y in women 30-65 if combined with HPV testing)

in a case control study, if the outcome is uncommon in the population, the odds ratio is a close approximation of the realtive risk

rare disease assumption

nightmare disorder

recurrent awakenings with associated dream content and ability to be consoled on awakening, child is alert, remebers dreams, and can be consoled more frequent in 2nd half of night during REM sleep

startly myoclonus

reflex myoclonus/body jerk elicited with loud auditory sitmulus and more commonly seen in prion-related dementias *Creutzfeldt-jakob*

pathophysiology of obstructive sleep apnea

relaxation of pharyngeal muscles leads to closure of airway loud snoring with periods of apnea *symptoms* daytime somnolence non-restorative sleep wtih frequent awakenings morning headaches affective + cognitive symptoms *sequelae* systemic hypertension pulmoanry HTN and right heart failure when OSA is suspected, *nocturnal polysomnography* is gold standard *apnea*: cessation of breathing for >10s *hypopnea*: reduced airflow causing SaO2 to decrease by >4%

pt has BPH. develops AKI. What test to be ordered?

renal ultrasound - assessing for hydronephrosis in those with worsening kidney function

anemia in lymphoproliferative disorders is caused by

repalcement of RBC progenitor cells with cancer cells in bone marrow

hepatic hydrothorax

results from *transudative fluid* through small defects in diaphragm - these defects permit peritoneal fluid to pass into the pleural sapce, which occurs much more commonly on *right side* due to less muscular hemidiphargm patients have dyspnea, cough, peluritc chest pain, hypoxemia dx = CXR tx = Na restriction and diuretic adminstration thoracentesis can be used in thsoe with prominent symptoms

gartner duct cyst

results from incomplete regression of the wolffian duct during fetal development these cysts may be single or multiple and are submucosal along lateral (parallel) aspects of upper anterior vagina

clinical manifestations of trace mineral deficiencies

riboflavin (b2) - cheiolosis, glossitis, seborrheic dermatitis, pharyngitis, edema and/or erythema of mouth pyridoxine (b6) - irritability, depression, dermatitis, stomatitis, elevated homocyteine (thromboembolic, atherosclerosis) cyanocobalamin (b12) - macrocytic anemia, peripheral neuropathy vitamin A - impaired adapation to darkness, photophobia, dry scaly skin, dry conjuctiva, dry conrea, and wrinkled, cloudy cornea

first line therapy for systemic manifestations of CLL

ritxumab - monoclonal against CD20 used in combo with fludarabine

overporudction of amino acid derived hormones

seen in neuroendeocrin tumors: carcinoid (serotonin) and pheochromocytoma (NE, epi)

serotonin syndrome causes

serotonergic meds in combo (SSRI/SNRI, TCA, tramadol) drug interactions: serotonergic meds + MAOI or linezolid overdose of serotonergic meds serotonergic drugs of abuse (MDMA)

juvenile myoclonic epilepsy

show progression from absence seizures beginning around age 10 to myoclonic seizures around age 15 finally, generalized tonic cloniz seizures may begina round age 16 *myoclonic jerks most prominent in first hour after awakening* hx of frequent jerkin in morning = myoclonus - worsened with sleep deprivation confusion in morning = post ictal from generalized tonic-clonic seizure

common etiologies of pediatric stroke

sickle cell disease (*most common cause*) prethrombotic disorders congenital cardiac disease bacterial meningitis vasculitis focal cerebral arteriopathy head/neck trauma

hemoglobin electrophoresis patterns

sickle cells - results in a valine for glutamic acid subsittion hydroxyurea - increases amount of HbF in circulation (>15%) *sickle cell trait* generally asymptoamtic and can lead healthy life increased risk of renal issues: most commonly painless hematuria from sickling inr enal medulla Hyposthenuria (impariment in concentrating ability) is also common - presenting as nocturia, polyuria

patient with cirrhosis + fever +ascities + diffuse abdominal pain suggests?

spontaenous bacterial peritonitis

testicular cancer metastases

spreads through regional lymphatics - retroperitoneal lymph nodes lungs liver

presence of S4

stiff left ventricle - S4 corresponds with atrial contraction --> sound of blood striking stiff LV restrictive cardiomyopathy or LV hyertrophy prolonged HTN

benign versus pathologic murmurs

stills = low pitched, musical at LLSB pulmonary flow = high pitched at LUSB

first step to perform in HIV+ individual with diarrhea

stool exam for culture, ova/parasites, clsotridium difficle antigen and an acid-fast strain (for cryptospridium) absence of bloody diarrhea makes infection with opportunisitc infection MORE likely

where does aspiration PA typically occur

supine = posterior segments of upper lobes and superior segments of lower lobes erect = bases of lower lobes and right middle lobe

mechanism of MDMA (ectasy, molly)

synthetic ampehtamine increases synpaticc: NE, DA, 5HT can be involved in increasing risk of serotonin syndrome ampheatmine - HTN, tachycardia, hyperthermia serotonin - sertonin syndrome, hyponatermia increase sociability exmpathy sexual desire

sequelae of untreated OSA

systemic HTN pulmonary HTN --> RHF

mechanism of harsh systolic murmur of HCOM

systolic anterior motion of mitral valve leads to anterior motion of mitral valve leaflets towards the itnerventricular septum contact between the mitral valve and the thickened septum during systole leads to *left ventricular outflow tract obstruction* and is responsible for *harsh systolic murmur* heard at apex and left lower sternal border

common signs of bulimia nervosa

tachycardia hypotension dry skin painless bilateral parotid gland swelling calluses/scarring on dorsum of hand erosion of dental enamel eletrolytes - metabolic alkasis, hypoklaemia, hypochloremia

methotrexate precaustions

test for HBV, HCV and TB prior to starting do not use in pregnant or planning to become pregnant do not use in renal insufficiency, liver dz, excessive alcoohol intake

target cells hypochromic microcytic

thalassemia b-thalassemi minor [defect in 1 gene] = hematocrit 28-40%, MCV 55-75 fl b-thalassemia major [defect in both genes] = severe anemia, tranfusion dependent

chronic malutrition in setting alcoholism/anorexia/pregnancy + AMS......

think Wernicke encephalopathy presents with traid of: encephalopathy, ocular dysfunction, gait ataxia give thiamine promptly, then IVNS+glucose *absent thiamine = decreased amino acid metabolism* *etiology of wernicke* chronic alcoholism malnutrition hyperemesis gravidarum *pathophy*: thiamine deficiency *clincially* encephalopathy oculomotor dysfunction: horizontal nystagmus, bilatearl abducens palsy postural and gait ataxia *treatment: IV thiamine, then glucose

renal vein thrombosis

thrombosis of renal vein can be acute and present with abdominal pain, fever, hematuria however, RVT is more commonly progressive, causing gradual worsening of renal function and proteinuria in an asymptomatic patient can occur in ANY nephrotic syndrome, but most commonly seen in *membranous glomerulopathy* occurs in patient with predisposing conidtion - hypercoaguablity, trauma, nephrotic syndrome, severe dheydration abdominal pain + hematuria

subdural hematoma

traumatic shearing forces cause tearing of bridging veins, leading to slow bleeding into subdural space patients with cerebral atrophy (elderly, alocohols) are at higher risk *acute* - 1-2d after injury impaired cosnciosuness (eg, coma), confusion headache, nausea, vomting = ICP *chronic* - insidoius onset weeks after injury headache, somnolence, confusion, liaghtehdedness focal neurologic signs noncontrast CT = crescent shaped hyperdenisty(acute) or hypodensity (chronic) d/c anticoagulants small hematoma = conservative tx large hematoma = urgent surgical evacuation

acute cholecystitis

triad = RUQ/epigastric pain, fever, leukocytosis guarding = peritoneal irrtiation occurs in setting of *cystic duct obstruction* due to gallstones patients can have preceding episodic periods of transient pain due to temporary obstruction of cystic duct by gallstones *minimally elevated alkaline phosphatase* [key for location of stone; extremely high levels seen in cholangitis or choledocholitiasis] common risk factors: obestiy, female, >40 y/o, pregnancy; rapid weight loss, hemolytic anemia, hyperTG's, biliary stasis (eg, DM) dx = u/s early cholecystecomy (within 72h) reduces disease duraiton, duration of hospitlization, and mortality

pt with parkinson's presnts with acute angle closure glaucome. What is the drug causing this

trihexyphenidyl (anticholineric) - used in symptoamtic treatment of parkinsons anticholinergics cause mydriasis, which can precipitate acute ACG

thyroid lymphoma

uncommon, but 60x greater chance in preexisting *Hashimoto thyroidtis* rapidly enlarging, firm goited with compressive smypotms (dysphgai, hoarseness) may have systemic B symtpoms: fever, night sweats, weight loss retrosternal etension --> venous comrpession with distended neck veins anf facial plethora core or excisional biopsy may be required thyroidectomy is needed

cataracts

vision impairing opacificaiton of lens caused by oxidative damage incidence increases with age, smoking, excessive sunlight, DM, glucocirtcoids symptoms = painless blurring of vision, glare and halos around lights patients expeirence worsening of distance vision intitally (myopic shift) ocular exam in early catarct can by normal with increasing opacificaiton - the red reflex is lost and retinal detail becomes less visible surgery is indicated when vision declines to point patient is unable to perform activities of daily living despite wearing glasses

recurrent vomiting causes depletion of fluid, acid, and sodum chloride, leaing to metabolic alkslosis, activation of RAAS, and incread urianry K loss.

volume resusitation with NS corrects contraction alkalosis add potassium to NS to treat hypokalemia

osteitis fibrosa cystic

von recklinghausen disease of bone presents with bone pain characterized by excessive osteoclastic resorption of bone, leading to fibrous tissue (brown tumors) very rare; seen primarily in parathyroid carcinoma or hyperpararthyroidism

retinal hemangioblastoma are associated with....

von-hippel lindau hemangioblastomas renal cell carcinoma

kallmann syndrome

x-linked recessive disorder - failed migration of GnRH and olfactory neurons hypogonadtropic hypogonadism and rhinencephalon hypoplasia normal phenotype and internal reproductive organs short stature delayed, absent puberty girls - primary amenorrhea, absent breasts boys - eunuchoid appearnce with small external genitalia and absent 2nd characteristics *anosmia* labs: low FSH, low LH

can panic attacks occur during sleep and produce abrupt awakenings?

yes

can high dose glucocirtcoids can psychosis?

yes psychotic symptoms occur usually in 1st week of glucocorticoid treatment but cna occur at any time can also can manic or depressive symptoms

impetigo

young child with erythematous skin lesion covered with thick, golden crust week long evoluation of these lesion, beginning as papules that progress to vesicles surrounded by erythema vesicles become pustules that rupture, thereby releasing the characteristic golden crust (honey colored) most commonly on face, extremities lesions are *painful* but *not pruritic* no fever dx = clinical most commonly Staph aureus, but some GAS *topical abx (mupirocin)* - treatment of choice po clindamycin is used for extensive impetigo complications = glomerulonephritis

rates of bacterial colonization in cystic fibrosis absed on age

young children = staph aureus (gram positive coccus in clusters) adolescent, adults = pseudomonas treat for pseudomonas in children with exacerbation too because pseudomonas clean lead to quick decline burkholderia does not colonize many, but those who it does, is associated with accelerated pulmonary decline and decreased survival

pilonidal disease

young males (15-30 y/o) obsese, sedentary lifestyle, deep gluteal clefts painful, fluctuant mass 4-5cm cephalad to anus in intergluteal region associated with mucoid, purulent or bloody drainage pain worse with activities causing stretching of the overlying skin develops when an edematous, infected hair follicle in intergluteal region becomes occluded - infection spread subcutenaoutly and forms and abscess which can rupture and create a pilonidal sinus tract hair and debris can get into tract and cause recurrent infection tx = drainage of abscess OPEN closure

adrenoleukodystraophy

young males - accumulation of VLCFA in adrenal glands adrenal insuffiency soon after birth

clavicular fracture

most occur in middle third of bone occurs typically following a fall on an outstretched arm or direct blow to shoulder present with pain and immobility of affected arm contralateral hand is classicaly used to support weight of affected arm shoulder on affected side is dispalced *inferior, posterior* all clavicular fractures need close neurovascular exam do to proximity to subclavian a. and brachial plexus if a bruit is hear = angiogram is needed tx = brace, rest, ice for middle third fractures distal third fractures may require operative reduction

congenital hypothyroidism

most ocmmon cause = *thyroid dysgenesis* appear normal at birth gradually develop apathy, weakness, hypotnoia, large tongue, sluggish movement, abdominal bloating and an umbilical hernia initally normal due to moderate amounts of materanl hormone in infant circulation screening is mandated at birth - T4 and TSH levels

anemia of prematurity

most often affects preterm infants phsyiologic RBC nadir is around 2-3m of life in term infants; however in preterm infants the RBC life span is shorter and frequent phlebotomy in NICU --> early onset anemia AOP is diagnosis of exclusions RBC's look *normal* under microscopy

acalculous cholecystitis

most often seen in severely ill patients in ICU with multiorgan failure, severe truama, surgery, burns, sepsis or prolonged parenteral nutrtion *risks* severe trauma or recent surgery prolonged fasting or TPN critical illness (eg, sepsis, ICU) *clinically* fever, WBC, LFTs, RUQ pain jaundice and RUQ mass less common *diagnosis* abdominal u/x - GB wall thickening and distention and presnce of pericholecystic fluid HIDA or CT if needed *treatment* enteric abx coverage cholecystostomy for inital drainage cholecystecomy once clinically stable likely due to choelstasis and gallbladder ischemia leading to secondary infection by etner organisms and resultant edema and necrosis of the gallbaldder can lead to sepsis and death if undetected other complications: gagrene, sepsis, emphysematous cholecystitis

diffuse axonal injury / glasgow coma scale

most signficant cause of morbidity in patients with traumatic brain injuries due to traumatic deceleration injury, results in vegetative state most occur at gray-white matter junction clinical features are out of proportion with CT findings CT = *numerous minute punctate hemorrahges with blurring of grey-white interface* patient loses consciousness instantenously and later develops persistent vegtatbive state

types of casts seen on urine sedmine

muddy brown granular = acute tubular necrosis RBC = glomerulonephritis WBC = interstitial nephritis, pyeloneohritis fatty = nephrotic broad and waxy = chronic renal failure

MRI in multiple sclerosis

multifocal, ovoid, subcortical hypo-/hyperintense lesions located in *white matter* of CNS, particularly the *periventcular* and subpial white matter of the cerebrum, optic nerves, brainstem and spinal cord LP = oligoclonal IgG bands in CSF

sleep changes in depression

multiple awakening early morning awakening decreaesd REM latency decreased restorative sleep

Tourette syndrome

multiple motor *and* >1 vocal tics that present *before age 18* more common in *males* tics may occur every day, or at regular intervals for at least 1 year motor tics: grimacing, eye blinking, nose twitching, head jerking, shoulder shrugging vocal tics: barking, grunting, squeaking, coughing, throat clearing symptoms are excerbated by stress and tend to subside during sleep comorbid conditions: ADHD, OCD *treatment* antipsychotics (severe cases) [use risperidone] alpha-2 adrenergic agonists (mild cases) behavioral therapy (most effective nonpharm = habit reversal training) must treat comorbid OCD or ADHD if present

what type of cancer should skeletal survery be used for

multiple myeloma - xray of chest, spine, skull and pelvis lesions in MM are *osteolytic* therefore, you can *not* do a bone scan

whipple's disease

multisystem disease from *Tropheryma whippelii* hx of chronic malabsorptive diarrhea: steatorrhea, flatulence, abdominal distention protein losing enteropathy weight loss mgiratory non-deforming arthritis lymphadenoapthy low grade fever extraintestinal late findings: myocardial or valvular involvement cause CHF; dementia or other CNS findings - supranuclear opthalmoplegia and myoclonus diagnosis made with *small intestinal biopsy and PCR* = *PAS+ macrophages* in lamina propria containig *non acid fast gram positive bacilli*

sturge-weber syndrome

mutation in *GNAQ* gene *clinical* port wine stain (trigeminal [CN V1/V2] distribution) - *nevus flemmus* leptomeningeal capillary-venous malformation intellectual disability seizures +/- hemiparesis visual impairment due to capillary-venous malfromations Glaucaoma *diagnosis*: MRI of brain w/ contrast *management* laser therapy - reduces port wine stain antieplieptic drugs intraocular pressure reduction

first line meds to decrease cravings for alcohol

naltrexone - mu opioid receptor antagonist [avoid in liver disease] acamprosate - glutamate inhibitor [avoid in renal imapirement]

theophylline toxicity

narrow therapeutic index toxicity can occur from accumulation by redeced clearence or decreased metabolism due to saturation of metbaolic pathways metabolized by CYP in liver inhibition of these enzymes by illness or drugs can raise serum concentration and cause toxicity CNS stimulation: headache, insomnia, seizures GI: nausea, vomiting cardiac: arrhhythmia

acute fatty liver of pregnancy

nausea, vomiting, abdominal pain and elevated LFT's in 3rd trimester more likely to have extrahepatic complications: leukocytosis hypoglycemia acute kidney injury HTN is *not* found in AFLP proteinuria is *not* found in AFLP

informed consent for minor

needed only frmo *one parent or gaurdian* - legally sufficient to justify proceeding with therapy

urate crystals

needle shaped negative birefringent: appear yellow when lying parallel to polarizing axis, and blue when lying perpendicular

gout crystals

needle shaped with negative birefringence

does neimann pick or tay sachs have HSM/areflexia?

neimann pick - sphingomyelinase defiencincy

midgut volvulus

neonate presenting with *bilious vomiting* malrotation refers to abnormal rotation of intestines during embrylogic development, most often with the cecum malpositoned in mid to upper abdomen and *duodenum abnomrally located in right abdomen* initially bowel is soft, nondistened, but ischemia can cause bloody stools, bowel perforation, abdominal distention, peritonitis bowel ischemia and perofration are potential life threatening complications abdominal xray is performed to exclude perforation - *coffee bean sign* shows vovlvulus contrast sutides are needed to localize obstruction if patient is stable best diagnostic test = *upper GI series* prompt surgical intervention required -*Ladd procedure* - fixes bowel in non-rotated position to minimize recurrent volvulus risk

burkitt lymphoma

neoplasm of mature B cells assocaited with EBV infection most present with either a mass involving the mandible or abdominal viscera high mitotix index is typical *histo = starry sky appearance* very aggressive but responds well to high dose chemotherapy

clinical features of metastatic brain cancer

neoplastic cells travel through vasculature and lodge into small caliber vessels at gray and white matter junction MRI of brain w/ contrast shows vasogenic edema at *gray and white matter junction*

membranoproliferative glomerulonephritis

nephrotic proteinuria + hematuria dense intramembranous deposits that stain for C3 caused by IgG antibodies (C3 nephritic factor) directed against C3 covnertase of alternative complement pathway these antibodies reacting with C3 convertase lead to persitent complement activation and kidney damage

ulnar compression in Guyon canal

nerve compression in the wrist prolonged pressure over heel of hand (eg, bicycling) or acute hamate injury entrapment causes motor weakness in intrinsi hand muscles responsible for adduction and abduciton of digits sensory - numbess in palmar surface of little finger and ulnar half of ring finger, and entire pinky and ring on dorsal suface if severe - clawing/flexion of last two digits

neurologic symptoms in hyperosmolar hyperglycemia is due to

neurologic symptoms (confusion to coma) are common and due to *high serum osmolality* (usually >320 mOsm/kg) the hyponatremia seen in these patients is "pseduo", and if you correct for the icnreased omsoles then the sodium would be normal

febrile neutropenia

neutropenia = ANC<1500 (severe neutropenia is ANC <500) ANC<1000 = overwhelming bacterial infection risk is increased due to absent neutrophil-mediated inflammatory response chemo can disrupt skina nd mucosal barriers - resulting in mucositis and tranlscoation of abcteria into bloodstream gram negative organizsms, particualry *pseudomonas*, are msot frequently found febrile neutropenia is medical emergency inital eval = blood + urine cultures, followed by IV braod spectrum antibitocs monotherapy with *anti-pseudomonal* beta-lactam (cefepime, meropenem, pip/tazo) provides both gram negative and gram positive coverage add antifungal meds if persistent fever after 4-7d of intal therapy in whom source of ifnection is not identified

status epilpeticus

new definition: single seizure lasting >5m or a cluster of seizures with patient not recovering a nromal mental status between cortical laminar necrosis is the hallmark of prolonged seizures and can lead to persistent neurologic deficits and recurrent seizures MRI will show evidence of cortical hyperinistey can lead to persistent neuro deficits and recurrent seizures

pediatric viral myocarditis

new holosystolic murmur = dilated cardiomyopathy and resulting funcitonal mitral regurgitation on cxr, healthy infants <1/yo have transverse cariothoracic ratio <60% children and adults healthy should have <50% *treatment* supportive - diuretics, inotropes

pellagra

niacin deficiency dermatitis: rough, hyperpigemtned scaly skin typically in sunexposed areas resembling *sunburn*; bilateral and symmetric diarrhea: abdominal pain, nausea, loss of appetite dementia: neuronal degenration in brain, spinal cord and can lead to memory loss, affective symptoms, psychosis niacin defiiency is seen in populations that subsist primarily on *corn* also seen in *carcinoid syndrome* (dpletion of trpytopharn) or *hartnup disese* (disorder of trpytophan absorption) prolonged isonizid therapy cna interfere with metabolism of tryptophan and occasionally lead to pellagra

healthcare worked exposed to blood from suspected/known HBV patient should receive...

no prior vaccination = complete HB vaccine + HB-IG prior vaccination = no post exposure prophaylxis; but many will receive HB booster vaccine

halo sign in aspergillous

nodules with surrounding ground glass opacities

sleep terror disorder

non-REM sleep incomplete awaeknings, unresponsiveness to comfort, no recall of dream content usually occur in 1st third of the night characerized by marked autonomic arousal and amnesia for episode *management* reassurance low dose benzo if episodes are recurrent + distressing

treatment of chronic stable angina

non-dihydropyridien CCB = verapamil, dilitazem used in combo with beta blockers, because monotherapy can result in reflex tachycardia and worsening anginal symptoms ranolazine = inhibits late phase of Na influx into ischemic cardiac myomytes; reduces caclcium influx, leading to reduction in ventricular wall stress and myocardial oxygen demand

parvovirus B19 infection

non-eveloped, single stranded DNA virus that ifnects red cell precusors children = slapped check rash adults = nonspecific morbilliform exanthem or no skin manifestation at all *symmetric polyarticular arthritis* - *self limited* resolves in 1-2 months; tx symptoms with NSAIDs acute, symmetric arthlargias w/ synovitis; normal ESR, exposure to msall kis = PB19

senile purpura

noninflammatory disorder that is most common in elderly but can also be seen in middle-aged patients with extensive sunlight exposure caused by *loss of elastic fibers in perivascular connective tissue* minor abrasias can rupture superficial blood vessels in elderly subsequent extravasastion of blood leads to ecchymosis over vulnerable areas (dorsum of hands, forearms) pt can have residual brownish discoloration from hemosiderin deposition

cell-free fetal DNA testing

noninvasive can be performed at >10 weeks 99% sensitvity for Downs, 92% for edwards, 80% for patau can identify fetal sex and detect some sex chromsoaml disorders normal results are generally reasurring and can reduce rate of invasive diagnostic procedures abnormal cffDNA results can be confirmed by CVS or amniocentesis patients who dont meet high risk criteria for cffDNA can undergo screening during 1st trimester with combined test (PAPPA, bhcg, nucal tranlusncy) - 85% detection for downs in second trimeste,r quadruple screen (afp, bhcg, estriol, inhibin A) - downs 80%

nonstress test

nonreactive NST are associated with fetal hypoxia from placental insufficiency and fetal cardiac or neurologic anomlies however, *the most likely cause of lack of accerleations* in a fetus with normal reproted fetal movenet is *fetal sleep* fetal sleep cycles can last as long as *40 minutes* [NST is 20m] - thus a nonreactive NST should be extended tor 40-120minutes to ensure fetal activity outside of sleep is captured due to high false-positive rate, a nonreactive NST should be followed w/ either biphysical profile or contraction stress test before conlcuding fetus may be hypoxic and needs intervention

antepartum fetal surveillance

nonreactive stress test requires further evlauation with a BPP or CST

large anterior mediastinal mass elevated b-hcg, AFP

nonseminomatous germ cell tumor - elevation of AFP only seen in noseminoamtous b-hcg seen in seminoma and non-seminomatous dx confirmed with biopsy testicular u/s performed to exlcuse small rpimary tumor almost all germ cell tumors in anterior mediastinum are primary rather than metastatic

lead poisoning in adults

nonspecific sympomts (fatigue, irritability, insomnia) are common battery manufacturing, plumbing, home restoration, distilation of alocho through partswith lead soldering lead disrupts heme syntehsis --> microcytic anemia *basophilic stippling* hyperurecemia (due to impaired purine metbaolism) is typical

cerebrospinal fluid analysis

normal CSF glucose = 40-70mg/dl or 2/3 of serum glucose

renal bx findings

normal architecture = mnimal change disease crescent formation = rapidly progressive glomerulonepehritis (good pastures, pauci-immune: granulomtosis with olyangiits, microscopic polyangiits) tickened BM w/ subepithelial spikes = membranous glomerulonephritis [common in adult nephrotic] mesangial hypercellularity = membraneproliferative glomerulonephritis [nephritic syndrome]

differential diagnosis of dysmenorrhea

normal exam + pain during menses = primary dymenorrhea *NSAIDs* are firs tline for primary dymenorrhea as they inhibit the PG production [PG's are released from sloughing endometrium and cause uterine contractions] OCPs used in primary dysmenorrhea OCPs decrease pain by thinning the endometrial lining, reducing PG release, decreasing uterine contractions

thymus xray

normal on cxr in children age <3 years located in anterior mediastinum snail sign - triangular shape, scalloped border, uniform density important organ in utero and during infancy and childhood for lymphocyte production and maturation hypoplasia, aplasia = DiGeorge normally atrophies and repalced by fat after pubertly, when it has completed production of T-lymphocytes

sign of impending respiratory failure in asthma excerbation

normal or elevated PaCO2 *clinical* extreme fatigue AMS absent/minimal wheezing (poor air entry) cyanosis chest wall retractions *labs* dec. PaO2 and pH (respiratory acidosis inc. pCO2

light criteria for pleural effusions

normal pleural pH = 7.6 transudate pH = 7.4-7.55 exudate pH = 7.3-7.45 empyema pH = <7.3

biophysical profile

normal score = 8, 10 = eclude hypoemia score 4-6 = repeat in 24 hours abrnoaml score (particuarly <4) = imminent risk of fetal demise, and dleivery is typically indicated

postpartum blues

normal, self limited conidtion occurs within few days postpartum *peaks at 5 days; resolves within 2 weeks* mild depressive smyptoms - tearfulness, irritbality, dysphoria, anxiety, insomnia, impaired concentration *most resolve spotnenously* monitor pt for postpartum depression (symptoms worsening or persiting >2weeks or suicidal ideation)

diuretic abuse and lab findings

normally, dehydrated patient with hyponatermia are expected to have low urine sodium (<20 mEq/L) however, diuretic abuse --> *elevated urine sodium* which suggets salt wasting normally, patients with hypokalemia respond by reducing urine potassium excretion, except in cases of renal potassium wasting

autoimmune hemolytic anemia

normocytic anemia evidence of hemolysis - jaundice, elevated indirect bili, icnreased LDH, dec. serum haptoglobin reticulocytosis splenomegaly - RBC entrapment spherocytosis microspherocytes elliptocytes polychromatophilic (reticulocytes) symptomatic patients receive high dose glucocorticoids

should pneumococcal vaccine be given in pregnancy

not typically it is safe to give for those with comorbidties (immunodeficiecny, chronic heart or lung disease)

gold standard diagnostic test for acute cervicitis

nucleic acid aplification testing (NAAT) - high sen/spec for chlaymdia and neisseria light mirscopic is *not* helpful as chlaymia is obligate itnracellular pathogen --> no oragnisms are visualized low sensitivty for identifying gram negative intracellular diplocci of n. gonorrhea on endocervical smears

rectovaginal fistula

obstetric injury is most common cause - presents within first 2 weeks postpartum most often occur after 3rd or 4th degree lacerations, inadeqaute wound repair or wound breakdown, and infection in less industrilized countries, RVF can occur due to poor intrpartum care and a prolonged 2nd stage of labor (ischemic pressure necrosis of rectovaginal septum from fetal head compression) malodourous brown/tan discharge diagnosis confimred by visualizing dark red, velvety rectal mucosa on posterior vaginall tx = surgery

granulosa cell tumors

presnt in middle aged women with ovarian mass and mesntrual abonralities *patho* - sex cord stromal tumor; granulosa cells convert testosteone to estradiol via aromatase and escrete inhibin (normally inhibits FSH) increased estradiol increased inhibin - *used as tumor marker* *clinical* complex ovarian mass juvenile subtype --> premature berast development and menses adult subtype - breat tenderness, AUB, postmenopaual bleeding *histo - call exner bodies (rosette pattern)* *management* endometrial bx - looking for cancer surgery - tumor staging premenopausal women desiring fertility who have a granulsoa cell tumor and no edometrial cancer can undergo a uterus-sparing procedure (eg, unilatearl salpingo-oophorectomy) in contrast, patients with a granulosa cell tumor and endometrail cancer require a hysterectomy and bilatearl salpingo-oophorectomy

lambert eaten syndrome

presynatpic membrane voltage gated calcium cahnnels associated with small cell lung cancer proximal muscle weakness autonomic dysfunction (eg, dry mouth, erectile dysfunction) cranial n. involvement (eg, ptosis) *diminished or absent DTRs* dx confirmed by checking for autoantbidoes against voltage gated calcium channels and EP studies repeat isometric contraction leads to temporary improvement of uscle weakness and reappearance of absent DTRs symptomatic tx is guanidine or 3,4-diamniopyridine to increase presynpatic Ach levels

meningococcal vaccination

primary at 11-12 y/o; booster at 16-21 y/o *high risk pt - vaccinate even if >18 y/o* complement defiency, asplenia college student in residential housing (<21y/o), military recruits travel to enedemicarea, exposure to community outbreaks

differential diagnosis of metabolic alkalosis

primary hyperaldosteronism has *high* urine Cl, as there is no stimulus for renal NaCl retention saline-unresponsive metabolic alkaosos presents with higher level of urinary chloride patients have have expanded ECF with hypercolgemia (eg, primary hyperaldosteornism, cushing syndrome, black licorice ignestion) or appear hypo/euvolemic (eg, bartter syndrome, gitelman syndrome) saline responsive metabolic alkalosis is due to loss gastric secrstions most commonly (eg, vomiting, NG suction) that results in ECF loss patients are typically volume depleted (eg, hypotension, orthostatic) and low serum Cl due to chloride loss in gastric secretions ECF loss leads to increased renal mineralocorticoids, increased renal Na, Cl reabsoprtion, and increased urianry H, K excretion

risk factors for neonatal herpes simplex virus infection

primary maternal infection longer duration of rupture of membranes vaginal delivery with active lesions impaired skin barrier (eg, fetal scalp electrode) preterm birth *cesarean delivery* is recommedned for all women who are in labor with *active* genital HSV lesions or prodromal symptoms pregnant women with hx of genital HSV inection should receive *prophylactic acyclvoir or valacycloviur - beginning at 36 weeks of pregnancy* these measures reduce risk of having outbreak at time of delivery, but do not decrease risk of transmission - so simply decrease risk of needing a c-section

pleurodesis

procedure that involves adhering the two pleura in order to destroy the pleural space indicated in cases of recurrent pneumothorax or recurrent pleural effusions can be perofrmed either chemically or surgillary in both moethds - parietal and visceral layers of pleura are irritated and inflamed causing them to scar and adhere together

tachycardia-mediated cardiomyopathy

progresive dyspnea + dec exercise tolerance + *Afib* w/ RVR = *tachycardia mediated cardiomyopathy* variety of tachyarrhythmias with prolonged RVR can lead to tachycardia mediated cardiomyopathy chronic tachycardia causes strcutural changes in the heart including LV dilation and myocardial dysfunction dx requires EKG, echo and assessment for other causes of LV dysfunction including CAD tx = aggressive rate control and *restoration of normal sinus rhytmn* due to potenitla reversibility of tachycardia-mediated cardiomyopathy and normalization of LV sysolic function *tx options*: AV nodal blocking agents, antiarhhythmic drugs, catheter ablation

clinical features of interstitial lung disease

progressive exertional dyspnea or peristent dry cough >50% have smoking hx pulmonary findings due to other underlying conidtions (silicosis, CTD, etc) lung exams: fine crackles during mid-late inspiration, possible digital clubbing *labs/imaging* cxr = reticular or nodular opacities high resoluation CT = fibrosis, honeycombing, traction bronchiectasis PFT: normal or increased FEV1/FVC, decreased DLCO, decreased TLC, decreased RV resting arterial blood gas can be normal or show mild hypoxemia exertion usually cuases signficant hypoxemia due to v/q mismatch

most important step to improve overall long term mortality in patients with STEMI

prompt recognition and restoration of coronary blood flow with priamry percutenous intervention or fibrinolysis PCI for acute STEMI *within 90 minutes* of first medical contact at PCI-capable place or *within 120 minutes* for pt who require transport to PCI capable hospital routine antiarrhytmics, beta blockers should NOT be used and delay time to PCI or fibrinolytics

conscientious refusal

provider refuses to provide care because doing so would conflict with the provider's beliefs provider conscience does *not* take precedence over other ethical principles: autonomy, jstuice, beneficience, nonmaleficience providers who are unable to provide car in good conscience are professionally and ethically *obligated to refer* patients in a timtely fahsion to others who can provide care

aspirin respiratory disease

pseudoallergic reaction to NSAIDs occur in pateints with comorbid asthma, chronic rhinosinusitis w/ nasal polyposis, or chronic urticaria asthmatic symptoms: cough, wheezing, tightness; nasal and ocular symptoms, facial flushing within 30m-3h of NSAID ingestion AERD involes increased production of pro-inflammatory LT's and decreased production of anti-inflammatory PG's COX1, COX2 is inhibited by aspiring; arachinodic acid is diverted to proudciton of LT's via 5-LPO pathway tx = mgt of underlying asthma and chronic rhinosintusitis, avoidance of NSAIDs, and densitization if NSAID use is required LT inhibitors (zileuton) and LT-antagonists (montelukast) can improve respiraory and nasal symptoms

young patient wtih MS who is immobilized. Develops sudden onset chest pain, dyspnea, tachycardia. CXR shows small pleural effusion. Dx?

pulmonary embolism patients with PE can develop small pleural effusion due to hemorrhage or inflammation the effusions tend to be exudative and grossly bloody, and can be associated with pain due to pleural irrtiation

gout xray and risk factors

punched out erosions with rim of cortical bone *risk factors* medications: direutics, low dose aspirin surgery, trauma, hospitlization volume dpletion diet: high protein, high fat, fructose, sweetened beverages heavy alochol underlying medical conidtions: HTN, obesity, CKD, transplant *decreased risk* dairy product intake vit C >1500mg/d coffee intke >6cups/d

delivery planning for nonviable fetus

purpose of planning ot minimize maternal morbidity and motrality vaginal delivery has lwoest risk of materanl complications (eg, hemorrhage, infeciton, injury, PE) and, therefore, is delivery modality of choice

putaminal hemorrahge

putamen = basal ganglia putaminal hemorrahge almost always involes ajdacent internal capsule leads to *contralateral hemiparesis and hemianesthesia* [dirsuption of CST and somatosensory fibers in posterior limb] and *conjugate gaze deviation* towards side of elsion [damage to frontal eye field efferents in anterior limb]

bell's palsy herpzes zoster causing bell's palsy

rapid onset of unilateral upper and lower facial weakness [acute peripheral neuropathy of CNVII] *common findings* inability to raise eye brow or close eye drooping of mouth corner disapperance of nasolabial fold decreased tearing hyperacusis loss of taste sensation over anterior 2/3 of tongue forehead muscle sparing is suggestive of intracranial lesion --> brain imaging for ischemia or tumors acute onset of symptoms (,2d) with maximal clinical paralysis apparent within 3 weeks for most, partial or complete recovery within 6 months lesion above facial nucleus (ie, above the pons) can result in contralateral hemianesthesia or hemiparesis, and dysarthria [Lesion in CNS cause contralateral lower facial weakness that spares the forehead] if caused by herpes zoster: ramsay hunt syndrome

spinal epidural abscess

rare infection of epidural space that can threaten spinal cord and cause paralysis most are from hematologic spread from distant infeciton, IV drug use, or direct incoulation during spinal procedure staph aureus is most common triad = fever, focal back pain, neurologic deficits (eg, motor/sensory change, bowel/bladder dysfunction, paralysis) WBC may be normal; ESR is always elevated *dx = MRI of spine* prompt initiation of broad spectrum IV abx (vanc + ceftriaxone) + uregent decompression of epidural spce with aspiration or surgery

DRESS syndrome

rare, potentially life threatening *drug reaction* charactersed by: *D*rug - mot commonly *allopurinol* and antiepilpetics (eg, phenytoin, carbamzepine) *R*eaction (rash) - morbilliform eruption that starts on face or upper trunk and becomes duffse (>50% of body) and confluent; facial edema is common *E*osinophilia *S*ystemic *s*ymptoms - fever, malaise, and *diffsue lymphadenoapthy*; >1 organ system affected *long latency* (2-8 weeks) between drug intiation and manifestation of symptoms diagnosis is clinical tx = *immediate cessation of inciting drug* and supportive care most patients recover within weeks or months

progessive multifocal leukoecephalopathy

reactivation of JC virus increased incidence in chronic HIV virus spraeds to CNS and lyses oligodendrocytes, causing *white matter demyelination* *symptoms* - slowly progressive AMS motor deficits ataxia vision abnormalities seizure *diagnosis* CT brain: white matter lesions with *no enhancement/edema* lumbar puncture: *CSF PCR* for JC virus MRI = focal, asymmetric lesions *treatment* often fatal if pt has HIV - antiretroviral therapy

X linked agammgaloblenmia

recessive disorder - defect in tyrosine kinase in B cells; results in failed development of bone marrow pre-B cells into mature circulating B cells, which also leads to low immunoglobulin production patients with XLA develop recurrent sinopulmonary (H flu, Strep pneumo) and GI (giardia) infections that can be severe or chronic *diagnosis* decreased immunoglobulins and B cells normal T cell concerntration no response to vaccinations underdeveloped lmyphoid tissue tx = IV IG and ppx abx live vaccines contraindcated

cluster headache

recurrent episodes of acute, severe right periorbital pain accompanied by autonomic manifestations (eg, ipsilateral miosis, lacrimation) but no vision changes = *cluster headache* paroxysms of cluster headache attacks begin during sleep, peak rapidly, last approximtely 90minutes and occur up to 8x a=daily for 6-8 weeks *100% oxygen* by facemask is most rapida cting and effective in aborting a cluster headache subcutenous sumatriptan can be used when there are no contraindications (ischemic cardiac disease, pregnancy) *verapamil, lithium* are key to management and should be started asap after onset of acute attack

mammary paget disease

red, scaly, unilateral, chronic eczematous rash over nipple devleoping into a plaque and then spreading to surrounding areola very well demarcated patients complain of pruritis or burning and often misdiagnosed with eczema important to recognize the associated underlying rbeast cancer does not respond to steroid cream first step - skin biopsy to confirm diagnosis *extrammamry* = located in genitalia, and represents primary adenocarcinoma of skin

how does weight loss help in PCOS

reduction in weight can restore normal ovulation through reduction in adipose tissue volume and resultant decreased peripheral estrogen conversion normalazation of estrogen resolves the LH/FSH imablance, alloweing for an LH surge and ovulation

most common place of origin of atrial flutter

reetrant circuit around tricuspid annulus

postpartum urinary retention

regional anesthesia reduces sensroy and motor impulses of sacral spinal cord, which suppresses micturition reflex and decreases detrusor tone (eg, bladder atony) resulting overflow incontinence urethral cath is more accurate than bladder u/s for diagnosis, and drainage of *>150mL* confirms retention

somatic symptom disorder management

regularly scheduled visits with same provider limit unnecessary workup and specialist referrals legitmize symptoms but make functional improvement the goal focus on stress reduction and imrpoving coping strategies mental health referral if patient will accept SSRI and CBT may be helpful if general measures fail do not try and provide reassurance and only having visits for symptoms; you must not legitizmize their concerns, and if you do routine visits, you stay on top of it

lentigo

result of intraepidermal melanocyte hyperplasia most common in older individuals and charaterized by a round or oval macule with even pigmentation

common fibular neuropathy

result of leg immobilization, leg crossing, protracted suwatting manfiestations are usually transient - foot drop, sensory changes of dorsal foot/latearl shin PE - impaired ankle dorsifelxion and great toe extnesion; preserved plantar felxion and felxes

vitamin K deficiency in newborns

result of poor placental transfer, absent gut flora, immature liver function, inadequately levels in breast milkd presnts with bruising, blood stools, and less commonly - intracranial hemorrahge diagnosis is confirmed by *reversal of s/s with vitamind K administraiton*

infants exposed to hyperglycemia in first trimester

result of poorly controlled prepgancny diabetes higher risk of congenital malforations congenital herat disease microcolon

acquire aplastic anemia

results from injury to bone marrow by radiation, drugs (chemo, abx such as chloramphenicol), insectivides, toxins (benze, carbon tetrachloride), infections drugs: NSAID, sulfonamides, etc. toxic chemicals: benzene, glue, etc. idiopathic viral ifnection: HIV EBV, etc. immune disorders thymoma s/s = pallor, fatigue, weakness, loss of appetite, easy brusiing, petechiae, mucosal hemorrahge, fever labs = normocytic or macrocytic anemia, leukopenia, reticulocytopenia, thrombocytopenia bone marrow bx is needed for diagnosis - hypocellularity with decrease in all cell lines and fatty infilitration of marrow

chylothorax

results from leakage of chyle into thoracic space, often from an obstruction of the thoracic duct can cause lymphocytic predominant effusion fluid is often turbid or milky white

traumatic esophageal rupture

results in pneumomediastinum left sided pleural effusion abnormal contour of mediastinum

polychromatophilic cells

reticulocytes

what side effect of hydroxychloroquine must be watched for?

retinopathy - most common after 5-7years of therapy

patient had recent cath, anticoagulated with heparin. five hours later: hypotension, diaphoretic, clammy, flat neck veins fails to imrpove with 1L bolus

retroperitoneal hematoma due to bleeding from arterial access site (with retroperitoneal extension) local vascular complication at cathter isnertion site - bleeding, hematoma, arterial disseciton, acute thromobsis, pseudoaneursym, AV fistula - are most common complications of cardiac cath most hemorrhage or hematoma form *within 12h* of cath *diagnosis* is confimed with *non-contrast CT scan of abdomen and pelvis* or abdominal u/s *treatment* = supportive, bed rest, IVF, tranfusions surgical repair of hematoma rarely needed since local hematoma formation is not uncommon, patients should be advised to avoid activity or lifting heavy objects 1 week post cardiac cath

scabies

sarcoptes scabiei mite; spread by direct person-to-person *type IV hypersensitvity* to mite, feces and eggs extremely pruritic pathognomonic burrows and small, erythematous papules rash located on interdigital web spaces, felxor wirsts, extensor elbows, axillae, umbilicus and genitalia diagnosis confirmed by light microscopy of skin scrapings revealing mites, ova, feces *treatment* topical 5% permethrin or po ivermectin

actinic keratosis

scaly papules or plaques, most commonly in fair skinned people chornic sun exposure - scalp, face, neck, dorsal surface of hands can progress to squamous cell carcinoma bx lesions that are >1cm in diameter, indurated, ulcerated, rapidly growing, or fail appropraite treatment histo = thickening of epidermis, retention of nuclei in stratum conreum (parakertosis), nuclear atypia, abnormal keratinization w/ thicekning o stratum conreum tx = cryotherapy, largeer areas may need fluoruracil

what diagnostic test should all patients with new dx of cirrhosis undergo

screening endoscopy to exclude varices, determine risk of variceal hemorrhage, and indcate strategies for prevention of hemorrahge esophageal varices are the major cause of morbidity and mortality in patients with cirrhosis

sudden onset of psychosis in child or adolscent workup

search for potenitally reversible conditions - medical disorders, substance abuse *common medical conditiosn to rule out* Systemic lupus erythematosus thyroidits metabolic or electrolyte disorders CNS infection epilepsy

trisomy 18 - Edwards

second most common autosomal trisomy observed in live births diagnosis supsected on prenatal u/s and karyotype confirms diagnosis intrauterine growth restriction microcephaly *VSD* closed fists with overlapping fingers micrognathia prominent occiput rocker bottom feet intellectual disability

ewing sarcoma

second msot common primary bone malignancy xray shows osteolytic lesion with periosteal reaction that produces layers of reactive bone - *onion skin* "moth-eaten" follows as there is extension into the soft tissue diaphysis tx = surgery, radiation and multi-drug chemotherapy radiation or chemo is used preoperatively

hypocalcemia + hyperphosphatemia + CKD

secondary hyperparathyroidism due to need to maintain normal calcium and phosphorus level over time causes parathyroid hyperplasia and secondray hyperparathyroidism results = renal osteodystrophy (pain, fractures) management = low phosphate diet and/or binders (calcium carbonate, calicum acetate, sevelamer); supplementaiton of calcium and vit D

condylomata lata

secondary syphilis plaque like, reddish brown velvety lesions w/o cyst formation broad base, flat surface, lobulated or plaque-like *secondary syphilis* diffuse maculopapular rash beginning on trunk, extending to extremities, involving palms and soles *epitrochlear LAD* = pathognomic grey mucosal patches raised grey genital papules (condyloma lata) widespread lymphadenopathy *tertiary syphilis* CNS - tabes dorsalis, dementia CV - aortic anerusym, aortic insufficiency cutenous (gummas)

rett syndrome ddx = Landau-Kleffner syndrome

seen in *females* *X-linked* MECP2 gene characterized by: normal development with subsequent regression of speech, loss of purposeful hand movements, gait abnormalities and development of stereotypical hand movements at age 6-18 months *decelearation in head growth* is an early sign *hand wringing* seizures occur in most cases with incraesing prevalance with age *landau-Kleffner* = regression of *langauge skills* due to severe epileptic attacks; skills deterioriate at age 3-6 years

coccidiomycosis

seen in Arizona (southwest) spores are easily aerosolized in dry months after a rainy season inhalation of single arthroconidium is sufficient to cause infection (usually 7-14d after inoculation s/s may be subclinicaly, but many develop CAP (fever, chest pain, productive cough, lobar infiltirate) accompanied by *arthalgias, erythema nodosum* or erythema multiforme symptoms last weeks or months diagnosis suspected in any pt living or traveling in edemic region who has lower respiraotry illness for *>1week* confirmation relies on *serologic testing* cxr often normal *treatment* mild-moderate = regular follow up to ensure resolution severe disease or immunosupressed = ketoconazole, fluconazole bx = spherules w/ endospores

CMV retinitis

seen in HIV full thickness retinal inflammation that moves centripetally along the vasculature, causing edema and scarring blurred vision, floaters, photopsia (flashing light sensation) lesion aner fovea, opitc nerve can cause blindness; and scarring increaes risk of retinal detachment dx = *fundoscopy*: yellow white, fluffy, hemorrahic lesions along vasculature blood tests for CMV (PCR) are not sufficient tx = *valganciclovir* HAART

molluscum contagiosum

self limited skin infection caused by poxvirus small skin colored *papules w/ indented centers* - occur anywhere except palms and soles dx is clinical self-limited (resolution within 6-12 months), but tx with curettage, cryotherapy or topical agents (eg, podophyllotoxin) may be considered to prevent further spread, reduce sx, improve cosmesis children most commonly affected transmission skin to skin or by fomites; can be sexual contact in older patients frequently in HIV patients with CD4<100 *impaired cellular immunity* have prolonged course with widely distrubuted disease HIV should be tested for if the lesionsa re widespread or involve the face

congenital rubella snydrome rubella (german measles) in children, adults

sensorineural hearing loss catarcts or glaucoma patent ductus arteriosus risk is highest when maternal infection is in 1st trimester *diagnosis* rubella IgM PCR teting *prevention* maternal immunization with live attenuated rubella vaccine *prior* to conception *children* fever postauricular and suboccipital adenopathy cephalocaudal spread of maculopapular rash [spares palms and soles] *adults* same as children + arthralgias/arthritis

most important intervention in shared psychotic disorder (foli a deux)

separate the pair to disrupt the mutually reifnorcing nature of the shared delusion and to enable a more careful assessment of each individual's pathology

pt underwent liver transplant 2 weeks ago. Today - RUQ pain, high fever, hypotension, inc WBC count. Suggests?

sepsis due to bacteiral infection

cervical mucus plug

serves as barrier to acending infection during pregnancy brown, red or yellowish thick mucus is typically shed before or during labor

splenic laceration / injury

setting of abdominal pain, tachycardia, and lef chest wall and shoulder pain after blunt abdominal trauma use FAST to find hemorrhage those with *normal* FAST but high risk features such as anemia or guarding shoulder undergo *subsquent CT* of abdomen stable with AMS --> CT immedaitely

consequences of thalamic stroke

several weeks to months following stroke, sensory deficits can improve some patients develop *thalamic pain syndrome* (Dejerine-Roussy syndrome) cahracterized by severe paroxysmal burning pain over the affected area and is classically excaberated by light touch (*allodynia*)

malignant (necrotizing) otitis externa

severe infection of external auditory canal and base of skull caused by Pseudomonas pt commonly have poorly controlled diabetes severe, unrelentind ear pain (prominent at night) purulent drainage with sense of fullness conductive hearing loss on affected side facial n. can be involved otoscopy: granulation tissue and edamtous external auditory canal osteomyltitis of skull base of TMJ can develop IV ciprofloxacin is tx

diagnosis of CLL

severe lymphocytosis and smudge cells flow cytoemtry - shows clonality of mature B cells LN and BM biopsies not generally needed

clinical features of severe pancreatitis

severe pancreatitis = pancreatitis + failure of >1 organ severe pancreatitis causes local release of activated pancreatic enzymes that enter vascular system and increase vascular permability within + around pancreas causes large volumes of fluid mirgating from vascular system to surrounding retroperitoneum net effect = widespread vasodilation, capillary leak, shock, end-organ damage tx = *several liters* of IVF

pathophysiology of hypothalamic amenorrhea

severe stress, weight loss or chronic illness cause decrease in amplitude and frequency of GnRH pulses by hypothalamus uworld = patient w/ BMI of 19. She recetly lost 44lbs after giving birth. She has not menstruated in a year. FSH is low. TSH normal. = *hypothalmic amenorrhea* although estrogen repletion can offset bone loss, *increasing caloric intake* and/or decreasing exercise is more effective means of icnreasing bone density

characterization of hepatorenal syndrome

signficant decrease in glomerular filtration in asbence of another cause of renal dysfunction minimal hematuria (<50 erythrocyes/hpf) lack of improvement with volume resuscitaiton HRS occurs as cirrhosis progresses and patients develop splanchnic arterial dilation and overall decrease in vascular resistance this activates RAAS and causes renal vasoconstriction with decreased perfusion and glomerular filtration therapy = reutrn of lvier function therough hepatic recovery or transplant temporary splanchnic vasocnonstrcters (midodrine, octreotide, NE)

patient was a sand blaster. what pneumocosis? what increased risk for?

silicosis - opacities in the upper lobe TB is a complication because silica is cytotoxic to alveolar macrophages work history of: miniming, sand-blasting, granite, glass and ceramic work

pruritic urticarial papules and plaques of pregnancy

skin condition developing in 3rd trimester classic finding on abdominal exam: *red papules within striae with sparing around umbilicus*, sometimes extending to extremities palms, soles and face rarely involved; helps to distinguish from Intrahepatic cholestasis of pregnancy

why do alcoholics go to doctor initially

sleep disturbance (as alcohol wares off at night, CNS hypearousal occurs and results in awakening) anxiety from mild withdrawal

erysipelas

small erytheatmous patch that progresses to red, indurated, tense and shiny plaque most commonly: *group A streptococcus* question stem: warm, tender, erythematous rash with raised well demarcated borders on left side of face, including left external ear generally strep pyogenes *raised, sharply demarcated margin* lmited to epidermis and superficial dermis overlying skin streaking and regional lymphadenopathy indicate lymphatic involvement *treatment* = IV ceftriaxone of cefazolin; w/o systmic symptoms can use po amoxicllin

postpartum hemorrhage

obstetrical emergency and major cause of maternal mortality hemostasis after placental delivery is achieved by clotting and compression of placental site blood vessels by myometrial contraction *definition* >500mL after vaginal delivery >1000mL after cesarean delivery *risks* prolonged or induced labor chorioamniotis multiple gestation polyhydramnios grand mulitparity operative delivery *causes* uterine atony [most common] retained placenta genital tract laceration uretine rupture coagulopathy *treatment* bimanual uterine masssage, oxytocin IVF, O2 uterotonics: methylergonivine[contraindicated in HTN], carboprost [containdcated in asthma], misoprostol intrauterine balloon tamponade uterine a. embolization hysterectomy primary PPH occurs <24h after delivery and is most commonly from *uterine atony* atony occurs when uterus is fatigued (eg, prolonged labor), over distended (fetal weight >4000g), unresponsive to oxytocin from oxytocin receptor saturation other risks: operative vaginal delivery and HTn disorders uterus will be *soft (boggy) and enlarged* (eg, above umbilicus) = uterine atony

bronchiolitis obliterans

obstructive lung disease caused by proliferative narrowing of medium and small bronchioles can occur following a viral infection or inhalation injury and is associated with rheumatologic disease

patient has cerebellar bleed

occipital headache necks tiffness n/v nystagmus *ipsilatearl* hemiataxia of trunk (cerebellar ermis) and/orlimbs (cerebellar hemisphere) if CN's are involves --> hematoma has compressed on brainstem areas

pulmonary contusion

occurs after blunt thoracic trauma *clinical* presents <24h after blunt thoracic trauma tachypnea, tachycardia, hypoxia *diagnosis* rales or decreased breath sounds CT scan (most sensitive) or CXR with patchy alveolar infilitrate *not restricted by anatomical borders* suggested by nonlobular airspace opacities - not always een on intiial cxr after rtauma, but generally develop <24h after trauma and resolve in about a week tx = pain control, pulmonary hygeine, O2

acute cerebellar ataxia

occurs following viral infection symptoms occur 1-3 weeks after infection; resovle in 2 weeks no specific diagnostic test; clinical dx after other conditions have been r/o presents acutely (hours, days) - ataxia, nystagmus, dysarthria vib/2pt not affected

scleroderma renal crisis

occurs in 20% with diffuse cutaenous systemic sclerosis usually occurs within first 5 years of SSc diagnosis increased vascular permeability, activation of coagulation cascade, and icnreased renin scretion sudden osnet of renal failure (w/o previous kidney disease) and malignant HTN (HA, blurry vision, nausea) periphearl smear = microangiopathic hemolytic anemia or DIC with fragmented RBC (eg, schistocytes) and thrombocytoepnia

postpartum thyroiditis

occurs in 8% within firsrt 6 months pt has brief hyperthyroid phase due to release of preformed thyroid subsequent hypothyroid phase often bring pt to medical attention exam - goiter, rbadycardia, diastolic HTN, LE edema, delayed DTR relaxation in hypothyroid phase: TSH elevated, free T4 is low self limited - return to euthyroid state over sever months

immune reconstitution inflammatory syndrome

occurs in patients with HIV initiated on HART treatment and marked by paraxoical worsening of infectious symptoms due to immune system improvement

bile salt diarrhea

occurs in patients with terminal ileal disease (eg, ileal resection, Crohn ileitis) impaired biel absoprtion in ileum leads to increased bile salts in colon, resulting in diarrhea (choleheic diarrhea)

acute angle glaucoma

occurs in people with pre-existing narrow anterior chamber angle aged 55-70 due to sudden narrowing or closure of anterior chamber angle in patients with ACG - lens is more forward and rests against iris; this partially covers anterior chmaber angle and prevents normal flow of aqueous humor, thereby *increasing intraocular pressure* more common in women, Asians, farsightedness severe eye pain pupil will be dialted and poorly responsive to light headache n/v vision loss if no treatment within 2-5 hours of symptoms uregnt opthalamologic consultation is inducated ocular *tonometry* measures IOP can can provide info gold standard = *gonioscopy* done by otphalmologist *treatment* IV mannitol acetazolamine pilocarpine - opens canals of schlemm timolol

catatonia

occurs in severely ill patients with mood disorder w/ psychotic features, psychotic disorders, autism, and medical conditions common features: decreased motor activity, lack of responsiveness udring interview, *posturing*, and waxy flexibility *treatment* benzos and/or ECT lorzepam challenge test resulting in partial, temporary relief within 5-10m confirms diagnosis catatonia generally response to lorazpeam within a week; use ECT if they dont improve

gallstone ileus

occurs when a gallstone passes through a biliary-enteric fistula into small bowel causing s/s of mechanical bowel obstruction as stone advances, it can cause intermittent tumbling obsturction until lodging in the iluem *hyperactive bowel sounds* patients may report distention and inability to pass flatus or stool and show signs of hypovolemia (eg, hypotension, tachycardia) *cholecystitis* - predisposes to biliary-enteric adhesions - is most important risk factor dx is confimed by CT - gallbladder thickening, pneumobilia, obsutrcting stone tx = surgical

severe hypotension after epidural placement

occurs when sympathetic fibers responsible for vascular tone are blockers, causing vasodilation (venous pooling) and decreased venous rturn to the right side of the heart can result in decreased placental perfusion, and fetal acidosis prevented by aggressive IVF prior to epidural placement tx = left uterine displacement (place patient on left side) to imrpove venous turn; additional IVF or vasopressors

warfarin skin necrosis

occurs within first few days of warfarin therapy warfarin inhibits vitaminKdependent clotting factors II, VII, IX, X, and anticoags protein C, protein S decreased protein C initially in relation to the cotting factors in a person with protein C defieincy has hypercoguably state tx = cessation of warfarin, administration of protein C concetrate

sigmoid volvulus

often seen in *elderly* patients who are institutionalized and have an underlying neurologic disorder colonic dysmolity and *redundant* sigmoid colon, likely frmo *chronic constipation* inncrease the risk of torsion of the sigmoid colon around its mesentery this can lead to mehcanical obstruction and ischemia of the intestines, predisposing the colon to dilation, necrosis and perforation most have *progressive* abdominal pain, obstipation, distention and n/v *high pitched bowel sounds* imply active itnestinal motility with severe narrowing or obstruction no stool in rectal vault xray = dilated colon (no hautra) appears in an *inverted U shape*; transition point at site of torsion leads to *no air in rectum*

high-grade squamous intraepithelial lesions

on pap test are concerning for severe neoplasia (eg, CIN2, CIN3) or invasive cervical cancer *all patients require evaluation with immediate colposcopy* colposcope evalutes cervix and vagina under magnification after application of acetic acid to contrast and identify abnormal (*aceto-white changes*) from normal cells cervical neopalsis typically occurs at the *transformation zone [squamocolumnar junction]* if this area is not visualized during colposcopy, an endocervical curettage is performed to evaluate the endocervical canal (this would be deferred during pregnancy due to risk of miscarriage and prterm) cervical biopsy is performed even in pregnancy is a lesion has high grade features (eg, abnormal vessels)

chronic-progressive loss of peripheral vision

open angle glaucoma

treatment of acute deep venous thrombosis/pulmonary embolism

oral FXa inhibitors (rivaroxaban, apixaban) are as effective as warfarin in treamtent of acute DVT or PE and dont increase risk of bleeding complications rapid onset, without need to overlap therapy or monitor INR particuarly good when pt has difficulty with dietary restrictions and frequent INR monitoring of warfarin cant use in renal insufficiency thrombolytics are reserved for hemodynamically unstable patients with PE patient with acute PE for first time should be anticoagulated for 3-6 months with warfarin with an INR of 2.0-3.0

focal seizure

originates from 1 cerebral hemisphere +/- loss of consciousness (generlized) [complex partial seizure] automatisisms involve both hemisperes and are seen in thsoe who lose consciousness motor - jarksonian march, turning of eyes/head/trunk senosry - paresthesias, vertigo, visual phenomena autonomic - sweating, epigastric risign sensation psychic - deja vu, affective changes (eg, fear) EEG will show abnormal electrical activity that is sustained with a distinct start and stop different from patient's background EEG focal seziures are *not* provoked by hyperventilation

tardive dyskinesia patho / management

orofacial dyskinesias and choreathetoid mvoements of trunk and extremities commonly associated with prolonged use of antipsychotic med common for TD to worsen or first appear following dose reudction or discontinuation patho: *doapmine D2 receptor upregulation and supersensitivity* resulting from chronic blockade of dopamine receptors discontinue medication if feasible switch to 2nd gen antipsychotic (quetiapine, clozapien) if continue antipsychotic is required treat with velbenazine

management of threatened abortion. pt is stable.

outpatient observation patients with threatened abortion frequently have uncomplicated pregnancies with normal outcomes

disinhibited social engagement disorder

overfamiliariy and unhesitant approach to unfamiliar adults

classic MRI findings in multiple sclerosis

ovoid plaques in periventicular region, corpus collosum and deep white matter

management of acute exacberation of chronic obstructive pulmonary disease

oxygen (target O2 88-92%) inhaled bronchodilators systemic glucocorticoids abx if >2 cardinal symptoms (inc. dyspnea, inc. cough, sputum production) oseltamvir if influenza NPPV if ventilatory failure tracheal intubation if NPPV failed or contraindicated

morton neuroma

pain between 3rd and 4th toes on plantar surface and with clicking sensation (mulder sign) that occurs when simultaenously palpating this sapce and squeezing the metatarsal joints

massive pulmonary embolism

abrupt increases in RA pressure to >10 mmHg PA pressure >40mmHg decresed cardiac output hypotension *obstructive shock* tx = thrombolytics

evaluation of primary amenorrhea

absence of menrache at age 13 w/o secondary characteristics absence of menarche at age 15 w/ secondary characteristics *complete mullerian agenesis* failure of duct development do not develop uterus, cervix, upper third of vagina does *not* affect ovarian development - thus, these patients have normal secondary charactertistics normal external genitalia

menopause

absent menses for 12 months median age 51 when loss of ovarian function leads to hypoestrogenemia and its sequale: -vasomotor symptoms: hot flashes, sleep disturbance -vulvoaginal atrophy -osteoporsis

biopsy of pemphigus vulgaris /clinical

acantholysis and intraepidermal cleavage *anitbody target*: desmosomes (desmogleins 1 and 3) *clinicaly* flaccid bullae and ulcers mucsoal erosions spearation of epidermis by light friction [nikolsky sign] *histo* intraepidermal cleavage acantholysis - detached keratinocytes tombostone cells along basal layer *immunofluroescence*: netlike intercellular IgG *treatment* systemic glucocorticoids corticosteroid-sparing agents aggressive wound care

skin conditions & associated diseases

acanthosis nigricans - insulin resistance, GI malignancy multiple skin tags - insulin resistance, pregnancy, crohn disease (perianal) PCT, Cryoglobulinemia - hepatitis C dermatitis herpetiformis - celiac dz Sudden psorasis - HIV recurrent herpes zoster - HIV dissmineated molluscum contagiosum - HIV severe seborrheic dermatitis - HIV, parkinson multiple itchy, seborrheic keratosis - GI malignancy pyoderma gangrenosum - inflammatory bowel dsiease

pathophys of Parkinsons

accumulation of slpha-synuclein within neurons of substantia nigra pars compact - leads to death of these neurons cardinal signs = rest tremor, rigidity, bradykinesia *narow based gait*; shuffling gait

acute liver failure

acetaminophen toxicity is msot common cause of acute liver failure in developed countries [*tyelnol will have low bilirubin*] *diagnostic requirements* severe acute liver injury (ALT, AST often >1000 U/L) signs of hepatic encephalopathy (eg, confusion, asterixis) synthetic liver dysfunction (INR >1.5) *indications for liver transplant* grade III or IV hepatic encephalopathy PT>100s serum creatinine >3.4 mg/dl one year survival following liver transplant for ALF is 80%

transient eryhtthroblastopenia of childhood

acquired Red cell aplasia occuring healthy childreen ebtween 6 months adn 5 y/o gradual onset of s/s - pallor, decreased activity tachycardia labs - normocytic normochromic anemia; Hb 3-8 g/dL, very low reticulocyte count

prevention of future gout attacks

acute gout = NSAIDs use prednisone is contraindications to NSAIDs

renal toxicity in etyhlene glycol intoxication

acute kidney injury - direct nephrotoxicity of ylcolate and obsutrciton of tubules by calcium oxalate crystals

favorable prognostic factors in schizophrenia

acute onset (lack of prodrome) identifiable precipitant older age at onset presnce of positive symptoms [opposed to negative] femal gender no family history

therapy terms

adjuvant - tx in addition to standard [radical prostatectomy + radiation] consolidation - given after induction therapy with multidrug regiments to further reduce turmor burden induction - inital dose of tx to rapidly kill tumor cells and send patient into remission (<5% tumor burden [induciton chemo for acute leukemia] maintenace - given after induction and consolidation to kill any residual tumor cells and keep patient in remission [antiandrogen therapy for prostate cancer] neoadjuvant - therapy given before standard therapy for a particular disease [radiation BEFORE radical prostatectomy] salvage - treatment for dsiesae when standard therapy fails [raiation for PSA reucrrence after prostatectomy]

macular degeneration

affects central vision one of eariest signs = distortion of straight lines such that they appear wavy Grid test is used to screen patients *visal acuity* is primary done by the macula primary risk factor is age smoking can increase risk as well atrophic: slowly progressive, bilatearl vision loss [ multiple sores in macular region] exduative: unilateral, aggressive vision loss [blood vessels that may leak, bleed and scar retina] progressive and bilateral loss of *central* vision; peripheral fields and navigational vision are maintained exam in dry MD shows drusen and patchy depigmentation in macular region

endometrial biopsy indications

age >35: atypical glandular cells on pap [gets colposcopy, endocervical currettage and endomtrial biopsy - as it could be either cervical or endoemtrail adenocarcinoma]

anabolic steroid use conseuqnces

aggression male pattern baldness gynecomastia impaired tesitcular function - decresed size and sperm count erythrocytosis HDL decreases

treatment of croup

aimed at reducing subglottic edema mild case = corticosteroid severe cases (stridor at rest) = nebulized recemic epinephrine *prevention* handwashing decontamine surfaces ensure proper ventilation

main substrates of gluconeogenesis

alanine, glutamine, lactate, Glycerol 3P durign fasting, glycogen reserves drop in first 12 hours, by which time gluconegesis starts to play role after 24h, gluconeogesis is sole source of glucose alanine is major gluconegic amino acid in the liver converted to pyruvate by alanine aminotransferase pyruvate is converted to glucsoe through series of reactions

common withdrawal syndromes

alcohol - tremors, agitation, anxiety, delirium, psychosis benzos - tremors, anxiety, perceptual disturbances, psychosis, insomnia [use long-acting benzo and taper it (diazepam) to help with withdrawal] *abrupt withdrawal of benzos --> seizures* heroin - nausea, vomtiing, abodminal crmaping, diarrhea, muscle aches stimulants - increased appetite, hypersomnia, intense psychomotor retardation, severe depression nicotine - dysphoria, irritability, anxiety, increased apeptite

alcoholic cerebellar degeneration

alcohol cessation and nutritional supplementation prevent disease progression, but ambulatory difficulties do not typically improve *other symptoms* intention tremor or dysmetria nstagmus muscle hypotonia --> pendular knee reflex

onset of hallucinations, HTN, tachycardia, hyperthermia, tremors, diaphoresis on 2nd hospital day in heavy alocohol user

alcohol withdrwal - abrupt cessation leads to reflex hyperactivity in certain parts of the brain and manifests as anxiety, insomnia, trmeors and diaphoresis hallucinations and withdrawal seizures can occur most serious effect of withdwawal = delirium trememnrs: disorientation, hallucinations, agitation, HTN, tachycardia, hypertehermia, diaphoresis lorazepam long acting benzos: chlordiazepoxide, diazpam can be used [but are metabolized by liver lorazepam and oxazpam are not metabolized by liver

macrovesicular fatty change on liver bx

alcoholic hepatitis nonalcoholic fatty liver disease

chronic primary adrenal insufficiency

aldosterone levels are *normal* in central (secondary / tertiary) insufficiency *treatment of primary adrenal insufficiency* = hydrocortisone [taken BID to mimic diurnal rhytm of cortisol] - hydrocortisone acts as replacement for *both mineralocorticoids and glucocirtcoids*

caustic ingestion

alkali substance [drain cleaner] - ulcerations of lips, buccal mucosa, pharynx dish soap glass cleaner lamp oil bleach

totoal anomalous pulmonary venous return

all 4 pulmonary veins fail to make normal connection to LA RA recieved blood from both pulmonary and systemic venous systems --> RA and RV enlargement RCK = RV hypertrophy and right axis deviation cxr = increased pulmonary markings due to overcirculation

normal creative and healthy behaviors for young children include imaginary friends, pretend paly, and storytelling with fanciful deatils

all common in elementary school

constitutionally small infant

all fetuses with estimated weight <10% for gestational age require serial u/s to assess growth and umbilical doppler evaluation to asess placental functiona nd prevent intrauterine fetal death doppler shows *appropriate interval growth*

treatment of rheumatoid arthritis

all patients diagnosed with RA should be started on DMARDs ASAP as jiont damage begins early in it course *nonbiologic DMARDs*: methotrexate, hydroxychloroquine, sulfsasalazine, leflunomide, azathioprine *biologic DMARDs*: etancerpet, infliximab, adalimumab, toclizumab, ritxuimab methotrexate is preferred inital DMARD in pateints with moderately to severely active RA patient who doesnt responda fter 6 months may require biologic DMARD such as TNFa inhibitors as stup up

management of blunt abdominal trauma in hemodynamically stable patients

all patients with blunt abdominal trauma, even those without specific signs of intra-abdominal injury, should be assessed for intraperitoneal hemorrhage most commonly used approach for alert and hemodynamically stable patients is the FAST

eryhropoietin therapy

all patients with signficant renal failure and hemoglobin <10g/dl are candidates up to 30% of pts on erythropoietin therapy develop new or worsening *hypertension*, which typically occurs 2-8 weeks after treatment generally mild, but can lead to severe end organ damage

carotid a. atensois management

all patients with stenosis should have intensive mgt - aspirin, statin, BP control; lifestyle changes symptomatic patients (TIA, stroke) + high grade stenosis (70-99%) --> carotid endarterectomy

routine prenatal laboratory tests

all pregnant women without contraindications shoudl receive the *inactivated influenza vaccination* as soon as it becomes available safe during every trimester and while breastfeeding women who are at risk for undiagnosed type 2 DM shoulder undergo screening during their initial prenatal visit with a HbA1c or glucose tolerance test everyone else should undergo glucose challenge at 24-28 weeks

pneumocystits jiroveci pneumonia

almost exclusively in *HIV* patients; but can be seen in patients taking *chronic glucocorticoids* corticosteroids are used in patients with impaired oxygenation (<92%, PaO2<70, A-a graident >25) b/c of the TMP-SMX transient increase in inflammation from lysed organisms pt on prolonged glucocorticoids shoudl receive TMP/SMX prophylaxis

ventilation perfusion of lungs / pathology effects

alveolar consolidation in pneumonia causes markedly impaired alveolar ventilation in affected portion of lung this results in hypoxemia due to *right-to-left intrapulmoanry shutning* of blood and extreme V/Q mismatch (V=0) *dead space ventilation* = ventilation areas of lung that are not perfused with blood (eg, pulmonary embolism)

low ACh activity + dementia s/s

alzheimers

central retinal artery occlusion

amaurosis fugax - painless, rapid and transient monocular vision loss "curtain descending over visual field" most common etiology = retinal ischemia due to atheroscleoritc emboli originating from ipsilateral cartoid a. opthalmic a. is first intracranial branch of ICA; supplies blood to eye via retinal a. and ciliary branches (supply choroid and aterior portion of globe) patients with vascular risk factors (HTN, HLD, smoking) should have *duplex u/s of neck* vision returns when embolus is broken up or displaced and retinal circulation is restored carotid bruits support the diagnosis risk factors - HTN, DM, CAD workup includes *u/s of carotids* to evaluate for stenosis fundoscipic exam = often normal, can show embolic plaques and retinal whitening *management* ocular massage carbogen therapy (5%CO2 and 95% O2) or hyperbaic oxygen showed ot be benefiical if given early carotid u/s atherosclerotic tx (eg, aspirin, statin) most develop *signficant permanent visual loss*

treatment for human bite wound treatment for cat bite

amoxicillin-clavulante - covers Gram positive, gram negative, and beta-lactamase-producing oral anaerobic organisms surgical debridgement may be necssary wounds are left open to drain and heal by secondary intention tetanus vaccination should be given to those who are not up to do *cat bite tx* = prophylaxis with amoxicillin-clavulante [activity against Pasteurella multocida and oran anaerobes]

workup for suspecetd pancreatitis

amylase rises within 6-12 hours of smyptoms; lipase rises with 4-8h [more useful and sensitive because it remains elevated longer] imaging NOT required in typical abdominal pain and elevated amylase/lipase once diagnosis of pancreatitis is confirmed, u/s can be used to find cause (eg, gallstones)

aromatase inhibitors

anastrozole letrozole used in postmenopausal estrogen receptor positive breast cancer increase osteoperosis baseline bone density scan required before initation

pt has inoperable pancreatic cancer. has a 7cm AAA. next step?

aneurysm should be repaired due to its large size

simple noninvasive test for peripheral vascular disease treatment of disease

ankle brachial index ratio of systolic BP in either posterior tibial or dorsal pedis to systolic BP in brachial artery normal ABI = 0.9-1.3 <0.9 = periphearl arterial disease <0.4 = severe ischemia diabetes with calcfied noncompressible vessels = falsely elevated ABI *treatment of PAD* smoking cessation, diabetes control, HTN control low dose aspirin + statin therapy supervised exercise program cilostazol - used in persistent symptoms despite antiplatelet therapy and exercise surgical revascularization is last step

treatment of chlaymdia and gonorrhea chlamydia & gonorrhea in women

annual screening for chlamydia and gonorrhea is recommended in all *sexually active women age <25* and women >25 with risk factors (eg, multiple sexual partners, inconsistent condom use) empiric: ceftriaxone + azithromycin Confirmed chlaymdia w/o gonorrhea: azithromycin or doxycycline confirmed gonorrhea w/o chalmydia: ceftriaxone and azithromycin [due to increasing cephalosporin resistance, current guidlines recommend combo of ceftriaxone and azithromycin]

nondominant parietal lobe lesions

anosognosia - dneial of ones diabilities contralatearl apraxia - inability to carry out learned purposeful movements

most common location in leg for compartment syndrome

anterior compartment - tibialis anterior, extensor hallucis longus, Anterior tibial A., deep fibular n. *compartment syndrome* results when a rise in intracompartmental pressure impairs arterial circulation leads to ischemia of tissues of the compartment and to necrosis if the pressure is not relieved clinical diagnosis; extremely tight /hard anterior leg to palpation equisite tenderness loss of sensation in nerve distrbution *treatment* = emergent surgical fasciotomy to prevent ischemic necrosis

treatment of fibromuscular dysplasia

anti-HTN: ACE inhibitors, ARBs PTA (percutenous transluminal angioplasty) surgery if PTA unsuccessful

antibodies in primary biliary cholangitis

anti-mitochondrial

goodpastures

antibodies to alpha3 chain of type IV collegen nephritic syndrome pulmonary symptoms fom hemorrage renal bx = liner IgG along GBM on immunoflouresnce is *diagnostic*

diagnosis/management of antiphospholipid syndrome

anticogulation - heparin, warfarin use *LMWH* to reduce risk of recurrent pregnancy loss when using warfarin, an INR of 2.5-3.5 is indicated *biggest risk factor for APS* = SLE all positive serology for APS needs to be repeated at 12 weeks as some healthy people have transient antiphospholipid antibodies *Lupus anticoagulant prolongs PTT* as it binds to the phospholipids in most assays This artificat does not correlate with bleeding in viva *prolonged PTT is an indidrect indicator presnce of Lupus Anticoagulant* and highly suggestive in correct clnical setting

OTC cold and cough preps contain ingredients that can cause confusion and hallucinatiosn

antihistamine = confusion, hallucinations alpha agents = agitaiton, psychotis via sympathomimetic properties dextromethorphan = dissociative ss, halluciantions via NMDA antagonist

antibodies seen in Hashimoto thyroidtis *myxedema coma*

antithyroid peroxidase antithyroglobulin *myxedema coma* complication of hypothyroidism AMS, hypothermia, hypotension, hypoventilation tx = IV T3 and/or T4, hydrocortisone, fluids, blanket, respiratory therapy

early diastolic murmur at left lower sternal border capillary pulsations in fingertips/nail beds

aortic regurg

systolic ejection murmur at right upper sternal border that radiates to carotids

aortic stenosis soft 2nd heart sound from poor mortion of aortic valve leaflets most common cause in elderly patient = degenerative calcification of aortic valve leaflets younger patients = bicuspid is most common nondeveloped countries = rheumatic valve disease

most appropriate treatment to prevent arterial occlusion (thromboembolism) in setting of atrial fibrillation

apixaban - novel anticoagulant (along with dabigatran, rivaroxaban, edoxaban) *cilostazol* can not be used in setting of acute limb ischemia this is a PDE inhibitor occasionally used for symptomatic management of patients with intermittent claudication

what is pathophys of vaso-occlusive crisis in sickle cell acute chest syndrome

pain is due to *microvascular occlusion* from isckled RBC, leading to local tissue damage, hypoxia and acidosis leukocytosis due to stress triggers are viral ifnecitons, dehydration, cold, stress tx = hydration, NSAIDs, opioids *acute chest syndrome* - most common cause of death in sickle cell patients sickling within pulmonary vasculature --> intrapulmoanry inflammation, increased permeability of pulmonary microvasculature, lveolar sonlidation characterized by new pulmonary infiltrate with alveolar consolidation on chest xray present with fever, chest pain, tachypnea, wheezing/coughing, hypoxia *tx* - RBC with Hb target no greater than 10, ceftriaxone, VTE prophylaxis

patients with psychiatric diagnoses can give informed consent as long as they have capcity, meaning that their judgement and decision making abilities are determined to be intact at time of treatment

pain medications can alter menstal status. If patient has no signs of sedation of incapability - then taking an opioid does NOT restrict their right to make decision

neuroblastoma

arise from *neural crest cells* (precursor cells of sympathetic chains and adrenal medulla) most common cancer in *first year of life* can arise anywhere in sympathetic nervous system - typically involves adrenal glands prsents as abdominal mass that *crosses the midline* with systemic symptoms *clinical* median age <2 abdominal mas periorbital ecchymoses (orbital metastases) spinal cord compression from epidural invasion (dumbbell tumor) opsoclonus[rapid eye movements] - myoclonus [rhytmic jerking of trunk] syndrome (antibody mediated 'dancing eyes and feet') calcifications and hemorrahges are seen on plain xray and CT scan *diagnostic findings* elevated catecholamine metabolites small, round blue cells on histology N-myc gene amplifcation prognosis depends on clinical factors, tumor histology and genetic characteristics (amplication of N-myc and hyperdiploidy)

herpetic whitlow

painful, vesicular hand rash - can occur on fingers, palms HSV2 if in contact with active genital lesion HSV1 - health careworkers exposed to orotracheal scretions symptoms = prodrome of fever, malaise; followed by development of focal area of grouped vesicles on eryheamtous base tingling, burning, pain are common most resolve in 2-3w, but immunocrompormised may require acyclvoir lesions recur in 20-50%

normal internal genitalia external virlization undetectable serum estrogen 46, XX

aromatase defieincy first manifests in utero with inability of placenta to convert androgens into estrogens, leading to transient masculinzation of mother that resolves after delivery at birth, female infants have normal internal genitalia and ambigious external genitalia due to high levels of gestational androgens in adolesence, patients have delayed puberty, osteoporosis, undetectable estrogen levels (eg, no breast development), and high concentrations of gonadrotropins that result in polycystic ovaries

presence of 1st degree AV block + wide QRS

associated with conduction delay below AV node, most often in bundle branhces unpredictable progression should have EPP testing for site on delay

ebstein anomaly

associated with maternal lithium use during pregnancy cyanosis and heart failure due to severe tricuspid reguritation triple or quadruple gallop: widely split S1 and S2 plus a loud S3 and/or S5 holosystolic or early sysolic murmur at left lower sternal border ekg = tall P waves, Right axis deviation cxr = extreme cardiomegaly from heart failure

indications for urgent hemodialysis

asterixis - bilateral, non rythmic, alternate flexion and extension movements at wright

aspirin exacerbated respiratory disease

asthma chornic rhinosinusitis with nasal polypsosis bronchospasm or nasal congestion following ingestion of aspirin or NSAIDs nasal polyp symptoms = bland tasting food [secondary to anosmia] and reucrrent nasal discharge polys = bilatearl, grey, glistening mucoid masses in nasasl cavities surgery provides temporary relief; but polyps recur, thus management is geared towards underlying etiology

open angle glaucoma

asymptomatic in early stages more common in AA, diabetics, fam hx of glaucoma gradual loss of peripheral vision over years, and eventual *tunnel vision* intraocular pressure = high; can have cupping of optic disc with loss of peripheral vision tx = timolol early in management; laser trabeculoplasty is adjunctive if pressure continues to increase, surgical trabceulotomy is done

indications for prophylactic administration for anti-D immune globulin for Rh(D)-negative patients

at 28-32 weeks gestation <72h after dleivery of RhD+ infant <72h after spontaenous abortion ectopic pregnancy threatened abortion hydatidform mole CVS, amniocentesis abdominal trauma 2nd and 3rd trimester bleeding external cephalic version

colonic angiodysplasia

painless bleeding in right colon characterized by dialted submucosal veins and AV malformations icnreased incidence after *age 60* more frequently diagnosed in patients with advanced renal dsiease and von willebrand disease angiodysplasia is more common in pt with aortic stenosis, due to acquired vW factor dificiency low volume (venous) bleeding diagnosis is made on *endoscopy* however it is not uncommon for angiodysplasia to be missed on colonscopy due to poor bowel prep or location behind a haustral fold asymptomatic = no treatment anemia or gross or occult blood = cautery

subclavian steal syndrome

atherosclerosis of left subclavian artery proximal to origin of the vertebral artery signficant stneosis or occlusion leads to decreased pressure in the distal subclavian a. and reversal of blood in ipsilatearl vertebral artery most are asymptomatic when symptomatic, patients most commonly have symptoms of *ischemia in affecter UE (eg, pain, fatigue, paresthesias)* less commonly will have veretbrobasilar ischemia if have concurrent athersclerosis of circle of willis exercersinga ffected UE causes arterial vasoidlation and futher lowering of distal pressure, which may exacerbate verebrobasilar symptoms physical exam shows *lower brachial systolic BP (eg, >15mmHg)* in affected arm and a *systolic bruit* in the supraclavicular fossa on affected side *diagnosis* = doppler u/s or MRA tx = lifestyle mangemnet (Statins, smoking cessation)

immune thrombocytopenia

autoantibodies are directed against platelet membrane antigens, leading to destruction of antibody-platelet complexes in the spleen course is usually self-limited with spontaneous recovery within 6 months besides CBC, only other labs to order are HIV and HCV if risk factors present

anti-NMDA receptor (anti-NMDAR) encephalitis

autoimmune ecephalitis that tends to present as a multistage syndrome with characteristic features meadian age of 21; 4x more commen in women >50% have associated *ovarian teratoma* flu-like prodrome Psychiatric: anxiety, psychosis, insomnia autonomic instability: hyperterhmia, HTN, tachycardia short term memeory impariment rigidity dystonia focal seizure if diagnosis is not made promptly, anti-NMDAR encephalitis can progress to mutism, hypoventilation and decreased consciousness clinical diagnsis *confirmed* by presence of CSF antibodies to *GluN1 subunit of NMDAR* prompt tumor removal has better outcomes regardless of tumor removal, *immunosuppression* is cornerstone of therapy 80% have minimal sequelae in 2 years

friedreich ataxia

autosmal recessive - trinucletide repeat (GAA) in frataxin protein (high in brain, heart, pancraes): *neurologic dysfunciton, cardiomyopathy, diabetes mellitus* most common type of spinocerebellar ataxia *symptoms usually begin before 22 y/o* neuro - loss of DTR, gait/limb ataxia in adolsence loss of position and vibratory hypertrophic cardiompathy - increased risk of arrhytmia and her tfailure skeleated - kyphoscoliosis and pes cavus dx = genetic testing death = 30-40y/o from cardiomyopathy and respiratory complications

lynch syndrome (hereditary nonpolyposis colorectal cancer)

autosomal dominant colorectal and endometrial cancer germline mutation in DNA mismatch repair gene once dx made - colonscopy screening endometrial screening begins at age 30-35 - prophylactic hysterectomy and oopohrectomy at age 40 or if childbearing complete

marfan syndrome

autosomal dominant - *fibrillin-1* gene results in systemic weakening of connective tissue joint hypermobility skin hyperelasticity long figners - arachnodactlyl, thumb sign pectus excavatum scoliosis/lyphosis long face, palate high arch, teeth crowded lens dislocation (ectopia lentis), iridodenoesis (rapid contraction and dilation of iris), myopia (from globe elongation) mitral valve prolpase *upward* lense aortic root dilation is most life threatening finding --> aortic regurg requires monitoring with echo for nauerys and aortic arch dissection first degree relatives should udnergo genetic testing

familial adenomatous polyposis peutz-jeghers syndrome

autosomal dominant - AFP mutation annual sigmoidosocpies starting at age 10-12 annual colonscopies once colorectal adenomas are detected or if pt is >50 y/o shuld have regular screening for upper GI tumors proctocoloectomy should be performed in pt who initially present with CRC or adenomas with high grade dysplasia *petuz-jeghers* GI tract harmatomatous polpyosis small, perioral, mucocutenous pigmented macuels

mode of inheritence of hypertrophic cardiomyopathy

autosomal dominant - cardiac myosin binding protein C gene, cardiac beta myosin heavy chain gene

osteogenesis imperfecta

autosomal dominant - type I collagen mutation (COL1A1) patients have frequent fractures from minor trauma once they are mobile (around age 1) dentinogenesis imperfecta: opalscent blue-gray or yellw-brown discoloration of teeth ause by discolored dentin shinning through translucent weak enamel joints are hypermobile due to ligemntous laxity scleral thinning --> blue sclerae other s/s = hearing loss (fracture of ossicles) [this can cause speech delay], short stature *prognosis = lethal if fatal perinatal type II disease* diagnosed via antenatal u/s findings of multiple fractures, shortened femur, hypoplastic thoracic cage, growth restriction

hereditary spherocytosis

autosomal dominant, northern european *clinical*: hemolytic anemia, jaundice, splenomegaly *patho* - defect in RBC membrane proteins (most commonly ankyrin), resulting in unstable, round RBC these fragile RBC cannot travel through tight spaces in microcirculation, such as the spleen neonate can present with jaundice that is refractory to phototherapy *labs* increased MCHC spherocytes increased indirect bilirubin negative coomb test increased osmotic fragility on acidifed glycerol lysis test abnormal eosin-5-maleimide bindnig *treatment* folic acid blood tranfusions splenectomy [decreases anemia and gallstone risk; but does not change the increases MCHC in the RBCs] *complications* pigmented gallstones aplastic crises from Parvovirus B19 infection

homocystinuria

autosomal recessive deficiency of cystathionine synthase (eznyme in methionine metabolism) Marfananoid habitus fair complexion thromboembolic events - pyridoxine can be given to help lower these risks intelluctal disability *downward* lens

wilson disease (hepatolenticular degeneration)

autosomal recessive disease of *younger indivudals* mutation of ATP7B presents in individuals aged 5-35 y/o Hepatic copper accumulation Leaked from damaged hepatocytes deposits in tissues (eg, basal ganglia, conrea) *clinical* heaptic: acute liver failure, chronic hepatitis, cirrhosis neurologic: parkinsonism, gait disturbance, dysarthria psychiatric: depression, personality changes, psychosis if presenting in acute liver failure - one exception to the ALF presentaiton - *low alk phos* *diagnosis* decraesed ceruloplasmin incresed urinary copper excretion kaysey-fleischer rings inreased copper content on lvier biopsy *treatment* chelators: d-penicillamine, trientine zinc: interferes with copper absoprtion liver transplant is curative

riley-day syndrome

autosomal recessive in Ashkenazi Jews gross dysfunciton of ANS with severe orthostatic hypotnesion

legg-calve perthes disease

avascular necrosis of the hip *clinical* boys age *3-12* [peak 5-7y/o] mild hip/knee pain and limp - *antalgic gait* resitred hip abduction, internal rotaiton positive trendelenburg sign inital xray = normal in early disease later - femoral head flattening, fragmentation, sclerosis MRI: avascualr necrotic femoral head *treatment* non-weight bearing splinting, possible surgical reapir

fracture of surgical neck of humerus may cause.... anterior shoulder dislocation posterior dislocation

axillary n. injury w/ paralysis of deltoid and teres minor muscles and sensory loss over lateral upper arm *anterior dislocation* are cuased by blow to externally rotated and abducted arm when head of humerus is displaced anteriorly, there is *flatenning of deltoid*, protrusion of acromion, and anxterior axillary fullness patient holds arm abducted and externally rotated *axillary n.* is most commonly injured by anterior shoulder dislocations - motor to deltoid, teres minor and skin over lateral shoulder *posterior dislocation* happens when there are severe muscle contractions secondary to electric shock or seizure present with arm internally rotated and adducted coracoid process will be prominent w/ flattening of anterior shoulder where humerual head used to be tx = prompt immobilization w/ sling until closed reduction in ER

clue cells

bacterial vaginosis - gardnerlla malodorous, thin, white vaginal discharge in absence of inflammation (eg, pruritis, erythema) pH>4.5 amine odor with KOH (whiff test) tx = metronidazole or clindamycin

cat-scratch disease

bartonella henselae: gram negative bacilli transmitted by cat scratch/bit *clinical* papule at scratch/bit site reigonal adenopathy in 1-2 weeks; LAD may take 1-2 months to resolve fever of unkown origin >14d *diagnosis* clinical +/- serology *treatment* self limited azithromycin

ulcerated pearly nodule with rolled border on sun exposed skin

basal cell carcinoma - most common skin cancer *possible features* persisent open sore that bleeds, oozes, crusts reddish patch or irritated area pearly or translucent nodule that is pink, red or white elevated or rolled border w/ central ucleration pale scar like area with poorly difned border if it occurs on the lip --> *upper lip* *treatment* - varies depending on size, depth, location low risk, extrmeities: ED&C facial lesion: Mohs Nodular, trunk: surgical excision

where do most hypertensive hemorrhages occur? what herniation pattern can be seen?

basal ganglia --> uncal herniation

amiodarone side effects

baseline CXR and PFT are usually obtained prior to intiating therapy longterm surveillance is guided by development of s/s

torus palantinus

benign bony growth located on midline suture of hard palate due to *genetic* and *environmental* factors younger, female Asians usually <2cm, but can increase in size throughout life thin epithelium over bony growth tends to ulcerate with normal trauma of oral cavity and heal slowly due to a poor vascular supply surgery is indicated for patients in whom mass becomes symptomatic, interferes with speech or eating, or causes problems with fitting of dentures later in life

mature cystic teratoma

benign ovarian tumor that occurs at age 10-30 physical exam - adenxal fullness or firm ovarian mass this prompts an u/s: ovarian cyst, typically with calfications lap cystecomy is tx of choice dermoid cysts have intraoperative appearnce of thick sebaceous yellow fluid with ectodermal (teeth, hair, mesodermal and endodermal components) intraperitoneal spillage of cyst contents should be avoided as it can cause chemical peritonitis

pt describes intermittent, short episodes of vertigo (sensationg of spinning), when rolling out of bed

benign paroxysmal positional vertigo secondary to displcement of otoliths from normal location dx = Dix-Hallpike maneuver tx = maneuvers to respoition displaced otolith such as Epley maneuver medications not very helpful

meningioma

benign primary tumors arising frmo meningiothelial cells more commonly found in middle-age to elderly women can cause signficant neurologic symptoms fi they become large enough to cause mass effect on critical neurovascular structures MRI - extra-axial well circumscribed or round homogenously enhacing dural-based mass tumors usually undergo *calcification* and can appear hyperdense on non-contrast CT diagnosis is confirmed intraoperatively tx = surgical resection

giant cell tumor of bone (osteoclastoma)

benign, locally aggressive skeletal neoplasm seen in young adults present with pain, swelling, decreased range of joint motin at involved site epiphyseal region of lonng bones, msot commonly distal femur and proximal tibia xray = expansile and eccentric lytic area (*soap bubble*) pathology shows sheets of large osteoclast giant cells that appear round-to-oval polygonal or elongated mononuclear cells *tx* = surgery

management of DKA & HHS

best markers indicating resolution of ketonemia is *serum anion grap* and direct assay of *beta-hydroxybutyrate*, which is predominate ketone in DKA BH is converted to acetoacetate and acetone which can be measured by the commonly used nitroprusside test, but this test doesnt detect BH itself

overdose on meds: bradycardia AV block hypotension diffuse wheezing

beta blocker overdose can produce cardiogenic shock, and the wheezing hypoglycemia, bronschospasm, neurologic dysfunction tx = glucagon - increases cAMP (can treat beta blocker and CCB overdose)

hydatidiform mole

bhcg level >*100,000*

characteristic features of neurofibromatosis 2

bilateral acoustic neuromas cataracts

looser zones

bilateral and symmetric pseudofractures characteristic of *osteomalacia*

cyanosis and respiratory distress during feeding that improves when infant cries

bilateral choanal atresia congenital nasal malforation caused by failure of posterior nasal passage to canalize completely: leaves bony or membranous obstruction Can be part of CHARGE syndrome: coloboma, heart defect, atresia choanae, retardation of growth/dvelopment, GU anomlies, ear abnomlriaties/deafness severity depends on infants ability to breath through mouth and whether one or both choanae is/are obstruction bilateral - cylic cyanosis worsening when infant cant breathe through mouth and recovers when they do *failure to pass catheter* through nares is suggestive diagnosis confirmed by *CT* first step in management - plce oropahryngeal airway and orogastric tube feeding defintive treatment reapiring obstruction w/ surgery or endoscopy

presbycrusis

bilaterally symmetric hearing loss - sensorineural hearing loss w/ aging [6th decade] - begins with high frequency noises subjectivine tinnitus advanced age absence of other neurologic signs

small for gestational age

birth weight <10th percentile for gestational age *maternal contributing factors* preeclampsia malnutrtion plancetal insufficiency multiparity drug use *fetal factors* genetic factors chromsoomal abnoramlities congenital ifnection inborn errors of metabolism *compliations* IUGR - symettrical vs. asymmetrical hypoxia perinatal asphyxia meocinium aspiraiton hypothermia - dec subq fat hypogylcemia - dec glycogen stores hypocalcemia - dec Ca tarnsfer across palcenta polycythemia (incraesed EPO from fetal hypoxia)

memantine

blocks action of glutamate on NMDA receptor used in moderate-severe Alzheimers

what is greatest risk of developing when receieving parenteral nutrition?

bloodstream infeciton - central line associated bloodstream infection

multiple myeloma manifestations

bone pain, fractures constitutional - weight loss, fatigue *labs* normocytic anemia renal insufficiency hypercalcemia --> constipation, fatigue monoclonal paraproteinemia >10% plasma cells on bone marrow biopsy is diagnostic bone marrow infilitration by neoplastic cells causes osteolytic lesions, fractuers, hypercalcemia and emia patients with MM are prone to *infection* - cause if ineffective antibody production and *Hypogammaglobulinemia* respiratory (eg, strep pneumo) and UTI are most common infections

infectious cause of *bilateral* facial n. palsy

borrelia burgdoferi - *lyme diseaes*

nonGI foodborne disease

botulism - descending paralysis ciguatera toxin - paresthesia scombroid - fluishing, urticaria listeria - meningitis vibrio vulnificus - cellulits, sepsis hepatitis - jaundice brucellosis - fever, arthralgias

pt has abdominal pain and bloody diarrhea after AAA repair

bowel ischemia - inadeqaute perfusion to left and sigmoid colon after loss of the IMA during aortic graft placemnet

complications of supracondylar fracture of the humerus

brachial a. injury (most common) median n. injury (most common) cubits varus deformity compartment syndrome/Volkmann icshemic contracture (<1% - humerus + forearm fractures) compartment syndrome will have 6Ps of arterial occlusion + firm tightness palpable in the area

patient has multifocal neurologic symptoms and multiple periphearl enhancing lesions on MRI

brain metastases

what is first signs of puberty in girls

breast development age 8-12 pubic hair follows therache onset of menarche (around tanner 4) = 2-2.5 years after breast bud development average age 12.5

maternal estrogen effects in newborns

breast hypetrophy (girls and boys) swollen labia physiologic leukorrhea (whitish vaginal discharge) uterine withdrawal bleeding

vitamin D deficiency rickets

breast milk needs to be supplemented with 400IU of vitamin D daily tx of established rickets = 1000-2000IU per day

main risk factor for developmental dysplasia of the hip

breech presentation in utero

what is more common in asbetsos exposure - pleural mesothiolioma or bronchogenic carcinoma

bronchogenic carcinoma - espeically in smokers

biopsy of lung lesion

bronchsocopy - central lesoins, lower diagnostic yield pecutenous - used for high suspcion lesions

digital clubbing

bulbous enlargement and braodening of the fingertips due to conenctive tissue proliferation at the nail bed and distal phalanx diagnosed when angle between anil fold and nail plate is >180 (*Lovibond angle*) can occur by itself or associated with hypertrophic osteoarthropathy: joint enlargement, periostosis of long bones, synovial effusions most common causes of secondary lcubbing = *lung malignancy, cystic fibrosis, R-->L cardiac shunts* megakaryocytes skip normal route of fragmentation within pulmonary circulation to enter systemic icruclation megakaryocytes become entrapped in distal fingertips due to large size release PDGF and CEGF --> growth promotion of connective tissue and capillary

clinical indicators of thermal and smoke inhalation

burns on face singeing of eyebrowns oropharyngeal inflammation blsitering or carbon deposits carbanceous sputum stridor carboxyhemoglobin >10% hx of confinement in burning building tx initally with high-flow oxygen; maintain low threshold for intubation in any pt with evidence of thermal damage to upper aiway

initial treatment for a hyperkelamia with ECG changes

calcium gluconate - stabilizes cardiac cell membrane this is only temporary effect other tx such as insulin, bicarb and/or cation exchange resin such as Kayexylate will be required to reduce K+ level

pseudogout

calcium pyrophosphate dihydrate crystals in joint sapce common complication of *hyperparathyroidism* with chronic hypercalcemia also asscoiated iwth hypothyroidism and hemochromatosis presents with acute pain, swelling, redness, and limited motion of involved joint [*knee most commonly affected*] *diagnosis* inflammatory effusion (15k-30k) CPPD crystals: rhomboid, +birefrigency chondrocalinosis (calcfication of articualr cartilage) *treatment* intraarticular glucocorticoids NSAID colchicine synovial fluid = inflammatory effusion; *rhomboid shaped, positively birefringent crystals*

thoracic aortic aneurysm

can be asymptomatic or present with chest, back, flank or abdominal pain depending on aneurysm location *ascending* start anywhere from aortic valve to innomniate artery most often due to cystic medial necrosis (occurs with aging) or CTD (marfan, ehlers-danlos) *descending* distal to left subclavian artery due to atheroscleorsis, HTn, hypercholesterlemia, smoking cxr = widened mediastinal silhoutte, increased aortic knob, tracheal deviation

hearing impariment in children

can be due to a variety of causes, both hereditary and acquired most common cause is *conductive hearing loss* due to repeated ear infections hearing impariment can be *mistaken* for other behavioral or pervasive developmental disordres if undetected, it can lead to poor language development, lack of social skills, and self-isolation if pt has normal audiometry exam, then after this exam, had multiple ear infecitons, you must *repeat audiometry testing* to assess for acquired hearing loss

urinary 5-hydroxindolacetic acid (5-HIAA)

carcinoid syndrome - intermittent flushing and bronchospasm, abdominal cramping, secretory diarrhea, right sided valvular disease primary carcinoid tumors are in the *small intestine*

37 y/o presnts to ER with weakness, dizziness. Two episodes of syncope in last 8 hours. For past week has ahd mid chest discomfort and left sided neck pain. Returned from hiking in CT 2 weeks ago - he had sore throat and dry cough. Does *not* recall tick bites. On PE, lungs are CTAB. Thready pulses over radial arteries that disappear with deep inspraiton. dx?

cardiac tamponade - result of viral pericarditis given recent hx of sore throat and dry cough pericarditis can cause retrosternal chest pain that radiates to left arm and shoulder - may account for symptoms that occurred the week before patient presented to hospital current sx of weakness, dizziness, syncope are explained by severely depressed cardiac output that occurs in patients with cardiac tamponade pulses paradoxus is typical freature of pericardial tamponade ddx: -acute myocarditis: does not have pulsus paradoxus

vesicoureteral reflux

cause of recurrent UTI in infants and cildren VUR causes urianry reflux from bldder into the kidney, and the regurgitant urine causes dilation of the ureters and kidneys definitive diagnosis made by *contrast voiding cysourethrogram* - done after recurrent UTI's recommended that children with first UTI at age 2-24 months undergo *renal and bladder ultrasound* to evaluate for any anatomic abnormlaities that might predispose to VUR recurrent and/or chronic pyelonpheritis can lead to blunting of calices and focal parenchymal scarring renal scintigraphy with dimercaptosuccinic acid is preferred modality for long term evluation of renal scarring monitor serial creatnieine, HTN, anemia

aminoglycoside ototoxicity

cause ototoxicity ) hearing loss) by damaging cochlear cells genatmicin is known for dmanging vestibular inner ear also causing a vestibulopathy patients experience *oscillopsia* - sensation of obejcts moving around in the visual field when looking in any direction abnormal *head thrust* test can help detect vestibular dysfunciton due to gentamicin pt looks at fixed taget; rapid head movement away fmor target normally causes eyes to remain fixe don target however, pt with vestibulopathy are unable to maintain eyes on target - the eyes move away and then return back to the target with a horizontal saccade

rocky mountain spotted fever

caused by *rickettsia ricketssii* edemic to US east coast [misleading name] causes small vessel vasculitis [petechial rash] incubation is 2-12 days prodrome: headache, malaise, fever rash appears 2-6 days late ron extremities (wrists/ankles) spreads cnetrally to palms/soles and trunk *PE* erythematous maculopapular rash appears rash may lead to cutenous necrosis AMS and/or coma can be seen in later stages *treatment* doxyclcine is first line for non-pregnant and children chloremphenicol = pregnanct

peptic stricture

caused by GERD, radiation, sclerosis, caustic ingestions slowly progressive dysphgia to solids without anorexia or weight loss as they progress, they block relfux, leading to improvemnt of heartburn symptoms symmetric, circumferential narrowing on barium swallow bx is necssary to rule out adenocaricnoma

multiple sclerosis patho of trigeminal neuralgia

causes *bilateral* trigeminal neurlagia by *demylination of the nulcues* of the trigeminal nerve or the nerve root, which causes improper signlaing of nerve and paroxysms of severe pain

acute exacerbation of COPD is characterized by...

change in >1 of the following: cough severity or frequency volume or character of sputum produciton level of dyspnea most common trigger = URI *cardinal symptoms* increased dyspnea increased cough (more frequent or severe) sputum proudction (change in color or volume) *diagnostics* cxr = hyperinflation abg = hypoxia, CO2 retention *management* oxygen: target O2 of 88-92% inhaled bronchodilators systemic glucocorticoids antibiotics if >2 cardinal symptoms or if mechanical ventilation required oseltamivir if evidence of influenza NPPV if ventilatory failure tracheal intubation if NPPV failed or contraindicated empiric abx = macrolides + respiratory fluroquinoline or penicllin/beta-lactamase abx for 3-7 d

interstitial lung disease

characterized by *pulmonary fibrosis* that leads to stiffening of lungs and decreased lung compliance progressive dyspnea and nonprodutive cough are most common presenting symptoms auscultation: velco like crackles PE: clubbing, s/s of cor pulmonale restrictive spirometry causes: chronci dust exposure, drug toxicity, connective tissue dz, idiopathic (>50% hve smoking hx)

major depressive disorder

characterized by SIG-E-CAPs 5/9 needed for diagnosis associated with hyperactivity of HPA axis --> increased cortisol levels decreased hippocampal and frontal lobe volumes REM sleep latency and slow wave sleep are *decreased* *adequate antideprssant trial* = 4-6 weeks inadeqaute dose or duration is common reason for perceived lack of response *treatment length* sing episode, unipolar major depression - 6 months after remission recurrent MDD (>2 years) - maintence of 1-3 years highly recurrent (>3 episodes) - tx indefinately

amyotrophic lateral sclerosis

characterized by asymmetric distal weakness combo of *upper and lower motor neuron* signs is characterisitic limb, axial, bulbar and/or respiratory muscle can be involved sensation is typically preserved cognitive dysfunciton can occur diagnosis is made on clinical grounds most affected >40 *riluzole* - glutamate inhibitor prolongs survival and time to tracheostomy side effects: dizziness, nausea, weight loss, LFT elevaiton, skeletal weakness

microscopic colitis

characterized by frequent *watery* bowel movements, fecal urgency, incontinence and *nocturnal diarrhea* risk factors: Age >50, female, smoking, NSAID use mechanism is unclear, but most likely an abnormal mucosal response in genetically predisposed poeple stool studies should be performed to r/o infection *colonscopy* is need to make diagnosis: *inflammatory infiltrates with a mononculaer predominance* management includes avoiding inciting agents such as NSAIDs and starting anti-diarrheal agents corticosteroids (budesonide) can be given for refractory disease

female sexual interest/arousal disorder

characterized by lack of, or significantly reduced, sexual interest/arousal diagnosis requires ruling out psyhcological, medical and substance/medication-related issues that may affect sexuality do *not* assume that as women age they become less interested in sex

delayed sleep wake phase disorder

characterized by sleep onset insomnia and excessive morning sleepiness "night owls"

communication failures between physicians during patient handoffs are a large contributor to medical errors and adverse patient outcomes

checklists are an important tool to prevent undesired medical outcomes that result from physicianc ommunication fialures during patient hadnoff process

approach to patient with suspected pulmonary embolism

chest CT can show *wedge-shaped, pleural based opacification* that is likely to occur distal to completely occluded pulmoanry artery PE is common cause of both transudative and exudative pleural effusion *acute onset dyspnea, pleuritic chest pain* tacyphnea, tachycardia, low grade fever most common ECG = *tachycardia* pathonomoic = S1, Q3, T3 *low O2 and afib* are associated with *poor prognosis*

patient presents with s/s of lambert eaton myasthenic syndrome. next step in diagnosis?

chest CT scan - looking for small cell lung carcinoma

what is common in the childhood of ppl with borderline disorder

childhood trauma - abuse, neglect

when should po abx be given for acute otitis media? clinical of acute otitis media

children with high fever, severe pain or bilateral pain children with lowgrade fever, mild/no pain, and nuilateral dz = consider analgesia *acute otitis media* infection of middle ear fluid younger pts prediposed due to narrow/straighter eustachian tubes AOM often follows URI; congestion allows fluid accumulation and bacterial growth in middle ear space, and ifnection tympanic membrane *decreased mobility on pneumatic insufflation* = middle ear effusion *bulging of tympanic membrane* = middle ear inflammation

reactive attachment disorder

childrenw tih hx of neglect, social withdrawal, lack of positive response to attempts to comfort and decrased emotional responsiveness the inconsistent care disrupts development of a healthy, secure attachment to caregivers seldom seek comfort, and do not response to attempts to comfort them

most common cause of sterile pyuria with associated urethritis in sexually active ptient...

chlamydia trachomatis

urethritis in men

chlaymdia is not seen on gram stain; dx made with NAAT testing

manifestations of sarcoidosis

chronic multisystem disorder due to *non-caseating granulomatous inflammation* definitive diagnosis requires bx showing granulomas - bronchoscopy with transbronchial bx is often performed to obtain tissue diagnosis cardiac sarcoidosis - complete AV block, restrictive cardiomyoapthy (early), dialted cardiomyopathy (late), valvaualr dysfunction, heart failure sudden death can occur due to complete AV block or ventricular arryhtmia *treatment for symptomatic sarcoidosis is oral corticosteroids*

chaga disease

chronic protozoal disease cause by trypanosoma cruzi common throughout latin america *primary manifestations* megacolon/megaesophagus [destruction of ernves controlloing GI smooth muscle] cardiac disease - prolonged myocarditis

psoriasis

chronic skin condition characterized by hyperkeratosis, leading to well demarcated erythematous plaques with a white or silver scale primarily on extensor surfaces (knees, elbows) additional complications = nail changes (pitting, onycholysis), ocular inflammation (conjuctivitis, uveitis), arthritis local skin trauma (koebner phenomnon) dx = history and PE skin biopsy may be necesarry tx = topical high potency glucocorticoids or vitamin D derivatives (calcipotriene)

chalazion

chronic, granulomatous inflammation of meibomian gland hard, painless lid nodule more common in patients with rosacea or eyelid margin blepharitis patients develop eyelid swelling and erythema that progress to solitary (usually painless), ruberry, nodular lesion besti visualized when eyelid is everted often resolve spontaneously, but larger lesions may beneift from *warm compress* to enhance drainage and speed healign persistent or severe lesion = resection and/or glucocorticoid injection

ichthyosis vulgaris

chronic, inherited skin disorder characterized by diffuse dermal scaling mutations in *filaggrin* gene skin is dry and rough with horny plates resembling scales condition worsens late rin life, during the winter due to decrease humidity if simple emollients are inefective, keratolytics and topical retinoids are useful for controlling symptoms f

primary biliary cholangitis

chronic, progressive lvier disease characterized by cholestasis with autoimmune destruction of intrahpeatic bile ducts *clinical* women, insidious onset insidious onset of fatigue and pruritis progressive jaundice, hepatomegaly, cirrhosis cutenous xatnthomas and xanthelasmas *labs* cholestatic pattern of lvier injury (increased Alk phos, increased LFTs) *antimitochondrial antibody* severe hypercholesterolemia *complications* malabsoprtion, fat soluble vitamin deficiencies metabolic bone disease: osteoporosis, osteomalacia, osteoperosis hepatocellular carcinoma first do u/s - suggests intrhepatic cholestasosis; next step is anti-mitochodnrial titers *positive ANTIMITOCHONDRIAL antibody* *ursodeoxycholic acid* is drug of choice UDCA is hydrophilic bile acid that decreases biliary injury by the more hydrophobic endogenous bile acids increases biliary secretion and may have additional anti-inflammatory and immunomodulatry effects UDCA *delays histologic progression in PBC* and may improve symptoms and possibly survival *should be initiated as soon as diagnosis is made, even in asymptomatic patients* advanced disease will need liver transplantation

pancreatic adenocarcinoma

cigarette smoking is most consistent reversible risk factor for pancreatic cancer tumor marker = *CA19-9* as tumor exapnds, they compress pancreatic duct and common bile duct (*painelss jaundice*), sometimes seen on imaging as double duct sign backup of bile leads to *intra- and extra-hepatic* biliary duct dilation, and a nontender, distended gallbladder [*Courvoiseier sign*] most originate in the *head* of the pancreas - jaudnice, steatorrhea jaundice --> u/s (head) no jaundice --> CT scan (body, tail) u/s is usually done first, if this is negative, get an abdominal CT if CT is nondiagnostic, consider an ERCP

duodenal atresia

classically presents with *biilous vomiting within first 2d of life* no abdominal distention is present as gas is unable to pass duodenum associated with *down syndrome* prenatal u/s = *polyhydramnios* due to inability to swallow and removal amniotic fluid xray = air trapped in stomach and first portion of duodenum = *double bubble sign* tx = holding enteral feeds, decompression with NG or OG tube placed to suction; surgical repair

surgical wound classification

clean - unifected operative wound in which there has been no violation of respiratory, alimentary, genital or infected urianry tract clean-cotaminated - respiratory, alimentary, genital or urinatry tract has been entered, but under controlled conditions and without unusal contamination of field contaomined - open, fresh, accidental wounds or surgical wounds in which there has been major breaks in sterile tehqniue or gross spillage frmo GI tract dirty - old traumatic wounds or operative fields with pre-existing infection

workup of pharyngitis

clinical: sore throat, dysphgia, odynophagia, pharyngeal/tonsilary eythema Viral symptoms: cough, rhinorrhea, conjuctivits, oral ulcers presnce of exudates, edema, palatal petechiae, absence of viral symptoms --> *rapid antigen test* if positive --> *po penicllin or amoxicillin* if negative --> throat culture (postive = strepo, negative = viral) rapid strep testing has low sensitvity (RSAT is signicant for diagnosis), but all negative RSAT need a throat culture throat culture is gold standard cannot use centor criteria in preadolscents [was developed for adults] antibiotic therapy in children should be reserved for *proven* cases of GAS empiric tx can be done once cultures have been obtained

watery diarrhea predominant

clostridium perfringens Enterotoxic e coli enteric viruses cryptosporidium cyclospora intestinal tapeworms

neonatal tetanus

clostridium tetani is ubiqutious in soil, and neonatal tetanus can result when at-risk infants are exposed C tetaine produces *teatnospasmin* (toxin) that prevent inhibitor neurotransmitter release at junction of upper and lower motor neurons unhibited LMN --> *spasms, hypertonicity* stridor + respitaory failure indciates diaphragm and upper ariway is conflicted *tx* - supportive, abx (penicllin), passive immunization with teatnus immune globulin

mechanism of tetnatus

clostridium tetani secrets toxin toxin binds to peripheral nerve terminals uses retrograde axonal transport arrives at CNS synpase - blocks release of *inhibitory NT's: glycine and GABA* from the synpatic cleft because of this long mechanism, symptoms occur within a few days to several weeks following inoculation and can include sweating, dysphagia, labile blood pressure, tachycardia

treatment of hoarding behaviors

cognitive behavioral therapy SSRI can be used adjunctively for comorbid depression and anxiety disorders

differential diagnosis for a crying infant

colic usually resolves by age 4 months; best to review calming techniques - swinging, swaddling, minimizing environemntal stimuli, holding/rocking abby

pancreatic pseudocyst

collection of pacnreatic fluid enclosed by a wall pseudocysts are common 1-2 weeks after onset of acute pancreatitis pseudo cysts are mature walled-off pancreatic fluid collections surrounded by a thick fibrous *capulse* and containing enzyme-rich fluid, tissue and ebris while usually asymptomatic, it may cause abdominnal pain, early satiety, and jaundice *diagnosis made by CT scan* if cyst is <6cm w/o signs of infection = NPO, observe if cyst >6cm + doesnt resolve within 8 weeks - endoscopic cystgasteotomy or cystduodenostomy; cyst drains into staomch *simple tx guidelines* minimal or no symptoms w/o complications = extecptant management (eg, sx tx, npo) signficant sx, infected pseudocyst, pseudoaneursym = endoscopic drainage *never* do needle aspiration fluid collection = pancreatic enzmyes, blood, fluid, tissue debris

diagnostic choice for suspected GI CMV in HIV

colonscopy w/ biopsy eosinophilic itnranuclear and basophiliic intracytoplasmic inclusions serology doesnt conclsuvely prove end organ disease (colitis)

graft-versus-host disease (GVHD)

common after bone marrow transplantation target organs are: skin: maculopapular rash involving palms, soles and face intestine: blood positive diarrhea liver: abnomral LFT and jaundice *pathophysiology*: recognition of host major and minor HLA-antigens by donor T cells and consequent cell-mediated immune response

herpes simplex encephalitis

common and severe form of viral encephalitis present with fever, headache, seizures, confusion and stupor over course of a few days CT, MRI, EEG shows abnormalities in *frontotemporal* region of brain [MRI is preferred to CT, as CT may be falsely negative] patients have temporal lobe pathology: temporal absed seizures, anosmia, gustatory hallucinations, bizarre behavior Kluver-Bucy syndrome: hyperphagia, hypersexuality; rare behavioral syndrome that cna be seen CSF = lymphocytic pleocytosis, elevated protein, elevated RBC, normal glucose RBC elveation from hemorragic destruction of frontotemporal lobes *PCR of HSV DNA in CSF* is gold stnadard for diagnosis *IV Acyclovir* is tx of choice

dermoid ovarian cyst (mature cystic teratoma)

common benign germ cell tumor occuring in premenopausal women *excessive growth of well-differentiated ectodermal cells* cyst contains sebaceous fluid, hair and teeth adnexal fullness on exam in otherwise asymptoamtic patient is common can cause ovarain torsion; not prone to rupture u/s = *hyperechoic nodules and calcifcations* tx =surgical removal

acute cholangitis

common bile duct obstruction by gallstone or malignancy fever, jaundice, RUQ pain, elevated alk phos biliary drainage by *ERCP* with sphincterectomy is suggested

neonatal polycythemia

common cause is *delayed clmaping of umbilical cord*, resulting in excess transfer of placental blood in-utero hypoxia, or poor placental gas exchange as hematocrit rises, the visocisity of blood increases and impairs blood flow to various organs increased RBC mass can lead to hypoglycemia and hypocalcemia due to increased cellular uptake asymptomatic = hydration by feeding and IVF symptomatic = partial exchange tarnsfusion [blood removed for NS to normalize HCT]

lactose intolerance mechanism

common cause of adult onset diarrhea due to malabsorption and presnts in adutls age20-40 lactose is preoceeded into glucose and galactose by intestinal lactase on the brush border of duodenum symptoms occur as the osmotic load of undigested lactose passes through the intesines, drawing water into the lumen and decreasing transiet time colonic bacteria ferment lactose, creating short chain fatty acids and hydrogen gas (bloating)

lumbar spinal stenosis

common cause of back and lower exremity pain in patients >60 spinal stenosis is msot commonly caused by *degenerative osteoarthritis* of spine narrowing of lumbar spinal canal leads to compression of nerve roots, leading to pain in back and lower extremities weakness and sensory symptoms can occur as well extension of lumbar spine further narrows spinal canal and worsens symptoms - *shopping cart sign* [exercise with spine flexes = no symptoms] classic s/s is *neurogenic caludicaiton* - lower extremity pain with *extension* of spine xray can show degnerative changes but *MRI* is more definitive

osgood-schlatter disease

common cause of knee pain in adolscent male athlets periods of rapid growth in which quadriceps tendon puts traction of the apophysis of tibial tubercle where pateller tendon inserts improves with rest; worsens with sports edema and tenderness over tibial tubecle firm mass from heterotopic bone formation pain reproduced from *extending knee against resistance* xray = nonspecific, anterior tissue swelling, lifting of tubercle from shaft, irregularity or fragmentation of tubercle tx = activity restriction, stretching, NSAIDs

bile leak

common complication after a lap chole low grade fever, RUQ pain, n/v after surgery assoicated leukocytosis and obstructive-appearing liver zneymes are present most cases present 2-10 days after procedure imaging should show *normal appearing biliary ducts* tx = surgery

intraventricular hemorrahge

common complication in neonates born at *<30 weeks gestation* or *<1500g* susceptibility to due to capillary fragility of subependymal germinal matrix and immature autoregulation of cerbral blood flow screening with *serial head u/s* is necessary as 25-50% are asymptomatic presentation - lethargy, hypotonia, high pitched cry, rapidly increasing head circumference, bulging fontaneles prevention of preterm labor and antenatal maternal corticosteroids are only intervention that can reduce icnidence of IVH and impove overall motrality

mechanism of antibiotic associated diarrhea

common complication of abx therapy (pencillins, cephalosproins, clindamycin) results from disruption of normal enteric bateria flora most commonly identified cause is C. diff - stool assay for C diff toxin producing gene can confirm diagnosis

superficial thrombophlebitis

common condition caused by inflammatory process that results in thrombus within superficial veins most often seen in lower extremities, but can also affect penis and breast or anywhere that an IV catheter has previously been placed present with painful, erythematous cords in affected area can only be diagnosed when DVT has been ruled out can progess to deep veins with time tx is aimed at controlling symptoms and consists of NSAIDs, elevation and support stockings anticoags and excision are only considered if thrombosis extended to deep veins pt should undergo repeat exam in 7-10d to look for progression

neonatal respiratory distress syndrome (hyaline membrane disease)

common in *premature* and *very low birth weight* (<1500g) incidence is related to gestational age; almost all in extremely preterm (*<28 weeks*) neonates primary problem = *surfactant deficiency*; immature alveoli are unable to produce sufficient surfactant to reduce alveolar surface tension *following symptoms develop within minutes to hours after birth in an attempt to compensate for diffuse alveolar collpase* tachypnea [RR>60] grunting [to increase end expiratory pressure] nasal flaring [decreases nasal airway resistance] retractions [intercostal muscels contract and pull in the compliant chest wall] hypoxia and cyanosis [reflects signficant atelectasis] cxr = diffuse, reticulogranular (ground glass) appearnce; air bronchograms, low lung volumes reduced risk from *maternal antenatal glucocorticoids* neonatal treatment = CPAP

bartholin glands pathology

paired, 1cm mucosal glands bilaterally at base of lbia minor; drain into vestibule at 4' and 8' oclock not palpable normally ducts of glands can be obstructed, causing nontender cystic swellings (bartholin gland cysts) cyst is *aymptomatic* unless it is large (>3cm) - symptomatic cysts can be I&D, followed by Word catheter if cyst becomes infection --> *abscess* (polymcirobial; E coli most commonly) abscesses are painful unilateral labial swelling - cant walk, sit or have sex exam - tender, flucutant mass in medial aspect of labium majus protruding into introitus tx - I&D and insertion of Word catheter reduces risk of recurrence allowing fistulous tract formation and imrpoved duct drainage marsupialization is reserved for recurrent abscesses once acute infection resovles

patient from developing country + GI discmofrt + malaborption + eosinophilia

parasitic infection - do stool analysis for ova and parasites

>4y hx of asymmetric rigidity, resting tremor, shortned stride. New onset exceutive and visuosptial disfunction, visual hallucinations. Cuase?

parkinson disease dimention PDD can be treated with cholinesterase inhiitors psychotic symptoms treated with dose reduciton in anti-parkinsonian agents and/or low potency antipsychotics (pimavenserin, quetiapine) if parkinsonism predates cognitive impairment by >1y, then PDD should be diagnosed

multiple system atrophy (Shy drager)

parkinsonism autonomic dysfunction: postural hypotension, abrnoaml swaeting, distburance of bowel/bladder, abnoraml salivtion/lacrimation, impotence, gastroperosis wdiespread neurologic signs: cerebellar, pyramidal, LMN

immaturity of hypothalamic-pitutairy-ovarian axis

common in adolsecents who recently undergone menarche failure to produce appropriate quanitties and ratios of GnRH, and therefore LH and FSH, to induce ovulation as a result, during first few years post menarche, the majority menstraul cycles are *anovulatory* and present as *painless, irregular, heavy bleeding* in anovulatory cycles, progesterone is not produced due to lack of corpus luteum formation endometrium continues to proliferate due to unopposed estrogen, and eventually sheds, leading to breakthough bleeding in patients with AUB, bleeding after exogenous progesterone administration confirms normal endogenous estrogen production and proliferative endoemtrium tx = progestin or with OCP to help regulat emenses anovulation typically resolves 1-4 years postmenarche, after which menstrual cycles normalize

renal artery stenosis

common in older patients; high prevalence in those with severe HTN or PAD most common correctable cause of secondary HTN and should be suspected in resistant HTn and duffse atherosclerosis aggressive risk factor reduction to prevent CV disease (aspirin, optimal diabetes and HLD control, smoking cessation) inital medical tx = ACE or ARB ACEI can cause a rise in serum createnine (acceptable rise is <30%) close monitoring is needed revascularization is not superior to medical therapy for BP control or reudction in CV outcomes with unilateral or bilatearl RAS; used in refractory cases

intertrigo

commonly due to *canida* *factors that increase risk*: disruption of skin barrier function due to friction (eg, obestiy) excessive moisture (eg, occlusive clothing, high heat/humidity) impaired immune function (eg, HIV, glucocorticoid therapy) local environment conducive to microbial grwoth (eg, diabetes with hyperglycemia) diagnosis mainly based on clinical features KOH prep or fungal cultures can confirm diagnosis candida appears as *pseudohyphae* with *buddying yeast forms* (blastoconidia) tx = topical antifungals (nyastatin, miconazole) with good skin hygeine and measures to keep affected area dry

hepatitis A

commonly presents with fever, vomiting, abdominal pain followed by jaundice and pruritis dark urine and pale stools may occur tender hepatomegaly LFTS >1000 U/L, bilirubinemia, elevated alk phos diagnosis = anti-HAV IgM antibodies in serum transmisison = fecal-oral; commonly in international travelelers, men-men, drug users *treatment* supportive completely recover in 3-6 weeks fulminant liver failure is rare; occurs in patients >50 with preexisting chronic liver disease postexposure prophyalxis with either HAV vaccine or HAV immuno globulin should be considered for close contacts HAV is now included in routine childhood vaccines

clomiphene citrate

commonly used in ovulation inudciton in patients with PCOS binds to and depletes estrogen receptors in the hypothalamus this blocks negative feedback effect of cirucalting estradiol allowing increased gonadotropin-releasing hormone pulse freqeuncy concentrations of FSH and LH are increased, which act to stimulate ovarian follicular development

what is affected in a positive drop arm test

compelte supraspinatus tear MRI is needed for diagnosis tx = surgery

vitiligo

complete depigmentaiton - *melanocyte destruction* *clincal manifestations* depigemtned macules on acral areas and extensor surfaces; face commonly affected lesions may be symmetrical, dermatomal, or unilatearl *clinical course* most cases progress gradually repigmentation is spontaneous in 10-20% increased incidence of other autoimmune disorder *limited disease* - topical corticosteroids *extensive/unresponsive dsiease* - oral corticostoeids, topical calcinuerin inhibitors, PUVA

turner syndrome

complete or partial *deletion of an X chromosome* results in *gonadal dysgensis* - presents as streak ovaries on pelvic u/s (ovaries with minimal or not follicles) associated with kyphoscoliosis = curvature of spine in 2 planes (AP and lateral) most common cardiac abnoramlity: bicsupid aortic valve > coarctation of aorta low estrogen - primary amenorrhea w/o breast develop increased FSH and LH due to low estrogen dx = karyotype *tx* = human growth hormone indicated if height falls <5th percentile [stopped once epiphyseal fusion has occurred] estrogen/progestin therapy - inudce sexual development, improve growth/height, increase bone mineral density

approach to childhood lead poisoning

confirmatory venous lead is needed if a screening capillary lead level is >5ug/dl if lead exposure is found on confirmed venous level; relocation to lead free enviornment is most imporatant step

diagnosis of bullous pemphigoid

confirmed with BIOPSY of lesion = subepidermal cleavage IF = linear pattern of Ig on basement membrane

diamond blackfan anemia

congenital *pure red cell aplasia* presents in first 3 months of life w/ pallor and poor feeding CBC = normocytic or macrocytic anemia w/ reticulocytopenia *triphalangeal thumbs* *pathogenesis*: congenital erythroid aplasia *clinical* craniofacial abnormalities triphalangeal thrumbs increased risk of malignancy *labs* macrocytic anemia reticulocyto*penia* normal plt, WBC *treatment* corticosteroids RBC tranfusiosn

supravalvular aortic stenosis

congenital LV outflow tract obstruction due to discrete or diffuse narrowing of ascending aorta causes a systolic murmur - *first R ICS* unequal cartoid pulses differenital BP in upepr extremities palpable thrill in suprasternal notch develop LV hypertrophy over time coronary a. stenosis can be associated these changes, along with increase in myocardial oxygen demand during exercise --> ischemia --> angina

gastrochisis

congenital abdominal wall defect lateral to umbilicus with herniation of *uncovered bowel* elevated serum AFP gastrochisis is generally an *isolated defect* inflammation increases risk of necrotizing enterocolitis and bowel obstruction --> short bowel syndrome nutrients are lost across expsoed bowel --> FGR, oligohydramnios tx - cover bowel with sterile dressing and plastic warp mmedately after delivery; NG --> abx --> surger

patient has semptic emboli off of aortic valve. just began treatment with IV abx. next step?

continue and observe if patient fails the abx, or develops signifcant dysfunction resulting in heart failure --> aortic valve surgery

indications for neuroimaging in child with headache

coordination difficulties presence of numbness, tingling or focal signs history of headache awakneing from sleep history of increasing headache freqeuncy

correction of calcium for lowered albumin

corrected calcium = (measured Ca) + 0.8 (4 - serum albumin) lowered serum albumin decreases amount of total Ca

acute bacterial rhinosinusitus

cough, nasal discharge fever face pain/HA *etiologies*: Strep pneumoa >nontypeable H flu > moraxella catahrrlis *diagnostic criteria - 1/3* persistent symptoms >10d w/o improvement severe onset (fever >39C + drainage) >3d worsening symptoms following initial improvement *treatment*: amoxicllin +/- clavulante

which childhood airway disease is associated with stridor?

croup - laryngotreacheitis parainfluenzavirus - fall/early winter inspiratory stridor barking cough hoarseness xray=steeple sign

trisomy 13 - Patau syndrome

cutis aplasia - asbence of epidermis over the skull micropthalmia holoproencephaly omphalocele

cutoff value

cutoff to higher value: sensitivity decreases, specificity increases cutoff to lower value : sensitvity increases, specificity decreases

abnormal uterine bleeding defintion

cycle occurs q24-38d lasts <7d any deviation from this is *abnormal uterine bleeding*

polycystic ovary syndrome

pathophysiology: -increased testosterone -increased estrogen -LH/FSH imbalance *oral glucose test* is needed for T2DM screening [more sensitive than standard fasting glucose and HbA1c] what cancer are PCOS pt's increased for? *endometrial* - decresed progesterone secretion due to chronic anovulatory cycles --> unbalanced proliferation of endometrium by estrogens tx w/ cyclic prgoresteon, combined OC's or progesterone releasing IUDs helps protect endometrium from hyperplasia and reduces cancer risk *first line treatment for menstrual regulation* weight loss and combined estrogen/progestin oral contraceptives COC's reduce hirsutism by blocking adrenal androgen secreion and increasing producion to SHBG (binds and decreases free testosterone) *spironolactone* [androgen receptor anatgonnist] - treatment of hirsutism

intranuclear opthalmoplegia {differential ddx included}

damage to *medial longitudinal fasiculus* MLF Is a paired neural tract that mediates communication between CNIII and CNVI nuclei, allowing for coorindated horizontal eye movements bilatearl lesions are seen in multiple sclerosis unilater lresions in lacunar stroke in pontine a. distrbution conjugate horiztonal gaze disorder affected eye (ipsilateral to lesion) is unable to adduct and contralatearl eye abducts with nystagmus) convergence and pupillary light reflex are preseved *differential* edinger-westphal nucleus lesion: parasympathetics to eye --> ipsilated fixed, dilated pupil that is nonreactive to light or accommodation lateral geniculate nulceus: relays info to ipsilateral primary visual cortex --> contralateral homonoymous hemianopsia trochlear nerve: ventrical diplopia that worsens when affected eye looks down and towards nose (walking downstairs, reading); comepsnate by tucking chin and tiling head awy from affected eye

hypertensive disorders of pregnancy

ddx: white coat HTN never has DBP >105 *normal BP changes* pregnancy causes marked systemic vasodilation that lowers BP by 5-10mmHg from baseline during first trimester; BP generalyl returns to baseline during 3rd triemster *maternal risks due to hyperetnsion* superimposed preeclampsia postpartum hemorrhage gestational diabetes abruptio placentae cesarean delivery *fetal risks due to hypertension* fetal growth restriction perinatal mortality preterm delivery oligohydramnios

when pt is volume depleted what is mechanism of them becomming hypolvolemic, hyponatremia

dec renal perfusion --> RAAS --> increased water and sodium reabsoprtion nonosmtic stimulation of ADH: angII increases ADH, hypovoelmia (stimulates stretch receptors in LA), hypotension (stimualtes baroreceptors in carotids) consequnt salt and water retention help correct hypoveolemia however, in setting of ongiogn ADH secretion, *hypotonic* hypovolemic hyponatremai develops due to retention of relative excess total body water ADH levels remain high until hypovolemia is roccted IV-NS can treat this and replnished salt stores, restores euvolemia and shuts of nonomstic stimuli for ADH release

patient is on chronic glucocorticoids and has cushing features. abruptly stops. what biochem abnormalities to be found?

decreased ACTH decreased cortisol normal aldosterone

patient has thoracentesis down and 2L of yellow fluid is taken off. 2 hours after procedure, patient is dizzy and diaphoretic; hypotensive, 91% sats on 40% O2. Dull to percussion on left, no breath sounds. Cause of symptoms

decreased LV preload - intercostal a. was most likely hit during the thoracentesis this would cause the hypotension, and hemothorax accumulation hemothorax will cause blunting of costophrenic angle or diaphragmatic surface if there is *>400mL of blood* thearpy for *confirmed* hemothorax = tube thoracostomy Thoracotomy and surgical exploration are required if inital draingae is >1000mL (*massive hemothroax), there is 150-200mL from tube after 2-4 hours, or hemodynamic stability remains compromised after tube placement

genitourinary syndrome of menopause

decreased estrogen causes atrophy in superficial and intemrediate layers of vagina and urethral mucosal epithelium diminished urethral closure pressure and loss of urethral compliants --> urgency, freqeuncy, UTI and incontinence (stress and urge) atrophic epithelium makes vulvae more susceptible to trauma, inflammation and infection patients often have vulvar irritaiton, vaginal bleeding, dyspareunia, urianry incontence PE - sparse pubic hair, loss of rugae, shortneed vagina

porphyria cutanea tarda

deficiency in *uroporphyringen decarboxylase* most common porphyrai painless blisters that heal with scarring increased skin fragility on dorsal surfaces of the hands facial hypertrichosis hyperpigmentation triggered by ignestion of certain stubactes (eg, ethanol, estrogens) most common in patients with underlying hepatitis C

what predicts prognosis of astrocytoma

degree of anaplasia Gliobastoma is a grade IV astocytoma = worst prognosis

long term supplemental oxygen therapy for COPD

demonstrated prolonged survival and quality of life with those with signifcant chronic hypoxemia resting arterial oxygen tension (PaO2) <55mmHg or SaO2 < 88% on room air PaO2 <59mmHg or SaO2<89% in patients with cor pulmonale, evidence of right heart failure or *hematocrit >55%* dose of supplemental oxygen should be titrated so that SaO2 is maintained at >90% during sleep, normal walking, and at rest survival benefits are when it is used >15 hours of a day

succinylcholine

depolarzing NM blocker that works by binding to postsynpatic ACh receptors to trigger influx of sodium and efflux of potassium ions through ligant-gated ion channels depolarization occurs and temporary paralysis ensues (delayed repolarization of skeletal muscle membrane) succinylcholine often used in rapid sequence intubation rapid onset (45-60s) and offset (6-10 minutes) in certain patients can cause life threatening cardiac arrhyhtmia due to severe *hyperkalemia* these pts have upregulation of post synpatic Ach receptors *which can cause massive efflux of K following succinylcholine*: burn patients diuse muscle atrophy denervation (eg, stroke, guillain barre syndrome, critical illness polyneuropathy) to avoid hyperkalemia - use *nondepolarizing blocking agents* (vecurnoium, rocurnoium) as they dont affted postsynaptic ligand-gated ion channels

indications for cognitive behavioral therapy

depression generalized anxiety disorder PTSD panic disorder COD eating disorders negative thought patterns

when is ECT first line for depression

depression with psychotic features severealy depressed elderly patients who are not eating ro drinking and required rapid intervention pregnancy imminent risk for suicide

difference b/w polymositis and dermatomyositis

dermatomyositis has typical skin findings

spinal cord compress characterized by injury to:

descending CST - lower extremity weakness and loss of rectal tone ascneding sensory spinothalamic - sensory level is 2 spinal cord segments below level of lesion descending autonomics in reticulospinal - urinary retntion/bladder faccidity/bladder hosck

workup for patient diagnosed with hypertension

detailed H&P *basic tests* urinalysis for occult hematuria and urine proteine/creatinine chemistry panel lipid profile baseline EKG

factitious disorder / malingering disorder

patient *intentionally* produces illness with goal of assuming sick role *absence* of external reward differenitates this from malingering *malingering* intentional proudction or exaggeration of pyhsical or psychological symptoms for *secondary gain* should be suspected when a patient is reluctant to be examined or treated and there is a discrepancy between symptoms and objective findings

prolactinoma overview

detected early in premnopausal women due to associated endocrine symptoms however, in men and postmenopausal women, prolacitnomas produce only minimal or nonspecific symptoms until they cause compressive symptoms in braid prolactin level *>200* is virtually diagnostic TSH may be normal *or* low - depends on compresive effect on thyrotroph cells *management in premenopausal* 1. MRI a.asymptomatic microprolactinoma (<10mm) - no treatment b. macroprolactinoma (>10mm) or symptomatic - dopamine agonists: cabergoline, bromocriptine - resection: very large tumor (>3cm); increased in size while on treatment

most common casue of aortic regurgitation

developing countries = rheumatic dz developed countries = aortic root rilation or congenital bicuspid valve early decrescendo diastolic murmur that begins immedaitely after A2 accentuated with patient sitting up and leaning forward while holding breath in full expiration valvular AR = LSB at 3rd and 4th ICS aortic root dilation AR = radiates towards right side and heard along RSB

anal cancer

develops from squamous epithelial cells due to *HPV* infection risk is greatest in men who have receptive anal intercourse and. those with advanced HIV *rectal bleeding* is most common manifestation of anal cancer and my be falsely attributed to hemorrhoids if the tumors is located above anal sphincter patients have anal apin and/or sensation of anal pressure exam = mass or *ulcerated* anal lesion spread via lymphatics may cause *firm, nontedner inguinal or femoral lymphdenopathy* diagnosis: biopsy of lesion

tension pneumothorax

develops when injured tissues forms one way valve, allowing air to enter pleural space but preventing it from escaping naturally can increase intrapleural pressure and displace mediastinal structures this compresses them and the contralateral lung (tracheal deviation, neck vein distention - SVC compression) TP can lead to rapid deevlopment of hypotension as the high intrathoracic pressure impedes venous return to RA by compressing vena cava if unstable --> needle decompression immedeitealy

diabetic retinopathy

diabetic retinopathy is leading cause of blindness in USA *3 main categories* background or simply retinopathy - microaneurysms, hemorrhages, exudates, retinal edema pre-proliferative retinopathy - cotton wool spots proliferative or malignant retinopathy - newly formed vessels patients typically are asymptomatic at first, despite early signs of reintopathy (eg, microaneurysms) visual impariment occurs with development of macular edema argon laser photocoagulation is suggested treatment for prevention of complications

first steps in diagnosis of a pleural effusion

diagnostic thoracentesis is preliminary investigation of choice in management of pleural effusion EXCEPT, in patients iwth classic signs and symptoms of congestive heart failure, where a trial of diuretic is warranted

protein gap

difference between total protein and albumin >4 g/dL indicated elevated nonalbumin in serum: polyclonal gammopathies (infeciton, connective tissue dsiease) excessive monoclonal protein (multiple myeloma, waldenstrom)

oropharnygeal dysphgia

difficulty itniating swallowing - stroke, demetnia, oropharyngeal malignancy, neuromuscular disorders food stuck in 'throat' not in esophagus have coughing, choking or nasal regurg on swallowing complications - aspiration, weight loss dx = barium swallow

treatment for perforated viscus

difintive management with uregent ex lap

primary vs secondary raynaud's phenomenon

dihydropyridine CCB used = nifedipine, amlodipine

management of hydatifiorm mole

dilation and usction curettage serial serum bhcg post evacuation contraception for 6 months

non-proliferative dibaetic reitnopathy

dilation of veins, microaneurysms, retinal hemorrhages, edema, hard exudates

physical exam findings of *severe* aortic stenosis

diminished and delayed carotid pulse due to flow obstruction delayed (slow rising) and diminishe (weak) carotid pulse - pulsus parvus and tardus mid to late peaking systolic murmur from tuberulence of stenosis soft and single S2 - thickening and calcifciation of aortic leaflets leads to reduced mobility; A2 is delayed and occurs with P2 --> single S2

treatment for acute dystonic reaction when starting antipsychotic

diphenhdryamine due to anticholinergic effects benztropine/trihexyphenidyl can be used too

treatment of acute dystonic reaction from haloperidol

diphenhydramine benztropine

reye syndrome

pediatric aspirin use during influenza or varicella present with vomiting, abnormal behavior quickly progresses to seizures and lethargy *no icterus* bili is usually *normal* *clinically*: acute liver failure, encephalopathy Increased AST, ALT incresed PT, INR, PTT Increased NH3 tx - supportive *microvesicular steatosis* on liver biopsy in context of acute hepatic encephalopathy = Reye syndrome

medication-induced esophagitis (pill esophagitis)

direct effect of certain medications on esophageal mucosa mucosal injury in pill esophagitis can be due to acid effect (eg, tetracyclines), omsotic tissue injury (potassium chloride), or disruption of normal GE protection (NSAID) sudden-onset of odynophagia and retrosternal pain that can sometimes cause difficulty swallowing most common in mid esophagus due to comrpession by aortic arch or an enlarged left atrium dx usually clinical; can be confirmed on endoscopy = *discrete ulcers with normal appearing surrounding mucosa* tx = stop offending medication

management of serotonin syndrome

discontinue all serotonergic meds supportive care, sedation with benzos cyproheptaidine (serotonin antagonist) if supportive measures fail

epidermal inclusion cyst

discrete benign nodule lined with squamous epithelium that contains a semisolid core of keratin and lipid EIC occurs when epidermis becoems lodged in dermis due to trauma or comedones, or it can arise de novo most commonly on face, neck, scalp, trunk can icnrease in size gradually; and may intermittently produce a cheesy white discharge EIC usually resolve spontaneously, but can recur dx is clinical - dome-shaped firm, freely movable cyst or nodule with *central punctum* excision is performed only for cosmetic reasons i&d is also needed for infected and fluctuant cysts that are painful and erythematous

first line test for palpable adnexal mass

pelvic ultrasound - entire pelvis can be visualized on u/s using a combo of transabdominal and transvaginal techniques will show uterus, ovaries and cul-de-sac fallopian tubes are *not* normall present unless pathology is present CA-125 is not ordered unless *sonography indicates* in premanopausal women CA125 can be elevated from benign conditions (endometriosis, leiomyomata, lupus, etc.)

slipped capital femoral epiphysis

displacement of femoral head on the femoral neck due to disruption of the proximal femoral growth palte *obese adolscent boys* with excessive shear stress, magnified by obestiy, the physis fractures and femoral head slips posteriorly and medially realtive to femoral neck pt presents with hip or knee pain of insidious onset that causes limping PE - loss of abduction and IR of hip; as well as ER of thigh while hip is being flexed diagnosis = frog leg, lateral view xray tx = surgical pinning

most common coagulopathy in patients with malignancies

disseminated intravascular coagulation (DIC) seen in gastric, breast and lung cancer, among others labs = thrombocytoepnia, decreased fibrinogen, increased INR, elevated LDH, elevated reitculocyte, elevated bilirubin microangiopathic hemolytic anemia schitocytes seen on peripheral smear

varicocele

distention of pampiniform plexus within spermatic cord Soft scrotal mass - bag of warms: decreases in supine, increases with valsalve/standina subfertility testicular atrophy *ultrasound* retrograde venous flow tortuous, anechoic tubules ajdacent to testis dilation of pampiniform plexus of veins *treatment* gonal vein ligation (boys and young men with tesitcular atrophy scrotal support + NSAID (older men who do not desire additional children)

drug that stimulates B-1 receptors in heart failure

dobutamine - mangement of severe heart filaure assocaited with severe left ventricualr systollic dysfunction and cardiogenic shock b1 receptors cause increased cAMP in cardiac myocytes, which leads to enhanced calcium mediated binding of actin-myosin complex to troponin C and increased myocardial contractility imrpoved ejection fraction, reduces LV-EDV, and symptomatic improvement of decompensated heart failure

trendelenberg sign

drooping of contralateral pelvis that occurs when patient stands on one foot normally, gluteus medius and gltueus minimus ms, which are both innervated by *superior gluteal n.*, function to abduct the thigh at the hip when standing on one foot or during normal ambulation when body's weight rests on only one foot weakness of these muscles --> trendenlenburg sign

evaluation of neonatal hydration

dry, flaky peeling skin of hands/feet is normal as skin adjusts to dry extrauterine environment appearnce of *brick dust* in neonatal diapers = *uric acid cystals* uric acid excreiton is high at birth and decreases until adolesnce uric acid cystals are commonly seen during first week as mother's milk is coming in, or in later months with morning void after infant sleeps through night healthy neonates lose *up to 7% of birth weight in first 5 days* due to excreiton of excess fluid from utero and during labor *birth weight should be regained by age 10-14 days* as general rule, number of wet diapers should equal age in days of first week of life

trachoma

due to chalmydia trachomatis serotypes A, B, and C leading cause of blindness worlwdie acitve phase is most common in children: *follicular conjuctivtis* and pannus (neovascularization) formation in cornea there is often a concomitant nasopharyngeal infection (eg, rhinorrhea, pharyngitis) repeated or chronic infeciton leads to *scarring* of the eyelides and *inversion* or the eyelashses (trichiasis) overtime, the lashes rub on the eye and cause *ulcerations and blindess - cicatricial trachoma* diagnosis made clinically by exam of the tarsal conjuctivae C. trachomatis may be visible by Giemsa stain of conjuctival scraping *azithromycin* is effective against C trachomatis in general, the entire region (eg, villiage, refugee camp) shuold be treted simultaenously for individuals with trichiasis, *eyelid surgery* is needed to preserve vision

anemia in chronic kidney disease

due to decreased erythropoietin production by failing kidneys tx = EPO goal hemoglobin 10-11.5 g/dL if pt has microcytic anemia and not responding to EPO therapy, you should given *iron* which is the msot common cause of inadeqaute response to EPO in patients on dialysis treatment of choice for iron deficiency in patients on dialysis is *intravenous iron*

stabismus (ocular misalignment) treatment / complications

penalizaiton therapy - cycloplegic drops to blur normal eye occlusion therapy - patch normal eye prescirption eyeglasses surgery *complications* abmlyopia diplopia

tx of syphilis in pregnancy / treatment of syphilis in all people

pencillin if allergic --> densisitzation then penicllin all patients with syphilis require nontremponemal titers (eg, RPR) at time of treatment and at 6-12 months to ensure treatment response (4-fold drop in titers)

second-trimester quadruple screening

performed in second trimester: 15-20 weeks patient with abrnoaml quadruple screening can be offered *cell free fetal dNA* testing

posterior urethral injury

due to length and positioning of male urethra, men with pelvic fractures are at significant risk for posterior urethral injury abrupt upward shifting of bladder and prostate can lead to urethral tearing, which most commonly affects the membranous ruethra at the bulbomembranous junction (dividing point between anterior and posterior urethra) findings consistent with PUI = *blood at urethral meatus*, inability to void, perineal or scrotal hematoma, *high riding prostate* on DRE *retrograde urethrogram* should be performed for suspected urethral injury extravasation of contrast from urethra or inability of contrast to reach bladder is diagnostic

subcortical lacunar stroke

due to occluded single penetrating branch of large cerebral artery (eg, MCA, basilar a.) present with: pure motor (*most common*), ataxic hemiparesis, pure sensory, senorimotor stroke, or dysathria with clumsy hand patients develop symptoms over short period with slow progression over next 24-36 hours do *not* hvae cortical signs (eg, aphasia, agnosia, neglect, apraxia, hemianopsia)

epigastric pain, intermittent melana

duodenal ulcer - most are caused by Hpylori or NSAIDs malignant ulceration should be considered in older patients clasically pain is worse on empty stomach [due to unopposed gastric acid emptying into duodneum] pain *improves with food* [due to alkaline fluid secreiton in duodenum] *treatment* antisecretaory therapy = PPI antibiotic eradication = amoxicllin + clarithromycin

normal NST reactive

during 20 minute intervale: baseline = 110-160/m moderate variability = 6-25/m >2 HR accelerations that >15/m over baseline and last >15s

dx/tx of hirscprung

dx = contrast enema shows level of obstruction rectal suction bx = gold standard tx = surgical resection of aganglionic segment followed by anastomosis of normal bowel to anus

diagnosis/treatment of premenstrual syndrome

dx = detailed menstrual history diary mild PMS = exercise, stress reduction severe PMS/PMDD = SSRI (fluoxetine)

chornic, intermittent epigastric pain and postprandial discomfort...

dyspepsia common causes of dyspepsia - NSAIDs, gastric/esophgeal cancer, functioanl dyspepsiea, GERD, Peptic ulcer disease [h pyolori] definitive diagnosis often requires endoscopy - considered in those age >55 or with alarm syptoms *management of GERD* <2 episodes/week = lifestyle changes, H2 receptor antagonist >2 episodes/week, evere syptoms, erosive esophagitis or laryngophargneal involvement = 8week course of PPI ddx: Dieulafoy lesion: large, tortuous arteriole of stomach wall

renal osteodystrophy

dystrophic bone disorder in which elevated phosphate and low calcium combine to increase PTH patients present with bone or joint pain, visaul defomrities, or pathologic fractures dx made when bone bx shows abnormal bone turnover and decreased bone desnity renal transplant and hemodialysis 5x/w have been shown to resolve renal osteodystrophy

clinical features of vertebral compression fracture

each vertebral compression fracture can decrease a patient's hieght by >1cm and lead to kyphosis - associated with decreased respiratory capcity and increased risk of atelectasis penumonia

premature adrenarche

early activation of adreanl androgens and more omcmon in obese children precocious development of pubic and axillary hair, acne, and body odor in children with *normal bone age*

intrapartum fetal heart rate monitoring

early decels are most commonly seen when anterior fontanel is close contact with cervix (dilation >5cm and station >0)

diagnosis and treatment of rhino-orbital cerebral mucormycosis

early diagnosis is cricical any pt with significant immunocompromise and sinusitis requires *sinus endoscopy* with cultures and biopsy to evaluate for mucormycosis

evaluation of suspected hyperaldosteronism

easily induced hypokalemia after starting thiazide = primary hyperaldosteronism

effect modification vs confounding

effect modification resutls when an extraneous varaible changes the direction or strength of an annosication b/w risk and a disease modified is associated with disease but not the risk factor confounding is when the bias the results when the exposure-disease relationship is obsucred by effect of an extraenous factor associated with both the exposure and the disease stratified analysis helps determine wheter a variable is a confounder or an affect modifier

most common location of ulnar nerve entrapment

elbow at the medial epicondylar groove decreaed sensation over 4th and 5th fingers and weak grip due to involvement of interosseous muscles

uremic percarditis

elevated BUN >60 inflammes visceral and parietal layers of pericardium renal failure + pleuritic chest pain pericardial friciton rub *EKG changes are NOT seen* - this is due to the percarditis being from fibrin deposition {not inflammation} tx = dialysis (r/o effusion prior to starting dialysis)

causes of malignant biliary obstruction

elevated alkaline phosphatase out of proportion to the transaminases suggets intrahepatic cholestasis or biliary obstruction

CSF of guillian barre syndrome

elevated protein normal WBC count *segmental demyelination of peripheral nerves* due to infiltrating T lymphocytes and macrophages

evaluation of hyperthyroidism

elevated ratio of alpha-subunit to TSH suggets a pituitary adenoma *symptoms of hyperthyrodism* anxiety, insomnia palpitations heat intolerance increased persipriation weight loss w/o decreased appetite *physical exam* goiter hypertension tremors involving fingers/hands hyperreflexia proximal muscle weakness lid lag atrial fibrillation

uric acid stones

elevated serum uric acid levels (eg, gout, tumor lysis syndrome) and/or acidic urine pH are factors that promote formation of uric acid kidney stones management = urine alkalnization w/ potassium bicarbonate or potassium citrate

acute cervical adenitis in children

empiric antibiotics for acute, unilateral lymphadeneitis = *clindamycin* - activity against MRSA and S. pyogenes

etiology of exudative effusion

empyema - purulent fluid, neutrophil predominant, positive gram stian/culture chylothorax - milky white fluid, increased TG's [congenital malforations, Down syndrome, Noonan syndrome, malignancy, trauma] malignancy - abnomral cytology tuberculosis - positive acid-fast bateirum stain/culture

which organisms are patients with asplenia at high risk for?

enacpsulated organisms: pneumoccal menigococcal h infleunze type B

optic disc in open angle glaucoma

enalrged with cup:disc >0.6 increase in cup size over time thinning of disc rim pale disc (optic n. atrophy)

esophageal cancer

endoscopic evaluation is needed to differenitate achalasia vs. pseudoachlasia easy to pass endoscope through LES when achlasia normal mucosa in achalasia if endoscopy shows malignancy os is nonrevieling and there is high concern, CT scan needed for staging or diagnosis

patient has inoperable pancreatic cancer. He has severe pruritis from conjugated hyperbilirubienmia. Treatment for pruritis?

endoscopic stent placement - relieves CBD obstruction in most patient and is less invasive and less risky than surgery surgical bypass (2nd lien) - anastomosis between gallbladder or CBD and jejunum this is a form of *extrahepatic* cholestasis

spontaneous bacterial peritonitis

enteric bateria are thought to *translocate* across the intestinal wall and seed ascitisc fluid within the peritoneal cavity fever and subtle changes in mental status are most common symptoms *paracentesis* is main diagnostic choice dx is made when neutrophil count is *>250* cultures often show gram negative organisms but can be engative

transjugular intrahepatic portosystemic shunting

performed when patient has ascites that does not respond to medical therapy (eg, diuretics) or has ongoing active or recurretn variceal bleeding after appropriate treatment with upper endoscopy TIPS is associated with Hepatic encephalopathy in up to 25% of patients due to NH3-rich blood bypassing the liver protein restriction is needed

breath-holding spells

episode of apnea precipitated by frustration, anger, or pain age 6 months to 2 years *cyanotic* - crying and breath holding in forced expiration followed by apnea, limpness and loss of consciousness event is breif with rapid return to baseline *pallid* - triggered by minor trauma; fleeting loss of consciousness followed by breath-holding, pallor, diaphoresis episode <1m with subsequent confusion and sleepiness for a few minutes diagnosis based on h&p parents should be reassured that BHS does not affect development some have episodes til 5 y/o; increased risk of vasovagal syncope later in life differentiated from seizures by a history of *provocation* preceding loss of consciousness

rosacea

erythema, edema, telangiectasias affecting primarily central face conjuctival hyperemia lid margin telangiectasieas flushing and local discomfort triggered by hot/spicy foods, emotional stressors, temperature flucuations *rhinophyma* - soft tissue and sebaceous hyperplasia of nose (large, red nose) *treatment* avoidance of triggers - alochol, spicy foods sun protection gental cleasners and emollients topical metronidazole for papulopusutal type laser or topical brimoidine (a2 vasoconstrictor) for erythematotelangiectatic

differential diagnosis & features of chest pain

esophageal origin = prolonged pain >1h, postpraindian, heartburn, dysphagia prinztmetal angina = recurrent attacks of chest pain lasting minutes (not hours) *vasospastic angina* - hyperreactivity of coronary smooth muscle *clinical* young pt <50 y/o smoking recurrent chest discomfort: at rest or during sleep; resolves within 15m *diagnosis*; ambulatory EKG: St elevation *tx*: CCB (preventinve)[*dilitizam* - potent coronary a. dilator], sublingual nitro *abortive)

tremor that is worse with motion without any other neurologic signs

essential tremor (tx propanolol)

gallstones in pregnancy

estrogen-induced increase in cholesterol secretion (prengnacy, OCP use) during pregnancy, estrogen causes increase in cholesterol secretion and progesterone causes a reduction in bile acid secretion, causing increased choelsterol saturaiton of bile progesterone slows gallbladder emtpying and thus facilitates formation of choelsterol gallstones during pregnancy

chemotherapy induced peripheral neuropathy

etiologies - vincristine, cisplastin, paclitaxel typically starts after weeks of tx and presents with symmetrical paresthiasias in figners and toes spreading proximally - *stocking and glove pattern* normally have early loss of ankle jerk reflexes, and loss of pain/temp sensation occasionally motor neuropathy --> weakness, bilateral foot drop

drug induced interstitial nephritis

etiology - pencillins, cephalosproings, sulfonamides clinical - fever, rash, arthlagia; peripheral eosinophilia, hmeaturia, sterile pyruia, eosinophiluria WBC casts can be seen in urine

older pt falls suffers hip fracture. Unknown cause for fall. next step?

evaluate surgical risk and ensure medical stability surgery can be delayed up to 72 hours - definitive surgical correction should take place as soon as reasonably possible for hip fracture

intrauterine fetal demise

even after an optimal evaluation, up to 50% of cases have *no identifiable etiology*

definitive initial tx for ovarian carcinoma

ex lap and tumor debulking - inspect entire abdominal cavity for metastases [surgical staging] followed by platinum-based chemotherapy

herpes simplex keratitis

exam = *corneal* vesicles with branching ulcers and opaciities; dendritic ulcers [*most common*] Retinal necrosis syndrome [seen in HIV] *fundoscopy*: widespread, pale, peripheral retinal lesions and central necrosis of the retina pain, photophobia, blurred vision, tearing, redness *antiviral tx [oral or topical] is effective in treating herpes simplex keratitis* *HSV finfection of eye is most common cause of corneal blindness in the US*

testicular cancer diagnosis

exam: firm, ovoid mass tumor markers: AFP, bHCG *scrotal ultrasound* staging imaging: CT, chest xray *radical orchiectomy* - inguinal incision is used to removal testicle when cancer is suspected

hyperthyroid bone disease

excess thyroid homrone ---> increased osteoclast actvity (bone resporption; dec. bone desnity; inc. fracture risk) hypercalcemia --> dec. PTH secretion --> net calcium wasting, hypercalciuria patients with untreated hyperthyroidism can develop rapid bone loss leading to osteoporsis and increased fracture

depression related cognitive impairment / cognitive impairment in elderly patients

exhibit features of MDD accompanied by memory impariment severe derpession (espeiclly in elderly), when combined with sx similar to dementia = *depression-related cognitive impairment* largely reversible with tx of underlying depression using *SSRI* and/or psychotherapy

gender dysphoria

experiences persistent incongurence between assigned and felt gender *initial management* assessment of safety support; psychotherapy referall to specialist srevices

cryptococcal meningoencephalitis

extremely high opening tap pressure on lumbar puncture - pt typically has many symptoms of increased intracranial pressure *tx*: amphotericin + flucytosine 2 weeks of IV AmB + flucytosin, followed by fluconazole for consolidation (8 weeks) and maintenance for >1 year

parinaud syndrome

eyelid retraction pressure on pretectal region of midbrain limited upward gae with doward gae preference bilateral eyelid retraction light-near dissocation associated with pineal tumors

fetal fibronectin presence in vaginal secretions

fFN is found in choriodecidual interface presence in vaginal secretions at *24-34 weeks* gestation is predictive of preterm delviery FFN levels are high until 20 weeks gestation, are low during mid-second and third triemsters, and icnrease again at term, when contractions disrupt the decidual-chorionic interface testing prior to 20 weeks is not helpful

cavernous sinus thrombosis

facial/opthalmic venous system is valveless, thus infection of skin, sinuses and orbit can spread to cavernous sinus results in life threatening CST and intracranial hypertension headache is msot common symptom low grade fever and perioribtial edema occur days later secondary to impaired venous flow in orbital veins vomiting from ICH fundoscopy = papilledema CNIII, IV, V, VI pass through cavernous sinus, which has anastomeses crossing midling unilaterl symptoms (hadache, binocular palsies, periorbital edema, hypoesthsia or hypestehsia in V1/V2) can rapidly become bilateral MRI with venography is modality of choice tx = braod spectrum IV abx and prevention of cerebral herniation

vitamin K physiology

fat soluble vitamin - plays role in hemoatsis as a cofactor for carboxylation on prthrombin complex proteins - 2, 7, 9 10, protein C and S absorbs vit K exogenously frmo intesine and endogenously fmor bacteiral production in itnestine liver normall stores 30 day supply, but in acutely ill person w/o liver dz, one can become deficient in 7-10d *risk factors for deficiency* inadeqaute dietary intake disorders of fat absortpion: cystic fibrosis, biliary atresia disorders of intestinal inflammation: celiac, IBD decreased porduciton by bacterial flora (frequent abx use) *clinical* easy brusing mucosal bleeding GI bleeding *Increased PT and INR* normal aPTT

differential diagnosis of DSM-5 anxiety disorders

fear of negative evaluation in social sitaution = social anxiety disorder when the fears are realted to being publically scrunitzed, embarssed or engaitvely judged in a social context, it is a social anxiety disorder

pelvic inflammatory disease

fever, lower abdominal pain, cervical discharge, cervical motion and adnexal tenderness PID preceded by gonorrhea or chalymdia, which disrupts the upper genital tract allowing *polymicrobial vaginal bateria* to infect normally sterile area complications: tubovarian abscess, perihepatitis *indications for hospitilization* pregnancy failed outpatient tx inability to tolerate oral meds noncompliant with tx severe presenttation (eg, high fever, vomiting) complications (eg, tubo-ovarian abscess, perihepatitis) *IV cefoxitin or cefotetan + PO doxycycline* or *IV clinda + gent*

dermatofibroma

fibroblast proliferation causing isolated or multiple lesions; commonly lower extremities nontender discrete, firm, hyperpigemnted nodules (<1cm) fibrous component that mcause cause dimpling in center when pinched dx = clinical tx = usually not required unless symptomatic, bleeds, changes in color

treatment of urgency incontinence

first line = bladder training sx despite bladder training = oxybutynin (antimuscarininc) Mirabegron (stimulates b3 receptors - relax bladder) can be offered to those who cant take anti-muscarinic drugs

treatment of alzheimers

first line = cholinesterase inhibitors (donepezil, galantamine, rivastigmine) memantidine = NMDA antagonist

renal cell carcinoma

flank pain, hematuria, palpable renal mass scrotal varicoceles (left side) paraneopalstic - anemia, erytheocytosis, thrombocytosis, fever, hypercalcemia, cachexia CT of abdomen is most sensitize and specific test

cellulitis

flat, indistinct borders fever, regional lymphagitis present leukocytosis dx = clinical may get blood culutres

west nile encephalitis

flavivirdae fever, head, confusion myelitis: acute paralysis syndrome characteried by asymmetric flaccid weakness in the limbs

which surface is atopic dermatitis (eczema) typically on?

flexural surfaces of arms (child/adult) extensor surfaces (infant) patho - improper synthesis of stratum conreum components; allergens disrupt skin barrier and generate an inflammatory response *risk factors* low humidity relatives with eczema, allergies, asthma *infant*: itchy, red, scaly, crusted lesions on extensor surfaces, trunk, cheeks and scalp *child/adult*: lichenified plaques in flexural creases *treatment* topical emollients +/- steroid ointment *complications* eczema herpeticum cellulitis/abscess discomfort interfering with daily activties and sleep

hydrocele

fluid collection within tunica vaginalis, a sac surrounding the testis during fetal development, an outpouching of peritoneum descends with the testis into scrotum and forms the processus vaginalis and the tunica vaginalis typically, processes vaginalis then obliteras; however, if it remains open, peritoneal fluid can accumunlate causing a communicating hydrocele noncommunicating - if processus obliteartes normally but fluid collected within tunica vaginalis doesnt reabsorb *painless* unilateral or bilatearl *scrotal swelling* may fluctuate with crying or straining in infants w/ a communicating hydrocele; noncumminicating are irreducible and remain constant *transillumination* spontaenously resolve by age 1 osberved during this period

medication of choice for pediatric depression

fluoxetine

most common nephrotic syndrome in adults

focal segmental glomerulosclerosis

anemia + macrocytosis + hyerpsegemetned neutrophils + normal methlymalonica cid

folate deficiency *etiologies* chronic hemolysis (eg, sickle cell( poor dietary intake - alocholics have poor body stores and can be deficient in 5-10 weeks malabsorption (eg, gastric bypass) medications (eg, methotrexate, trimethoprim, phenytoin) methotraxate and trimethoprim inhibits DFR phenytoin inhibits folic acid absorption in small intestine *Folinic acid (leucovorin* is indicated to reserve chemotherpatuic anti-folate effect of methotrexate

postconcussive syndrome

follows traumatic brain injury TBI of any severity can lead to ( afew hours or days later) postconcussive snydrome clinically described by constellation of symptoms: headache, confusion, amnesia, difficulty concentrating or with multitasking, vertigo, mood alteration, sleep disturbance, anxiety resolve with sympomtatic treatment within a few weeks to months following TBI some can have persistent symptoms lasting >6months

methemoglobiemia

formed by oxidation for Fe2+ to Fe3+ iron in hemoglobin Fe3+ is unable to bind oxygen, and it also increases the affinity of Fe2+ to oxygen, cuasing left shift in oxygen dissociation curve standard pulse ox readings are low (~85%) due to absorption spectrum of methemoglobin and dont repsent true oxygen saturation supplemental oxygen DOES NOT improve cyanosis, blood color or pulse ox readings beucase arterial blood gas testing analyzes unbound arterial oxygen, the *PaO2 is normal* and overestimates degree of true oxygen saturation functional anemia due to reduced oxygen delivery to tissues occurs after exposure to xodizing agenst - dapsone, ntirates, topical/local anesthetics *tx*: methylene blue - acts as electron acceptor for NADPH and is reduced to leucomethyle blue; reduces methemoglobin back to hemoglobin

beta-d-glucan

fungi

galactose-1-phosphate uridyl transferase deficiency

galactosemia presents in first few days after birth with jaundice, hepatomegaly, failure to thrive after consumption of breast milk or regular infant formula eliminination of galactose is needed to prevent growth failure and other organ dysfunction elimination may allow for catarcts to regress ddx - galactosemia = cataracts (nothing else)

common problems related to lactation

galatocele - milk retention cyst that occurs a few weeks to months afet cessation of breastfeeding, when milkd stagnates deposited proteins in the lactiferous duct cause ductal blockage with milk accumulation behind obstruction asymptomatic - no tx symptomatic - aspirated u/s = diagnosis plugged cut = *focal*

common causes of gastric outlet obstruction

gastric malignancy peptic ulcer disese crohn disease strictures (w/ pyloric stenosis0 from ingestion of caustic agents gastriz bezoars *+abdominal succussion splash* - reatined gatric materal >3h after meal will generate splash sound

features of malabsorption in celiac disease

general - bulky, foul smelling, floating stools fat and protein - loss of muscle mass, loss of subq fat, fatigue iron - pallor, fatigue calcium and vit D - bone pain, fracture (osteoporsis) vit K - easy bruising vit A - hyperkeratosis

clinical manifestations of graves disease

general - heat intolerance, weight loss, sweating eyes - lid lag (sclera seen above iris on doward gaze), proptosis, diplopia skin - hair loss, infiltrative dermopathy (pretibilar myxedema) cardiovascular - tachycardia, HTN, afib nails - onycholysis (separation of nail frmo nail bed, clubbing (arcopachy) endocrine - hyperglycemia, hypercalcemia, bone loss, menstrual irregularitis GI - diarrhea neurology - tremors, hyperreflexia, proximal muscle weakness *graves otphalmopathy*: ocural irritation, impired extraocular moition, proptosis causd by T cell ativation and stimulation of orbital fibroblasts by thyrotropin (TSH) receptor autoantibodies, leading to expansion of orbital tissues

spinal muscular atrophy (werdnig-hoffmann disease)

generalized symmetric proximal muscle wekaness hyporeflexia degeneration of anterior horn cells and cranial nerve motor nuclei greater weakness in lower extremities compared to upper extremities NBME q 2x4cm ulcerative lesion with cruster base and slighlty raised erythematous edge on occipital prominence -- *decubitus ulcer*

best way to *confirm* muscular dystrophy

genetic testing - deletion of dystrophin gene on Xp21 Duchenne muscular dystrpphy presents at age 2-5 with bilatearl calf pseudohypertrophy and Gower sign serum CK and adolase levels are elevated prior to clinical signs as disease progresses, these levels drop as more muscle is repalced by fat and fibrosis

most common cause of postpartum hemorrhage after operative vaginal delviery

genital tract injury even after a laceration was repaired; always inspect genital tract for other injuries that may have been missed on inital inspection

indicated procedures and appropriate covergae in high risk cardiac conditiosn

gingival manipulation or repsiratory tract incision: virdians strep - amoxicllin GU or GI procedure in setting of active ifnection: enteroccocuss - ampcillin surgery on ifnected skin or muscle: staph - vancomycin surgical placement of prosthetic cardiac materal: staph - vancomycin

acute rheumatic fever / antibiotic prophylaxis for rheumatic fever

pharyngitis precedes onset by 2-4weeks if pt has self-resolving pharyngitis, the ARF is still possible and they should receive 10d course of pencillcin *diagnosis*: preceding GAS infection with either 2 major or 1 major + 2 minor *major* migratory arthritis of large joints carditis [percarditis gets NSAIDs] nodules (subcutenous) eryhtema marginatum sydenham chorea [tx = steroids] *minor* fever, arthralgias, ESR/CRP prolonged PR itnerval pt with history of rheumatic fever are at high risk for recurrence and progression of rheumatic heart disease with repeated episodes of GAS pharyngitis preferred continuous abx prophyalxis is *IM benz pen G q4w*

profuse, clear, thin mucus prior to ovulation

physiologic "similar to uncooked egg white" thought to facillitate sperm transport into uterus for conception

evaluation of nipple discharge

physiologic galactorrhea = bilateral, gray, nonbloody can also be yellow, brown, gray or green

opportunistic infections most common in solid organ tansplant

pneumocytis pneumonia: pulmonary symptoms; rarely goes systemic CMV [diagnosied with CMV DNA PCR]: pulmary, GI, tissue invasive CMV diesease

how to confirm genital HSV

polymerase chain reaction (PCR) viral culture is an alternative; but has low sensitivty

symettrical proximal *stiffness* + elevated ESR/CRP

polymyalgia rehumatica

proximal muscle wekaness + elevated CK

polymyositis symmetrical proximal muscle weakness; affects UE >LE dysphagia can be present due to involvement of esophageal muscles; facial muscles are never affected CK levels are elevated, corresponding to disease severity *positive ANA and anti-jo-1* EMG: fibrillations and high freqeuncy action potentials *definitinve dx = muscle biopsy*: mononuclear infiltrate surrounding necrotic and regenerating muscle fibers polmyositis does *not* affect respiratory muscles

immune response to pneumoccocal vaccine

polysaccharide (PPSV23) - T cell independent B cell response [less effective in young children and elderly] conjugate vaccine (PCV13) - T cell dependent B cell response [improved immunogeneicity due to formation of higher affinity antibodies and memory cells]

diabetic foot infection

poor glycemia control, neuropathy, and/or peripheral a. disease start with localized skin erythema, warmth, tenderness, edema deeper infection should be suspected in thsoe with long standing wounds (>1-2w), systemic symptoms, large ulcer size (>2cm), elevated ESR, presnce or palpation of bone in ulcer *polymicrobial* - staph, strep, pseudomonas, anreobic can cause osteomyeltitis by continguous spread

potter sequence

poor urine output in utero results in oligohydrmanios as fetal urine is major source of amniotic fluid oligohydramnios in 2nd trimester is ominous and associated with high perinatal mortality because normal amniotic fluid levels are required for lung development low amniotic fluid also restricts fetal movement, leading to a cascade of physical anomlaies including fat facies and limb deformities

diagnosis of lactose intolerance

positive hydrogen breath test - rise in measured breath hydrogen after ingestion of lactose, indicating bacterial carbohydrate metbaolism diagnosis is often established in patients who ahve hx of consuming lactose products and have symptoms; then symptoms resovle after intiating lactose free diet

acute mediastinitis

possibly complication of cardiac surgery that is usually due to intraoperative wound contaomination pt present postop (within 14d) with: fever, tachycardia, chest pain, leukocytosis, sternal wound drainage or purulent discharge cxr = widened mediastinum requires drainage, surgical debridement with immediate closure, prolonged abx therapy

acute cervicitis

postcoital bleeding thick, mucopurlent discharge pelvic exam: shows discharge and friable cervix tx is empiric with *azithromycin and ceftriaxone* but NAAT should be perofmed for infection confirmation empiric tx is recommended as a delay increases risk for ascending infection and pregnancy complcations

lateral medullary infration

posterior inferior cerebellar a. occlusion loss of pain/temp over ipsilateral face, contralateral body ipsilater bulbar weakness (nucleus ambiguus) vertigo/nystagamus (vestibular nuclei) horner syndrome (ascending sympathetic fibers)

evaluation of precocious puberty evaluation on nonclassic congenital adrenal hyperplasia

girls <8 boys <9 cental - early activation of HPG axis; pulsatile GnRH stimulations elevated FSH and LH these patients need *MRI* of brain to evaluate for hypothalamic or pituitary tumor activating the HPG axis if MRI is negative, likely idiopathic precocious puberty and GnRH therapy can be initiated [prevents premature epiphyseal plate fusion and maximizes adult height potential] peripheral - gonadal or adrenal reelase of excess sex hormone; basal FSH and LH are low and remain low following GnRH agonist stimulation *nonclassic congenital adrenal hyperplasia* 21-hydroxylase (CYP21A2) deficiency - 17-hydroxyprogesterone is shunted toward adrenal androgen overporudciton (ie, precosiou puberty) however, in nonclassic CAH, sufficient glucocorticoid and minearlocorticoid are maintained; normal electrolytes obese children are at high risk as adiposity cna trigger excess insulin --> stimulates adreanls to produce sex hormones

metabolic effects of thiazide diuretics

glucose intolerance / hypercholesterlemia (inc. LDL, TG's): impaired insulin release from pancreas and glucose utilization in peripheral tissues hyponatermia: inhibit Na/Cl cotransporter in distal tubule hypokalemia: compensatory rise in renin and aldosterone hypercalcemia: increased reabsorption in distal tubule hyperuricemia: increased reabsorption in proximal tubule

anti-endomysial antibodies antie-tissue transglutaminase

gluten enteropathy (celiac disease) diagnosis of celiac is highly correlated with positive resutls on serologic studies - *IgA anti-tissue translgutaminase* and *IgA anti-endomysial antibodies* however, many patients iwth biopsy confirmed celiac will have negative results on IgA antibody testing due to *selective IgA deficiency*, which is common in celiac d-xylose will not be absorbed in patients with celiac disease due to small itnesinal mcuosal disease [pt with enzyme deficiency can absorb x-xylose since it is the msot simple monosaccharide] biopsy = *villous atrophy* minor GI symptoms iron defieincy, steatorrhea, weight loss

time to presentation of neonatal conjuctivtis

gonococcal = 2-5d (IM ceftriaxone) chlamydial = 5-14d (PO macrolide)

transient global anterograde amenesia

grade amnesia for time and place NO associated loss of personal identity memory loss resolves within 24h

MALT-lymphoma of gastric tissue

h pylori - chronic inflammation stimulation of large number of antigen-dependent B and T cells in gastric lamina chronic activation/proliferation --> monoclonal population of B cells tx = quadruple therapy; many achieve *complete remission* with abx therapy

maternal thyroid testing in pregnancy, first trimester

hCG (shares common alpha subunit with TSH) stimualtes TSH receptors euthyroid patients will respond well to pregnancy changes and have labs of hypotrhoid but be euthyroid patients with impaired thyroid function cannot increase thyroid hormone produciton, resutling in relative hypothyroid state if pt is on a stable dose of levothyroxine, you need to increase dose by abotu 30% when pregnacny is detected; follow with TSH using pregnacny-specific norms

murmur of TOF

harsh, systolic ejection murmur over the left upper sternal border from pulmoanry stenosis Single S2 = poor pulmonary blood flow through stenotic pulmonary valve

incisional hematoma

postoperative serosanguineous drainage and incisional pain abnormal collection of blood at the icnision site often due to inadeqaute surgical hemostasis risk factors = obesity, hypOcoagulability (eg, anticoagulation, coagulopathy) hematomas can reopen surgical potential spaces (eg, incisional separation) and create a collection of stagnat fluid therefore, incsional hematomas can become niduses for bacterial growth and increase risk of surgical site infection tx of large symptomatic hematomas = opening incision, removing clot, obtaining hemostasis, reclosing incision

types of bias / errors in studies

hawthoren - tendency of study population to affect otucome because these people are aware they are beings tudied sample disortion - when the estimate of exposure and outcome association is biased because study sample is not representative of target population information bias - imperfect assessment of association between exposure and outcome as ar esult of errors in the measurement of exposure and outcome status confounding bias - presence of one or more variables associated independently with both exposure and outcome observer - investigator's decision is adversely affected by knowledge of the exposure status respondent - outcome is obtained by patient's response, and not by objective diagnostic methods [eg, migraine headache] selection - manner in which the subjects are selected for study, or frmo the selective losses from follow-up lead time - incorrect assumption or conclusion of prolonged apaprent survival and better prognosis due to a screening test [actually, detection of dseiase was made at earlier point in time] attrrion bias = loss to follow up, a form of selection bias latency concept - exposure to risk factors and the initial steps in disease pathogenesis soetimes occur years before clinical manifestations are evident; in addition, exposure to risk modifiers may need to be continuous over a certain period before influencing outcome selective survival - case control studies when cases are selected from the entire disease population instead of just those are newly diagnosed ecological fallacy - interpretation of data where inferences about the nature of individuals are deduced from inference for the group to which individuals belong [if average score is 50%, assuming person has equal likelihood of being above and below 50% if false, there could be many at 40%, and one at 100%] generalizability (external validity) - applicability of study results to other populations (eg, the results of a study in middle ged women would not be expected to be applicable to elderly men)

postpartum endometritis

postpartum endometritis is an *infection of the uterine decidua* and is msot common pathologic cause of pastpartum fever diagnosed by *fever* >24h postpartum, uterine tenderness and purulent lochia results from direct inoculation of the uterine cavity by vaginal flora during labor and is empirically traeted with broad spectrum abx (gent + clinda) for *poymicrobial* ifnection pelvic abscess and septic thrombophlebitis are *less common* causes of postaprtum fever; should be conisdered in patients who remain febrile >48h treatment with bax

heat stroke

heat stroke can be exertional or nonexertional nonexertional occurs in pt with chronic medical conditions, often because they cannot remove themselves from inciting stimulus and/or have impaired thermoregulation due to medications and undlerying illness management for non-exeritaionl emphasizes *evaporative cooling* (spraying lukewarm water), rather than ice-water immersion exertional HS defined as: body temp >40 + CNS dysfunction exertional occurs in otherwise healthy individuals undergoing conditioning in extreme heat and humitidy; the body loses its ability to dissipate heat when humidity is >75% and temperature is elevated body temp >41 (105.8) may cause rhabdomyolysis and organ system damage in heat stroke, thermoregulatory center fails to dissipate heat at a rate necessary to maintain a euthermic state although inadeqaute fluid and salt repalcement may contribute to heat stroke, it does not cause it [can cause *heat exhaustion* but CNS dysfunction does not occur in inadeqaute H20/e- replacement]

myelodysplastic syndrome

hematopoietic stem cell neoplasm risk: increased age, previous *chemo/radiation* can become acute leukemia cytopenias: anemia (weakness, fatigue), leukopenia (infecitons), thrombocytopenia (bruising, bleeding) macrocytic anemia with insufficient reticulocytosis dysplastic eryhtrocytes (ovalomacrocytosis) dysplastic granulocytes (hyposegmetnation, hypogranulation) *diagnosis*: dysplastic red and white BC on smear *bone marrow bx = hypercellular marrow* - needed for dx smear classically shows dysplastic erythrocytes and granulocytes (reduced segmentation [pseudo-pelger-huet] tx: tranfusions chemo stem cell transplant

complications of sickle cell trait

hematuria/papillary necrosis, hyposthenuria splenic infarction, venous thromboemebolism, priaprism exertional rhabdomyolsis *hyposthenuria* in response to hypoxic, hyperosmolar conditions of renal medulla, RBC sickle in vasa rectae, impairing free water reabsorption and countercurrent exchange patients present with polyuria and nocturia despite fluid restriction urine osmolality is low however, *normal serum sodium* due to intact ADH no specific tx required

brown-sequard syndrome

hemisection of cord (most often penetrating injury) ipsilatearl: weakness, spasticity, loss of 2pt/proprio contralateral: pain/temp 1-2 levels below corn injury bcause LST decussates 1-2 levels above entry point for corresponding sensory neuron

inidications for *urgent ex lap* / diaphragm and abdominal anatomy

hemodynamic instability peritonitis: rebound tenderness, guarding evisceration (ie, externally exposed intestines) blood for NG tube or on rectal exam FAST equivocal + unstable pt + pentrating wound --> laparatomy [if was blunt, use DPL first] *diaphragm movement* can rise as high as 4th thoracic dermatome on right and 5th thoracic dermatoma on left (ie, nipples) goes down to 12th thoracic dermatoma on both side son inspiration pentrating wounds to thorax can involve the abdomen cavity

management of SVT

hemodynamically stable - vagal manevurs, adenosine [L-type Ca channel blocker] unstable - synchronised cardioversion

diagnosis of sickle cell disease differential diagnosis of bone pain in sickle cell disease

hemoglobin electrophoresis - confirms prescne of sickle hemoglobin *vaso-occlusive crisis* acute severe pain pain at *>1 site* (eg, dactylitis) low grade fever erythema and warmth may be preceded by trigger (eg, dehydration) *osteomyelitis* acute or subacute pain focal pain at 1 site (eg, long bone) prolonged fever erythema and warmth *positive blood culture* *avascular necrosis* *chronic*, worsening pain (eg, femoral head) absence of fever absence of warmth or erythema

extravascular vs intravascular hemolysis

hemolytic anemia from intravascular eryhrocyte trauma can cause labs similar to other types of hemolytic anemias - increased indirect bili and urinary urobilingen intravascular RBC destruction results in free hemoglobin in serum and urine, and increased serum LDH haptoglobin binds free hemoglobin and promotes its excretion by reticuloendothelial system *haptoglobin* decreaes in intravascular hemolysis remember - *prosthetic heart valves* are a common cause of hemolytic anemia

lab findings of SLE

hemolytic anemia, thrombocytoepnia, leukopenia hypocomplimentemia (C3, C4) antibodies: ANA, Anti-DsDNA, Anti-Sm renal involvemnet: proteinuria, elevated creatinine

brain hemorrahge vs. stroke onset of symptoms

hemorrage = sudden focal deficits that gradually worsen over minutes to hours embolic stroke = maximal at onset ischemic stroke = stuttering fashion progression

treatment of DVT in pregnancy

heparin - typically, daily LMWH inejctions are used for long-term therapy treatment of DVT during pregnancy is continued for at least 3 months [throughout the remainder of pregnancy and the first few weeks postpartum]

nonalcoholic fatty liver disease

hepatic injury in absence of viral hepatitis or autoimmune disease typically middle aged, obese, and have metabolic syndrome can range from bland steatosis to inflammation and necorsis to fibrosis/cirrhosis histologically looks like alochol dz = macrovesicualr fat deposition, peripheral dispalcement of nuclei NAFLD can be due to: -increaesd transport of FFA from adipose to liver -decreased oxidation of FFA in lvier -decreased clearence of FFA from lvier realted to *insulin resitance* leading to increase peripheral lipolysis, TG synthesis, hepatic uptake of FA hepatic FFA increases oxidative stress and production of proinflammatory cytokiens (eg, TNFa) *treatment* diet, exercise consider bariatric surgery if BMI>35

congenital syphilis

hepatomegaly nasal discharge - snuffles osteoarticular destruction maculopapular rash *later findings:* interstitial keratitis hutchinson teeth saddle nose saber shins deafness CNS involvement for infants who develop congenital syphilis, *penicllin* therapy is curative and prevents development of late manifestations

aldose B deficiency

hereditary fructose intoerlance fruits and vegetables into diet is followed by accumulation of fructose-1-P affected infants have vomiting, poor feeding, lethargy seizures or encephalopathy follow if fructose is not removed from the diet

osler-weber-rendu syndrome

hereditary telangiectasia autosomal dominant diffuse telengiectasias recurrent epistaxis widespread AV malformations most occur in mucosal membranes, skin, GI tract; but may be prsent in liver, brain, lung

management of cervical intraepithelial neoplasia

high grade dysplastic lesion of squamous epithelium all nonpregnant patients age >25 --> cone biopsy (diagnostic and therapeutic) if the specimen margins are clear of dsiease and no evidence of invsaion is found, pap testing with HPV co-testing in 1 and 2 years postprocedure is required

management of primary ovarian insufficiency

hormone replacement threapy used to mitigate the consequences of estrogen defieicny: vasomotor flushes infertility sexual dysfunction increased CV risk *osteoperosis* *risk of POI* when pt has had chemo - chemo attacks rapidly dividing cells, so when menses do return in these patients, it is often for a shorter period of time hormone reaplcement w/ estrogen + progestin is proivded until age 50 years old common side effects of HRT = mood symptoms, bloating, breast soreness, small elevations in BP, vaginal beleding (can improve with prolonged use) infertility treatment = in vitro ferilization or oocyte/embro donation

human chorionic gonadotropin

hormone secreted by syncytiotrophoblast responsible for preserving the corpus luteum during early prograncy in order to maintain progesterone secretion until the placenta is able to produce progesterone on its own production of hcg begins about 8days after fertilization levels of hCG double q48h until peak at 6-8w gestation alpha subunit is common to: hcg, TSH, LH, FSh beta subunit is specific to hcg - basis of all pregnancy tests other biological funtions of hcg = promotion of male sexual differentiation, stimulation of materanl thyroid gland

next steps when psychiatric patient is decompensating and shows potential to hard himself or others

hospitlize try to voluntarily, but involuntary commitment should be implement if they refuse

parents who are themselves minors can give consent to medical care for their child

however, consent is not required in emergency situations, and parents cannot refuse life saving treatment for their child

human milk vs formula

human milk is ideal nutritional source for full term infants recommends breastfeeding until 6 months of age exclusively; then continuation of breastfeeding aong with solid foods until infant is 1 year old human milk is more easily digested and promotes gastric emptying minearls in human milk are better absorbed, but is low in vitamin D exclusively breastfed infants need supplemental vitamin D human milk has lactoferrin, lyosozyme and IgA associated with less reflux and colic than formula

TMJ dysfunction

hx of nocturnal teeth grinding patients interpet pain coming from ear due to referred sense of it pain worse with chewing patient may have audible click or creptius in TMJ with jaw movement no radiology needed tx = conservative measreus such as nighttime bight guard; surgery in refractory cases

clinical features of pineal gland masses

hydrcephalus from blockage of the aqueduct of sylvirus

treatment of invasive cervical carcinoma

hyesterectomy radiation chemo depends on stage

metabolic changes in hypo-thyroidism

hyperlipidemia - decreased LDL receptors and/or decreased LDL receptor activity hypertriglyceridemia - decreased LPL activity hyponatremia - decreased free water clearnece normocytic, normochromic anemia - decreased RBC mass

young pt with exertional lightheadedness systolic murmur over LSB that increases with staning ECG: t wave abnoramlities

hypertrophic cardiomyopathy tx = proanolol, non-dihydropiridne CCB, no strenouous activity these protect against symptoms; but do not decrease risk of sudden death risk of sudden death = place implantable cardioverted-defbrilation *increased risk for sudden death* family hx of death syncope nonsustained ventricualr tachycardia LV thickeness >3cm failure to increase BP by at least 20mmHg during exercise LV apical anerusym

waldenstrom macroglobulinemia vs multiple myeloma vs monoclonal gammopathy of undetermined signficance

hyperviscosity syndrome = diplopia, tinnitus, headache, dilated/segmented funduscopic findings *monoclonal gammopathy of undetermined signficiance* most common IgA, IgG or IgD smaller M spike (<3 g/dL) bone marrow biopsy <10% monoclonal palsma cells no end organ effects

esophageal manometry in systemic sclerosis

hypomotility incompetence of LES

characteristic findings of SIADH

hyponatremia - nausea, forgetfullness severe hyponatremia - seizures, coma labs: hyponatremia, decreased BUN, decreased Uric acid patient is *euvolemic* serum osmolality <275 urine osmolality >100 (inapprorpiately elevated) urine sodium >40 mEq/L *euvolemic* patient: moist mucous membranes, no edema, no jVD

adverse effects of oxytocin

hyponatremia - similar structure to ADH [prolonged aministration of high doses of oxytocin can cause water rention and hyponatremia] hypotension [important in immedaite postpartum period when high doses of oxytocin boluses given in postpartum hemorrage] tachysystole - >5 contractions in 10 minutes

magnesium toxicity

hyporeflexia lethargy headache respiratory failure cardiac arrest magnesium is *excreted by the kidneys* - common risk factor for toxicity is renal insufficiency toxic at concentration >8mg/dL *antidote* = calcium gluconate

when should urinary catheters be removed postoepratively to reduce risk of UTI?

ideally *within 24-48 hours* resudces risk of UTI, shortens length of hospital stay, and reduces mortality without increasing risk of postoperative urinary retention

cohort

identify cases with risk factor, and cases without risk factor compare either prospectively or restrospectiely to see if outcome occurs

management of delirium

identifying and treateting underlying medical disorder and managing behavioral agitation low dose haloperidol can be used when severe agitation or psychotic symptoms place patient at risk for harm avoid polypharmacy, physical restrains maintain normal slee-wake cycle provide frequent reorientation treat underlying cause (eg, antiboditcs)

acute gouty arthritis

if a patient is on an anticoagulant, you cannot use NSAIDs - must use colchichine ex: aspirin, clopidogrel, apixaban *cholchicine* inhibites polymerization of beta-tubulin microtubules, preventing migration and activation of neutrophils adverse effects: nausea, abdominal pain, dairrhea do not use in elderly or those with severe renal dysfunction

suicide-risk assessment in adolescents should include direct and nonjudgemental questions to determine the nature and intesnity of suicidal thoughts confidentiality should not be promised as it cannot be maintained if patient is at high risk of self harm

if adolsecent is suicidal, the doctor must inform parents that patient is going to be hospitalized with or without consent

dissociative disorders

if amenesia is associated w/ travelling or wandering the term 'dissociative fugue' is used as specifier for dissocaitve amensia treatment of Dissociative identity --> *trauma focused psychotherapy*

pediatric constipation

if dietary modifcations dont work --> oral laxativces and titrate to produce daily soft bowel movements considered safe/effective enemas are next step if oral laxatives dont work

treatment of hypertriglyceridemia

if patient has CAD risk factors use statin first if the statin doesnt help lower TG's enough, use adjunctive fibrates

burn wound sepsis

immediately after burn = gram positive >5 days = gram negative common in apteints with surface area >20% earliest sign = change in appearnce (partial to full thickness) or loss of viable skin graft T<97.7 or >102.2 HR>90 RR>30 SBP<90 dx requires quantitative wound culutre (>10^5 bacteria/g of tissue) *and* bx for histopathology (to determine tissue invasion depth) tx = empiric braod spectrum IV abx (pip/taco, carbapemem, vanc, aminoglycoside)

lichen planus

immune-mediated skin disorder most often seen in middle-aged adults 4Ps: pruritic, purple, polygonal, papules or plaques commonly found on extremities (wrists, ankles) and trunk LP can affect mucous membranes wickham striae are fine white reticulations seen on surface of lesions and in oral cavity and are very specific for the disease upon observation of initieal lesions, the disesae will spread symmetrically over 1-4 weeks *histo* 1. damaged basal epidermal keratinocytes 2. linear arrangement of lymphocytic infilitrate in papilalry dermis at interface with epidermis (known as lichenoid pattern) *clinical course*: chronic, relapsing path for up to 5 years *treatmnet* - for localzied lesions, mainstay of treatment is medium to high potency topical corticosteroids

esophageal atresia with TE fistula

improper formation during 4th/5th gestational weeks most common defective arrangement is proximal esophageal atresia with a fistula b/w trachea and distal esophagus prenatal u/s = polyhydramnioas excessive drooling, choking, coughing and regurgitation with initial feeding attemps are seen immediately after bith *insertion of radiopaque NG tube is initial diagnostic procedure* - wont be able to pass NG into stomach presence of enteric tube in proximal esophagus on xray and inability to pass a feeeding tube into stomach is suggestive of EA TE fistula permits air entry into GI tract, and stomach and intestines can become quite distended with each breath gastric fluid can reflux into distal esophagus through fistula into trachea and lungs --> aspiration pneumonia workup for VACTERL should be considere

attention-deficit hyperactivity disorder

inattentive and/or hyperactive/impulsive symptoms for >6 months inattentive: difficulty focusing, distractible, doesnt listen or follow instructions, disorganized, forgetful, misplces objects Hyperactive: fidgety, untable to sit still, 'driven by motor', hyper-talkative, interrupts, blurts out answers presents *before age 12* symtoms occur in at least 2 settings and cause functional impairment *treamtent* stimulants: methylphenidate, amphetamines nonstimulates: atomoxetine [NERI], a2-agonists behavioral therapy

diagnostic criteria for cyclic vomiting syndrome

incidence is highest in children whose parents have migraine headaches - thought to be linked to abnormal mgiraine, which generally presents with abdominal pain as primary symptom tx - hydration, antiemetics, reassurance ; sumitriptan if fhx of mgiraines most resolve in 5-10y

pt has core needle biopsy of breast showing lobular carcinoma in situ. Next step?

incidental finding on breast biopsy and occurs in younger premenopasual women although LCIS is not cancer itself, it is a marker for increased risk of breast cancer surgical excision and radiation therapy do not decrease risk of breast cancer associated with LCIS however, once LCIS is found on needle biopsy, an excision biopsy should be performed to rule out ductal caricnoma in situ or an invasive cancer tamoxifen associated with 50% reduciton in cancer in women with LCIS

resumption of postpartum menstruation

postpartum period is the 6-8 week interval after delivery during which pregnacny-related changes resolve and patient return to pre-pregnancy state initial postpartum period is marked by rapid decrease in estrogen and progesterone HPO axis begins to normalize and ovulation resumes in patient who is not breasfeeding, ovulation resumes at *6-12 weeks* and *menses* at *8-14 weeks* postpartum because lactation suppreses ovulation, about 50% of women who are exlcusively breastfeeding will *resume ovulation at 6 months* postpartum after delivery of placenta, the endometrium is regerneated this regneration is partly accomplished by *lochia*, the normal *shedding of blood and uterine decidua* after delviery lochia can continue for as long as 2-3 months and has virations in color and consistency transitions from red/brown to serosangionous to white lochia can be there for SEVERAL months

causes of primary hypoparathyroidism

postsurgical (most common cause) autoimmune (most common non-surgical cause) congenital absence of parathyroid galnds defective CaSR Destruction by infiltrative diseases (hemochromatosis, Wilson, neck irradiation)

stent thrombosis

potentially fatal complication of coronary artery stenting, and long-term *dual antiplatelet therapy* with *aspirin + P2Y12 receptor blocker* (clopidogrel, prasugrel, ticagrelor) is recommended to reduce risk of thrombosis after intracoronary drug-eluting stent placement *premature discontinuation* of antiplatelet therapy is strongest pridctor of stent thrombosis within first 12 months pt will have an STEMI in the same distrbution that was just stented

cardinal symptoms of COPD exacberation / pathogenesis of inflation

increased cough increased dyspnea sputum production *pathogenesis of hyperinflation* negative pressure created by chest wall and positive pressure creating by lungs are at equilibrium at fucntional residual capcity (FRC) in COPD, *decreased elastcitiy* of alveoli results in decreased position pressure created by lungs to expel air thus, alveoli retain more air volume at icnreased lung volume, this decrease in positive pressure created by lungs is balance by a decrease in negative pressure by chest wall neq quilibrium reached at a *high lung volume* *air stacking* - expiratory is prolonged in COPD due to resistance; when exertional demands trigger increase in minute ventilation, pt has to begin inhalation prior to completion of exhlation --> additional tapping and hyperventilation *diaphragmatic flattentin* and muscular shortening caused by hyperinflaiton result in difficulting decrease intrahtoracic pressure during inspriation and *increase work of breathing*

risk factors for vulvovaginal candiadiasis

increased estrogen level (eg, pregnancy) immunosupression diabetes mellitus

ascites fluid characteristics

increased hydrostatic pressure within hepatic capilalry beds = portal HTN increased capilalry permability = malignanct ascites (SAAG<1.1)

pt presents with headache worse at night, n/v, mental status changes.. conerning form?

increased intracrnial pressure symptoms can worsen with maneuvers that icnrease ICP: leaing forward, valsalva, cough cushing relfex: rbadycardia, hypertesnion, respiratory dpression - worrisome of brainstem compression

clinical features of rheumatoid arthritis

increased level of proinflammatory cytokines, corticosteroid therpay and lack of physical activity can contribute to local or genearlized loss of bone mass increased risk of osteopenia, osteoporsis, bone fractures degree of bone loss correlated with disease activity most docs have low threshold for starting bisphosphonates in RA patients cervical spine involvement - neck pain, stiffness, radicular pain sublaxation w/ spinal cord somrpession - hyperreflexia, +Babinski

differential diagnosis of flaccid paralysis

infant causes: environmental dust, raw honey

congenital torticollis

infant presents with *neck mass* and *head tilt to one side* with chin deviation to the other CMT is postural deformity that presents between age 1-6 months with limited ROM of neck PE - palpable, well circumscribed mass, that does not transilluminate in the inferior portion of SCM *risks:* crowding in uterus - multiple gestation, breech, oligohydramnios *associated conidtions* [realted to itrauterine positoining]: developmental dysplasia of hip, metatarsus adductus, clubfoot *treatment* increasing tummy time passive stretching physical therapy *positional plagiocephay* - flattening of head with ipsilateral anterior displacement of ear and forhead [common consequnce of CMT]

infant of diabetic mother complications

infants of diabetic mothres, regardless of pre-gestional or gestational are at increased risk of *RDS, preterm, macrosmoia* maternal hyperglycemia, with fetal hyperinsulinemia, delays cellular maturaiton thus, immature pneumocytes in fetal lungs are unable to produce surfactant, resulting in RDS *maternal hyperglycemia* is physiologic process of pregnancy that facilitates diffuse of glucose across placenta for fetal growth however, excessive maternal hyperglycemia due to gestational diabetes can result in *fetal hyperglycemia* --> icnreases fetal apcnreatic insulin and causes fetal hyperinsulinemia This can lead to macrosomic fetus

herpes zoster opthalmicus

infection by varicella elderly, immunosupressed VZ is in trigeminal ganglion - during period of immunosupression, travels via V1 to forehead and eye fever, malaise, burning, tiching in periorbital region exam shows vesciualr rash in V1 conjuctvitis and *dendriform corneal uclers* characterize eye ivnolvement high dose acyclvoir within 72h of eruption

setting of pleural effusion : pleuritic pain + fever

infectious or inflammatory etiology cytokines released during inflammation or infection *increase capilalry permeability*, resulting in tarnlscoation of cells and fluid frmo vasculture into the pericapilalry space lymphocytosis + very elevated protein + elevated LDH ---> *tuberculosis effusion*

episcleritis

inflammation seen at white ofe eye, WITHOUT involvement of uveal tract strongly associated with RA and IBD

multiple sclerosis

inflammatory demylinating disorder of CNS that affects women age 15-50 and presents with neurologic deficits dissmeminated in space and time optic neuritic (painful monocular vision loss evolving over hours to day, imrpoves after weeks ) is common first symptom

adult still disease

inflammatory disorder recurrent high fever arthritis/arthralgias salmon-colored macular or maculopapualr rash ESR elevated

hypocalcemia after a blood transufsion is most likely due to / diagnostic approach to hypocalcemia

infused citrate can chelate serum calcium, causing hypocalcemia most likely after massive transfusions of the equivalent of more than one blood volume over 24h *other etiologies of acute hypocalcemia* neck surgery (parathyroidectomy) pancreatitis sepsis tumor lysis syndrome acute alkalosis chleation: blood (citrate), EDTA, foscarnet

cyclosporine, tacolimus, mycophenalata, azzathioprine

inhibits transcirption of IL-2 and other cytokines, mainly the T-helped lymphocytes nephrotoxicity is most common and serious side effect hypertension neurotoxicity glucose intolerance infection malignancy - inc squamous cell of skin and lymphprolfierative disease *gigival hypertrophy* *hirsutism* IG manifestations nephrotoxcity, hyperkaelmia, hypertension, gum hypetrophy, hirsitusm, tremor *tacrolimus* is simlar except *no* hirsutism or hum hypertrophy *mycophenolate* = bone marrow suppression *azathioprine* = dose related diarrhea, leukopenia, hepatotoxicty, *pancreatitis*

clinical manifestations of hereditary hemochromatosis

inital eval in HH includes serum *iron studies* - inc. serum iron, ferritin and transferrin saturation diagnosis confimed with genetic testing for hemochromatosis-associated mutations [*HFE* mutation] athropathy is associated with calcium pyrophosphate crystal deposition disease long term management = phelbotomy to deplete excess iron stores remember it cna cause *erectile dysfunction* [hypogonadism] patients have a 20x increase risk of *hepatocellular carcinoma* - accounts for 45% of deaths in HH patients

management of small bowel obstruction

initial: bowel rest, NG suction, correction of metabolic derangements complications (fever, instability) = surgery

cancer pain management

initially try nonopioids if inital interventions are not effective, intermittent doses of short acting opioids should be offered if pain requires frequent dosing or if bedtime dosing does not provide relief through the night, a long acting opioid may be added

medrxoyporgesterone injection

injection q3months DMPA causes menstrual irregularites such as prolonged bleeding and/or spotting, especially during first 6 months of use 50% ahve amenorrhea ater 1 year of use weight gain common side effect, fatigue, nasuea, breast tenderness [can mimic pregnancy] significant risk of loss of bone mineral density - do not use in adolscents

klumpke palsy

injury to inferior trunk - C8, T1 caused by suedden upward traction on arm muscles supplied by ulnar n. are ocmmonly affected (intrinsic muscles of hand)

femoral nerve

innervates muscles of naterior compartment of thigh (quadriceps, sartorius, pectineus) sensation of anterior thigh and medial leg (via saphenous branch)

amnioinfusion

instillation of saline through intrauterine pressure catheter into amniotic sac to decrase cord compression during contractions and eliminate variable decelreations (abrupt drops in FHR of varying depth and duration below baseline)

pt has suicidal ideation but no specific plan or intent. Tx?

intensive outpatient tx, but not necessarily hospitalization (eg, treat underyling disorder with medicaiton and/or psychotherapy, icnrease frequency of clinical contact, mobilize supports)

jejunal atresia

intesinal atresia can occur anywhere along the GI tract atresia of jejnum or ileum is thought to occur due to *vascular accident in utero* that causes necrosis and resorption of fteal intesine, sealing off and leaving behind blind proximal and distal ends of intestine risk factors - maternal use of vasoconstrictive meds or drugs such as cocaine and tobacco presnce of *triple bubble sign* and *gasless colon* on abdominal xray reflects gas trapping in stomach, duodenum, jejunum tx = resuscitation and stabilization of patient, followed by surgical correction

hypomagnesemia induced hypokalemia

intracellular magnesium inhibits potassium secretion by renal outer medullary potassium channels in collecting tubules of kidney therefore, low intracellular magnesium concetrnations result in excess renal potassium loss and refractory hypokalemia normalization of magnesium levels restores ROMK channel potassium transport regulation, deceases renal potassium losses, and allows for successful correction of hypokalemia with oral (preferred0 or IV potassium repalcemnt

clinical features of paroxysmal nocturnal hemoglobinuria

intravascular + extravascular hemolysis hemoglobinuria genetic defect that reuslts in lack of glycosylphophatidylinositol anchor - which connects CD55, CD59 to cell surface these proteins normall inhibit activation of complement on RBC, but their abscence allows the *membrane attack complex* for form and results in hemolysis

timeline of infant nutrition

iron deficiency anemia is single most common nutritional deficiency in infants and children and is often asymptomatic Most infants have iron stores to last for 4-6 months regardless of dietary intake Presence of maternal iron deficiency, prematurity, and early induction of cow's milk increses risk of iron defiency all exclusively breastfed infants need 400IU of *vitamin D* within first month *exclusive breastfeeding until age 6 months is recommedned* pureed fruits/vegetabls --> pureed proteins

brain death

irreversibly cessation of brain activties *essential elemts* 1. evaluating cortical and brain stem funcitoning 2. proving irresrsibility of brain activity loss (eg, sufficient observaiton length, no hypothermia, etc) *absent cortical and brain stem funcitons* absent pupil reaction, oculoverstibular reaction apnea test - no spontaneous respiration at PCO2 >50 [no lower brainstem] spinal cord may still be functioning [DTR's can still be seen] *isoelectic EEG* can be a confirmatory test, but is not necessary

contact dermatitis

irritant CD is *nonimmunologically mediated* symptoms are typically *chronic*, leading to excoriations, hyperkeratosis, and fissuring of involved skin *emollients* and use of *protective barriers* can relieve symptoms however, identification and avoidance of offending agent are also essential

patient has type 2 diabetes. Has rapid onset nephrotic syndrome, hematuria, RBC casts. next step?

kidney biopsy to establish clear diagnosis diabetic nephropathy is common cause of nephrotic syndrome of adults; however it is insidious in onset, and does not have hematuria or RBC casts thus a definitive diagnosis needs to be made so that the approrpaite treatment can be made

clinical features of crystal-induced acute kidney injury

kidney rapidly excretes acyclovir into urine, but drug has low urine solubility as a result, it precipitates in renal tubules, causing intraltubular obstruction and direct renal tubular toxicity crystal induced obstruction = <7 days interstitial nephritis = >7 days

labor and vaginal delviery are contraindcated after a classical cesarean delivery or extensive myomectomy [with uterine cavity entry] due to signficant risk of uterine rupture

laboring patients at high risk of uterine rupture require lapartomy and delivery

most common cause of metabolic acidosis in patients requiring hospitlization

lactic acidosis - sepsis is common tx = IV resustiviation with crystalloid, possible vasopressors, abx

lacunar stroke

lacunar infarcts produce deficits over minutes to horus and symptoms may follow stuttering course lacunar strokes are small (<15mm in diameter) subcortical infarcts resulting from occlusion of deep penetrating branches of major cerebral arteries most commonly associated with *chronic hypertension* --> arteriolar sclerosis and vessel occlusion

greatest efficacy in treating bipolar depressive episodes [+ side effects of drug}

lamotrigine drug rash - mild form of morbiliform rash severe form = Steven Johnson syndrome and toxic epidermal necrolysis lamotrigine should be discontinued at first sign of rash most cases of lamotrigine-induced rash develop within first 2 months of therapy

which type of STEMI can have the complication of LV thrombus in subsequent days

large anterior ST elevation MI high risk of LV trhombus and ateroapical aneurysm formaiton patients have EF <40% high risk for systemic embolization and require immediate anticoagulation andv ascular surgery evlation TTE can be used to screen for LV thrombus

acute stress disorder

lasts 3d to 1 month after exposure to actual or threatened trauma intrusive memories, nightmarkes, flashbcks amenesia for event, detachment, avoidance of remindres negative mood hypervigilence, impaired concentration, irritbaility *management* CBT pharmacotherapy for insomnia, itnense anxiety monitor for development of PTSD education on symptoms and course of acute and post-traumatic stress disorders normalizing stress response, while explaining that symptoms can sometimes cause distress and impairment, would be helpful education of comorbid substance abuse

sudden infant death syndrome

leadign cause of mortality in infants 1 month to 1 year in the US

diabetic nephropathy

leading cause of ESRD in USA increased ECM, basement membrane thickening, mesangial expansion, fibrosis earliest renal abnormality = *glomerular hyperfiltration* best screening method = *spot microalbumin to creatinine ratio* earliest change that can be quantitated = *thickening of glomerular basement membrane*

fetal alcohol syndrome / common causes of intellectual disability

leading preventable causes of birth defects and neurodevelopmental problems FAS is characterized by 3 pathognominic facial dysmophisms: 1. small palpebral fissues 2. smooth philtrum (vertical groove bove upper lip) 3. thin vermilion border height and/or ewight growth is cormpmised microcephaly is often present cognital + behvaior disorders intellecutal disability ADHD social withdrwal delyas in motor and language milestones

what is best long term contraception that is not associated with weight gain?

levonorgestrel-cotaining IUD - long-acting, reversible contraception efficacy of >99%; used for 5 years common side effect = amenorrhea less commonly = mood changes, breast tendreness, headache

borderline personality disorder

lifelong pattern of unstable, chaotic relasitonships labile mood poor sense of self impulsive and go to great lengths to avoid abandoment, cinluding attempting suicide or making suicidal gestures during periods of severe stress, transient paranoid ideation or dissociative symptoms can occur and last minutes to hours

painless hematuria in sickle cell trait

likely due to renal papillary ischemia or necrosis low local partial pressure of oxygen in vasa rectae preidosposes the affeted RBC to sickling papillary nercosis can occur with massive hematuria, but episodes mild and resolve sponteanously other renal complications in Sickle CEll - inability to concentrate urine: vasa rectae damage with inability to main concentrated medulalry gradient

subacute thyroiditis (de quervain thyroidits)

likely postviral inflammatory process prominent hyperthyroid and fever symptoms *painful/tender goiter* elevated ESR and CRP low radiodine uptake *tx* beta blockers for thyrotoxic symptoms NSAIDs for pain

what should patients with recurrent renal calculi do with their sodium intake

limit Na intake - reabsorption of Na and calcium is coupled via complex mechanisms involving the CaSR in thick ascending limb of loop of Henle increased Na intake enahnced Ca excretion, and low sodium promotes Na and Ca reabsorption

patient responds to antipsychotics while in the hospital, but continually relapses when out of the hospital. Next step?

long acting injectable antipsychotic - patient most likely has medicaiton nonadhereance patients with unstable illnesses who live along and have poor social support systems, poor insight and frequent medication nonadherence are good candidates for LAI antipsychotics

arterial blood gasses in salicylate toxicity treatment of salicylate toxicity

low PaCO2 low HCO3 near-normal arterial pH *treatment* - remember ABC's trump everything if within 1h = gastric lavage within few hours = activated charcol NaHCO3 = alkanize urine

pediatric brain tumors

low grade *astrocytoma* [pilocytic astrocytoma] is most common brain tumor in children supratentorial - seizures, weakness, sensory changes posterior fossa - cerebellar dysfunction craniopharyngioma - arise in sella turcica and appear as cystic structures with calcifications on imaging ependymoas - glial tumors from ependymal lning of ventricles and spinal cord; most commonly in 4th ventricle in posterior fossa medulloblastoma - 2nd most common tumor of posterior fossa in children; typically arise from cerebellar vermis - vomiting, HA, ataxia

thoracentesis of malignant pleural effusion

low pH <7.2 low glucose <60 very high LDH cytology is low yield use PET or CT to identify soruce to biopsy most common causes of malignant pleural effusion = breast, lung

stasis dermatitis

lower extremity venous valvular incompetence resulting in pooling of venous blood and increased pressures in psotcapillary venules increased pressure damaged capillaries causing loss of fluid, plasma proteins and erythrocytes into the tissue erythrocyte extravasation causes hemosiderin deposition and coloration of stasis dermatitis inflammation of venules and capillaries as well as fibrin deposition and platelet aggregation cause microvascualr dz and ulcerations occur xerosis = early dz lipodermatosclerosis + ulcers = late dz

chronic granulomatous disese

majority of cases X-linked recessive recurrent pulmoanry and cutaneous infections catalase positive pathogens: staph aureus, serratia, burkholderia, aspergillus *diangoisis*: testing neutrophil function via detection or absence of oxidative burtst dihydrorhodamine 123 test nitroblue tetrazolium test *treatment* abx prophylaxis IFN-y can be used to booth intracellular killin in severe cases

complications in DES daughters

males - cryptorchidism, microphallus, hypospadius, testicular hypoplasia

gilbert syndrome

males; most common inherited disorder of bilirubin glucurnoidation *decreased UDP glucurnosyltransferase activity --> increased unconjugate dbilirubin* AR or AD mutation in *UGT1A1* - UDP-glucuronosyltransferase intermittent mild jaundice provked by stress (eg, infection, fasting, vigorous exercise, surgery) *diagnosis* unconjuaged hyperbili on repeat testing normal CBC, blood smear, reticulocyte count normal AST, ALT, alk phos *treamtnet - none* important to educate pts about *benign* nature of the condition and its inheritance pattern to prevent unnecessary diagnostic studies

tinea versicolor (pityriasis veriscolor)

malessezia globosa skin flora grows in exposure to hot+humid weather hypopigemented, hyperpigemnted, or mildly eryhtematous lesions +/- fine scale +/- pruritis *diagnosis*: KOH prep shows hyphae and yeast cells in sphaghetti and meatball pattern *treatment*: topical ketoconazole, teribinafine, selenium sulfide

postmenopausal women on HRT. Palpable breast mass. next step?

mammography you dont need to d/c the estrogen replacement until the mass is proven to be malignant

elder abuse

manifestations of physical abuse in elderly: unexplained pain, injuries in multiple stages of healing, or injuries in unusal locations elderly individuals are also at risk for financial exploitation, psychological abuse, sexual abuse, and neglect

mecahnism of maternal diabetes causing RDS

maternal diabetes --> fetal hypergylcemia fetal hyperinsulinism --> antagonize cortisol and block maturation of shingomyelin

pt presents complaining that 7am glucsoe measreuemnt was 215 mg/dl. Level was checked before breakfast and prior to giving morning insulin dosage. next step?

measure glucose at 3am - any time pt has increased morning glucose, measure it at 3am before making changes to insulin regimen the patient does this and reports a glucose of 150; the most likely cause of the 7AM hyperglycemia is? *dawn phenomenon* - result of early morning growth hormone sections; pt will be *hyperglycemic* in middle of night ddx: *Somogyi effect* - overtreatment causing pt to be *hypoglycemia* at night; 3AM glucsoe would be low; pt counters hypoglycemia and becomes hyperglycemic in morning *next step after realizing dawn phenomenon* evening basal insulin should be increased [glargin and determir are more stable of overnight insulin, preferred over NPH]

predisposing conditions for aspiration pneumonia

measures to prevent pneumonia in hospitilized patients include: -oral care -diet modifcaiton for pt with dysphagia -compenstaory techniques: eelvating head of bed to 30-45 degrees pt presents with indolent symptoms (days to weeks), foul smelling sputum, concurrent periodontal disease tx = clindamycin for anareobic coverage

iron poisoning

mechanism of iron poisoning is free radical production and lipid peroxidation, which impairs various cell processes, leading to systemic manifestations *deforaxamine* = antidote for *serious* iron poisoning

glucocorticoid induced mucsle atrophy

mediated by inhibition of AKT-1, and intracellular signaling molecule with serine/threonine kinase activity intereference with ILFG1 decrease muscle cell differenitation and protein synthesis

inability to break down fatty acid chains

medium chain acyl-CoA dehydrogenase deficiency results in hypoketotic hypoglycemia in fasting states (eg, illness)

hypersegmented neutrophils

megaloblastic anemia - B12, folate both folate and combalamin are used in conversion of homocysteine to methionine thus deficiency of either results in *elevated homocystine levels* combalamin is invovled in convesion of methylmalonyl-CoA to succinyl-CoA, thus defieincy in B12 results in *elevated methylmalonic acid* *b12* is needed for demythlation of folate if pt has combined b12 and folate delificiency if you replenish the folate, the megaloblastosis will resolve; however the neurologic deficits will get worse

what nephrotic syndrome is most commonly associated with malignancies

membranous glomerulopathy - *spike and dome pattern* of IgG and C4 associated with: syphillis, HCV, malaria, malignancy, SLE, gold, pencillamine solid cnacers: lung, colon, prostate, breast

patients have the right to know their diagnosis if family members request that the diagnosis not be revealed to patient, the underlying reasons should be explored before deciding how to proceed

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dihydropyridine CCB can cause peripheral edema

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fluroquinolone use is assocaited with tendinopathy and tendon rupture

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in absence of an advance directive, a life saving blood transfusion can be given to a jehovah's witness who lacks deicion making capcity

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in cases of HIV, public health laws require reporting of patient's positive test results to local health department health department usually contacts the patient's contacts

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in clinical trails, randominization is said to be succesful when a similarity of baseline characteristics of the patients in the treatment and palcebo groups are seen

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medical information should be shared with family members only with the patient's permission

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patients with PAD and intermittent claudication have 20% 5-year risk of nonfatal myocardial infarction and stroke

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the p-value is the probablity of observing a given (or more extreme) result due to change along, assuming the null hypothesis is true

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when dealing with an angry patient, the most appropriate response is to remain nondefensive, acknowledge the patient is upset, and being discussion with open ended question

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*in case of amputation injury, amputated parts shoulder be:* wrapped in saline-moistened gauze sealed in a plastic bag placed on ice brough to ED with patient

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correlation coefficient (r) shows strength and direction (positive, negative) of linear association between 2 varaibles **it does not necessarily imply causality**

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functional murmur can occur in patients with anemia due to flow across aortic and pulmoanic valves

****** no click or splitting

assessment of malignancy risk for solitary pulmonary nodule

*1st step is always compare to previous film* if no prior cxr --> do CT to further characterize lesion large size, low desnity, spiculated, eccentric calcfication = carcinoma SPN with stabile size and appearnce for 2-3y has low malignancy risk and can be given reassraunce malignant nodules tend to double in size over course of month to a year ground glass lesions have high risk and require yearly assessment even with stable size low malignant potential should be followed with serial CT scans

hepatitis B causes what nephrotic syndrome

membranous nephropathy -deposition of HBeAg or its corresponding antibody in glomeruli HBV vaccination dramatically reduced these cases

infertility in cystic fibrosis

men - obstructive azoospermia women - malnourished and subfertile from pubertal delay and amnoerrhea; viscous cervical mucus can obstruct pserm entry

abdominal aortic aneurysm screening recommendation

men age 65-75 with history of smoking should get a one time screening with u/s

acute knee pain + limited joint extension + twisting injury

meniscal tear *younger patient*; rotational force on planated foot *older patient*: degeneration of meniscal cartilage *symptoms* acute popping sensation catching, locking, reduced ROM slow onset joint effusion *exam* joint line tenderness pain or catching in provocative tests: Thessaly, McMurray *diagnosis*: MRI, arthroscopy *management* mild sx, older pt: rest, activity modification persistent sx, impaired activity: surgery

serotonin syndrome clinically

mental status changes - anxiety, agitation, delirium atunomic dysregular - diaphoresis, HTN, tachycardia, hyperthermia, vomiting neuromuscular hyperactivity - tremor, myoclonus, hyperrfelxia

mesonpehros vs paarmesonephron

mesonephros = seminal vesicles, epididymis, ejaculatory ducts, ductus deferens paramesonephron = fallopian tubes, uterus, part of vagina

mechanism of calcium oxolate crystals in ehtylene glycol poisoning? mechanism of calcium oxolate crystals in crohns?

metbaolism via alocohol and aldhehyde dehydrogenase prodcues glycolic acid, which is converted to oxalic acid oxalic acid binds to calcium --> hypocalcemia and preciptiation of calcium oxalate crystals in urine *crohns* normally, calcium binds oxalate in gut and prevents its absoprtion in pt with fat malabsoprtion, calcium is preferentially bound by fat leaving oxalate unbound and free to be absorbed in bloodstream failure to adequately absorb bile salts in states of fat malabsorption cause decreased bile salt reabosprtion --> excess bile salts dmage colonic mucosa --> increased oxalata abosprtion

which beta blockers have been shown to imrpove long term survival in heart failure patients

metoprolol carvediolol bisoprolol

lead poisoning

microcytic anemia --> fatigue, exertinoal dyspnea stocking/glove neuropathy peripheral neuroatphy - foot or wrist drop GI - abdominal pain, constipation MSK - joint pains, muscle aches occupation: plumbing, smelting, battery manufacturing, recycling tx = dimercaprol - increases urianry and fecal exretion of lead oral succimer is chelating agent for children (when lead >45 ug/dl) hospital admission for IV chelation is when serum lead >70 ug/dl

williams syndrome

microdeletion of long arm chromsome 7 region lost includes elastin gene *presentation* distinctive 'elfin' facies mental retardation hypercalcemia - increased sensitvity to vitamin D well developed verbal skills extreme friendliness with strangers musical talent supravalvaular aortic stenosis pulmoanry stenosis septal defect

trousseau's syndrome

migratory superficial thrombophlebitis hypercoaguable disorder that presetnsw ith unexplained superficial venous thrombosis in unusal sites (arm, chest, etc) associated with cancer of pancreas (most common), lung, prostate, stomach, colon, acute leuemia tumor releses mucins that reac w/ platelets to form platelet rich microthrombi CT of abdomen should occur in suspected pancreatic cancer

what is msot common valvular abnoramltiy in infective endocarditis in all people infective endocarditis in IV drug users

mitral valve diesease - usually MVP with coexisting MR *infective endocarditis in IVDU* HIV ifnection increases IE risk staph aureus is most common tricuspid valve involvement mroe common thana ortic valve holosystolic murmur increases w/ inspiration indicating tricuspid involvement septic emboli common fewer periphearl IE meanifestations heart fialure more common in aortic valve involvement but rare with tricuspid valve disease

short systolic murmur at cardiac apex that disappears with squatting...

mitral valve prolapse systolic click and/or mid to late systolic murmurs of mitral regurg squatting increases preload and LV volume --> decreasing itesnity of murmur chronic severe mitral regurg can lead to heart failure symptoms displaced apical impulse, holosystolic murmur, S3 chornic severe MR can cause LA dilation --> atrial fibrillation [pt feels palpitations] S3 does not necssarily mean CHF, but it means LV volume overload

treatment of nacolepsy

modafinil - nonamphetamine medication that pormotes wakefulness less abuse potenital compared with traditional stimulants signficant cataplex = sodium oxybate should be added

twin gestations

monochorionic monoamniotic [single placenta, single amniotic sac] = highest prganncy related complication single placenta = risk of twin-twin tranfusion single amniotic - umbilical cord entaglement and intrauterine fetal demise *delivered at 32-34w via C-section* dichorionic diamniotic [2 placentas, 2 amniotic sacs] = can have a 'fused' placenta showing *lambda sign* monochorionic diamniotic [1 placenta, 2 sacs] = thin intertwin membrane that meets palcenta at 90 degree angle - *t-sign*

mechanism of renal insufficiency in multiple myeloma

monoclonal light chains clog renal tubules, causing intratubular cast formation and toxicity pt with cast nephropathy have normal UA with little proteinuria (UA detects albumin but not monoclonal protein)

maintence therapy for bipolar

monotherapy = lithium, valproate, quetiapine, lamotrigine if patient has renal failure = *valproate* is used if pt has inadeqaute response to monotherapy and/or frequent episodes often require combination therapy Lithium or valproate combined with 2nd gen antipsychotic lifelong illness that requires maintence therapy to reduce risk of recurrent episodes most require tx for many years, and lifelong maintence is indicated for those with severe course: freqeunt episodes suicide attempts severe symptoms hospitalization *lithium has shown reduced risk of suicide in bipolar patients*

HIV-associated dementia [HIV-associated neurocognitive disorder table pictured]

more likely to be present in untreated HIV patients with *CD4 <200* and in patients with *long standing HIV* disease macrophage-medaited signaling pathways and associated toxicity may lead to neuronal dysfunction onset is typically subacute and characterized by increased apathy and impaired attention mood and behavior disturbances are common subcortical (eg, basal ganglia, nigrostriatal) dysfunction occurs early with symptoms such as slowed movement and difficutly with smooth limb mvoement this is followed by significant cortical neuronal loss and memory decline diagnosis is based primarily on clinical presentation MRi can show diffuse increase in intensity of whtie matter adherence to HAART decreases chance of developing HIV dementia resuming HAART may improve HAD symptoms

clinical features of psoriatic arthritis

morning stiff is present deformity of involved joitns, dactyltitis, nail invovlement are very common onycholysis (separation of nail bed) *treatment* NSAID methotrexate anti-TNF agents

infective endocarditis - modified duke criteria

most appropriate first step when suspecting IE is to *obtain serial blood cultures* - minimum of 3 blood cultures from separate venipuncture sites over specified period [typically 1 hour] *before* intiation antibiotics

autosomal dominant polycystic kidney disease

most are asymptomatic hematuria, flank pain HTN palpable abdominal masses - right kidney is easier to palpate because it leis lower than left kidney proteinuria chronic kidney disease *extrarenal* cerebral aneurysms hepatic and pancreatic cysts [most common extrarenal manfiesation] cardiac valve disorders (mitral valve prolpase, aortic regurg) colonic diverticulosis ventral and inguinal hernias dx = ULTRASOUND showing multiple renal cysts *management* follow BP and renal function aggressive control of CV risk factors (HTN) ACE inhibitors for high BP ESRD: dialysis, renal transplant

contact lens associated keratitis

most are due to gram negative organisms (pseudomonas, serratia) medical emergency and can lead to conreal perforation, scarring, permanent vision loss painful, red eye, and opacification and ulceration of cornea tx = removal and discarding of contact lens, IV broad spectrum abx

acute myeloid leukemia

most common adult leukemia; median age 65 *manifestation* fatigue is common; other B symptoms unusal anemia: fatigue, weakness thrombocytopenia: bleeding, bruising granulocytopenia: ifnection DIC if APML (pyomyelocytic) *labs* cytopenias elevated Lactate dehydrogenase peripheral smear - myeloblasts with auer rods *diagnosis* bone marrow bx - usually hypercellular with myeloid blasts

red man syndrome

most common adverse effect of vancomycin characterized by hypotension, dyspnea, prurits and erythema above the wait seen with rapid IV infusions can be prevented by lenghtening the infusion time tx = discontinue vanc infusion +/- antihistamines once the symptoms have resolved, you can restore the infusion at slower rate

costochondritis

most common cause of MSK chest pain presents with tenderness of >1 anterior chondral joints caused by joint aggravation during physical activity localized pain of anterior chest that *worsens with movement*, deep inspiration, or coughing *tender to palpation* on ffected portion benign, self limting in matter of weeks management = reassruance with topical or systemic analgesics (acetaminophen, NSAID's)

acteminophen toxicity

most common cause of acute live failure overporudce of toxic metabolite NAPQI --> hepatic necorisis safely detoxified through *glucuronidation* in the liver chronic alcohol use can deplete glutathione levels and impair glucuronidation process NAC increases glutathiona levels and bings NAPQI acute renal insufficiency is common in ALF with acteimophen due to drugs direct renal tubular toxicity *low* bilirubin [unlike other causes of ALF]

posterior urethral valves

most common cause of chronic renal insufficiency/failure in children distal urianry tract obstruction can cause secondary urianry reflux but condition only affects boys abnormal folds in dsital prostatic urterha obstruct urinary flow, resulting in progressive dilation of bladder, ureters and kidney prenatal u/s - bladder distention, bilateral hydroureters and bilateral hydronpherosis can cause potter sequence can present with poor urinary stream, straining with voiding, urosepsis, failure to thrive, renal failure dx = voiding cystourethrogram and cystoscopy tx = PUV ablation and urianry diversion

secondary bacterial pneumonia

most common complication of influenza suspected in any pt who has worsening fever and pulmonary symptoms after initial symptomatic imrpovement staph aureus and strep pneumo are 2 most common s. aureus is severe, necrotizing and rapidly progressive: high fever, hypotnesion, dyspnea, hemoptysis, confusion young patients typically do not develop secondary pneumonia however, exception with CA-MRSA creating the necrotizing pneumonia that is rapidly progressive and fatal --> high fever, hemoptysis, leukopenia, *multilobular cavitary infiltrates* requires admission to ICU --> broad spectrum, empircin abx [vanc or linezolid]

complete atrioventricular septal defect

most common congenital heart defect in *Down syndrome* failure of endocardial cushions to merge results in VSD and ASD as well as a common AV valve due to poor mirtal and tricuspid valve development heart fialure develops from blood mixing between chambers and severe AV valve regurgitation, leading to volume overload and excessive pulmonary flow diaphoresis/dyspnea with feed and crackles manfiest around *6 weeks* as PVR falls cxr = increased vascular markings from excessive blood floow *auscultation* loud S2 (pulm HTN) systolic ejection murmur (increased flow across pulmonary valve from L-->R shunt across SD) Holosystolic murmur of VSD

ventricular septal defect

most common congenital heart malforation holosystolis murmur at left lower SB apircal diastolic rumble from increased flow across mitral valve large VSD = large shunts causing pulmonary overcircumation, pulmoanry HTN, growth failure, heart failure can ultrimately can Eisenmenger syndrome *echo* needs to be performed to determine location and size of defect and to r/o other defects small VSDs close spontaneously in 75% of children by age 2 w/o long-term sequelae large defects have *softer murmur* due to less turbulence these are the defects that need to be repaired to prevent pumloanry overcirculation --> pulm HTN --> CHF + eisenmnger syndrome

meckel's diverticulum

most common congenital small-intesintine anomaly that results from incomplete oblieration of vitelline (omphalomesenteric) duct most contain hterotopic gastric mucosa, some have pancreatic tissue HCl from gastric mucosa causes mucsoal ucleration *epidemiology* 2% prevalence 2:1 male to female ratio 2% symptoamtic at age 2 located within 2ft of the ileocecal valve *clinical* asymptoamtic incidental finding (most common presentation) iwth painless bleeding painless hematochezia intussusception intesinal obstruction volvulus *diagnosis* techneitum-99m pertechnetate scan *treatment* surgery for symptomatic patient

biostats

precise - ordered, clustered nature of results, litter variation [measure of random error] the tighter the confidence interval, the mroe precise the result accuracy - ability to reflect actual picture and not subject to any bias cohort study is best for determining the incidence of disease comparing incidence of dsiease in 2 populations, with and without a givenr isk factor, allows for calculation of realitve risk ecologic studies - unit of observation is a population; disease rates and exposures are measured in >2 populations, and association between disease rates and exposures is detemrined however, results about assoications at the population level may not translate to indivudal level Matching is used in case-control studies becasue it is an efficient method to control confounding attributable risk percent (ARP) [etiologic fraction] - impact of a risk factor being studied ARP = (risk in exposed - risk in unexposed) / risk ine xposed ARP = (RR-1)/RR

constitutional growth delay

most common cuase of prepubertal short stature and pubertal delay Delayed puberty is absence of testicualr enlargement after 13y or absence of breast growth after 12 years in girls normal sized at birth, but shortly thereafter expeirence a deceleration in linear growth that results in downward crossing of growth percentiles until about 3 years of age AFter 3 years of age, they resume normal growth veloicty for remainder of prepubertal years at expected time of puberty, they experience 'drop off' the growth curve, because delay of puebrtal growth spurt in relation to peers the onset of puberty, the pubertal growth spurt, and catch-up growth occur later than average in these patients they eventually attain normal adult stature and sexual development these patients are *not* deficient in growth hormone; so do not GH bone xray are younger than chronological age delayed pubertal development family hx of late puberty low height/weight but has been consitently linear since birth *familial short stature* - fhx of short stature and slow growth rate during first 3 years life, followed by low-normal growth rate Xray are within nromal limit for chronolgical age onset of puberty is not delayed

prenatal testing

*1st trimestercombined test* - plasma protein, bhcg, nuchal tranlusncy 9-13w early screening not diagnostic *cell free fetal DNA* >10w high sensitvity and specificty for aneuploidy not diagnostic *chorionic villus sampling* 10-13 weeks definitive karyotpic diagnosis invasive; risk of abortion *2nd trimester quadruple screen* - serum AFP, estriol, bchg, inhibin A 15-22w screens for NTD and aneuploidy not diagnsotic *amniocentesis* 15-20w definitve karyotpic diagnosis invasive; risk of membrane rupture, fetal injury, pregnancy loss *2nd trimester u/s* 18-20 weeks measure fetal gorwth, fetal anatomy, confirms palcenta position cannot idenify all abrnomlaties, some findings are of uncertain signiance

congenital adrenal hyperplasia

*21 hydroxylase deficiency* inhibited conversion of progesterone to 11-deoxycorticosterone [precursor of aldsterone] --> dehydration, salt wasting inhibited conversion of 17-hydroxyprogesterone to 11-deoxycortisol [precursor of cortisol] ---> fasting hypoglycemias increased conversion of 17-hydroxyprogesterone to androstenedione [precursor to testeoerone] --> virilization and ambigious genitlia in females; males have no abnormal newborn genital findings *elevated 17-hydroxyprogesterone* confirms diagnosis of *classic CAH* tx = glucorticoid and mineralocrticoid replacement

preterm labor management

*34-36 6/7* betamethasone pencillin if GBS+ or unkown *32-33 6/7* betamethasone tocolytics penicllin if GBS+ or unknown *<32* betamethasone tocolytic MgSO4 - used for fetal neuroprotection penicllin if GBS+ or unknown

disorders of sexual development

*5-alpha-reductase deficiency* low levels of more potent DHT, which is normally responsible for converting fetal external genitalia into characteristic male phenotye ambiguous genitalia at birth is presentation *complete androgen insensitivty* 46, XY but phenotypically female tissues unresponsive to androgens, thus resulting in external feamle genitalia and minimal to absent body hair breast development occurs because it is estrogen-driven (testosterone is aromatized to estrogen) cyrptochoid gonads have 1-5% risk of developing dysgermina or gonadoblastoma fater puberty in general, benefits frmo undergoing a gonad-stimualted puberty (eg, attainment of adult height), outweight low risk of malignancy *gonadectomy* can be *derferred until completetion of pubery*

causes of meningitis in children

*<3 months* GBS - most common [intrapartum abx does not eliminate colonization; therefore, has not changed icnidence of horizontally transmitted, late onset GBS sepsis] E coli Listeria - mom will have flu like symptoms HSV *3 months - 10 years* Strep pneumonia N. meningitidis *>11 years* N. meningitidis

prosthetic joint infection etiology

*<3 months* staph aureus gram neg rods anaerobes *3-12 months* coag neg staph (staph epidermidis) propionibacterium species enterococci *>12 months* staph aureus gram neg rods beta hemolytic strep

palpable breast mass workup

*<30 --> ultrasound* +/- mammogram simple cyst --> needle aspiration (if pt wants); typically will reeaxmine in 2-4months for resolution instead complex cyst [solid mass] --> image guided core biopsy *>30 --> mammogram* +/- u/s suspicious for malignancy --> core biopsy only way to *confirm* diagnosis = *biopsy* excision biopsy - large, suspicious masses core biopsy = solid, acellular (eg, stromal) masses FNA = cystic, small mass

characteristics of different grade squamous intraepithelial lesions

*HSIL* increased nuclear to cytoplasmic ratio (>50%) thickened, irregualr nuclear membranes irregular chroamtin distribution with increased granularity nuclear/cytoplasmic maturation discrepancy *colposcopy or LEEP* *ASCUS* double nuclei parakeratosis mild hyperchromasia nuclear enlargement (25%) *followed in 1yr w/ cytology* *LSIL* mature cells w/ enlarged nuclei and evenly distrbuted chromatin nuclear to cytopalsmic ratio may be increased (but <50%) *follow up in 1yr with cytology*

maternal hypothyroidism in pregnancy

*TSH* low/suppressed during first trimester dueo thyroid-stimulating actions of b-hcg First trimester TSH: 0.1-2.5 Second trimester TSH: 0.2-3.0 Third triemster TSH: 0.3-3.0 *management* increase lveothyroixine by 30% monitor TSH q4w adjust dosage to maintain TSH within pregnancy reference ranges by trimester estrogen increases synthesis of TBG and decreases TBG clearance --> increased pool of bound thyroid hromone hCG (shares common alpha subunit with TSH) directly stimulates tSH receptors in patients with normal thyroid funciton, the net effect can resemble subclinical hyperthyroidism with *increased total T3 and T4, normal free T4, suppressed TSH* although patient is clinically euthyroid

klinefelter syndrome

*XXY* *most common sex chromsome abnoramlitity causing primary hypoganidism* newborns have normal male external genitalia after puberty, small testes and tall stature become apparent testicular fibrosis azoospermia gynecomastia decreased intelligence increased axial growth high FSH, high LH increased risk of extragonadal germ cell tumors

migraine therapies

*abortives* triptans: sumitriptan NSAIDs: naproxen acetaminophen antiemetics: metoclorpamide, prochlorperazine, promethazine ergots: dihydroergotamine *preventives* topiramate divalproex sodium tricyclic antidepressants beta blockers (eg, propanolol) *prophylactic medications can be considered in pt who*: frequent (>4/month) or long lasting (>12h) episodes disabling sx that prevent regular activities unable to take or have had no relief with abortive meds overuse abortive meds and have rebound headache

clinical features of absence seizure & inattentive staring spells

*absence* occurence during all activities length <20s lack of response to vocal or tactile stimulation presence of automatisms (eyelid fluttering, lip smacking, etc) *inattentive staring spells* occurence primarily during boring activities variable length, often >1m response to vocal or tactile sitmulation lack of automatisms

evaluation of subacute (3-8 weeks) or chronic (>8 weeks) cough

*ace inhibitor cough* accumulation of kinis and substance P ace-inhibition also activates arachidnoic pathway, leading to increased levels of thromboxane

lithium toxicity / tetaratogenic effects

*acute* GI - n/v/d late neurologic sequale *chronic* confusion agitation ataxia tremors/fasciuclations *management*: hemodialysis for severe cases *first trimester* esbtein anomaly - atrialization of RV *2nd, 3rd trimester* goiter transient neonatal neuromuscular dysfunction

differential diagnosis of stridor

*acute* croup foreign body aspiration *chronic* laryngomalacia vascular ring *vascular ring* abnormal development of aortic arch - causes tracheal, bronchial, and/or esophageal compression up to 50% also have cardiac anomaly present in pateints *age <1* with respiratory and/or esophageal symptoms stridor is *biphasic* and more porminent during expiration, *improves with neck extension* [decreases tracheal compression]

causes of hirsutism in women

*adrenal mass* - overproduce DHEAS, which is conversted to a more potent androgen (androsteneione and testosterone) LH is low from negative feedback *ovarian mass* - can release large amounts of Testosterone DEAS would be normal as adrenal androgen secretion is regulated by ACTH rather than LH DHEAS and DHEA have negligble intrinsic androgenic action but are converted to androstenedione and then testosterone in peripheral tissues

neonatal conjuctivitis

*all infants should receive topical prophylaxis within an hour of birth* [typically done with *erythromycin ointment*] *gonococcoal* copious exudate and eyelide swelling at age 2-5 days gram stain: gram-negative intracellular diplocci [not always seen --> culture] positive culture on Thayer-Martin media Treatment: IM ceftriaxone or cefotaxime prevention: erythromycin ointment complications: corneal ulcers, scarring, blidness *chemical conjuctivitis* = reassurance + saline flush

clinical findings of congenital infections

*all* IUGR HSM jaundice blueberry muffin symptoms *cytomegalovirus* *periventricular* calcfications *toxoplasmosis* *diffuse* intracerebral calcfications severe chorioretinits *syphilis* rhinorrhea abnormal long-bone radiographs (eg, metaphyseal lucencies) desqumating or bullous rash *rubella* cataracts heart defect (eg, PDA)

High PaCO2, low PaO2 suggests A-a gradient

*alveolar hypoventilation* pulmonary/thoracic disease - COPD, OSA, obesity, scoliosis neuromuscular: myasthenia gravis, lambert-eaton, guillain-barre drug-induced: anesthetics, narcotics, sedatives primary CNS: brainsteam lesion, stroke A-a gradient is normal in pt with reduced inspired oxygen tension and hypoventilation in v/q mismatch - decrease in PaCO2, decrease in PaO2 These patients will have an elevated A-a gradient A-a gradient can be used to help find cause of hypoxemia *normal A-a* = <15 elevated = >30

cervicofacial actinomyces

*anaerobic* acid-fast negative

structures of mediastinum on CT

*anterior* thymoma retrosternal thyroid teratoma lymphoma *meiddle* bronchiogenic cyst tracheal tumor pericardial cysts lymphoma lymph node enarlgement aortic aneruysms of arch *posterior* neurogenic tumors - meningocele, enteric cysts, lmyhoma, diaphragmatic hernias, esphageal tumors, aortic aneruysms MRI needed for posterior structures

common drugs associated with photosensitivity reactions

*antibiotics*: tetracyclines (eg, doxycycline) *antipsychotics*: chlroproamzine, prochlorperazine *diuretics*: furosemide, hydrochlorothiazide *others*: amiodarone, promethazine, piroxicam *pathology*: phototoxic drug reactions result in production of reactive oxygen species by the itneraction of drug metbaolites with UV radiation these reactive oxygen products directly damage cell membranes and DNA reactions mimic sunburn, with erythema, pain and bullae however, reactions may have exaggerated severity, and the solar exposure needed to cause symptoms may be much less than that needed of non-phototoxic sunburn

choice of treatment in graves hyperthyroidism

*antithyroid drugs* (thionamides) *agranulocytosis*[very rare, no need to monitor WBC count] methimazole: 1st trimester teratogen, cholestasis propylthiouracil: *hepatic failure*, ANCA-associated vasculitis *radioidine ablation* permanent hypothyroidism worsening of ophthalmopathy possibly radiation side effects *surgery* permanent hypothyroidism risk of recurrent laryngeal n. damage risk of hypoparathyroidism

narcolepsy

*associated features* shortened REM sleep latency [enter REM sleep within 15 minutes of sleep onset] increaed REM density hypnagogic or hyponopompic hallucations sleep paralysis dx = polysmnography to r/o other sleep disorders and multiple sleep latency test that shows *decreased lseep latency and sleep onset REM periods*

bullous pemphigoid

*autoantibody target* hemidesmosomes = bullous pemphigoid antigens 1 and 2 *histopathology* subepidermal cleavage no acantholysis *immunofluorescence* LINEAR IgG at basement membrane *sub*epidermal cleavage *clinical features* predominalty elderly, elderly, neurological disorders urticarial or eczematous prodrome TENSE bullae rare oral/mucosal involvement *treatment* high potency topical glucocorticoids [topical clobetasol]

babesiosis

*babesia microti* - ixodes scapulais tick bite (lyme disease and HGA) Northeast USA often asymptoatmic or mild patients with immunocompromise, age >50, or hx of *splenectomy* have higher risk of severe ilnness *manifestations* flu like symptoms: fever, fatigue, myalgias, headache severe: ARDS, CHF, DIC, splenic rupture *anemia, thrombocytopenia* increased bili, LDL, LFTs = intravascular hemolysis *diagnosis made by thin blood smear* - intraerythrocytic rings - *Maltese cross* *treatment* atovagquona + azithromycin quinine +clindamycin if severe

does parkinsons tremor get better or worse with movement?

*better* with movement trihexyphenidyl is used in younger patients where tremor is predominant symptom

benign breast disease

*breast cyst* solitray, well circumscribed, mobile mass *fibrocystic changes* multiple, diffuse nodulocystic masses cyclic premenstrual tenderness *fibroadenoma* solitary, well-circumscribed mobile mass cyclic premenstrual tenderness *fat nerosis* post-trauma (eg, seatbelt injury) / surgery (eg, breast reduction/reconstruction) firm, irregular mass u/s = hyperechoic mass *bx = fat globules and foamy histiocytes* mammography: calcfications [can be conerning for malignancy] thus leads to excision many times +/- echyymosis, skin/nipple retraction risk of cancer is *not increased*

breast engorgement / lactation suppression

*breast engorgement* 3-5d after dlievery when colostrum is replaced by milk bilateral, symmetric breast fullness, tenderness, warmth WITHOUT fever cool compresses, tylenol, NSAIDs can help with symptoms s/s should improve with breastfeeding and pumping *lactation suppression* wear comfortable, supportive bra avoid nipple stimulation and manipulation apply ice packs to breast NSAID tor educe inflammation and pain do *not* do breast binding [increased risk of mastitis, and pain] *no medication* is approved

breastfeeding jaundice vs breast milk jaundice

*breastfeeding jaundice* first week of life insufficient intake of breast milk resulting in: decreased bili elimination, increased enterohepatic circulation clinically: suboptimal breastfeeding, s/s of dehydration *breast milkd jaundice* starts at age 3-5d; peaks at 2w high levels of b-glucuronidase in breast milk deconjugate intestinal bilirubin and icnraese enteroheaptic circulation clinically: adeqaute breastfeeding, normal exam

evaluation of minimal bright red blood per rectum colon cancer screening guidelines

*bright red blood per rectum screening* <40y/o *anoscopy* 40-49y/o *sigmoidoscopy or colonscopy* >50 y/o *colonscopy* *colon cancer screening guidelines* colonoscopy beginning at age 50 q10 years, until age 75 flex sigmoidoscopy q5y combined with FOBT q3y high sensitive FOBT in three consecutive stool samples every year

aphasia syndrome location

*broca* - sparce and nonfluent speach dominant frontal lobe right hemiparesis *wernicke* - fluent and voluminous but lacks meaning dominal temporal lobe right superior visual defect *conduction*-fluent with phonemic erros dominant parietal lobe

differential diagnosis for hemoptysis in children

*bronchiectasis* dilated and fragile bronchial arteries hx of chronic and recurrent airway inflammation small or large volume hemoptysis *acute respiratory infeciton* local trauma and inflammation acute uppe respiratory symptoms small volume hemopysis, typically blood streaked sputum *foreign body aspiration* local trauma acute onset of cough/wheeze/stridor without preceding symptoms +/- hx of choking event

diagnosis of p jiroveci

*cannot* be cultured diagnosis requires exam of respiratory samples using *microscopy* with specialized stins induced sputum is least invasve if this doesnt yield diagnosis, bronchoscopy with *bronchoalveolar lavage* is required

complications of anorexia nervosa indications for hospitlization treatment of AN

*cardio* - myocardial atrophy, bradycardia, hypotension, arrhyhtmias *renal* - poor urianry concentration, dehydration *neurologic* - seizures, cognitive impairment *dermatologic* - dry skin, lanuga *gynecological* - amenorrhea, inferitlity *GI* - gastroparesis, constipation *hematological* - cytopenias *other* - electrolytes, osteopenia, increased cholesterol, increased carotenemia *euthyroid hypothroxinemia* - normal TSH, normal/decreased serum T4 and T3 *indications for hospitilizaiton* HR<40, hysrhyhtmia BP<80/60, orthostasis T<35C electrolyte disturbance, marked dehydraiton organ comrpomise: renal, hepatic, cardiac BMI<15 *treatment* psychotherapy: CBT nutritional rehab olanzapine if severe/refractory

acute interstitial nephritis

*causes* drugs - pencillins, TMP/SMX, cephalosporins, NSAIDs *clinical* maculopapular rash fever new drug exposure arthralgias *labs* acute kidney injury pyuria, hematuria, WBC casts eosinophilia, *urinary eosinophils* renal biopsy: inflammatory infiltrate, edema *management* discontinue offending drug +/- systemic glucocorticoids

spinal cord compression

*causes* spinal injury malignacny: lung, breast, prostate, myeloma infection (eg, epidural abscess) *s/s* gradually worsening, severe local back pain pain worse in recumbent position / at night [distention of epidural venous plexus while laying down] early s/s: symmetric lwoer extremity weakness, hypoactive/absent DTR late: bilateral babinski reflex, decreased rectal sphincter tone, paraparesis/paraplegia with increased DTR, sensory loss *management* IV glucocorticoids emergency MRI radiation/oncology and neurosurg consults

cephalohematoma vs caput succedaneum vs subgaleal hemorrhage

*cephalohematoma* subperiosteal hemorrage - limited to 1 cranial bone firm, nontender, *does not cros ssuture lines*, no skin discloration most cases are uncomplicated and resorb spontenously within few weeks to months [inc risk of hyperbilirubinemia from blood breakdown] *caput succedaneum* scalp swelling superficial to periosteum *that crosses suture lines* edema uusaly involves portino of head prsenting during vertex delivery and is typically identified at birth *subgaleal hemorrage* blood between periosteum and aponeurosis due to shearing of emissary veins during delivery pt has fluctant scalp swelling that can move, cross suture lines, and expand for days after delviery tachycardia, pallor - due to excessive blood loss

characteristics of ulcerative sexually transmitted diseases

*chancroid* - haemophilus ducreyi lesion is *painful* multiple and deep ulcesr base have gray to yellow exudate organisms often clump in long parallel strands - school of fish *genital herpes* - HSV1, HSV2 [more common] lesion is *painful* multiple, small, grouped ulcers shallow with erythematous base multinucleated giant cells and intranuclear inclusions (Cowdry type A) *tx* = acyclovir, famciclovir or valacyclvir majority will have recurrences; most common during first year after infection and then become less freqeunt as cell mediated immunity imporves *granuloma inguinale* - klebsiella granulomatis lesion is *not painful* extensive and progressive ulcerative lesions *without* LAD base may have granulation tissue deeply staining gram-negative intracytoplasmic cysts - Donovan bodies *syphilis* - treponema pallidum lesion is *not painful* single, indurated well circumscribed ulcer clearn base thin, delicate, corkscrew shaped organisms on dark filed microscopy *lymphogrnauloma venerum* - chlamydia trachomatis lesion is *not painful* small and shallow ulcers large, painful, coalsced inguinal lmyph nodes - buboes intracytoplasmic chlamydial inclusion bodies in epithelial cells and leukocytes

retropharyngeal abscess

*children 6 months to 6 years* fever odynophagia/dysphagia drooling neck stiffness *muffled voice* trismus xray = widened preveretbral sapce suggests retropharyngeal abscess *CT is preffered imaging modality for retropharyngeal abscess* - xray allows differenitation of abscess from epiglottisis, but CT allows abscess vs. cellulitis [allows extent of infection to be seen] early dx ang tx are essential to prevent rare but fatal complications (airway compromise, bacteremia, carotid a. rupture, jugular venous thrombosis) most with RPA have pre-existing URI RPA results from direct spread of bacterial ifnection from pharyngitis, tonsillitis, otitis media or siusitis abscess is usually *polymicrobial*, involving strep pyogenes, staph aureus, anaerobes infection within retropharyngeal sapce darins inferiorly to *superior mediastinum* - spread to carotid sheath can cause thrombosis of the IJV and deficits in CNIX, X, XI and XII extension through the alar fascia into 'danger space' (between the alar and prevertebral fasciae) can rapidly transmit infection into posterior mediastum to the diaphragm *acute necrotizing mediatinitis* ife life threning complication: fever, chest pain, dyspnea, odynophagia urgent surgical eval

chondrosarcoma fibrosarcoma

*chondrosarcoma* [pictured] occurs in 5th or 6th decade xray = fusiform defect with scalloping *fibrosarcoma* malignant spindle cell neoplasm patients 30-60 y/o painful mass xray = osteolytic lesion whose margins can be well defined or ragged and moth-eaten

varicella infection / post-exposure prophylaxis

*clinical features* aerosolized transmission with 2 week incubation prodrom: fever, malaise maculopapular rash followed by succesive crops of vesicles --> *different stages* *prognosis* usualyl self limiting antiviral therapy for immunocompromised or complicated disease (eg, cerebellar ataxia, pneumonia) *prevention*: 2 doses of varicella-zoster virus vaccine (ages 1 and 4) immunity = 2 doses of vaccine (age 1 and 4) or prior infection for immunocompetent w/o immunity give VZV vaccine for susceptible individuals who cant reeive live virus vaccines (eg, immunocomrpomoised or pregnnat), PEP can be with varicella immunoglobulin

chronic lymphocytic leukemia

*clinical* LAD - cervical, supracalvicular, axillary HSM mild thrombocytopenia, anemia often *asymptoatmic* *diagnostic* severe lymphocytosis + smudge cells flow cytometry lymph node + bone marrow bx not generally needed *prgnostic* medial survival = 10 years worse prognosis = multiple chain LAD, HSM, anemia + thrombocytoepnia *complications* infection***** autoimmune hemolytic anemia secondary malignancies (eg, Richter transformation)

telogen effluvium

*clinical* acute, diffuse, noninflammatory hair los scalp and hair fibers appear normal hair shafts easily pullsed out *triggers* severe illness, fever, surgery pergnnacy, childbirth emotional distress nedocrine and nutrtional disorders *management* address underlying cause reassurance {*Self limited disorder} ddx *alopecia areata* - autoimmune disorder, circumscribe dpatches of hair loss; hair shafts show narrowing close to surface and my be broken off

achalasia

*clinical* chronic dysphagia to solids *+* liquids, regurgitation heartburn weight loss *diagnosis* manometry: inc. LES resting pressure, incomplete LES relaxation, dec. peristalsis of distal esophagus [*most sensitive test*] barium esophagram: smooth 'bird-beak' narrowing at GE-junction *management* upper endoscopy to exclude malignancy laparoscopic myotomy or pneumatic balloon dilation botulinum toxin injection, nitrates, CCB

small-bowel obstruction

*clinical* colicky abdominal pain, vomiting inability to pass flatur or stool if complete (no obstipation if partial) hyperactive --> absent bowel sounds distended adn tympanitic abdomen *diagnosis* dilated loops of bowel with air-lfuid levels on plain film or CT [more specific] partial: air in colon complete: transition point (abrupt cutoff), no air in colon *complications* ischemia/necrosis (strangulation) bowel perforation *management* bowel rest, NG tube suction, IVF surgical exploration for complications

mitral stenosis

*clinical* dyspnea, orthopnea, PND, hemopytsis atrial fibrillation, systemic thromboembolism voice hoarsenss from reurrent laryngeal n. comrpession due to LAE (ortner syndrome) *physical exam* mitral facies - pinkish-purple patches on cheecks Loud S1, loud P2 if pulm HTN early diastolic sound after 2nd heart sound (opening snap) *characteristic murmur* low pitched diastolic rumble, best heard at apex as stenosis progressing, diastolic murmur is heard *earlier* in cardiac cycle and eventually heard immedateily after opening snap *diagnosis* CXR: pulmonary blood flow redistuption to upper lobes, dilate dpulmonary vessels, LAE, flattened left heart border EKG: *p mitrale* - braod and notched p waves, atrial tachyarrhytmias, RVH (Tall R in V1, V2) TTE: MV thickening/calcifcation/dec mobility, coexisting MR

uterine leiomyomas (fibroids)

*clinical* heavy, prolonged menses pressure symptoms - pelvic pain, constipation, urinary frequency *obstetric complications* - infertility, pregnancy loss, preterm labor enlarged irregular uterus some fibroids will be diagnosed for first time during pregnancy by *size-date discrepancy* aborting submucous myoma = firm, smooth, round mass at cervical os = prolpasing leiomyoma uteri expulsion causes labor-like pain due to mechanical cervical dilation by the solid mass *workup*: u/s *treatment* asymptomatic: osbervation symptoamtic: CHC, surgery

vasovagal syncope

*clinical* inciting event: stress, prolonged standing prodrome: pallor, nausea, diaphoresis consciousness regained rapidly (eg, <1m) *diagnosis* mainly clinically upright tilt table testing in uncertain cases *treatment* reassurance avoidance of triggers *counterpressure techniques for recurrent episodes* [eg, leg crossing with tesnsing of muscles, handgrip and tesning of arm muscles with clenched fists] - during prodromal phase can imrpove venous return and cardiac output, sometimes aborting syncopal episodes

HELLP syndrome

*clinical* preeclampsia [HTN, proteinuria] n/v RUQ pain *labs* microangiopathic hemolytic anemia elevated liver enzymes Low plt count *treatment* delivery Mg for seizure prophylaxis anti-HTN drugs serious liver problems = centrilobular necrosis, hematoma formation, and thrombi in portal capillary system these processes cause *liver swelling with denstion of Glisson's capsule* --> RUQ or epigastric pain

frostbite

*clinical* superficial pallor and anesthesia blistering, eschar formation deep tissue necrosis and mummification *management* rapid rewarming in 37-39C water bath analgesia and wound care thrombolysis in severe, limg threatening cases debridement is not indicated until tissue is rewarmed and accurate surery of devitalized tissue can be performed IV-warm fluids is *not* for frostbite; it is indicated for systemic hypothermia

clinical features of meningococcal meningitis

*clinical* symtpoms: headache, n/v, myalgias signs: neck stiffness, AMS, petechial/purpric rash, menigdeal signs complications: multiorgan failure, DIC, adrenal hemorrhage, shock *treatment* 3rd gen cephalosporing + vancomycin do *not* use glucocorticoids [not beneficial] chemoprophylaxis (eg, rifampin, ciprofloxacin, ceftriaxonne) of all respiratory conntacts

cardiac tamponade

*clinical* - becks: hypotension, JVD, dec heart sounds pulsus pardoxus inability to palpate PMI = large effusion *diagnosis* ecg - low QRS, electrical alternans chest xray - enlarged cardiac silhouette, clear lungs echo - RA and RV collpase, plethora of the IVC

bacterial meningitis in children age <1 month

*clinically* fever increased ICP - vomiting, AMS, HA meningeal irritaiton *workup* CBC, blood cultures, LP for CSF herniation is very rare in infants as their fontanelles are open and can accommodate brain swelling CT is done in those who are comatose, ahve focal signs, or having a neurosurgical procedure (eg, VP shunt) *treatment* IV vanc + ceftriaxone or cefotaxmine dexamethasone for H flu type B etiology = strep pneumonia, n. meningitidis

absence seizures

*clinically* sudden impairment of consciousness - staring spells preserved muscle tone unresponsive to stimulation short duration: <20s simple automastisms present easily provoked by *hyperventilation* *no postictal confusion* *diagnosis*: EEG - 3hz spike-wave during episodes *comorbidities* - ADHD, anxiety *treatment* - ethosuximide

sunburn

*clinically* symptoms begin ours after exposure; resolve by day 3-7 mild moderate: erythema, tenderness severe: blistering, systemic symptoms (fever, vomiting, headche) *treatment* *mild-moderate* topical: cool compresses, calamine lotion, aloe vera oral: NSAIDs *severe* hospitilizaiton IVF + analgesia wound care po and topical steroids are *not* recommended due to limited evidence of benefit

transient synovitis

*clinically* well appearing afebrile able to bear weight (painful, limp walking) boys age 3-8 after a mild viral illness *diagnosis* normal or midly elevated WBC, ESR, CRP unilateral/bilateral u/s effusion dx of exclusin *treatment* conservative: rest, NSAIDs children recover within 1-4w w/o complications

hairy cell leukemia

*clonal B cell neoplasm* middle-age/older adults *BRAF* mutation *pancytopenia* due to bone marrow fibrosis granulocytopenia --> infections anemia --> fatigue, weakness thrombocytopenia --> bleeding, bruising *splenomegaly* (early satiety) rare to have hepatomegaly or LAD *peripheral smear ---> hairy leukocyte cells* bone marrow bx = dry tap (fibrosis w/ cytoepnias) *tx* chemo for moderate/severe life expectancy is near-normal

alpha-1 antitrypsin deficiency

*codominant genetic disease* pt with SOB, productive cough, *lower lung lobe* destruction in absence of smoking [smoking is upper] *basilar predominant disease* Panacinar (panlobular) emphsema [smoking is centrilobular] *more prominent in lower lobes* [smoking is upper lobes] AAT freqently has liver disease: neonatal hepatitis, cirrhosis or hepatocellular carcinoma skin can be affected: *panniculitis* *diagnosis confirmed* by measuring serum AAT levels PFT should be performed hepatocytes containing granules that are PAS positive and diastase-resistant cirrhosis and periportal eosinophilic inclusion bodies *treatment* IV supplementation with pooled human AAT

neuroleptic malignant syndrome

*common labs*: elevated CK, leukocytosis *type B adverse drug reaction*: unexpected, dose-independent pharmacologc effect (eg, Steven johnson syndrome with lamotrigine) rhabdomyolysis, followed by myoglobinuria that can cause acute renal failure [known complication] discontinuation of causative agent is single most important intervnetion supportive care dopamine agents: bromocriptine, amantidine

intracerebral hemorrage

*common sites* basal ganglia internal capsule thalamus cerebellum *causes* hypertension trauma AVM coagulopathy tumors amyloid angiopathy (elderly - lobar hemorrhages) s/s - lethargy, headache, obtrundation PE - focal motor, sensory deficits *treatment* prevent elevation of ICP - raising head of bed, limit fluids, treat HTN, give nimodipine if ICP increased: mannitol, hyperventilate, steroids, VP shunt

primary renal causes of nephrotic syndrome

*complications of nephrotic syndrome* hypercoagulation - los of AT3, increased platelet aggregtion, hyperfibrongemia, impaired fibrinolysis protein malnutition iron-resistant microcytic hypochromci anemia (transferring loss) vitamin D deficiency (urinary loss of cholecalciferol binding protein) decreased thyroxin levels (loss of thyroxine binding globulin) increased susceptibility to infection

transtenotorial (uncal) herniation lesions

*compression of contralateral crus cerebri against tentorial edge* ipsilatearl hemiparesis *compression of ipsilateral CNIII by herniated uncus* loss of parasympathetic innervation causes mydirasis loss of motor innervation causes ptosis and down and out gaze of ipsilateral pupil due to unoppoched trocheal and abducent action *compression of ipsilatearl posterior cereal a.* contralateral homonoymous hemianopsia *compression of reticular formation* altered level of consciousness; coma

initial step of cushing syndrome diagnosis

*confirm hypercortisolism* [2/3 must be abnormal] late-night salivary cortisol 24h urine free cortisol overnight low dose dexamthesone suppression test if hypercortilism is confirmed: ACTh level measured

common pigmented lesions in childhood

*congenital melanocytic nevus (CMN)* benign proliferation of melanocyte cells presents within first few months of life and usually solitary, hyperpigemnted lesions with increased desnity of overlying dark, coarsehairs CMN's can grow during infancy and appear as hetergennously pigemnted and raised risk of transofrmation ot melnoma is up to 5% with increasing size large lesions are *removed to reduce risk of melanoma* *cafe au lait* flat, hyperpigemnted elesions that can be isolated or associated with McCune-Albright or neurofibromatosis *congenital dermal malanocytosis (Mongolian spots)* flat, gray-blue patches that are poorly circumscribed fade with time classically on lower back and sacrum more common in asian and african americans

perianal dermatoses

*contact dermatitis* most common cause in infants spares creases/skinfolds tx: topical barrier ointment or paste *candida dermatitis* second most common cause in infants beefy-red rash involving skinfolds with satellite lesions tx: topical antifungal therapy *perianal streptococcus* school aged children bright, sharply demarcated erythema over perianal/perineal area associated with pruritis and pain, partiuarly with stooling tx: oral antibiotics

contraindications & precautions to diptheria-, tetanus-, &/or pertussis-containing immunizations

*contraindications* anaphylaxis to vaccine ingredies *contraindcations to pertussis* anaphyalxis to vaccine progressive neurologic disorder - unctrolled epilepsy, infantile spasms encephalopathy within a week of previous vaccine dose

treatment of acne vulgaris

*contributing factors to acne* increased sebum production follicular hyperkeratinizaiton bacterial colonization (propionibacteirum acnes) inflammatory response oral abx used in severe nodular cystic acne, or in widespread inflammatory acne making topica tx impractical

differential diagnosis of dementia subtypes

*creutzfeldt-jakob disease* rapidly progressive dementia myoclonus, akinetic mutism, cerebellar or visual disturbance pyrmindal/extrapyrimidal dysfunction (hypokinesia) periodic sharp wave complexes or Positive 14-3-3 CSF assay *diagnosis defintive by*: brain biopsy (gold standard) or PRNP gene mutations

retained placenta

*definition*: no palcental expulsion within *30 minutes* of infant delivery due to: placental detachemnt failure (adherens) morbid placental attachment (accreta) placental entrapment *risk factors* gestational age *24-27 weeks* stillbirth placenta accreta hx of prior retained placenta *complications* postpartum hemorrhage endometritis *mangement* manual placenta extraction dilation and currettage

fetal growth restriction

*definition*: weight <10th percentile for gesttaional age *asymmetric* = palcental dysfunction during 2nd and/or 3rd trimester causes head sparing growth *symmetric* = first trimester conditions [chromsomal, infections] *appearnce* large anterior fontanel thin umbilical cord loose, peeling skin minimal subq fat *evaluation* placenta histopathology consider karyotype, urine tox, serology *neonatal complicatinos* polycythemia hypoglycemia hypocalcemia poor thermoregulation

pelvic organ prolapse

*definitions* cystocele - bladder rectocele - rectum enterocele - small insteine procidentia apical prolapse - uterus, vaginal vault *risks* obesity multiparity hysterectomy postmenopausal age *clinical* pelvic pressure obstructed voiding urinary retention urinary incontinence constipation fecal urgency, incontinence sexual dysfunction *management* weight loss pelvic floor exercises [used initially, but if compltete herniation has occurred, need pessary or surgery] vaginal pessary surgical reapir [try conservative first, especially as these are older women typically with comorbidities]

common causes of thrombocytopenia

*dereased production* viral infections; EBV, HCV, HIV chemotherapy myelodysplasia alcohol use congenital (eg, Fanconi syndrome) b12 or folate deficiency *increased destruction* SLE meds (eg, heparin) ITTP, DIV, TTP-HUS ALP syndrome *other* dilutional due to massive RBC tranfusion splenic sequestration

diagnosing acute pancreatitis

*diagnosis requires 2 of the following* acute epigastric pain radiating to back icnreased amylase or lipase >3x ULN abnoramlities on imaging consistent w/ pancreaitis CT is not needed in pt with pain and incrased labsof classic pancreatitis *other findings* ALT >150 U/L suggests biliary pancreatitis severe disease: fever, tachypnea, hypoxemia, hypotension ultrasound is advised for all patients susepcted of gallstone pancreatitis if u/s is nondiagnostic and high suspicion for common bile duct disease, ERCP may be used

bone tumor locations

*diaphysis* round cell lesions ewing tumor malignant lymphoma myeloma fibrosarcoma nonossifying fibroma bone cyst *metaphysis* osteosarcoma chondrosarcoma *epiphysis* giant cell tumor chondroblastoma

etiology/treatment of lymphedema

*disruption of lymphatic system* obstruction - malignancy lymph node dissection chronic inflammation - recurrent cellulitis congenital - turner syndrome parasitic - filariasis *nonpitting edema* firm, thickened skin deposition of subq collagena nd adipose tissue Stemmer sign = inability to lift skin on dorsum of 2nd toe *treatment* weight loss limb elevation, compression physiotherapy

intrapertioneal baldder rupture

*dome of bladder* - superior and lateral bladder walls and directly abuts the peritoneal sapce rupture results in urine lekakage intrapertioneal --> chemical peritonitis (eg, diffuse abdominal pain, guarding, rebound) irritation of peritoneal lining of right or left hemidiphargm may cause reerred pain to ipsilatearl shoulder as sensory innerveation to shoulder originates from C3-C5 spinal nerve roots - *kehr sign*

complications of roux-en-y gastric bypass surgery

*early* anastomotic leak = sepsis bowel ischemia = diffuse pain *late* anastomatic stricutre: dysphagia, bowel obstruction marginal ulcer: abdominal pain, bleeding, peri-anastomatic perforation cholecystis: RUQ pain dumping syndrome: diarrhea, crampy pain, vasomotor

causes / treatment of QT prolongation

*electrolytes* hypocalcemia hypokalemia hypomagnesemia *medications* abx: macrolide, fluoroquinoline psychotropics: antipsychotics, TCA, SSRI opioids: methadone, oxycodone antiemetics: ondansetron, granisetron antiarrhthmics: quinidine, procainamide, flecainide, amiodarone, stolol *inherited* jervell & lange-nielsen syndrome [AR] romano-ward syndrome [AD] *treatment* refarain from vigorous exercise avoid meds that lengthen QT maintain Ca, K, Mg Beta blockers pacemarker may be indicated

perinatal hepatitis B virus infection

*epidemiology* 90% risk of vetrical transmission w/o prophyalxis <2% risk after prophylaxis chronic infection in 90% of perinatally infected *risks* high materanl viral load materanl HBeAg+ *transmission* perinatal exposure to genital secretions [*most common*] transplacental - rare *not transmitted by breastfeeding* *prevention* HBV vaccine (active immunizaiton) *and* HBIG (passive immunization)

bacillary angiomatosis

*epidemiology* Bartonella henselae/quintana cat exposure or homelesness (lice) advanced HIV (CD<100) *manifestations* vascular cutaneous = papular, nodular, peduncular systemic = fever, night sweats, fatigue organs (rare) = liver, bone NS *diagnosis*: lesional *biopsy* with microscopy/histopathology bright red, friable, exophytic nodules in an HIV infected patient tx = *doxycycline* or *erythromycin* + HAART

neurocysticercosis

*epidemiology* Taenia solium (pork tapeworms) eggs Fecal-oral human transmission associated with travel to endemic areas (Central and South America) *manifestations* prolonged incubation: months to years ICH - headache, vomiting, AMS causes seizures CT/MRI - *cysts*: mixture of enhacing, nonehancing, and calcfied lesions tx = albendazole, seizure management, corticosteroids

testicular cancer

*epidemiology* age 15-35 risk factors: family history, cryptorchidism *manifestationsn*: uniltearl, painless tesicular nodules dull lower abdominal ache metastatic symptoms: dyspnea, neck mass, low back painn *diagnosis* exam: form, ovoid mass tumors markers: AFP, bHCG scrotal u/s staging imaging: CT scan, chest xray do *not* transilluminate *treatment* radical orchiectomy chemo cure rate 95%

acute epididymitis

*epidemiology* age <35 = STI [chlamyida, gonorrhea] age >25 = bladder outlet sobtruction [coliform bacteria: *ecoli*] *symptoms* unilateral testicular pain epididymal edema dysuria, freqeuncy (with coliform infection) *diagnosis* UA/culture NAAT from chlamydia and gonorrhea *treatment* ceftriaxone/doxy = STI levofloxacin = coliform abcteria

penile cancer

*epidemiology* age >60 risks: HPV, phimosis, cigarette smoking most are squamous cell carcinoma *manifestations* painless ulcer/nodule inguinal LAD distant spread rare until late *diagnosis* biopsy lymph node assessment *treatment* excision chemo (depending on stage)

scurvy (vitamin C deficiency)

*epidemiology* alcohols, drug users, mlanourished, poor fruit/vegetable intake arise within *3 months* of defiicency *manifestations* cutenous - petechia, follicular hemorrahge, burisng, coiled hairs gingiva - bleeding, receeding guns, dental carries constitioanl - arthalgias, weakness, malaise, deprssio impaired wound healing vasomotor instability *dx* -s erum ascorbic acid level *tx* - oral/injectable vitamin C resolves most symptoms within days

essential tremor

*epidemiology* family history often present up to 5% of population affected *action/postural* tremor in UE that worsen at end of goal directed activities (eg, reaching for pen) usually affect bilateral upper extremities PE shows woresning tremor with outstretched arms or finger-to-nose testing *treatment* beta blockers - proranolol anticonvulsants - primidone small amounnts of alcohol benzodiazepines - clonazepam

vibrio vulnificus

*epidemiology* gram negative, free living *marine* environments ingestion of oysters or wound infection increased risk in lvier disease: *hemocrhomatosis*, cirrhosis, heaptitis *manfiestations* rapidly progressive: <12h septicemia - spetic shock, bullous lesions cellulitis - hemorrhagic bullae, necrotizitng fasciitis *diagnosis* blood and wound cultures *treatment* empiric in those with likely illness as highly fatal IV ceftriaxone + doxycycline

cutaneous larva migrans

*epidemiology* hookworm larve: dog (ancylostoma caninum) or cat (a brazilense) humans are incidental hosts barefoot ontact with contaominated sand or soil *clinical* primarily lower extremity cutaenous infectin erytheamtous, prurtic papule at site of entry intensely pruritc, migrating, serpinginous, reddish-brown tracks *diagnosis* history and clinical findings eosinophils usually normal *treamtnet* antihelmintic - *ivermectin*

leprosy

*epidemiology* mycobacterium leprae primary in: Asia, africa, south america respiratory droplets/nine-banded armadillo low infectivity *manifestations* macular, anesthetic skin lesions with raise dborders nodular, painful nearby nerves with loss of sensory/motor funciton *diagnosis* full thickness biopsy of skin lesion [active edge] M leprae is not culturable *treatment* dapson + rifampin (paucibacillary) add clofazimine if severe (multibacillary) lesions take months or years to heal completely

vulvar lichen sclerosus atrophic vaginitis vs. lichen sclerosus

*epidemiology* prepubertal girls perimenopausal or postmenopausal women *clinically* thin, white, wrinkled skin over labia major/minoa atrophic changes that may extend over the perineum and around anus excoriations, erosions, fissures from severe pruritis dysuira, dyspareunia, painful defection the skin classically described as *ciagrette paper* (thin, white crinkled) LS is a vulvar *premalignant lesion* as vulvar SCC occurs with greater frequency in these patients *workup* punch biopsy of adult onset lesions to exclude malignancy *treatment* superpotent corticosteroid ointment (clobetasol) if pt develops severe adhesions/scarring - vulvoperineoplasty

mycoplasma pneumonia

*epidemiology* respiratory droplets close quarters/young (eg, school, military) fall or winter *clinical* indolent headache, malaise, fever, persistent dry cough pharyngitis (nonexudative) *diagnostic* normal leukocyte count subclinical hemolytic anemia (cold agglutinins) interstitial infiltrate (chest xray) *treatment* usually empiric macrolide or respiratory fluroquinolone

carbon monoxide poisoning

*epidemiology* smoke inhalation defective heating systems motors operating in poorly ventilated areas *mild to moderate* headache, confusion malaise, diziness, nausea pt often have pinkish-red skin hue *severe* seizure, syncope, coma MI, arrhyhtmias *diagnosis* ABG-carboxyhemoglobin level - shifts oxygen dissociation curve to left, impairing ability of heme to unload oxygen at tissue level --> tissue hypoxia; chronic CO toxicity --> *secondary polycythemia* ECG, cardiacc enzymes if ischemia on ddx *treatment* *high flow 100% O2* intubation/hyperbaric O2 tx if severe case

blastomycosis

*epidemiology* south/south-central states, Mississippi and Ohio River Valley, Upper Midwest, Great Lakes, Canada Disseminated disease can occur even in *immunocompetent*; but generally more severe in *immunocompromised* patients (wisconson has highest infeciton rate) *clinical* Lung: acute and chornic pneumoina: usually mild to moderate; but can be severe *skin* wartlike lesions, violaceous nodules, skin ulcers *bones*: osteomyelitis *GU*: prostatitis, epididymo-orchitis *CNS*: menigitis, epidural or brain abscess *diagnosis* {*yeast*} culture: blood, sputum tissue speciemns microscopy: body fluids, sputum, tissue specimns antigen testing: urine blood cxr = consolidation, lytic bone lesions *treatment* mild pulm dz in immunocompetent: may not tx mild-moderate pulm disease, mild disseminated: po itraconazole severe pulm dz, severe disseminated, immunocompromised: IV ampho B

sporotrichosis

*epidemiology* sporothric schenckii (dimophic fungus) decaying plant matter/soil gardners and landscapers *manifestations* subacute/chronic skin papule --> ulcerations with nonpurulent, odorless drainage proxima lesions along lymphatic chain lymphadenopathy, deeper spread and sustemic symptoms are rare *diagnosis* cultures (aspirate fluid or biopsy) *treatment* 3-6 months of oral itraconazole

behcet disease

*epidemiology* young adults turkish, middle eastern, asian descent *clinically* recurrent, painful oral apthous ulcers [pictured] genital ulcers eyes lesion (eg, uveitis) skin lesions (eg, erythema nodosum, acneiform lesions) thrombosis *evaluation* - clinical diagnosis pathergy - exaggerated skin ulceration with minor trauma (eg, needlestick) biopsy - nonspecific vasculitis of different sized vessels pathergy test - inserting 20guage needle; check site 24-48h later for development of >2mm papule

optic neuritis

*epidemiology* young women [ 20-40 y/o] associated with multiple sclerosis immune-mediate demylination *mannifestationns* *ACUTE*, peaks at 2 weeks monocular vision loss eye pain w/ movement washed out color vision *afferent pupillary defect* central scotoma fundoscopy is usually normal as inflammation occurs behind optic nerve head *diagnosis* MRI of orbits and brain *Tx* IV steroids 35% recur

acute HIV infection

*epidemiology* - 2-4 weeks after exposure *clinical* mononucleosis like syndrome (fever, LAD, sore throat, arthalgias) generalized macular rash GI symptoms painful mucocutenous ulcerations (characteristic manifestation) *diagnosis* viral load >100,000 HIV antibody testing may be negative (not yer seroconverted) CD4 count may be normal *inital workup* HIV-1/2 antigen/antibody immunoassay if negative, no further testing if positive, then do subsequent immunoassay to differenitate two strains to get better idea of specific infection person has *mangement* combo antiretroviral therapy partner notifcaiotn, consider secondary prophylaxis

selective IgA deficiency

*epidemiology* - most common primary immune deficiency *clinically* usually asymptomatic recurrent sinopulmonary and Gi infections associated with autoimmune (eg, celiac) and atopy (eg, asthma, eczema) anaphylaxis during transfusions *diagnosis* low or absent IgA normal IgG, IgM, B cells *treatment* supportive emdical alert bracelt for tranfusion reactions require *washed* blood tranfusions [removes excess IgA]

common skin infections

*eryspielias* - strep pyogenes superficial demris and lymphatic raised, shapely *demarcated edges* *rapid spread and onset* fever early *cellulitis (nonpurlent)* - strep pyogenes, MSSA *deep* dermis and subq fat *flat edges* w/ poor demacation indolent - over days localized; fever late in course *cellulutis (purulent) * - MSSA, MRSA purulent drainage folliculitis furncules - follicilits --> dermis --> abscess carbuncle - multiple furuncles

rosacea 4 primary manifestations

*erythematotalgiectatic raoscea*: erythema and facial flushing, telangiectasias, roughness or scaling, and burning discomfort *papulopusutal rosacea*: small papules and pustules resembling acne *phymatous rosace*: chronic irregular thickening of the skin, usually involving the nose *ocular rosacea*: involvement of cornea, conjuctiva, and lids with burning or foriegn body sensations, blepharitis, keratitis, conjuctivtis, corneal ulcers and recurrent chalazie

toxic alcohols and treatments

*ethylene glycol treatment* Fomepizole (inhibitor of alochol dehydrogenase) or ethanol prevents further breakdown of ethylene glycol into its toxic metabolites and is an integral part of treatment NaHCO3 may help alleviate acidosis hemodialysis may be required

chronic aortic regurgitation

*etiologies* congenital biscuspid aortic valve postinflammatory - rheumatic heart, endocarditis aortic root dilation - marfan, syphilis *patho* backflro from aortia into LV --> Inc. EDV LV compensates initally with eccentric hypertrophy --> inc SV and CO Eventual LV dysfunction --> dec SV and CO --> HF *clinical* diastolic decrescendo murmur widened pulse pressure rapid rise-rapid fall (water hammer) pulsation [due to the increased SV seen in AR] abrupt cartoid sitenion and collpase, pistol shot femoral puslses pulsations in fingertips from PP

acute pericarditis clinical features / diagnosis + treamtent

*etiologies* infection: viral most commonly, bacterial iatrogenic: surgery, trauma, radiation, drug related CTD: RA, SLE cardiac: dressler syndrome, 1-6w after an MI; peri-infarction pericarditis (<4d after MI) uremic: BUN >60 malignancy: cancer or treatment of cancer pleuritic chest pain (dec when sitting up) pericardial friction rub (*high specific*) EKG - diffuse St elevation, PR depression echo: effusion *treatment* NSAID + cholchicine for viral or idiopathic variable for other etiologies use *aspirin* for dressler syndrome corticosteroids can be used in refractory cases or when NSAID are contraindicated dialysis for uremic pericarditis in peri-infarction percarditis avoid NSAIDs and corticosteroids as they can disrupt collagen deposition and cause severe post-MI complications

clinical features of amyloidosis

*etiology of amyloid* AL: production by clonal plasma cells [multiple myeloma, waldenstrom macroglobulinemia] - light chains (lambda) AA: secondary to chronic inflammation [RA is msot common cause] - usually made of abnoramlyl folded proteins: b2-microgloblin, apolipoprotein or transthrytein ATTR: age related or familial AB2M: secondary to hemodialysis renal bx = amyloid deposits that stain with congo red and show apple-green birefringence under polarized light on EM = randomly arranged thin fibrils

acute pancreatitis CT / etiology / diagnosis

*etiology* alcohol, gallstones (most common) hypertriglyceridemia (>1000 mg/dl) infections: CMV, legionella, aspergillis recent ERCP trauma cystic fibrosis cholesterol emboli *medications that can cause pancreatitis* diuretics: furosemide, thiazides IBD drugs: sulfasalzine, 5ASA Immunosupressive agents: azathiprine HIV realted medications: didanosine, pentamide abx: metronidazole anti-seizure: valproate *diagnosis* (2/3) acute epigastric pain radiating to the back inc amylase or lipase >3x normal limit abnormalities on imaging *treatment* supportive (pain, IVF, bowel rest) for uncorrectable caues of acute pancreaitis (eg, hypotnesion, ischemia, virsues, therembolism) most attacks are self limiting and imporve in 4-7 days with conservative management

chronic pancreatitis

*etiology* alochol use cystic fibrosis (common in children) ductal obstruction (eg, malignancy, stones) autoimmune *clinical* chronic epigastric pain w/ intermittent pain free intervals [epigastric pain that is partially relieved by sitting upright or *leaning forward*] malabsorption - steatorrhea, weigh loss diabetes mellitus *secretin test* - measures ability of pancreatic ductal cells to produce bicarbonate *labs* amylase/lipae can be normal and nondiagnostic CT scan or MRCP show calcfications, dilated ducts, enlarged pancreas *treatment* pain management alcohol, smoking cessation frequent, small meals pancreatic enzyme supplements *findings on CT* multiple calcifcations dilation of pacnreatic duct pancreatic enlargement steatorrhea - impaired secretion of digestive enzymes from pancreas malaborption - weight loss and fat soluble vitamin deficiencies epigastric abdominal pain diabetes mellitus (advanced dseiase) etiologies msot commonly alocohol normal labs do not rule out diagnosis

primary hyperaldosteronism

*etiology* bilateral adrenal hyperplasia (most common) unilateral adenoma *clinical* hypertension hypokalemic alkslosis: muscle weakness, paresthesias do *not* have peripheral edema due to spontaneous diuresis (aldosterone escape) *diagnosis* elevated plasma aldosterone low plasma renin activity aldosterone remains elevated following oral saline load best screening test = early morning plasma aldosterone concetration to plasma renin activity elevated aldosterone (>15) with a PAC/PRA >20 = PH confirmatory with adrenal suppression testing [salt loading that doesnt suppress serum aldosterone] next step = CT if unilateral = adrenalectomy bilateral = aldosterone antagonists if CT does not show discrete unilatearl mass, adrenal vein sampling [most sensitive test for differenitation] is recommended to differentiate between hyperplasia and adenoma

coarctation of the aorta

*etiology* congenital acquired (rare) (eg, Takayasu arteritis) *patho*: thickening of tunica media of aortic arch near ductus arteriosus narrowing of descending oarta located just distal to subclavian artery created proximal arterial pressure load affecting upper body *clincial* systolic ejection murmur at left interscapular area HTN in UE *upper body* = well developed, HTN = headache, epistaxis *lower body* = underdeveoped, caludication *brachial-femoral pulse delay* dec perfusion to LE --> dec post ductal O2sat, dec femoral pulses, LE claudication Heart failure cardiogenic shock (ifnants) palpable pulsations of iftercostal vessels (adults) *diagnosis* brachial-femoral delay UE, LE BP differential ECG = LV hypetrophy cxr = inferior notching of 3rd-8th ribs; '3' sign due to aortic identation *echo = diagnostic confirmation* *tx*: balloon angioplasty +/- stent palcement surgical PGE can be used to maintain patency of duct

pulmonic valve stenosis

*etiology* congenital - usually isolated defect rarely acquired (eg, carcinoid) *clinically* severe: RHF in childhood mild: dyspnea in early adulthood crescendo-decrescendo murmur (inc on inspiration) systolic ejection click and widened split of S2 *diagnosis* - echocardiography *treatment* percutenous balloon valvulotomy - preferred surgical reapir in some cases

popliteal (baker) cyst

*etiology* extrusion of fluid frmo knee joint space into semimembranosus/gastrocnemius bursa *risks* trauma (eg, meniscal tear) underlying joint disease (eg, OA, RA) *clinical* asymptomatic bulge behind knee that diminishes with flexion postior knee pain, swelling, stiffness can use ultrasound to r/o DVT and confirm poplitearl cyst *complcations* venous compression (leg/ankle swelling) dissection into calf (erythema, edema, positive homan sign) cyst rupture (acute calf pain, warmth, eythema, ecchymosis)

fat embolism syndrome

*etiology* fracture of marrow containing bone orthopedic surgery pancreatitis *clinical* 24-72h after event triad: respiratory distress, neurologic dysfunction (confusion), petechial rash cxr normal at start; can show bilateral infilitrates wtihin 24-48h *diagnosis* is clinical *prevention/tx* early immobilizaiton of fracture supportive care (eg, ventilation) most make FULL recovery

severe combined immunodeficiency

*etiology* gene defect leading to failure of T cell development [absent CD3] B cell dysfunction due to absent T cells [low CD19] *adenosine deaminase deficiency* [autosomal recessive form] all gene defects in SCID prevent IL-7-driven maturation of T cells in thymus *inheritance* x-linked recessive autosomal recessive *clinical* recurrent, severe viral, fungal, or opportunistic (ie, Pneumocystis) infections failure to thrive chronic diarrhea absence of lymphoid tissue *labs* lymphopenia hypogammaglobulinemia *detection* absence of T cell receptor excisin circles (crular DNA excreted by developting T cells in the thymus) - *newborn screening* *treatment* stem cell transplant - fatal early in childhood unelss transplantation occurs

serum sickness-like reaction

*etiology* immune complex formation abx: beta-lactam, sulfa acute hepatitis B *clinical* symptoms 1-2 weeks after exposure fever, skin rash [urticaria], polyarthralgia patient appears *ill* *labs* - elevated ESR, CRp, low complement [labs consistent with type III hypersentivity reaction] *treatment* remove/avoid offending agent - resolves symptoms in 48h supportive care steroids or plasmapheresis if severe

anal fissures

*etiology* local trauma (eg, constipation, prolonged diarrhea, anal sex) inflammatory bowel disease (eg, Crohn disease) malignancy spasm of the sphincter contirbutes to pain and creates tension across the wound, leading to a chronic fissure *clinical* pain with bowel movements bright red blood on toilet paper most common at posterior anal midline chronic fissure may have *skin tag* at distal end *treatment* high fiber diet and adeqaute fluid intake stool softners sitz baths topical anesthetics and vasodilators (eg, nifedipine, nitroglycerin)

acute colonic pseudo-obstruction (ogilvie syndrome)

*etiology* nonoperative trauma infection (eg, pneumonia) cardiac (eg, heart failure, myocardial infarction) abdominal / pelvic / orthopedic surgery neurologic (eg, parkinson, multiple sclerosis, alzheimer disease) *clinical*: presents *3-7d* after surgery abdominal distention, pain, n/v constipation, osbtipation or paradoxical diarrhea if ischemia/perforation: gaurding, rigidity, extreme tenderness partial/total colonic dilation *without* anatomic obstruction on CT scan

left ventricular aneurysm

*etiology* scar tissue deposition following transmural MI *clinical* several months following MI heart failure and angina ventricular arrhythmia (eg, ventricular tachycardia) systemic embolization (eg, stroke) *diagnosis* ECG: persistent ST elevation, deep Q waves echo: thin and dyskinetic wall

zollinger-ellison syndrome

*etiology* - gastrinoma age 20-50 80% sporadic/20% MEN1 most common location = duodenum tumor location is determed with u/s or radionuclide octreotide scanning [somatostatin receptor scintigraphy or 111IN pentretreotide SPECT] *clinical* multiple + refractory peptic ulcers ulcers distal to duodenum chronic diarrhea endoscopy - thickened gastric folds, multiple peptic ulcers, refractory ulcers despite PPI use, ulcers distal to duodenum in jejunum *diagnosis* fasting gastrin level (off PPI for 1w); <110 = no gastrinoma; >1000 = gastrinoma gastrin level of 110-1000 is nondiagnostic, requires secretin test - stimulates release of gastrin by gastrinoma cells normal gastric G cells are inhibited by secretin;therefore, secretin adminsitration should nto cause a rise in serum gatrin concentrations in pts with other causes of hypergastrinemia markedly elevated serum gastrin (>1000pg/ml) in presnce of normal gastric acid (pH<4) *workup* endoscopy CT/MRI and somatostatin receptor scintigraphy for tumorm localization

prerenal acute kidney injury

*etiology* decreased renal perfusion true volume dpletion decreased EABV (eg, heart failure, cirrhosis) displacement of intravascular fluid (eg, sepsis, pancreatitis) renal artery stenosis afferent arteriole vasoconstriction (eg, NSAIDs) *clinical* increased serum creatinine decreased urine out BUN/Cr >20:1 FeNa <1% bland urine sediment *treatment*: restoration of renal perfusion in absence of clear signs of volume overload (eg, elevated JVP, lung crackles), patients with suspected prerenal AKI should be treated with *IV NS bolus*

complications of inappropriate pregnancy weight gain and recommendations for appropriate weight gain

*excessive weight gain* gestational diabetes fetal macrosmia cesarean delivery *inadeqaute weight gain* fetal growth restriction preterm delivery *recommendations for weight gain* underweight (BMI <18.5) - gain 28-40lbs normal weight - gain 25-35 pounds overweight - gain 15-25 pounds

type of stress test

*exercise ECG* increas HR, increase BP not for: LBBB, pacemaker, patient unable to reach tHR *adenosine, dipyramole* nonselective adneosin agonist dilates coronary arteris without increasing Hr or BP not for: reactive airway dz, patients on dipyridamole, theophylline *dobutamine stress echo* b1 agonst increases HR +/- BP not for: tachyarrhythmias

persistent asthma: daily medication prevention of exercise induced bronchoconstriction

*exercise-induced bronchochronstriction* response to mast cell degranulation triggered by passage of high volumes of dry, cold air beta agonists used 10-20 minutes prior to exercise, are typically sufficient to prevent symptoms anti-LT can be used 15-20m prior to exercise for those who cannot tolerate a beta agonist

diagnosis of hypercalcemia

*familial hypocalciuric hypercalcemia* benign autosomal dominant mutation of *CaSR* normally high calcium level supresses PTH , but in FHH, higher clacium concentrations are required to suppress PTH release the defective CaSR leads to increased reabsorption of calcium in renal tubules patients with FHH have *very low urinary calcium levels* *urine calcium/creatinine cleareance ratio* UCCR <0.01 = FHH UCCR >0.02 = primary hyperparathyroidism *hypercalcemia of immobilization* is due to increased osteoclastic bone resorption risk increased in pt with pre-existing high rate of bone turnover (young pt, Paget disease) tx = *bisphosphonates*

Fetal heart tracing with moderate variability and fetal tachycardia (>160/m) etiologies fetal bradycardia etiologies

*fetal tachycardia* HR>160 maternal infection poorly controlled maternal hyperthyroidism meds (eg, terbutaline) abruptio placentae prematuirty sympathomimetics *fetal bradycardia* HR<110 prolonged cord compression cord prolapse fetal hypoxia congenital heart block *normal fetal heart rate* = 110-160

antihypertensives during pregnancy

*first line* beta blockers: Labetolol calcium channel blockers: nifedipine hydralazine methyldopa *second line* clonidine thiazides *contraindicated* ACE-inhibitors Ang II blockres direct rening inhibitors nitroprusside aldosterone antagonists

stages of labor

*first stage*: contractions begin to complete dilation of cervix latent: gradual cervical dilation (0-6cm) [lasts up to 20h for nullipara, 14h for multipara] active: rapid cervical change (6-10cm) [protacted means that cervix is dilating slow - may need to give oxytocin) [1.2cm/h in nullipara, 1.5cm/h in multipara] arrested active phase = 2 horus without progress in active phase *second stage*: 10cm diation to delivery of fetus nulliparous: >2h is prolonged [>3 if epidural] mulitparous: >1h is prolonged [>2 if epidural] *third stage*: delivery of infant to expulsion of placenta [>30m is considered prolonged]

workup of thyroid nodule

*follicular thyroid cancer* peak incidence at age 40-60 presents as firm thyroid nodule shows as nonmetabolically active nodule diagnosis via FNA is not possible as the cytologic findings (large numbres of follicular cells arranged in microfollicles, clusters and clumps) are similar in both FTC and benign adenoma FTC is characterized by *invasion of tumor campsulse and/or blood vessels* - only seen on excised nodule FTC tends to metastasize via *hematogenous spraed* to distant tissues *papillary thyroid* - most common thyroid cancer large cells iwth ground glass cytoplasm, psomommama bodies lymph node involvement *hurthle cells* - large, polygonal cells with eosinophilic cytoplasm containing large quantities of mitochondria

listeria monocytogenes

*gram positive bacillus* primarily a foodborne illness transmitter via raw meats/vegetabsl, *unpasteurized milk products* and prepackaged meats (hot dogs, deli meat) healthy adults are rarely sympomtatic, but may develop self-limited, febrile gastroenteritis if large inoculation occurs patients at extremetes of age (<2, >50), pregnant or immunocompromised have greater risk of invasive disease (eg, bacteremia, meningoencephalitis) which can present shortly after the gastroenteritis or can have prolonged incubationn

secretory diarrhea vs osmotic diarrhea

*hallmarks of secretory diarrhea* larger daily stool volume (>1L/d) occurs during fasting or sleep occurs when luminal ion channels are disrupted in GI tract, resulting in a state of active secretion *common etiologies of secretoary diarrhea* bacterial infection (eg, cholera) viral infection (eg, rotavirus) cystic fibrosis early ileocolitis *postsurgical chagnes* - after bowel rsection or cholecystectomy when unabsrobed bile acids reach colon and result in stimulation of luminal ion channels *stool osmotic gap* SOG = plasma osmolality - 2 (stool Na + stool K) in *secretory diarrhea*, the SOG <50 mOsm/kg in *osmotic diarrhea*, there are nonasborbed and unmeasured osmotically active ingredients in the GI tract thus: SOG >125 mOsm/kg ex = *lactose intolerance*

extremity vascular trauma

*hard signs* observed pulsatile bleeding presnce of bruit/thrill over injury expanding hematoma signs of distal ischemia *soft signs* hx of hemorrhage dminished pulses bony injury neurologic abnomlitiy *evalution* hard signs or sianbility --> surgical exploration otherwise ---> injured extrmeity index (like ABI), CT, duplex dopply u/s

osteomyelitis in children

*healthy children* staph aureus low likelihood MRSA: nafcillin/oxacillin or cefazolin high likelihood or MRSA: clindamycin or vancomysin *sickle cell* salmonella (2/3 of cases) OR staph aureus (1/4 of cases) as above PLUS 3rd gen cephalopsorin (ceftriaxone, cefotaxime) *pathogenesis* hematogenous spread *clinical* fever, irritability limited funciton bony tendenress, swelling *diagnosis* elevated ESR, CRP, WBC blood culture xray often normal, MRI definitive: bone biopsy/culture

local vascular complications of cardiac catheterization

*hematoma* +/- mass NO bruit *pseudoaneurysm* bulging, PULSATILE mass SYSTOLIC bruit defect in arterial wall causes bleeding that remains confined within surrounding layer of periarterial conenctive tissue inadeqautely post-procedural arterial compression is strongest risk factor dx confirmed by u/s *AV fistula* no mass CONTINUOUS bruit caused when inadeqaute hemostasis of arterial puncture site allows blood to communicate with an inadvertently puncture adjacent vein

screening tests for diabetes mellitus

*hemoglobin A1c* - preferred test in nonfasting state >6.5 = diabetes 5.7-6.4 = increased risk <5.7 = normal *fasting blood glucose* - no caloric intake for >8h >126 = diabetes 100-125 = incresed risk <100 = normal *random glucose* >200 + symptoms = diabetes 140-199 = incresed risk <140 = normal *oral glucose tolerance test* - msot sensitive test 75g glucose load with glucose testing for 2h >200 = diabetes 140-199 = increased risk <140 =normal glucose appears in urine when serum concentration is >180

solid liver masses

*hepatic adenoma* = well demarcated, hyperechoic lesions on u/s surgical excision preferred; do*not* do bx as this can cause bleeding *colorectal cancer* is most common source of liver metastases [blood frmo colon moves through portal circulation directly to liver] liver metastases are usually *multiple* hepatoc nodules, but *solitary* are not uncommon

herpangia versus herpetic gingivostomatitis

*herpangia* Coxsacki A virus 3-10 years summer/early fall fever, pharyngitis, gray vesicles/ulcers on *posterior* oropharynx tx = supportive *herpetic gingivostomattisi* HSV1 6 months - 5 years no season in particular fever, pharyngitis, erythematous gigiva, clusters of small vesicles on *ANTERIOR* oropharynx tx = po acyclovir

differentiating features of Hirschsprung disease and meconium ileus

*hirschprung* down syndrome obstruction: rectosigmoid normal meconium consistency positive squirt sign *meconium ileus* cystic fibrosis obstruction: ileum inspissated meconium negative squite sign

allergic bronchopulmonary aspergillosis

*history* asthma cystic fibrosis present with symptoms of poorly controlled asthma with recurren exacberations severe disease - recurrent infiltrates, fever, cough of brown sputum, hemoptysis *chest imaging* recurrent fleeting infiltrates bronchiectasis on CT *diagnosis* eosinophilia positive skin test for asperigllus positive aspergillus IgG elevated aspergillus IgE *treatment* oral corticsoteroids for several months + Itracanazole

central cord syndrome

*hyperextension* injuries - elderly paitents with pre-existing degenerative changes in C-spine causes damage to central portion of CST and decussating LSTT weakness in upper extremities loss pain/temp in arms

hypertensive complications

*hypertensive urgency* severe HTN (>180/120) with *no* sx of acute end-organ damage *hypertensive emergency* severe HTn with acute, life-trheatning , end-organ complications *malignant HTN*: severe HTN w/ reitnalhemorrahge, exudates, or papilledema *HTN ecephalopathy*: severe HTN w/ cerebral edema and non-localizing neurologic s/s

emphysematous cholecystitis

*hypoactive bowel sounds* - causes and ileus not an obsutrction

causes of gout

*increased urate production* primary gout aka idiopathic myeloproliferative/lymphoprolfierative disorders tumor lysis syndrome hypoxanthine guanine phopshoribosyl transferase deficiency *decreased urate clearence* chronic kidney disease thiazide/loop diuretics

cervical conization

*indications* CIN 2 CIN3 can be with scalpel (cold knife conization) or via electrocautery (LEEP) *complications* - directly related to amount of tissue removed cervical stenosis preterm birth preterm premature rupture of membranes second trimester pregnancy loss

differential diagnosis for non-traumatic joint swelling

*infectios* acute, constant pain can not bear weight single joint increased WBC/plt, increase inflammatory *inflammatory/rhematologic* subacute/chronic, wors ein mroning can bear weight multiple joitns increased WBC/plt, decreased RBC, icnreaesd inflammatory *neoplastic* subacute/chronic worse in evening/night variable weight bearing variable # of joints derased WBC/plt

operative vaginal delivery (vacuum/forceps)

*inidcations* protracted 2nd stage of labor fetal HR abnormalities maternal contraindications to pushing -neuromuscular disorder causing ineffective pushing -valsvae contraindicated: Cerebrovascular dz, cardiac dz *fetal complications* laceration cephalohematoma facial n. palsy intracranial hemorrahge shoulder dystocia *maternal complications* genitourianry tract injury urianry retention hemorrhage

management of ST-segment elevation myocardial infarction (STEMI)

*initial stabilization* = O2, full dose aspirin, P2Y12 blocker, nitro, beta blocker, anticoag *guidelines for primary PCI* within *12h of sx onset* and within *90 minutes from medical contact to dvice* at a PCI-capable facility or within 120 minutes from first medical contact to deviece time at non-CI capable facility

clinical features of hyperkalemia

*insulin* is fastest acting way to move potassium into cells; given with glucose inhated beta agonists can also be used rapidly [can precipitate angina in pt with CAD] IV calcium chloride/gluconate is used to *stabilize the myocardium*; has no effects on serum potassium level

biliary atresia

*intiially well appearing, followed by development of the following over 1-8 weeks* jaundice acholic (pale) stools, dark urine hepatomegaly conjugated hyperbilirubinemia mild elevation in transaminases no neurologic sx of kerniterus because this is *conjugated* bilirubinemia and conjugated bilirubin cannot cross BBB *diagnosis* u/s = absent or abnormal gallbladder hepatobiliary sctingiraphy = failure of tracer excretion liver bx = expanded portal tracts w/ bile duct obstruction + proliferation; portal tract edema, fibrosis + inflammation intraoperative cholangiogram (*gold standard*) = biliary obstruction *treatment* hepatoportoenterostomy (*Kasai procedure*) liver transplant

liver disorders unique to pregnancy

*intrahepatic cholestasis of pregnancy* is functional disorder of bile - develops in 2nd, 3rd trimesters intolerable generalized pruritis worse on palms and soles, and at night elevated LFT's, mildly elevated alk phos and bili tx = symptoms; prurity resovles in weeks following delivery ursodeoxycholic acid increases biel flow, relieving itching *early delivery is recommended once fetal maturity* to avoid fetal complications [IUD, neonatal RDS] maternal prognosis is good

warfarin affect on lab values reversal of warfarin drugs/supplements that affect warfarin metabolism

*lab values* increased PT plt count and BT are not affected *reversal of warfarin* IV vitamin K - takes 12-24 hours to be effective prothrombin complex conetrate - contains II, VII, IX, X and offers rapid (minutes) and short-term (hours) reversal of warfin FFP can be used if PCC is not avaiable

child with lytic bone lesion, rash and s/s of diabetes insipidus

*langerhans cell histiocytosis* *clinical* lytic bone lesions: skull, jaw, feur skin lesions: purplish papules, eczematous rash lymphadenopathy, hepatosplenomegaly pulmonary cysts/nodules central diabetes insipidus *diagnosis* langerhands cells on bone/skin biopsy *treatment chemo: prednisone +/- vinblastine desmopressing for diabetes insipidus

key respiratory tract infections in children

*larngotracheitis - croup* parainfluenza virus 6m-3y Barky cough, *stridor*, hoarse voice *epiglottitis* h flu unvaccinated children sore throat, dysphagia, drooling, *tripod* *bronchiolitis* RSV <2y wheezing, coughing

congenital heart disease

*left to right*: tachypnea, poor weight gain, sweating with feeds VSD ASD isolated PDA *right to left*: cyanosis TGA TOF Tricuspid artresia APVR tuncus arteriosis [as PDA closes, pulmoanry blood flow decreaes and cyanosis becomes more apaprent] immedaite first step in these conditions = *PGE1* *interrupted LV output*: pallor, shock, acidosis coartctation of aorta hypoplastic left heart syndrome

screening tests for patients at average risk

*lipids* screening men at average risk = 35 y/o screening women at increased right = 45 decreased benefit in elderly patients 5 year interval is recommended

common causes of low back pain

*lumbosacral strain* is the most common cause of back pain

causes of hyperandrogenism in pregnancy

*luteoma* solid ovarian masses on u/s (50% bilateral) management primarily involes clnical monitring and u/s eval as masses and symptoms *regress spontaenously after delivery* however, patient should be informed that a symptomtatic maternal luteom puts a female fetus at *high irsk for virlization* size of luteoma needs to be monitored for rare risk of mass effect (hydronpherosis, obstructive labor) and ovarian torsion

pathophysiology of pulmonary edema in preeclampsia/eclampsia

*management* O2 fuid restriction direusis be careful with restriction of fluids as plasma volume is decreased through 3rd spacing and placental perfusion can be compromised

autism spectrum disorder

*management* early diagnosis and intervention comprehensive, multimodal tx (speech, behaioral, educaitonnal) adjunctinve pharmacotherapy for psychiatric comorbidities suspect ASD in child with impaired social interactions, restricted interests or repetitive behaviors

polycythemia vera

*manifesttions* increased blood viscotiy - HTN, eryhtromelagia (burning cyanosis in hands feet); transient visual distuabcens increased RBC turnover (goutry arthritis) Aquagenic pruritis [itching acter warm shower] bleeding *exam* - facial plethora, splenomeally *labs* - elevated Hb, leukocytosis, thrombocytosis, *low EPO*, *JAK2+* *complications* - thrombosis, myelofibrosis, acute leukemia *treatment* - phlebotomy, hydoxyurea *erythromelalgia* - thrombotic complication that presents with red, burning extremities that is relieved by *aspirin + cold temperatures* and made worse with warmth Seen in disorders causing thrombocytosis (eg, PV and essential thrombocytosis)

pathophysiology of submasive/massive pulmonary embolism

*massive PE* abrupt increases in PVR and thus, RV pressures elevated RV pressures cause increased RV wall tension, cardiac muscle stretching and RV dilation this increases RV oxygen demand and decreases coronary artery perfsuion, which causes supply/deman mismatcha dn RV ischemia consequent, *RV dysfunction*, leads to inability to pump blood through pulmonary circulation, decreaes venous return to LA, decreased cardiac output, and potential hemodynamic collapse *echocardiogram* bowing of septum into LV (due to RV pressure exceeding LV diastolic pressure) RV free wall hypokinesis with sparing of apex presence of RV dysfunction + elevated BNP + elevated troponins = *increased mortality*

breastfeeding benefits & contraindications

*maternal benefits* more rapid uterine involution and decreased postpartum bleeding faster return to prepartum weight improved child spacing imrpoved maternal infant bonding *reduced risk of breast and ovarian cancer* *maternal contrainducations* active TB [can breastfeed after 2w of therapy] maternal HIV infection herpetic breast lesions varicella ifnection <5d prior to or within 2d of delivery specific maternal medications chemo or ongoing radiation abuse of drugs or alcohol *infant beneits* improved immunity improved GI funciton prevention of: otitis media, gastroenteritis, respiratory illnesses, UTI's decreased risk of childhood cancer, T1DM, necrotizing enterocolitis *infant contraindcations* galacotsemia

causes of chronic low back pain

*mechanical* - muscle strain, disc degeneration normal neuro exam paraspinal tenderness *radiculopathy* - herniated disc radiation below knee +straight leg test neuro deficits *spinal stenosis* pseudoclaudication relieved by leaning forward *inflammatory* - spondyloarthropathy worse with rest, better with activity sacroiliitis *metastatic cancer* age >50 worse at night not relieved with rest *infectious* - osteo, discitis recent infection or IVDU feevr, focal spinal tenderness

traumatic carotid injuries

*mechanism* penetrating trauma fall with object in mouth (eg, toothbrush, pencil) neck manipulation (eg, yoga, sports) intimal injury to internal carotid a. can result in dissection or thrombus formation, which occurs over hours to days and can extend into middle and anterior cerebral arteries *presentation* gradual-onset hemiplegia aphasia neck pain thunderclap headache *diagnosis* CT or MR angiography

antipsychotic with highest potential for increasing prolactin

*mechanism* blockade of dopamine in the tuberoinfundibular pathway can lead to *hyperprolactinemia* and symtpoms such as: *gynecomastia, galactorrhea, menstrual dysfunciton, decreased libido* high potenecy, 1st gen meds (haloperidol, fluphenazine) 2nd gen: risperidone, paliperidone aripiprazole and quetiapine are *least likely* to produce hyperprolactinemia

radial head sublaxation

*mechanism*: axial traciton on farearm with elbow extended radial head slips through parts of the annular ligament *PE*: arm heald extended+pronated; no swelling, deformity or focal tenderness *treatment* hyperpronation of forearm or supination of forearm + flexion of elbow immobilization with sling/cast is NOT needed patient should experience immedaite return of normal function after manual reduction

common causes of vertigo

*meniere disease* - increased volume and pressure of endolymph (endolymphatic hydrops - decreased resorprtion) recurrent episodes lasting 20 minutes to several hours sensorinueal hearin loss tinnitus and/or fullness of ear *tx* - restric Na, caffeine, nicotine, alochol; benzos, antihistamines, antiemetics can relieve acute symptoms diuretics can be used long-term management *BPPV* - loose calcium debris in semicircular canal brief episodes triggered by head movement dix-hallpike maneuver causes nystagmus *vesitbular neuritis* - inflammation of membranous labyrinth acute, single episode that can last days often follows viral syndrome abnormal head-thrust test *migraine* vertigo associated with headache or other migrainous phenomenon (eg, visual aura) symptoms resolve completely between episodes *brainstem/cerebellar stroke* sudden-onset, persistent vertigo usually other neurologic symptoms

metatarsus adductus vs congenital clubfoot

*metartasus adductus* = most common congenital foot defomirty medial deviation of forefoot, neutral hindfoot >90% are *flexible* that overcorrect both passively and actively into lateral deviation this most commonly correct *spontaneously* *clubfoot* rigid medial and upward deivatino of both forefoot and hindfood most respond to manipulation and casting refractory --> surgery

disease-modifying antirheumatic drugs

*methotrexate* purine antimetabolite hepatotoxicity, stomatitis, cytopenia *leflunomide* pyrimidine synthesis inhibitor hepatoxocity, cytopenia *hydroxychloroquine* TNF and IL1 suppressor retinopathy *sulfasalazine* TNF IL1 suprpessore hepatotoxicity, stomatitis hemolytic anemia *TNF inhibitors*: adalimnab, certolizumab, etanercept, golimumab, inflixmab infeciton, demyelination, CHF, malignant

nocardia

*micro* gam positive rod (beaded or branching) partially acid-fast aerobic******* *epidemiology* endemic in soil disease from inhalation or traumatic incoulation into skin ummocompromised or elderly patients *clincial* pneumobia - similar to TB CNS involvement - brain abscess cutaneous involvement imaging shows *nodular or cavitary lesions* in the *upper lobes* bronchsocopy with broncholaveolar lavage is needed for diagnosis *treatment* TMP/SMX (usually for 6-12 months) surgical drainage of abscesses

dehydration in children

*mild* (3-5% loss): hx of decreased intake or increased loss with minimal or no clinical symptoms *moderate* (6-9% loss): decreased skin turgor, dry mucus embranes, tachycardia, irritability, delayed capillary refill (2-3s), and decreased urine output *severe* (10-15% loss): cool, clammy skin, delayed feill (>3s), cracked lips, dry mucuous membranes, sunken eyes, sunken fontanelle, tachycardia, lethargy, minimal or no urine output *treatment* mild-moderate = oral rehydraiton therapy severe = normal saline resustiation isotonic crystalloid is only crystalloid solutation recommended for IVF in children

mixed cyroglobulinemia (table shows type I vs MCS)

*mixed cryoglobulinemia* immune complex depoistion in small to medium blood vessels causes endothelial injury and end organ damage *palpable* purpura proteinuria hematuria *nonspecicifc s/s* arthalgias HSM hypo-complementemia neuropathies demonstration of circulating cryoglublins is confirmatory and *low complement* many have underlying *HCV* infection to diagnose type 1 = *bone marrow biopsy*

breast cancer risk factors

*modifiable* hormone repalcement therapy nulliparity increased age at first live birth alcohol consumption [dose dependent] *non-modifiable* genetic mutation or breast cancer in 1st degree relatives white race increasing age early menarche or later menopause *screening mammorgaphy at age >50* due to risk of cancer with increased age

diverticulosis

*most common cause of gross lower GI bleeding in adults* bleeding is *painless*, but large volume can be associated with hemodynamci instability low-volume = passage with stool, hematochezia dark stool high volume = frank red blood hemorrahge usually *resolves sponatenously*, some need intervetion (endoscopic, surgical) outpouchings of colonic wall that form at poitns of weakness; most in signmoid colon incidence increases with age usually asymptomatic, but can have hemorrahge and infection strongly associated with chronic constipation dx = *colonscopy* incidence of acute diverticular complications is lower in individuals with high intake of fruit and vegetable fiber increased risk: heavy meat consumption, aspirin or NSAID use, obestiy, possibly smoking

transposition of great vessels

*most common congenital cyanotic heart disease in neonatal period* *characteristic findings* cyanosis within 24 hours of life single S2 (absent pulmonary component of S2 because aorta is anterior to pulmonary artery) *egg on a string xray* - narrow mediastinum pulmonary artery arises from LV; aorta arises from RV cyanosis and signs of heart fialure prsent within first few hours of life cxr = *egg on a string* appearance - heart is enarlged and appears like an egg lying on its side with narrow vascular pedicle because aorta nd pulmonary artery positions and mediastinum narrowing dx = echocardiography tx = infuse PGE1 to prevent closure of ductus cardiac cath, ballon atrial septostomy and surgery follow

clincal features of dermatomyositis

*muscle weakness* proximal, symmetric UE = LE *skin* gottron's papules heliotrope rash *extramuscular* interstitial lung disease dysphagia myocarditis *diagnosis* increased CPK, aldolase, LDH anti-RNP, anti-Jo-1, anti-Mi2 diagnostic uncertainty = EMG, biopsy [skin/muscle] *management* high-dose glucocorticoids PLUS glucocorticoid-sparing agent screening for malignancy most common malignancies: ovarian, lung, pancreatic, stomach, colorectal, non-hodgkin

prophylaxis criteria for lyme disease

*must meet all 5* attached tick is adult or myphal Ixodes capularis (deer tick) tick attached for >36h or engorged prophylaxis started within 72h of tick removal local borrelia burgdorferi infection rate >20% no contraindications to doxycycline

hemodynamics of shock

*myocardial contusion* caused by blunt trauma to chest - sternal fracture most commonly LV dysfunction (elevated PCWP after NS infusion) shows as = tachycardia, new BBB or arrhythmia immediate echo needed

features of necrotizing fasciitis

*necrotizing surgical site infection* occurs more commonly in diabetics polymicrobial considered emergency if involve fascial plane and. develop into necrotizing fasciitis debridement = *most important step*

nephrotic versus nephritis syndrome

*nephrotic* clinical - edema, fatigue, proteinuria, NO hematuria, hypoalbuminemia pediatric - minimal change disease adult - FSGS, membranous nephropathy, membranoproliferative glomerulonephritis *nephritic* clinical - HTN, oliguria, hematuria, proteinuria, csts pediatric - PSGN, HUS adults - IgA nephropathy, membranoproliferative glomerulonephritic, crescentic glomerulonephritis

neimann-pick disease versus Tay-sachs disease

*niemann-pick* sphingomyelinase deficiency autosomal recessive; Ashkenazi jewish 2-6months Loss of motor milestones hypotonia feeding difficulties cherry macula *Hepatosplenomegaly* *areflexia* *tay-sachs* b-hexosaminidase A deficiency autosomal recessive; asheknazi jewish 2-6 months loss of motor milestones hypotonia feeding difficulties *no* HSM *hyperreflexia*

antipsychotic extrapyramidal effects and dopamine pathways other dopamine antagonists causing EPS

*nigrostriatal* = extrapyramidal effects *mesolimbic*[ventral tegmental to limbic system] = antipsychotic efficacy *tuberoinfundiublar* hyperprlactinemia *dopamine antagonists* = metocloprmaise, prochlorperazine, promethazine - can cause EPS side effects

fibromuscular dysplasia

*noninflammatory* and *nonatherosclerotic* condition cause dby abnormal cell development in arterial wall that can lead to vessel stenosis, aneurysm, or dissection dx is usually confirmed with noninvasive imaging: *CTangio of abdomen or duplex u/s*

osteoperosis risk factors

*nonmodifiable* advanced age postmenopausal low body weight white/asian malabsorption hypercotilism, hyperthyroidism, hyperparathyroid inflammatory disorders chroinc lvier or renal disease *modifiable* smoking excessive alcohol sedentary lifestyle meds: glucocorticoids, anticonvsulants vit D deficiency, iandeqate calcium estrogen deficiency estrogen dificiency reuslts in increased RANK-ligand expression --> precursors more likely to become osteoclasts

renal tubular acidosis

*normal anion gap acidosis* *failure to thrive* screening labs will show a low serum HCO3 and hyperchloremia --> normal anion gap metbaolic acidosis

postpartum period findings / care

*normal findings* transient rigors / chills peripheral edema lochia rubra (red/brown vaginal discharge - shedding of uterine decidua and blood; after 2-3 weeks dsicharge becomes white/yellow = lochia alba) uterine contraction & involution (becomes firm and globular, with fundus 1-2cm above/below umbilicus) breast engorgement *routine care* rooming-in / lactation support serial exam for uterine atony /bleeding perineal care voiding trial pain management

normal vs abnomral features of lymph nodes

*normal* soft mobile <2cm no systemic symptoms tx = observe, most regress within weeks *abnormal* firm, hard immobile >2cm systemic symptoms - fever, night sweats, weight loss requires further evaluation - CBC, viral titers, inflammatory markers, etc.

tocolytics

*not given >34 weeks* *indomethican* COX inhibition First line: <32 weeks maternal - gastritis, plt dysfunciton fetal - olighydrmanios, closure of ductus arteriosus *nifedipine* CCB first line: 32-34 weeks maternal - tachycardia/palpitations, nausea, flushing, headache *terbutaline* beta agonist short term tocolytic: inpatient use maternal - tachycardia, arrythmias, hypotension, hyperglycemia, pulmonary edema

clinical features of asbestosis

*occupations*: mining, shipbuilding, insulation, pipe work prolonged abestos exposure (eg, shipyard, minig) symptoms develop *>20y* after initial exposure progressive dyspnea, basilar fine crackles, clubbing icnreased risk for lung cancer and mesothelioma *lung cancer (bronchiogenic carcinoma) is higher risk* *diagnostic* pleural plaques on chest imaging imaging, PFT, and histo consitent w/ pulmonary fibrosis restrictive pattern = normal or elevated FEV1/FVC ratio; decreased lung volumes; reduces DLCO and pulm compliance

small bowel obstruction versus ileus vs ogilvie syndrome

*ogilvie syndrome* s/s of bowel obstruction w/o mechanical obstruction gross dilatation of cecum and ascending colon causes: trauma, serious illness, meds, neurological disease, abdominal/pelvic surgery clinically: n/v/constipation, pain, labored breathing PE: tympanic abdomen w/ bsx4 tx = stop offending med, supportive therapy

interpretation of weber & rinne tests otosclerosis

*otosclerosis* common cause of conductive hearing loss in adults (20s, 30s) abnormal remodeling of otic capsule thought to be possible autoimmune stapes footplate becomes fixed to oval window, resulting in loss of its piston action tx = hearing amplificaiton or surgical stapedectomy

curb 65

*outpatient* macrolide or doxycycline fluroquinolone or beta-lactam + macrolide *non-icu* fluroquinolone beta lactam + macrolide *ICU* beta lactam + macrolide beta lactam + fluroquinolone

pelvic pain in patient with known ovarian mass should be suspected as...

*ovarian torsion* mass on ovary puts weight on the adnexa and makes it vulnerable to twisting around its supporting structures, which contain ovarian blood supply unilateral pain with possible n/v/fever dx with u/s (absent blood flow to ovary) tx = surgical detorsion, cystectomy, and possible removal of adnexa if necrosis despire restoration of circulation

differential diagnosis of anterior knee pain in young patient

*patellofemoral pain syndrome testing* *patellofemoral compression test* - pain elicited by extending knee while compressing patella; and reproductive of pain with squatting

hereditary angioedema

*patho* C1 inhibitor defiency - autosomal dominant excessive bradykinin *clinical* swelling without urticaria laryngeal edema colicky abdominal pain, vomiting, diarrhea *diagnosis* *low C4, low C1 inhibitor protein* depressed C4 is from exaggerated cleavage of C4 by C1 complex *management* C1 inhibitor concentrate bradykinin antagonists (eg, icatibant) kallikrein inhibitor (ecallantide) ******ACE inhibitors are most common cause of acquired angioedema it is important to note that angioedema from ACE inhibitors can occur *ANYTIME*, not just within weeks of medication

mastoiditis

*patho* complication of acute otitis media most commonly from streptococcus pneumoniae *clinical* fever, otalgia inflammation of mastoid deivation of ear opacificaiton of mastoid air cells on CT scan or MRI mastoiditis can extend into nearby structures - CNS (meningitis, brain abcess), labyrinth (deafness), occipital bone (osteomyelitis) *management* IV antibiotics (against strep, staph; coverage for pseudomonas should be used if recent abx use) drainage of purulent material

guillian barre syndrome

*patho* immune mediated demyelinating polyneuropathy preceding GI or respiratory infection [campylobacter is associated with >90% of cases] *periphearl motor nerves* [sensory and autnomic may be affected in late disease] paresthesia, neuropathic pain ascending symmetrical paralysis over *days to weeks* decreased/absent DTR sensation is usually normal autonomic dysfunction occurs in 70% CSF - high protien, few cells abnormal EMG and nerve conduction tx - IVIG, plasmapheresis

hemolytic uremic syndrome

*patho* initial insult from Shiga toxin (E coli O157:h7) vascular damange + microthombi formation *clinically* preceding bloody diarrhea microangiopathic hemolytic anemia --> fatigue, pallor thrombocytopenia --> brusing, petechiae acute kidney injury --> oliguria, edema *labs* hemolytic anemia = schistocytes, inc. bilirubin; decreased haptolgobin thrombocytoepnia AKI: inc. BUN, inc. Cr *treatment* fluids, electrolytes blood transfusions (Hb <6) dialysis (eg, anuria) *most improve within 2-3 weeks*

features of primary ciliary dyskinesia

*patho* mutations in ciliary dynein arms lead to absent or dysmotile cilia and poor mucociliary clearance *clinical* recurrent sinpulmonary infections bronchiectasis +/- situs ivnersus (*kartagener syndrome*) - dextrocardia, displaced heart sounds and PMI to right *diagnosis* low nasal nitric oxide levels bronchoscopy and electron microscopic visualizaiton of ciliary abnormalities genetic testing

hypertrophic cardiomyopathy

*patho* mutations in sarcomere protein genes autosomal dominant *clinical* asymptomatic or identified by family screening fatigue, chest pain, palpitations, syncope SEM exacerbated by dehydraiton / impiared LV filling *diagnositc* EKG: LVH, repolarization abnoramlities TTE: LVH, increased LVOT gradient, SAM of mitral valve exercise testing family screening *management* avoidance of volume depletion Beta blockers / calcium channel blockers surgery if persistent symptoms *complications* sudden cardiac death heart fialure stroke

transient tachypnea of the newborn

*patho* retained fetal lung fluid - dleayed resorption and clearence of alveolar fluid normally - mature fetal lungs begin to reabsorb liquid in late gestation in response to increased catecholamine signals; this mechanism increaes during labor *risks* cesarean delivery prematurity maternal diabetes *clinical* tachypnea, increased work of breathing clear breath sounds [fluid is in interlobar fissures] chest xray - hyperinflation, fluid in fissures *managementn* supportive care (eg, oxygen, nutirtion) self-resolution in 1-3 days

lactational mastitis

*patho* skin flora (eg, staph aureus) enters ducts through nipple and multiples in stagnant milkd *rsks* hx of msatitis engorgement and inadeqaute milk drainage due to: -sudden increase in sleep duraiton -replacing nursing w/ formula or pumped milk -weaning -pressure on duct (tight bra, prone sleeping) -cracked or clogged nipple pore -poor latch *clinical* fever firm, red, tender, swollen quadrant of unilateral breast do not need breast u/s when clinically pt has mastitis *treatment* frequent breastfeeding or pumping - nurse q2-3h dicloxacillin - narrow spectrum penicllin; covers 2 most frequent pathogens - MSSA, GAS Cephalexin can be used too

malaria

*patho* transmission of P. falciparum, P vivax, P ovale, P malariae Anophele mosquito *clinical* periodic febrile paroxysms malaise, HA, n/v, abdominal pain, diarrhea, myalgia, pallor, jaundice, petechiae, HSM *complicaitons* children: seizure, coma, hypoglycemia, metabolic acidosis adults: jaundice, acute renal failure, acute pulm edema *diagnosis: thin and thick peripheral blood smears* *protetion* hemoglobinopathies (HbS, HbC, thalassemia partial immunity from previous malarial illness *prevention* atovaquione-proguanil doxycyline mefloquine chloroquine hydroxychloroquine insecticide treated nets household insecticide residual srpaying

epidural hematoma

*patho* trauma to sphenoid bone with tearing of MMA *clinical* brief loss of consciousness followed by *lucid interval* hematoma exnapsion: increased intracranial pressure: impaired consciousnss, headache, n/v *uncal herniation*: ipsilateral CNIII palsy, hemiparesis *diagnosis* Biconvex (lens-shaped) hyperdensity that does not cross suture lines *tx*: urgent surgical eval for symptomatic patients

colonic ischemia

*patho* usually nonocclusive, watershed ischemia underlying atherosclerotic disease state of low blood flow (eg, hypovolemia) *clinical features* moderate abdominal pain and tenderness hematochezia, diarrhea leukocytosis, lactic acidosis *diagnosis* CT - colonic wall thickening, fat stranding endoscopy - edematous and friable mucosa *management* IVF, bowel rest abx with enteric coverage colonic resection if necrosis develops

eosinophilic esophagitis

*patho*: chronic, immune mediated esophageal inflammation [triggered by food allergens] *clinical* dysphagia chest/epigastric pain reflux/vomiting food impaction associated atopy *diagnosis*: endoscopy + biopsy (>15eos/hpf) 2 month PPI trial is part of diagnosis; as pt will fail this *treatment* dietary modifcation +/- topical glucocorticoids

herpes zoster (shingles)

*patho*: reactivation of varicella-zoster virus frmo sensory nerve ganglion commonly occurs after recent stress, immunosupression *clinically* prordrome: tiching, tingling, burning in dermatomal distrbution rash: grouped papules and vesicles on eryhematous base; ulceration and crusting; acute neuritic pain posterheptic neuralgia: persistnent neuritic pain >4 months after rash onset *treamtnet* antiviral: acyclovir, valacyclovir, famciclovir [shortens the course if given within first 72h] postherpetic neuralgia: TCA, pregabalin, gabapentin

staphylococcal scalded skin syndrome

*patho*: staphylcoccus aureus exfoliative toxin in neoantes source is often umbilicus or circumcision site older children - nasopharyngeal colonization or primary skin lesion (eg, pustule) *clinical* fever, irritability generalized eythema is followed by flaccid blisters/bullae on flexural areas exposed to mechanical pressure mucosal areas are *spared* epidermal shedding - *nikolsky sign* dx is generally clinical; but blood cultures and infectious source cultures should be obtained symptoms typically resolve in 1-2 weeks; low mortality rate *management* antistaphylococcal antibiotic - nafcillin, vancomycin wound care

neonatal herpes simplex virus infection

*patho*: vertical transmission: intrauterine, perinatal, postnatal *clinical* skin-eye-mouth: mucocutenous vesicles, kertaoconjuctivits CNS: seziures, fever, letheraly; temporal lobe hemorrage dissmineated: sepsis, hepatitis, pneumonia *diagnosis* viral surface cultures HSV PCR: bloood CSF *tx* acyclovir

sheehan syndrome

*pathogenesis* obstetric hemorrhage complicated by hypotension postpartum pituitary infarction *clinical* lactation failure: decreased prolactin amenorrhea, hot flashes, vaginal trophy: dec FSH, LH fatigue, bradycardia: dec TSH anorexia, weight loss, hypotension: dec ACTH decreased lean body mass: dec GH *management* replace deficient hormones

paget disease of bone (osteitis deformans)

*pathogenesis* osteoclast dysfunction increased bone turnover early lesions have predominance of osteoclast activity, later progressing through mixed osteoclastic/osteoblastic phase, a predominantly osteoblastic phase and residual sclerotic phase *clinical*: most are asymptomatic skull: headache, hearing loss spine: stenosis, radiuclopathy long bones: bowing, fracture, arthritis of adjacent joints giant cell tumor, osteosarcoma *complications* benign giant cell tumors osteosarcoma *labs* *elevated alkaline phosphatase* elevated bone turnover markers (PINP, urine hydroxyproline) *calcium and phosphorus are normal* *imaging* xray: osteolytic or mixed lytic/sclerotic lesions bone scan: focal increase in uptake *treatment = bisphosphonates*

tabes dorsalis

*pathogenesis* syphilis spirochetes directly dmage dorsal sensory roots secondary degeneration of dorsal columns *epidemiology* increased incidence of syphilis men who have sex with men & HIV-infected patients HIV-positive patients develop neurosyphilis more rapidly *clinical* sensory ataxia lancinating pains neurogenic urianry incontinence Argyll robertson pupils *treatment* IV pencillin for 10-14 days - has adeqaute CSF penetration

biliary cyst (choledochal cyst)

*pathogenesis* type 1 is most common: extrahepatic, single cystic dilatation of bile duct *clinical* classic triad of pain, jaundice and palpable mass majorty of cysts present at age <10 years infants may have jaundice and acholic stools older children can have pancreatitis *diagnosis* visualization on u/s ERCP *treatment* surgical resection to relieve obstruction and prevent malignant transformation

endometriosis **remember endometriosis can cause infertility**

*pathogenesis*: ectopic implantation of endoemtrial glands *clinical* *hallmark 3Ds*: dysmenorrhea, dyspareunia, dyschezia inferility - due to ectopic foci of hemorrhage and adhesions that distort pelvic anaomty and impair fertility by obstructing oocyte release or sperm entry chronic pelvic pain *PE* immobile uterus cervical motion tenderness adnexal mas recto-vaginal septum, posterior cul-de-sac, uterosacral ligament nodules *diagnosis* direct visualization and surgical biopsy: powder-burn lesions, flesh colored or dark nodules, collections of 'chocolate' fluid (endomtrioma) *treatment* NSAIDs and/or OCC are first line empiric treatment if incidentally found in asymptomatic pt - observe for development of future symptoms, initiate tx if needed leuprolide - GnRH agonist --> induces menopause; poorly tolerated failure of conservative treatment, presence of an adnexal mass, and infertility necessitate laparscopic evlauation

acute respiratory distress syndrome

*pathophy* gas exchange imparied due to V-Q mismatch Lung compliance is decreased due to loss of surfactant and increaed elastic recoil of edematous lungs pulmonary arterial pressure is increased (pulm HTN) due to hypoxic vasoconstriction, destruction of lung parenchyma, and compression of vascular structures from positive airway pressure in ventilaed patients *ventilatory* Low tidal volume ventilation prevents likelihood of overdistening alveoli and provoking barotrauma due to high plateua pressures goal arterial pressure at 55-80 (saturation 88%-95%) icnreases PEEP improves oxygenation; try and keep FiO2<0.6 due to oxygen toxicity risk

congenital umbilical hernia

*pathophys*: incomplete closure of abdominal muscles *associated with*: hypothyroidism ehlers-danlos beckwith-widermann down syndromes *can be seen in normal newborns* *clinical* soft, nontender bulge at umbilicus protrudes with increased abdominal pressure typically reducible *management* observe for spontaenous closure electrive surgery around age 5 small hernias close spontaenous as rectus abdominis muscles grow together and fasial layers fuse large (1.5cm) hernias are less likely to close

flail chest

*pathophysiology* >3 contiguous ribs fractured in >2 locations usually from blunt thoracic trauma *findings* paradoxical chest wall motion with respiration - due to negative intrathoracic pressure during inspiration chest pain, tachypnea, rapid shallow breaths CXR: rib fratures +/- contusion/hemothorax resp failure, often due to pulmonry contusion and resultant collection of edema/blood in alveoli can occur ARSD and pneumonia are other potential complications *management* pain control, supplemental oxygen PPV if respiratory failure MPPV helps to correct the paradoical moition by replacing the nomral negative intraplerual pressure with positive intrapleural pressure and forcing the segment to move outward with rest of rib cage during inspiration complications of MPPV = lung puncture due to sharp rib edges causing tenosion pneumothorax -bilateral chest tube prior to intubation minimize this risk

lesch-nyhan syndrome

*pathophysiology* X-linked recessive deficiency in hypoxanthine-guanine phosphoribosyl transferase enzyme hypoxanthine and uric acid accumulation development of dopaminergic pathways are particuarl yaffected --> progression neuropsych manfiesations *clinical* delayed milestones and hyptonia in infancy early childhood: intellectual disability, EPS (dystonia, chorea); pyrimidal (spasticity, hyperrelfixa) self-mulitlation goutry arthritis in late, untreated disease

sickle cell disease / management of sickle cell anemia

*pathophysiology* beta globin mutation (glu --> val) autosomal recessive *clinical* vaso-occlusive pain crises hemolytic anemia *most common cause of sepsis* = non-vaccine serotypes of *s pneumoniae* *labs* dec hematocrit inc reticulocyte count smear: sickled RBC Hb electropheresis: inc HbS, dec HbA *maintence* pneumococcal vaccine penicllin (until age 5) folic acid supplementation hydroxyurea *acute crisis* hydration analgesia +/- transfusion

laryngomalacia

*pathophysiology* increased laxity of supraglottic structures *clinical* inspiratory stridor *worsens when supine* peaks at age 4-8 months *diagnosis* usually clinically confirmation by flexible laryngoscopy for moderate/severe cases omega-shaped epiglottis and collpase of supraglottic structures during inspiration *management* reassurance for msot cases supraglottoplasty for severe symptoms collapse of supraglottic structures during inspiration

ankylosing spondylitis

*peak age*: 20-30; males > females stiffness >3months relieved with exercise nocturnal pain low back pain is due to inflammation at sites of ligamentous insertion (enthesitis) Enthesitis can occur at any tendon or ligament - *insertion of achielles tendon* is most prominent prestnation chronic complications of enthesitis are fibrosis and calcfication aoritc regurg is common in chronic AS AS eventually leads to destruction of the articular cartilage, espeically at the SI-joints and apophyseal joints of the spine *labs* elevated ESR and CRp *HLA-B27 association* *xray of sacroiliac joints* = imaging *bamboo spine* *complications* osteoperosis/vertebral fractures [inncreased osteoclastic activity from chronic inflammation (TNFa, IL-6) aortic regurgitation cauda equina *restrictive lung pattern* on PFT is due to restricted chest wall and spinal mobility, thus limting lung expansion reduced VC and TLC but normal FEV1/FVC FRC and RV are *normal* due to fixation of rib cage and not lung pathology

pertussis

*pertussis tx & post-exposure prophylaxis* age <1 month: azithromycin x5d Age >1month: azithromycinx5d or clarithromycin x7d or erythromycin x14d *prophylaxis* is recommedned for *all close contacts* despite vaccination status avoid anti-tussive meds in children <6 due to increased risk of toxicity

PE/treatment of allergic rhinitis

*physical exam* allergic shiners: infraobirtal edema + darkening allergic saltue: transverse nasal crase pale, bluish, enalrged turbinates pharyngeal cobblestoning allergic facies: high arches palate, open mouth breathing *treatment* allergen avoidance intranasal corticosteroids

enterobius vermicualaris

*pinworm* adult worms live in intestines, females migrate distally to deposit eggs on perianal skin, primarily at night, causing ymptoms perianal pruritis, especially at night vulvovaginitis can be presenting symptoms in prepubertal girls *diagnosis* - eggs on tape test *treatment* - albendazole OR pyrantel pamoate for patient and all household contacts

major malaria species

*plasmodium falciparum*: Africa fever, chills, flu like symptoms often *severe* (AMS, organ failure) no dormant phase tx: *chloroquine* or arterminsin-bsed combo *plasmodium vivax*: non-africa fever, chills, flu like symptoms lower severity *REACTIVEATION* - dormant in liver hepatic hyponzites tx: *primaquine*

clinical features of chronic hepatitis C

*porphyria cutanea tarda* - uroporphyinogen decarboxylase deficiency fragile, photosensitive skin that develops vesicles and bullae with trauma or sun exposure photosensitvity is due to accumulation of porphyinogens that react with Oxygen on excitation by UV light healed lesions typically *scar* and can form both hypo- and hyper-pigemnted areas increased plasma and urine porphyrins *elevated plasma or urine porphyin levels* tx = serial phlebotomy or hydroxychlorouqine along with management of underlying cause (eg, HCV) *diagnosis of hepatitis C* 2 step process since 50% clear the virus requires both: 1. positive serologic test for HCV antibody 2. confirmatory molecular test for circulating HCV-RNA

management of gallstones / postcholecystectomy syndrome

*postcholecystectomy syndrome* PCS refers to persistent abdominal pain or dyspepsia that occurs either postop (early) or months to years (late) after a cholecystercomy PCS can be due to *biliary* (eg, retained common bile duct or cystic duct stone, biliary dyskinesia) or *extra-biliary* (pancreatitis, peptic ulcer disease, coronary artery dsiease) Labs = elevated alk phos, midly abnormal LFT's, dilated common bile duct on abdominal u/s next step = endoscopic ultrasound, ERCP or MRCP for final diagnosis and guinding therapy

adverse effects of drug regmiens for pneumocystis pneumonia

*preferred regimen* TMP/SMX - rash, neutropenia, hyperkalemia, elevated LFT's *alternate regimens* pentamide - nephrotoxic, hypotension, hypoglycemia, cardiac arrhyhtmias, panreatitis, elevated LFT's atovaquone - GI distress, rash TMP + dapson - hemolytic anemia in G6PD clindamycin + primaquine - methoglobinemia, hemolytic anemia in G6PD

theca lutein cysts

*presentation*: multilocular, bilateral, 10-15cm ovaries *pathogensesis: ovarian hyperstimulation gestational trophoblastic disease multifetal gestation infertiliy treatment *resolve with decreasing b-hcg levels* u/s = multiseptated bilateral cystic masses do *not* present outside of pregnancy

mechanical prosthetic valve thrombosis (aortic & mitral valve)

*prevention* aspirin 75-100 mg/d mitral INR: 2.5-3.5 aortic INR: 2.0-3.0 inadequate anticoagulation is stongest risk factor for PVT PVT causes valvular obstruction and has clinical manifestations similar to mitral stenosis *clinical* inadeqaute anticaogulation mitral valve risk > aortic valve risk obstructive thrombus mimics valvualr stenosis heart failure, cardiogenic shock systemic thromboembolic events (eg stoke) *diagnosis and treatment* echocardiogram visualizes thrombus anticoagulation (eg, heparin) fibrinolytic therapy (avoidid if possible) immediate surgery for severe heart failure or large thrombus

common causes of hypogonadism in men

*primary* congenital: klinefelter, crpytochidism drugs: alkalyting agents, ketoconazole orchitis, trauma, torsion chronic kindey disease *secondary* gonadotroph damage: tumor, cranial trauma, infiltrative dz (eg, hemochromatosis), apoplexy gonadotropin suppression: exogenous androgens, hyperprolactinemia, diabetes mellitus, morbid obestiy *combined primary and secondary* hypercortolism cirrhosis

cryptosporidium

*protozoan* spread through drinking water, animal contact, person-person contact common cause of diarrhea woldwide oocytes release sporozites that penetrate intestinal epithelial cells, resulting in altered villous architecture most develop, *profuse watery diarrhea* self limited in immunocompetent, but cause severe chronic infeciton in AIDS (CD4<180) stool exam = *modified acid fast stain* - cryptosporidal *oocytes* tx = supportive and HAART spontanous resolution in 10-14d in those with immunocompetence

causes of delirium

*psychotic disorder due to a medical condition* the patient's history, exam or labs results must provide evidence that psychosis is a *direct* pathophysiological consequence of a medical condition (eg, hallucinations due to brain tumor)

temporality of different study designs

*relative risk is used in cohort studies*

approach to adult cardiac arrest

*reversible causes of asystole/PEA* 5Hs, 5Ts hypovolemia hypoxia hydrogen ions (acidosis) hypokalemia or hyperkelmia hypothermia tension pneumo tamponade toxins - narcotics, benzos thrombosis - pulm or coroanry trauma

felty syndrome

*rheuamtoid arthritis* severe erosive joint disease and deformity rheumatoid nodules vasculitis (mononeuritis multiplex, necrotizing skin lesions) *neutropenia* (ANC<1500) *splenomegaly* *diagnosis* anti-CCP and RF positive in >90% markedly elevated ESR (>85mm/hr) peripheral smear and bone marrow biopsy to rule out other cuases of neutropenia

endometrial hyperplasia/cancer

*risk factors - excess estrogen* obesity [conversion of andorgens into estradiol in adipose cells] chronic anovulation/pcos nulliparity early menarche, late menopause tamoxifen use *clinical* heavy, prolonged, intermenstrual and/or postmenopausal bleeding *evaluation* endometrial biopsy = gold standard pelvic u/s = postmenopausal women *treatment* hyperplasia = progestin therapy or hysterectomy cancer = hysterectomy

cerebral palsy

*risk factors* *PREMATURITY* [spastic diplegia is most common in pretern - hypertonia in lower extremities] IUGR intrauterine infection antepartum hemorrhage placental pathology multiple gestation maternal alcohol consumption maternal tobacco use *acute intrapartum hypoxia is responsible for MINORITY of cases* *management* physical, occupational and speech therapies baclofen and botulinum toxin for spasticity *comorbidities* intellectual disability epilepsy strabismus scoliosis

initial tx for septic arthritis

*risk factors* abnormal joint: OA, RA, prosthetic joint, gout age >80 diabetes IVDU, alcoholism intra-articualr glucocrtcoid injetions *clinical* acute monoarthrtis: hot, swollen, decraesed ROM fever elevated ESR, CRp *diagnosis* blood cultures synoviral fluid: leukocytosis >50k, gram stain, culture *treatment* gram positive cocci: vancomycin gram negative rod: 3rd gen cephalosporin negative microscopy: vancomysin(+3rd gen cephalopsorin if immunocomrpomised)

developmental dysplasia of the hip

*risk factors* breech positioning positive family hx excessive tight swaddling *clinically* Positive ortolani test disclocated hip limited hip abduction limb length discrepancy asymmetric gluteal/inguinal/thigh creases *management* Age <4m = hip ulstraound Age >4m: hip radiograph red flags --> refer to orthopedic surgery confirmed DDH = Pavlik harness - spint holds hip in flexion and abduction while preventing extension and adduction

infective endocarditis

*risk factors* congenital heart disease or prosthetic valve previous endocarditis intravascular cathters IV drug use *PE* new regurgitant murmur skin - janeway lesions, osler nodes roth spots (eyes), splinter hemorrhages (nails) splenomegaly wide-reaching septic emboli *diagnositc* hematuria/protienuria - immune complex mediated glomerulonephritis positive blood cultures TEE >TTE for detecting vegeation *positive rheumatoid factor* - antibody production *treatment* acute - vancomycin [empiric] subacute - bsaed on cultures

orbital cellulitis

*risk factors* local infection - sinusitis, dental infeciton, skin infection orbital trauma *clinically* painful eye movement, opthalmoplegia proptosis visual changes *diagnosis* clinical CT is uncertain *treatment* IV abx surgical drainage if abscess

placenta previa

*risk factors* prior placenta previa prior C-section multiple gestation *clinical* - painless vaginal bleeding >20 weeks gestation *diagnosis* - transabdominal followed by transvaginal sonogram FHR tracing is usually *unaffected* *management* no intercourse no digital cervical exam inpatient admission for bleeding episodes Cesaren delviery is shceduled for *36-37* weeks gesattion c-seciton is done at 36-37 weeks to avoid complications associated with sponteanous birth (hemorrhage!!!)

preterm labor risk factors, screening/prevention

*risk factors* prior spontaneous preterm delivery [most important risk factor] multiple gestation short cervical length cervical surgery (eg, cold knife conization): cervical scarring and loss of cervical stroma cigarette use *screening and prevention* cervical length measured by TVUS [done in 2nd trimester - <2cm w/o hx or <2.5 w/ hx = short] progesterone administration: given in thsoe with hx of preterm birth; decreases recurrence cerclage placement

intra-amniotic infection (chorioamnionitis)

*risk factors* prolonged rupture of membranes (>18h) prolonged labor internal fetal/uterine monitoring devices repetive vaginal exams presence of genital tract pathogens patients with IAI usually have nausea, vomiting and uterine fundal tenderness *diagnosis* maternal fever PLUS >1: -fetal tachycardia: >160/m -maternal leukocytosis -purlent amniotic fluid -maternal tachycardia: >100/m -uterine funal tednerness *management* broad spectrum antibiotics: ampicillin, gentamicin, clindamycin delivery antipyretics + IVF --> dec maternal fever --> improves fetal tachycardia *complications* maternal: postpartum hemorrahge, endometritis neonatal: preterm birth, pneumonia, encephalopathy

congenital toxoplasmosis

*risk factors* raw or undercooked meat unwashed fruits/vegetabes cat feces *clinical* macrocephaly chorioretinitis hydrocephalus *diffuse* intracrnial calcfications nonspecific - jaundice, growth restiction, HSM, blueberry muffin spots *diagnosis*: serology *treatment*: pyrimethamine, suladizine, folate

intussusception / target sign

*risk factors* recent viral illness or rotavirus vaccination [75% occur at age <2 following viral illness and hve no lead point] - illness is thought to cause hypertrophy of *peyer patches* in the lymphoid-rich terminal ileum, serving as a nidus for telescoping *pathologic lead point* congenital malformation of intesintes (eg, meckel diverticulum) henoch-schonlein purpura celiac diseae intestinal tumor polyps *clinical* severe, intermittent abdominal pain - episodic inconsoable crying (lying with legs drawn to abdomen) followed by periods of normal activity currant jelly stools sausage shaped mass lethargy, AMS workup = abdominal u/s [*target sign] frollowed by diagnostic and theraptuic *air enema* surgery to remove lead point

abdominal aortic aneurysm

*risk factors* smoking - most important modifiable risk factor for growth of AAA *atherosclerosis* Male, >60, white *screening* = screening male active or former smokers aged 65-75 years with a one-time abdominal u/s to evaluate for an AAA *diagnosis = ultrasound* *symptoms* mostly asymptoatmic abdominal, back, flank pain rupture - abdominal distneion and shock when AAA ruptures there is massive *retroperitoneal* hemorrhage causing the back and abdomen pain that can radiate to groin or legs *management* smoking cessation aspirin + statin elective repair for size >5.5cm

otitis externa

*risk factors* water exposure trauma (eg, cotton swab) foreign material (eg, hearing aid, headphones) dermatologic conditions (eg, egzema, contact dermatitis) *micro* pseudomonas aeruginosa staphlococcus aureus *clinically* otalgia, pruritis, discharge, hearing loss pain with auricle manipulation ear canal erythema, edema, debris *treatment* remove debris tropical fluroquinoline +/- topical glucocorticoid

cryptorchidism

*risk fators* prematurity small for gestational age low birth weight (<2.5kg) genetic disorders *clinically* empty, hypoplastic, poorly rugated scrotum or hemiscrotum +/- inguinal fullnness testes that have no descended by age 6 months are unlikely to descend spontaneously and require surgery *treatment* orchipexy before age 1 year *complications* inguinal hernia testicular torsion subfertility [early surgery improves fertility] testicular cancer [risk remains elevated even after orchopexy]

takayasu arteritis

*risk* female asian age 10-40 *symptoms* consititonal: fever, weight loss arterio-occlusive: claudication, ulcers; in the upper extremities arthralgias, myalgias *exam* BP discrepencies pulse deficits arterial bruits *diagnosis* elevated inflammatory markers (eg, ESR, CRP) chest xray: aortic dilation, widenend mediastinum *CT MRI* - wall thickening, narrowing of lumen****** HY *treatment*: systemic glucocorticoids

ABO hemolytic disease

*risk* infants with blood types A or B born to mother with blood type O *clinical* jaundice within 24h of birth anemia increased reticulocytes hyperbilirubinemia positive coombs test *management* serial bilirubin levels, oral hydration and phototherapy for most neonates exchange transfusion for severe anemia/hyperbilirubinemia if dad is blood group AB - child with either be A or B - these ABO incompatbility cases are typically *mild* and only show in 30% of infants - mildly anemic, some get jaudnice which responds to phototherapy

necrotizing enterocolitis

*risk* prematurity very low birth weight (<1.5kg) enteral feeding (formula > breast) *clinically* vital sign instability lethargy feeding inolterance bilious emesis, bloody stools, abdominal distention newborn may be *hypothermic* *xray* pneumatosis intestinalis portal venous gas pneumoperitneum - free air under diaphragm *treatment* bowel rest; parenteral nurition broad spectrum IV abx +/- surgery

ectopic pregnancy

*risk* previous ectopic previous pelvic/tubal surgery PID *clinically* abdominal pain, amenorrhea, vaginal bleeding hypoveolemic shock in rupture ectopic cervical motion, adnexal and/or abdominal tenderness +/- palpable adnexal mass *ruptured* = syncope, hypotension, tachycardia; diffuse abdominal pain, cevical motion tenderness, shoulder pain, urge to defecate *diagnosis* positive hcg pregnancy test combined with *transvaginal* ultrasound transabdominal cannot reliably visualize a gestational sac in early pregnancy *management* stable - methotrexate unstable - surgery

tumor lysis syndrome

*risk*: initation of cytotoxic chemotherapy *severe electrolyte abnomralities* icnreased: potassium, phosphorus, uric acid decreased: calcium [Pi binds and precipitates calcium] *acute kidney injury*: due to uric acid / calcium phosphorus cardiac arrhyhtmias *treatment* continous telemtry aggressive electrolyte monitroing/treatment *prophyalxis* IVF allopurinol or rasburicase

clinical features of subarachnoid hemorrhage

*risks* HTN smoking, heavy alochol use family history sympathomimetic drugs *clinical* most commonly due to rupture saccular aneurysm severe and sudden onset of headache different frmo pervious headache pattern "worst headache of my life" n/v, brief loss of cosnciouss, focal neurologic deficits, or meningismus *diagnosis* noncontrast head CT is 90% sensitive in 2-6h of SAH onset lumbar puncture required to exclude SAD definitive in patients with negative head CT xanthochromia confirms diagnosis (usually >6h frmo SAH onset) cerebeal angiography to identify bleeding source

toxic megacolon

*risks* IBD clostridium difficile infection *diagnosis* systemic toxicity: fever, tachycardia, hypotension bloody diarrhea abdominal distention/peritonitis marked colonic distention on imaging *diagnosis confirmed by*: xray and fever >100.4, P>120, WBC>10,500, anemia *initial testing if suspecting toxic megacolon is abdominal xray*: dilated right or transverse colon (>6cm), possibly air-fluid levels, and thick haustral markings that do not extend across entire lumen do *NOT* do colonscopy -- increased risk of perforation *management* bowel rest, NG suction, antibiotics *corticosteroids if IBD-associated* surgery if unresponsive to medical mangement

squamous cell carcinoma of the skin

*risks* UV, inonizing radiation immunosupression chronic scars / wounds / burn injuries *clinical* scaly plaques / nodules +/- hyperkeratosis, ulceration neurologic signs with perineural invasion *most common malignancy of lip* - 95% on lowerlip vermilion *diagnosis* *BIOPSY* - dysplastic / anaplastic keratinocytes [bx must include deep reticular dermis to assess depth of invasion] pathology: invasive cords of squamous cells with keratin pearls *tx* small, low risk = excision or local destruction high risk or face = Mohs low risk of metastases *marjorlin ulcer* = SCC associated in wound or burn is increased risk of metastases

amniotic fluid embolism

*risks* advanced maternal age gravida >5 (live births or stillbirths) cesarean or instrumental delivery placenta previa or abruption preeclampsia *clinical* cardiogenic shock hypoxemic respiratory failure disseminated intravascular coagulopathy coma, seizure *tx* respiratory, hemodynamic support +/- transfusion

pyelonephritis in pregnancy

*risks* asymptomatic bacteriuria diabetes mellitus age <20 tobacco use *clinically* fever, flank pain, dyspnea, hypoxia [ARDS] preterm labor potenitally in 2nd, 3rd trimesters, elevated progesterone causes urinary stasis and hydronephrosis predisposing to pyelonephritis fetal tachycardia is commonly observed and resolves with tx of the pyelonephritis and maternal defervescence can see infilitrates onn chest xray *pathogens* e coli - most common klebsiella enterobacter group B strep *Complications* preterm labor low birth weight acute respiratory distress syndrome *treatment* IV antibiotics supportive therapy

acute mesenteric ischemia

*risks* athersclerosis (acute on chronic) embolic source (thrombus, vegetations) hypercoaguably disordres *labs* leukocytosis elevated hemoglobin (hemoconcentration) elevated amylase metabolic acidosis (inc. lactate)

pubic symphysis diastasis

*risks* fetal macrosomia multipartiy precitious labor operative vaginal delivery increased levels of progesterone and relaxin increase pelvic mobility and rpomote physiologic widening of pubic symphysis to facilitate delviery however, after a *traumatic deliery*, pateints can develop *pubic symphysis diastesis* *presentation* difficulty ambulating radiating suprapubic pain to back or hips pubic symphysis tenderness intact neurologic exam *diagnosis* clinical point tenderness to palpation over pubic symphysis and can have waddling gait *management*: most recover within 4 weeks postpartum conservative NSAID physical therapy pelvic support

iatrogenic hyponatremia

*risks* hyptonic fluid hydration [eg, 0.45% NS] children, premenopausal women, elderly hypoxia CNS disorders to avoid this = maintence IVF should always be 0.9%NS, dextrose can be added, since it doesnt affect tonicity as surgar is raidly taken up by cells *clinical* headache n/v encephalopathy (eg, mental status changes, seizure) *management* hypertonic (3%) saline serial measurement of electrolytes increase serum sodium 6-8 mEq/L in fisrt 24 hours

placental abruption

*risks* maternal HTN or preeclampsia/eclampsia - *matneral HTN is most common risk factor* abdominal trauma prior placental abruption cocaine and tobacco use *clinical* sudden onset vaginal bleeding abdominal or back pain high frequency, low intesnity contactions hypertonic, tender uterus due to physiologic hypervolemia of pregnancy, a pregnant patient may appear hemodynamcially stable up to 20% of blood volume is lost *diagnosis* clincial u/s (not needed) to r/o placenta previa; may show retroplacental hematoma *treatment* first step = aggressive fluid resuscitation with crystalloids placed in left lateral decubitus to displace uterus off the aortocaval vessels and maximize cardiac output *maternal complications* hypovolemic shock DIC - TF released by deciudal bleeding *fetal complications* hypoxia preterm delivery

diagnosis of carpal tunnel syndrome

*risks* obesity pregnancy diabetes hypothyroidism rheumatoid arthritis *clinical* pain + paresthesias in *median n.* disbutrtion [first 3.5 digits] positive phalen + Tinel test severe disease: weakness of thumb abduction and opposition, atrophy of thenar eminence only way to *confirm* diagnosis is with *nerve conduction studies* - show slowing in median nerve at the wrist *treatment* wrist splnting glucocorticoid injection surgery for severe or refractory symptoms

vesicovaginal fistula

*risks* pelvic surgery pelvic irradiation prlonged labor / childburth trauma genitourinary malignancy *clinical* painless, continous urine leakage from vagina presents within 1 month of inciting event cystitis may be complication *diagnostic* physical exam dye test cystourethroscopy *tx* bladder cath in immediate post op period allows a small fistula to heal otherwise, surgical correction is indicated

uterine rupture

*risks* prior uterine surgery (eg, cesarean delivery, myometomy) induciton of labor/prolonge dlabor congenital uterine anomalies fetal macrosmia *clinical* vaginal bleeding intraabdominal bleeding (hypotnesion, tachycardia) fetal heart decelerations loss of fetal station palpable fetal parts on aboaminal exam loss of intrauterine pressure focal, *intense abdominal pain* prior to rupture that is relieved by the rupture; but resumes shortly after in *diffuse distribution* presenting fetal part may restract - *loss of fetal station* - pathognomonic for rupture suspectived rupture requires emergency laparatomy to confirm diagnosis and expedite dleivery

clostridium difficile colitis in adults

*risks* recent abx hospitilizaiton PPI advanced age *pathogenesis* disruption of intestinal flora --> C difficile overgrowth exotoxins cause mucosal inflammation/injury *clinical* profuse diarrhea fulminant colitis, toxic megacolon *diagnosis* stool PCR *treatment* *initial episode*: oral vanc or fidaxomicin *first recurrnce*: po vanc in prolonged pulse or findamoxicin if vanc was used in inital episode *multiple reccurence*: po vanc followed by rifaxmin; fecal microbiota tranplant *fulminant*: IV metronizole + high dose po vanc; surgical eval *infection control* hand hygeine with soap and water contact isolation sporicidal disinfectants (eg, bleach) exotoxin penetrate colonic epithelial cells, resulting in apopotiss and loss of tight junctiosn

common causes of shoulder pain

*rotator cuff impingement, tendinopathy* PAIN with abduciton, ER subacromial tenderness normal ROM with +impigement tests *rotator cuff tear* similar to tendiopathy *weakness* with ER age >40 surgery best to be performed within 6 weeks of injury *adhesive capsulitis* decreased passve + active ROM more stiffness than pain diagnosis confirmed on exam with >50% reduction in both passve and active ROM *biceps tendinopathy/rupture* anterior shoulder pain pain with lifting, carrying, or overhead reaching weakness less common *glenohumeral osteoarthritis* uncommon, usually caused by trauma gradual onset of anterior or deep shoulder pain decreased active and passive abduction and ER

contraindications to rotavirus vaccine

*rotavirus* is most common cause of gastroenteritis in infants and young children woldwide highly contagious via fecal-oral route fever, vomiting and watery osmotic diarrhea affected chidlren suffer severe dehydration vaccine is typically given at *age 2-6 months* small risk of intussusception with vaccine *side note:va do not give multiple live attenuated vaccines on same day*

apgar score and routine newborn care

*routine care of newborn* 1. airway secretions cleared by shunction 2. dried and warm 3. neonatal gonococcal opthalmia prevention 4. IM vitamin K

bronchiectasis

*s/s* cough with daily mucopurulent sputum produciton rhinosinusitis, dyspnea, hemoptysis crackles, wheezing *patho* infectious insult with impaired clearance *etiologies* obstruction (eg, cancer) rheuamtic (eg, RA, sjogren) toxic inhalation chronic or prior infection (eg, aspergillosis, mycobacteria) immunodeficiency (eg, hypogammaglobulinemia) congenital (eg, CF, A1-AT) *eval* HRCT scan of chest - *needed for dx* immunoglobulin quantification CF testing, sputum culture [bacteria, fungi, mycobacteria] PFT's

estrogen-progestin contraceptives: benefits & risks

*side effects & risks of combination oral contraceptives* breakthrough bleeding breast tenderness, nausea, bloating amenorrhea hypertension [due to increased Angiotensinogen synthesis be estrogen during hepatic first pass metabolism] VTE decreased risk of ovarian & endometrial cancer increased risk of cervical cancer liver disorders (eg, hepatic adenoma) increased triglycerides (due to estrogen component)

febrile seizure

*simple febrile seizure* are GENERALIZED, last <15m, do not recur within 24h; minimal postital period require *no further evluation* and can be discharged home with education abotu seizure precuations - they can recur, most are short and do not lead to epilepsy

management of pneumothorax spontaneous vs tension pneumothorax [image]

*small (<2cm) spontaenous* observation and oxygen *large and stable spontatenous* needle spiraiton or chest tube *tension pneumo* urgent needle deocmpression or chest tube placement *anatomy* - 2nd ICS MCL [fails in 50%], altenrative site: 5th ICS MAL

granulomatosis with polyangiitis

*small and medium vessel* upper respiratory tract is most common site of disease involvement lower respiratoryt ract - can have tracheal narrowing w/ ulceration; cxxr showing lung nodules with cavitation anemia of chronic disease renal - elevated creatinine, necrotizing,crescenteric, pauci-immune glomerulonephritis

treatment of morning hyperglycemia

*somogyi effect* - low at night, high in morning reactive hyperglycemia to hypoglycemia from too much NPH insulin at night Decrease NPH insulin in evening *dawn phenomenon* - normal at night, hyper in morning normal release of counterregulatory hormones; not enough insulin to maintaine euglycemia Increase NPH insulin in evening

lyme disease by stage

*spirochete - borrelia burgdorferi; carred by ixodes capularis *early: days-1month* erythema migrans [*pathognomic for lymes; only manifestation that allows for diagnosis without lab confrimation*] systemic: malaise, fatigue, arthalgia regional lymphadenopathy *early disseminated: weeks-months* multiple erythema mirgrans unilateral/bilateral CN palsy (eg, CNVII) meningitis carditis: AV block migratory arthalgias *Late: months - years* arthritis encephalitis peripheral neuropathy *Diagnosis* clinical : if erythema migrans is present B burgdorferi serology (if neurologic/cardiac disease) - ELISA and western blot testing serology is usually positive within 1-2 weeks after onset of EM *treatment* oral antibotics (doxy) - skin/mild disease IV antibiotics (ceftriaxone) - neurologic/cardiac dsiease oral amoxicllin: <8 y/o, pregnant women

vaginal cancer

*squamous cell* age >60 risks: HPV16, HPV18, hx of cervical dysplasia, cigarette use location: upper 1/3 of posterior vaginal wall *clear cell adenocarcinoma* age <20 risks: in utero exposure to DES location: upper 1/3 of anterior vaginal wall *clinical features of vaginal cancer* malodorous vaginal dsichrage postmenopausal or postcoital vaginal bleeding irregular mass, plaque or ulcer on vagina

most common type of urinary incontinence during pregnacny

*stress urianry incontinence* - involuntary leakage of urine with increased intra-abdominal pressure risks - multiparity, obestiy due to decreased pelvic floor muscle and urethral sphincter strength, as well as increased bladder pressure from fetal prseenting part and weight of gravid uterus

infant hydrocephalus

*symptoms* poor feeding irritability decreased activity vomiting *physical exam findings* tense and bulging fontanelle prominent scalp veins widely spaced cranial sutures rapidly icnreasing head circumference *CT of brain* is intiial choice for acutely symptomatic patient *MRI* is best for stable, asymptomatic patient

acute scrotal pain

*testicular torsion* severe pain involving entire testis profound testicular swelling high riding testis cremasteric reflex absent *epididymitis* urianry frequency/urgency induraiton, swelling and tenderness of epididmyis pyuira, bacteriuria Most common cause = *Chlamydia* [if <35], *ecoli* [if >35] *fournier gangrene* severe painf rom anterior abdomen into scrotum and penis skin edema, crepitus, blisters/bullae urgent surgical evaluation required

hereditary thrombophilias

*testing is recommended in:* young (<45 y/o) with unprovoked DVT/PE pt with recurrent DVT/PE unusual site of thrombi (cerebral, mesentery, portal veins) *factor V leidein* high in caucasians FV cannot respond to activated protein C, leading to continued thrombin formation PT, PTT are often normal

tetralogy of fallot

*tetralogy* VSD overriding aorta RVOT - *determines clinical presentation* RVH cxr = *boot shaped heart* from RV hypertrophy moderate obsturction can cause subtle symptoms during infancy and intead present during childhood with tet spells due to right-to-left shunting during exertion or agitation harsh, systolic ejection murmur over mid to left upper sternal border due to RVOT obstruction squatting reduces symptoms (cyanosis) and increases intesnity of murmur; this is due to increased SVR and decreases R-->L shunting across VSD *TET* spell: agitation, exertion --> increases PVR --> increases R-->L shunt and caues sudden cyanosis

provacative meaneuvers for meniscal tear / MCL

*thessaly test* patient standing on affected leg with knee flexed 20deg internal and external rotation of knee POSITIVE: pain, catching, palpable crepitus *McMurray test* knee held in internal and then external rotation flex and extend knee while palpating knee joint POSITIVE: pain, audible or palapble click *MCL tear = valgus stress test* uncomplicated MCL tear = RICE complicated MCL tear = MRI + surgery

beriberi

*thiamine deficiency* *infantile* ages 2-3 months fluminant cardiac sydrome - cardiomegaly, tachycardia, cyanosis, dyspnea, vomiting *dry beriberi* symmetrical periphearl neruopathy accompanied by sensory and motor impiarments espeically prominent in distal extremities *wet beriberi* neropathy + cardiac involvement (cardiomegaly, cardiomyopathy, CHF, periphearl edema, tachycardia)

causes of hematuria

*throughout urianry stream* renal mass glomerulonephritis urolithiasis PKD pyelonephritis urothelial cancer trauma *terminal hematuria* urothelial cancer cystitis (infecitous / post radiation) urolithiasis BPH prostate cancer *initial hematuria* urethritis trauma (eg, cath)

glaucoma medications

*trabecular outflow* muscarinic agaonists *uveoscleral outflow* prostaglandin agonists *aquous humor inflow* beta blockers alpha2 AR agonists CAI's

cyanotic heart disease in newborns

*transposition of the great vessels* single S2 +/- VSD murmur egg on string heart - narrow mediastinum *tetralogy of fallot* hrash pulmonary stenosis murmur, VSD murmur boot shaped heart (RV hypetrophy) *tricuspid atresia* single S2, VSD murmur minimal pulmonary blood floow *truncus arteriosus* single S2, systolic ejection murmur (increased flow through truncal valve) increased pulmonary blood flow, edema *TAPVR* severe cyanosis, respiratory distress pulmoanry edema, 'snowman' sign (enalrged surpracardiac veins and SVC)

oppositional defiant disorder

*treatment* parent management training psychotherapy: anger managemnet, social skills training no pharmacotherapy for ODD but assess for comorbid ADHD and treat if present

neonatal thyrotoxicosis

*treatment* self resolving methimazole + b-blcoker persistent increased thyroid hormone can cause growth resitrction, developmental/behvaioral problems levothyroxine does *NOT* cross placenta maternal thyroid hormone does *NOT* cross placenta it is the *antibodies* that cross the placenta

chemotherapy-induced cardiotoxicity

*type 1*: anthracyclines [doxorubicin, daunorubcin, epirubicin, idarubcin] myocyte necrosis and destruction - *fibrosis* progression to overt clinical heart failure less likely to be reversible *type 2*: trastuzumab myocardial stunning/hibernation without myocyte destruction *asymptomatic* LV systolic dsfunction more likely to be reversible

neural tube defects

*types* anencephaly encephalocele spina bifida, myelomeningocele *risk factors* low folic acid intake methotreaxate, antiepileptics diabetes mellitus prior pregnancy with NTD *prenatal screening* 2nd trimester u/s maternal serum afp *prevention* average risk: 0.4mg folic acid high risk: 4mg folic acid

imaging modalities used in suspected kidney stone

*ultrasound* provides good imaging of kidney and proximal ureter low radiation preferred when low likelihood of alternate diagnosis or pregnant pt *non-contrast spiral CT* quick, very sensitve and specific can visualize small or non-calcium stones cannot be used in renal insufficiency or pregnancy

major herniations of the brain

*uncal* supratentorial brain herniates downward and compreses CN3 *central* may press downward resulting AMS or a tear of basila a. causing fatal Duret hemorrhage pt may ahve hyperventilation and Cheyne stokes respirations *cingulate* no well defined s/s, headache *tonsillar* downward cerebellar herniation cerebellar tonsils move through foramen magnum causing compression of medullay causing respiratory and cardiac dysfunction

treatment of primary hyperaldosteronism

*unilateral* preferred = surgery aldosterone antagonists (spironolactone, eplerenone) - poor surgical candidates or patients refusing surgery *bilateral* aldsterone antagonists

echinococcus granulosus (hydatid cyst)

*unilocular* cystic lesion; smaller daughter cysts may be present most hydatid cysts are diagnosed incidentally when patients are being evluated for other probolems (eg, cholelithiasis) these cysts can cause s/s from compression of surrounding tissues *eggshell calcfication* of hepatic cyst on CT is highly suggestive *treamtent* = surgical resection under cover of albendazole

primary nocturnal enuresis

*urianry incontinence age>5* *management* UA to r/o secondary causes lifestyle changes - minimize fluid before bedtime, avoid sugary/caffeinated beverages, void before bed, reward system enuresis alarm desmopressin therapy - ADH analogue [relapse rates are high]

young pt + URI + heart failure s/s

*viral myocarditis* relatively young adult (<60y/o) viral prodrome: fever, malaise, myalgias heart failure: dyspnea, orthopnea, edema chest pain sudden death *diagnosis* ECG: nonspecific diagnosis made by echo: dilated ventricles with diffuse hypokinesia and low ejection fraction cardiac MRI: late enhancement of epicardium biopsy = lymphocytic infiltration, viral DNA or RNA tx is supportive meds: diuretics, ACE inhibitor, beta blocker temporary ventricular assist device if needed heart transplant if no recovery

indications for renal & bladder ultrasound

*voiding cystourethrogram* if hydronephrosis or scarring is seen in renal u/s newborns <1 month children <2 years with recurrent UTI or first UTI from organism other than E coli

acute lymphoblastic leukemia

predominant type of leuekmia in children from ages 2-10 years patienst with down syndrome are at increased risk about 30-50% present with infections, and about 50% with lymphadenopathy and splenomegaly *clinical* nonspecfic b=systemic symptoms bone pain LAD, HSM pallor (anemia) petechiae (thrombocytoepnia) lymphoblasts are seen on peripheral smear carying degrees of anemia, neutropenia, and thrombocytopenia are seen *>25% lymphoblats in bone marrow is diagnostic* lymphoblasts lack peroxidase positive granules but often has PAS positive materanl immunostaining for TdT is positive in >95% of patients [TdT is expressed only by pre B and pre T lymphoblasts]

medical therapy for benign prostatic hyperplasia

preferred inital tx = alpha 1 blocker (eg, terazosin, tamsulosin) b/c they provide rapid relief symptoms 5a-reductase inhibitors (eg, finasteride) can be used in addition to alpha blockers or as an alternative for thsoe who cant tolerate alpha blockers (eg, hypotension) -much slower onset of action

body dysmorphic disorder

preoccuptaion with >1 perceived physical defects defects are nto observable or apepar slight to others repetitive behavior or mental acts performed in response to the preoccupation signficant distress or impairment specific insight: good, poor, absent/delusional beliefs *management* antidepressants - SSRI CBT patients with BDD *rarely* respond to reassrurance; you *must treat*

positive nitrates on UA

presence of enterobacteriaceae

empyema

presence of rank pus or bacteria in pleural sapce presents with acute sx (fever, pleuritic pain), and pleural fluid shows prominent neutrophilic leukocytosis (>50K)

simple renal cyst

present in about 30% of population and have no clinical signficance simple cyst = uniform, w/o wall thicekning, septations or calcfication features that suggest malignacy: size >3cm, irregular thick septations [hypoechoic], calcfication, and invasion if clearly simple cyst on u/s = no follow up necessary, watchful waiting is appropriate any hint of malignancy, u/s or CT follow in 6 months to look for interval change if clearly malignacy --> nephrectomy or radiofreqeuncy ablation

histoplasma capsulatum

most common endemic mycosis in US - exposure is Midwest (Ohio, Mississippi river valleys) proliferates in soil with *bird/bat droppings* - chicken coops, farm buildings, bird roosts, caves symptoms present 2-4w after expousre: subacute fever, chills, malaise, HA, mylagias, dry cough cxr = *hilar lymphadenopathy* with focal *reticulnodular*, or miliary ifniltrates *symptoms of disseminated disease* fevres, chills, malaise weight loss, cachexia pulmoanry - cough, dyspnea mucocutenous lesions (papules, nodules) reticuloendothelial (HSM, LAD) *labs of disseminated* panctopenia inreased LFT increased LDH and ferritin dx = *histoplasma antigen testing* of urine or blood + serology tissue dx = granulmoas with narrow based buddying yeats caseating granulomas are most common; but non-caseating granulomas can be seen most resolve w/o intervention; some require po intraconazole or even IV amphetercin B *disseminated tx* = Amphotericin B for 1-2 weeks, followed by po itraconazole for 1 year can resemble sarcoidosis (hilar adenopathy, erythema nodosum, non-caseating granulomas) but will not respond to steroids

adenoid hypertrophy

most common etiology of persistent nasal obstruction during childhood affected pts have nasal conngestion refractory to medical management hx may suggest chronic upper airway obstruction (eg, recurrent sinus and ear infeciton, mouth breathing, sleep disturbances, snoring due to apnea) adenoids are not easily accessible and *not* visaulized during physical exam mucopurulent nasal discharge, postnasal drip and elongated/flattned facial features (due to changes in structure of palate, jaw and teeth) may suggest diagnosis

analgesic nephropathy

most common form of drug-induced chronci renal failure seen in females who habitually use combined analgesics (eg, aspirin and naproxem) generally seen after cumulative ingestion of 2-3kg of the index drug *papillry necrosis* and *chronic tubulointerstitial nephritis* are the most cmomon pathologies seen polyuria and sterile pyruia (WBC casts) are early manifestations microscopic hematuria + renal colic occur following sloughing of renal papilla HTN, mild proteinuria, impaired urianry concentration occur as disease advnaces severe cases = nephrotic proteinuria other complications of chronic analgesia abuse = premature aging, atherosclerotic vascular disease, urinary tract cacner

AV malformations of brain

present in adults with hemorrhage, seizure, HA or focual neurolgic signs characteristic dark flow voids and little surrounding edema on MRI present in presons age 10-40

zenker diverticulum

most common in elderly men posterior lower cervical esophagus near cricopharnygeus muscle ZD velops immediately above esophgeal sphincter with posterior herniation between fibers of cricopharyngeal uscle *clinical* usually age >60, male dysphagia halitosis variable neck mass *complciations* tracheal compression ucleration w/ bleeding regurigation aspiration Dx = contrast esophagram, esophageal manometry tx = surgery, circopharyngeal myometry

diaphragmatic hernia

presents after blunt abdominal trauma with mild respiratory distress and abnormal cxr consitent with diaphragmatic hernia blunt trauma --> sudden increase in intraabdominal pressure that overcomes strength of diaphragm and leads to large radial tears in muscle intabaodminal contents compress lungs and mediastinal deviation more common on left acute - respiratory ditress elevaution of hemidiaphragm on chest xray may be only abdomnal finding mortality rate of undiagosed injury and subseuqnet strangulation of bowel can be 30-70% depending on extent of assocaited injuries most reuire surgical repair and exploration of abdomen for other traumtic injruies

management of diabetic gastropersis

presents with anorexia, n/v, early satiety, postprandial fullness hypoglycemic episodes can occur if insulin is given after meals and there is delayed gastric emptying *treatment* optimizing diabetes control small freqent meals increased fiber intake metoclopramide erythromycin (IV for acute exaerbations)

digoxin toxicity

presents with n/v, decreased appetite, confusion, weakness visual symptoms = scotomata, blurry vision with cahnges in color, blindness digoxin is cleared by the kidneys; inciting events (illness, diuretics) can cause volume depletion or renal injury that acutely elevates digoxin level hypokalemia increases suceptibility to toxic effects of digoxin *mechanism of action of digoxin* inhibits ATP-ase dependent sodium-potassium pump and increases intracellular sodium reduces sodium-calcium exchanger activity, resulting in an increase in intracellular calcium enhanced vagal tone and slows conduction through AV node

ventricular aneurysm post MI

5d-3m post MI conists of thin and scarred or fibrotic myocardium in remodeled areas VAs present with ECG findings of *persistent STsegment elevation after a recent MI* and *deep Q waves in same leads* large VA's can lead to progressive LV enalrgement, causing herat failure, refractory angina, ventricular arrhytmias, mural trhombus with embolization, or mitral annular dialtion with MR diagnosis is confirmed with *echo* - thinned, dyskinetic LV prtoin in area of prior MI

clinical features of ADHD

6 months of symptoms inattentive s/s - difficulty focusing, distractible, doesnt listen or follow instructions, disorganized, forgetful, lsoes/misplaces objects hyperactive s/s - fidgety, unable to sit still, hypertalkative, interrupts, blurts out answers symptoms before age 12 symptoms in 2 settings *treatment* stimulants (eg, methylphenidate): can cause appetite loss, weight loss, insomnia nonstimulant options - *atomextine* (non addictive) - best used in adults other options: bupropion, TCA's a2 agonists: clonidine, guanfacine - used in ADHD in childrne; no efficacy in adults

malignant melanoma

most common in skin; but can occur wherever there are pigmented cells, such as the eye and GI mucosa in a patient with multiple pigmented lesions, a lesion with appearance that is substantially different from the others (eg, dark brown rather than light brown, nodule rather than falt) may represent melnoma (*ugly duckling sign*) melanomas frequently arise in preexistent dysplastic nevi *vertical growth [breslow depth]* increses metastatic risk; distance from epidermal granular cell layer to deepest visible melanoma cells *excision biopsy* with margins of 1-3mm should be done if melanoma is suspected *gross features that suggest melnoma rather than benign melanocytic nevus* - ABCDE asymmetric shape border - irregular, jagged color: brown, black, red, blue, unpigmented diameter: >6mm evolution in size and appearance over time

minimal change disease

most common nephrotic syndrome in children T cell mediate dinjury to podocytes causes increased permability to albumin most casesa are *idiopathic* *clinical* - edema, fatigue; NO hematuria *diagnosis* - proteinuria, hypoalbuminemia, renal bx *without microscopic changes* prednisone should be started prior to biopsy to see if clinical response occurs as bx is invasive *treatment - corticosteroids*

pressure ulcers

most common over bony prominences: sacrum, ischial tuberosities, malleoli, heels, 1st or 5th metatarsal head constant, unrelieveed pressure causes necrosis of overlying skin and muscle as blood flow to soft tissues is impeded risk factors - impaired mobility, malnutirion, AMS, decresed skin perfusion, reduced sensation tx - reposintoing, pain control nurtional support shallow = semipermable dressing full thickness = debridement, compelex dressing

steven johnson syndrome & toxic epidermal necrolysis

<10% BSA: SJS; >30%: TEN *clinically* 4-28d after exposure to trigger acute infleunza like prodrome rapid onset eryheamtous macules, vesicles, bullae necrosis and sloughing of epidermis mucosal involement *drug tirggers* alloupruniol abx - sulfonamides anticonvulsnats - carbamazepine, lamotrigine, phenytoin NSAIDs - piroxicam sulfasalzine *other triggers* mycoplasma pnuemoniae vaccinatino GvH disease *treatment* supporive - wound care, aggressive fluids

acetaminophen intoxication

<4h = activated charcol Rumack-Mathew nomogram provides likelihood of hepatotoxic effects based on plasma acetaminophen level and hours since ingestion This tool guides use of *NAC* First data point is at 4hours if suspected pt has toxic levels, even before 4 hours - obtain a serum level

diagnosis of RV-MI

>1mm ST segment elevaiton in right sided leads V4-V6 RV failure leads to decreased preload and resulstant hypotnesion in addition to stardard MI therapy, give ptient boluses of IVF to improve RN preload and facilitate LV filling

urine sodium in renal tubular necrosis

>20 mEq/L

risk of myoglobin-induced renal failure occurs when CPK concentration is...

>20,000 units/L causes acute tubular necrosis from excessive filtered myoglobin mannitol and urine alkalinization may be helpful

how many words should a 2 year old know?

>50 words 2 word phrases unstead half of childs speech folloding 2 step commands run, throw ball overhand, kick a ball copy a straight line engage in parallel play

clinical manifestations of foreign body aspiration

>50% of aspirated FB's end up in right mainstem bronchus standard of care for both dx and tx is immediate bronchoscopy

osteosarcoma

most common primary bone tumor afftecting childrena nd young adults in children - metaphyses of long bones (femur, tibia, humerus) constittional symptoms are suaully absent On pe - most important: *tender soft tissue mass* *METAPHYSES* xray = spiculated 'sunburst' pattern and periosteal elevation (Codman triangle) Alk phos and LDH are elvated from turnover of damaged osteocytes tx = tumor excision, chemo

familial hypercholesterolemia (hyperlioproteinemia type IIA)

most common type of familial hyperlipoprotienemia deficiency in LDL receptor defective apoB100 this causes very high LLDL levels and development of cardiovascular disease Plasma TG, HDL, VLDL levels are normal xanthelasma palpberarum is most common of xanthomas and typically appears in hpyperlpiedemia tendon xanthomas are common as well *hyperlipoproteinemia type V* - defect in apoCII elevated chlyomicrons, VLDL and *Triglycerides* - increased pncreatitis

leydig cell tumor

most common type of testicular sex cord stromal tumor can occur in all age groups, including young children leydig cells are principal source of testosterone; can produce estrogen due to icnreased aromatase expression estrogen production is increased in tumor growths with secondary inhibitor of LH, FSh most common endocrine manifesattion = gynecomastia [adults], precocious puberty [children]

scaphoid fracture

most commonly fractured fractured carpal bone pain at radial wrist proximal to base of the thumb tenderness in shallow depression at dorsoradial wrist bounded medially by tendon of EPL and laterally bt tendons of ABL and EPL - *anatomic snuffbox* signifcant risk for *osteonecrosis* becsuee blood supply enters at distal pole and flows proximally, and can be disrupted by fracture [blood supply = radial a.] inital xray can be normal if nondisplcaed repeat xray in 7-10d nondisplaced = wrist immbolization cast; serial xray [in 7-10d] to rule out osteonecrosis dispalced = surgical internvetion

what kind of diagnosis is acute appendicitis appendicial abscess

CLINICAL - if pt has classic presentation do *not* do imaging --> go straight for lap appy CT and u/s are useful in patients with nonclassic symptoms, equivocal findings on itial aseessment, or delayed presntation *appendicial asbcess* delayed presentation (>5d of symptoms) - appendceal rupture within a contained abscess significicant fever and leukocytosis benign abdomen on palpation; maneuvers that ssess deep abdominal spaces (eg, psoas sign, obturator sign, rectal exam) may be more informative CT will confirm diagnosis in this case if stable, manage with IV abx, bowel rest, percutenous drainage; return in 6-8w for eletive appendectomy

clinical features of corneal abrasian

CN-V1 (opthalmic - nasociliary fibers) is responsible for corneal sensation

steppage gait

most commonly from L5 radiculopathy or neuropathy of common peroneal nerve L5 = back pain raidiating to foot, weakness of foot inversion and plantar felxion Peroneal neuropathy = compression of nerve at lateral aspect of fibula [associated with paresthesias and sensory loss over dorsum of floot, normal inversion / planartar flexion] dx can be calrfied with EMG and nerve conduction studies

pathophys of g6pd defiency

G6PD is responsible for catalyzing reduction of NADP to NADPH, the first step in hexose monophosphate shunt this is the only souce of NADPH in RBC - NADPH is needed to form reduced glutathione, which protects RBC from oxidative injury in absence of G6PD and presnce of oxidzing agnets (toxins, sulfa drugs, fava beans), Hemoglobin becomes oxidized to form methmgolobin, denatured globin and sulfhemoglobin these molecuesl form insoluble masses - *heinz bodies* - that attach to RBC membrane, decreasing membrane pliability, and promiting RBC removal in spleen's reticuloendothelial system *labs* hemolysis - low hemoglobin, increased indirect bili, increased LDH, decreased haptoglobin bite cells with heinz bodies on smear negative coombs test G6PD deficiency (may be normal during attack) *management* remove or treat responsibly agent/condition supportive

serological markers for hepatitis B

HBsAg: first marker in serum after inoculation; rpeced clinical s/s and elevation of FLTs Remains elevated during entire symptomatic phase of acute Hepatitis B and suggests infectivity Anti-HBs: appears in serum after either successful HBV vaccination or clearance of HBsAg, and remains detectable for life in most Inidcates non-infectivity and immnuity WIndow period: dissaperance of HBsAg and appearnce of anti-HBs HBcAg: not detectable in serum as normally sequested within HBsAg coat Anti-HBc: IgM apepars after emergence of HBsAg and can be only marker during window period HBeAg: detectable shortly after appearnce of HBsAg and indicates viral replication/infectivity anti-HBe: suggests cessation of active viral replication and ifnectivity

kaposi sarcoma

HHV-8 + HIV occurs when CD4<200 AIDS-defining illness lesions begin as papules, and develop into plaques or nodules color can chagne from light brown to violet, and patients often have multiple lesions dx made clinically, but bx is advised for confirmation KS regresses if underlying HIV is treated with HAART severe/refractory KS may require systemic or itnralesional chemo

release of information clause

HIPPA protects health information by reuqiring *verbal OR written* authorization for release of infromatin hospitals and physicians' offices frequently have additional policies requiring written forms for release of information and porcedures to verify identity of phone callers always, only disclose minium info necessary

clinical features of irritable bowel syndrome

IBS msot commonly presents in young women as chronic, crampy abdominal pain with alternating episodes of constipation and diarrhea clonoscopy performed on IBS pt shows normal colonic mucosa

beckwith-wiedemann syndrome

IGF-like 2 is on 11p15 --> growth promotion screening abominal u/s and AFP should occur every 3 months from birth to age 4 abominal u/s every 3 months from age 4-8 years renal ultraound from age 8 through adolsence

tenderness at lateral knee during flexion and extension

IT band syndrome

intrauterine device levonorgestrel vs copper

IUDs can be placed ast *any* point in cycle; menstruation is not a contraindication *levonorgestrel* 3-5 years mechanism: thickens cervical mucus, impairs implantation benefts: decreased menstrual flow contraindcations: active liver dsiease, brast cancer, acute pelvic infection *copper* 10 years *mechanism: cytotoxic endoemtrail finalmmation, impairs sperm funciton, impairs implantation benefits: nonhormonal, can be used as emergency contraception contradincations: wilson disease, copper allergy, heavy mesntrual bleed, acute pelvic ifnection

duodenal hematoma

most commonly occur after *blunt* trauma seen more in children: thinner abdominal wall, less abdominal walla dipose, more pliable ribs [absorb less force] DH occurs when blunt force rapidly compresses the duodenum against vertebral column blood collects between submucosal and muscular layers of duodenum causing partial or complete obstruction may initally only have symptoms of abdominal wall trauma, which may improve befoere clnical deterioration pt presents 24-36 hours after initial event with epigastric pain and vomiting due to obstruction from hematoma *diagnosis by CT* most resolve in 1-2 weeks mangement = decompression by NG, and in many - parenteral nutrtiion surgery considered if nonoperative mangement fails

neurodermatitis (skin picking disorder)

most commonly seen in chronic mental illness and characterized by repeated scratching and picking at the skin lesions are located in areas easy reach of hands predominantly excoriations and nodules

diabetes medication points to remember

most guidelines recommend adding insulin to metformin in patients with HBA1c>8.5%

despite advances in therapy, overall survival rate for patients with sudden cardiac arrest remains poor

most important factors in patient survivalre arre: prompt effective resuscitation with adequate bystandaer CPR prompt rhytmn analysis debfribillation in patients found to be in shockable rhytmn

preconception counseling and hemoglobinopathies

most important inital test = CBC if patient is of AFrican descent, a Hb electropheresis is usually obtained along with inital CBC test the partner, if the patient's hemoglobin is abnormal

HIV management during pregnancy

most important interventino for preventing spread of HIV from mother to child is *combination antriretroviral therapy* to mother throughout pregnancy antenatal combo therapy is best way to suppress materanl HIV and prevent tarnsplacnetal or perinatal acquistion *zidovudine* should be administered to neonate for >6 weeks

clinical features of wallenberg syndrome

most likely due to occluded intracranial vertebral a. or posterior inferior cerebellar a. vestibulocerebellar findings are almost always present and include nystagmus, vertigo w/ falling to side of lesion, difficulty sitting upright w/o support ipsilateral face, contralateral trunk/limbs sensory loss ipsilater bulbar weakness (nucleus ambiguues) ipsilatearl horners (autonomic dysfunction) motor function and face and body is *spared* dx = MRI

treatment overview of suspected cyanide poisoning

smoke fire --> cyanide + CO [two major products of combustion] prolonged infusions or high doses of nitroprusside + renal insufficiency --> cyanide toxicity must treat before definitive diagnosis as HCN is fast acting cyanide inhibits cyt-oxidateA3 in ETC --> prevents oxidative phosphorylation --> *lactic acidosis* --> hyperventilation --> low PaCO2 early toxicity - neurologic and cardiorespiratory stimulation --> headache, vertigo, dizziness, hypernveitlation, tachycardia n/v hyperreflexia (due to thiocyanate accumulation) cardiovascular (arrhyhtmias) tachypnea followed by respiratory depression skin = flushing later - neurologic, respiratory, CV depression --> coma, seizures, bradycardia, hypotnesion, cardio arrest HCN can cause anoxic brain injury --> permanent defects *markedly elevated lactate level [typically >10mEl]* - metabolic acidosis *hydroxycobalamin or sodium thiosfulfate* directly bind cyanide molecules methemoglobinemia with nitrates to increased Fe3+ in ciculating hmeglobin - cyanide binds to this

pseudocyesis

somatization of stress affects HPO axis and causes early pregnancy symptoms, or when bodily changes (eg, weight gain, amenorrhea) are misinterpreted nonsypchotic patient who believes they are pregnany; can be a such strong belief that they interpret negative pregnancy tests as being positive pseudocyesis is a form of somatization and requires psychiatric evlauation and treatment

somatostatinoma

somatostatin secreting tumors of duodenum or delta cells of the pancreas *somatostatinoma syndrome* diabetes mellitus diarrhea/steatorrhea cholelthiasis hypochlorhydria weight loss *diagnosis* - u/s or CT of abdomen *treatment* = surgical resection

sphincter of oddi dysfunction

sphincter of Oddi is muscular valve controlling the flow of bile and pancreatic juice into the duodenum can develop following any inflammatory process (eg, surgery, pancreatitis), encompasses 2 separate phsyiologic entites: *dyskinesia* and *stenosis* of the sphincter of oddi obstruction of flow may result in retention of bile, causing *functional biliary disorder* that mimics a structural lesion recurrent *episodic pain* in the RUQ or epigastric region, with correspond LFT and alk phos elevation visalizaiton of *dilated CBD is absence of stones* increases likelihood opioid (eg, morphine) may cause sphincter contraction and precipitate symptoms fo SOD sphincter of oddi *manometry* is gold standard sphincterectomy is tx of choice in most

once Guillian Barre Syndrome is suspected in hemodynamically stable patient, what is next step?

spirometry - assess pulmoanry function as respiratory failure is a life-threatening complication FVC and negative inspiratory force monitor respiratory muscle strength serial PFTs should be done given potential of GBS to have rapid respiratory failure FVC <20ml/kg suggests impending failure warranting intubation; other indicators: severe distress, severe dysautonomia, widened pulse pressure

most commonly involved colonic segment in ischemic colitis

splenic felxure - junction of SMA, IMA rectosigmoid junction - simgoid a. and superior rectal a. CT w/ contrast = thickened bowel wall; urgently perofmred to identify ischimic colitis that may need emergent surgery (extensive damage, perforation) if surgery notneeded: give IVF, abx and colonscopy to confirm dx (pale mucosa w/ petechial bleeding, bluish hemorrhaic nodules, cynaotic mucosa w/ hemorrhage)

pituitary apoplexy

spontaenous hemorrhage into pituitary gland and occurs most commonly in patients with pituitary adenoma acute headache visual field defects decreased visual acuity

types of spontaneous abortion

spontaneous abortion are msot commonly result of *Fetal chromosomal abnormalities* bhcg can remain elevated for up to 6 weeks in serum after complete abortion *definition* pregnancy loss <20 weeks *risks* advanced maternal age previous spontaneous abortion substance abuse *treatment options* expectant medical induction (misoprostol) suciton curettage if infection or hemodynamic instability *aditional management* rho-d immune globulin pathology exam *complcations* hemorrhage retained POC sepctic abortion urterine perforation intrauterine adhesions

diminished ovarian reserve

spontaneous pregnancy rates decrease with increasing age sharp decline in conception >35 y/o regular menstrual erpiods still occur due to continuing ovulation, but conception rate decreases due to diminished oocyte quaity *decreased oocyte number and quality*

what lung cancer should be suspected if xray show upper lobe cavitary lesion in a smoker?

squamous cell = 85% of malignant cavitary lung lesions

clinical presentation of pancoast tumors

squamous cell and adenocarcinoma are most common SPS tumors smoking is strongest risk factor

treatment for regular, wide complex tachycardia consistent with monomorphic vtach major side effects of amiodorone

stable = amiodarone unstable = cardioversion pts on amiodarone need to be monitored with periodic thyroid and hepatic function markers

assessment of chest pain in the emergency department

stable patients should receive: O2, IV access, EKG, CXR patient with possible ACS and low risk for aortic dissection should be given aspirin as soon as possible unstble patients: stabilize hemodyanmics, check for cause

staph scaleded skin syndrome

staph aureus exfoliation of skin caused by toxin skin is tender/warm, sand-paper like diffuse eryhteamtous rash bullae, +Nikolsky sign, facial edema, perioral crusting, dehydration children < 6 y/o

foodborne disease causing vomiting

staph aureus bacilis cereus norovirus

evaluation of vertebral osteomyelitis

staph aureus accounrs for 50% of cases back pain, fever, equsitite focal tenderness epidural abscess can result if extension into epidural space causing severe back pain w/ motor and sensory abnormalites IVDU, sickle cell and immunosuppressed at highest risk for osteomyelitis most are chronic (>6w) and insidious with minimal symptoms many have pain unrelieved by rest minimal symptoms; but *tenderness to gentle percussion* over SP of involved vertbrae is important initial workup = CBC, blood cultures, ESR, CRP, plain spinal xray Xray can be normal in first 2-3 weeks of ifnection MRI is modality of choice for patients with suspected vertebral osteomyelitis [can also detect epidural abscess and cord compression] *brodies abscess* - chronic osteomyelitis shown as a central lytic bone defect with surrounding sclerosis

case control study

start by finding cases with certain outcome and controls without the outcome cases and controls assessed retrospectively for presence of risk factors uses *odds ratio*

asthma severity for patients not on controller medication

step 1: SABA prn step 2: ICS step 3: ICS + LABA or medium dose ICD step 4: medium dose CIS + LABA step 5: High dose ICS + LABA step 6: high dose ICS + LABA + po corticosteroid pt whose condition remains well controlled on same therapy for 3 months should be considered for step down in medication

diseases associated with erythema nodosum

streptococcal infection sarcoidosis tuberculosis endemic fungal dsiease inflammatory bowel disease behcet disease *characterization* symmetric, tedner, erythematous subcutenous nodules on anterior lower extremities histo = septal panniculitis elevated ESR tx = resolution of underlying etiologic factor supportive therapties - leg elevaiton, aspirin, NSAID

tinea manuum

superfical fungal infection of hands pruritic, hyperkeratotic patches on palms annular erythematous lesions resembling tinea corporis on dorsum of hands and finger webs most have concrreunt tinea pedis

tinea captius

superfical fungal skin infection of scalp most common in pre-pubertal boys, african-americans infection by dermatophyes: trichophyton, microsporum acquired through direct contact with the fungus *pruritic scalp w/ patchy hair loss* single or multiple scaly patches on scalp alopecia w/ small black dots frmo broken-off hairs cervical lymphadenopathy *kerion* - inflammatory plaque w/ drainage and crusting *favus* - perifollicular erythema progresses to yellow cupping

craniopharyngiomas

suprasellar mass that can create pressure on optic chiasm --> bitemporal hemianopsia pressure on pituatiry can cause a range of endocrinopathies commonly seen in children and adults >50 *key features* low-grade malignancy derived from remnants of rathke pouch optic ciasm compression --> bitemporal hemianopsia pituitary stalk compression --> endocrinopathies suprasellar, calcified mass on imaging

primary tx for papillary thyroid carcinoma

surgical resection histo - ground glass cytoplasm and pale nuclei containing inclusion bodies and central grooving after srugery, adjuvant radio-iodine ablation is warranted for pt with incrased risk of tumor recurrence TSH can stimualte growth of occult residual or metastatic disease for this reason, pt at increased risk of recurrence should receive adeqaute *levothyroxine* to suppress TSH secretion

dystonia

sustained muscle contraction resulting in twisting, repetitive movements or abnormal postures can be focal (affecting one muscle) or diffuse can be congenital, idiopathic, secondary to trauma or local inflammation, or drug indced common meds responsible: typical antipsychotics, metoclopramide, prochlorperazine

pt is 6 weeks pregnant. has had T2DM for 4 years, takes po metofrmin 2x a day. Fasting = 100-115mg/dl. 2hr post prandial = 150-180ml/dl. Next step?

switch pt to insulin therapy for pregnacny for better control over surgars

PMS/PMDD

symptom diary over 2 menstrual cycles should demonstrate recurrence of symptoms during luteal phase (*1-2 weeks prior to menses*) and *resolution during follicular phase* (onset of menses or a few days after) symptoms severtiy must reach point of socioeceonomic impact (eg, missed work) to qualify as PMS or the more severe variant, PMDD SSRI are first line COC can be used because they induce anovulation

UTI in infancy

symptoms are nonspecific and vague abdominal/flank pain and ysuria can be difficult to recognize fever >102.2 in any child age <3y/o should prompt evaluation for occult UTI mid-stream tach can be used for those who do not wear diapers infants and toddlers in diapers need straight cath to obtain a sterile urine

features of septic arthritis in children

synovial fluid showing >100,000WBc, >90% neutrophils and purulent fluid should be considered for emergency surgical drainage debridement and irrigation of joint sapce is most important intervention in preventing long-term disability

misoprostol

synthetic PG causes uterine contractions commonly used in medical management of spotnenous abortions can be used to *prevent* NSAID-induced gastric ulcers

side effects of oral isotretinoin therapy

teratogenic (eg, spontaneous abortion, fetal malformations) hyperlipidemia chelitis dry skin myalgias pseudotumor cerebri Isotretinoin is administered orally to treat severe, recalcitrant nodulocystic acne associated with signifcant scarring that has not responded to other therapies, including systemic antibitoics retinoids inhibit follicular epidermial keratniaiton, thereby loosening the keratin plugs of comedonnes and facilitating their expulsion retinoids also reduce size of sebacous glands and inhibit sebum production absolutely ocntraindicated in pregnancy for female patients, 2 negative pregnant tets (urine or serum) are required prior to intiation, and monthyl pergnancy test required duringn treatment must be abstient or use 2 forms of highly effective contraception

treatment of choice for large or symptomatic transudative effusions and malignant exudative effusion

therapeutic thoracentesis - needle in the midaxillary line between 8th and 10th ICS

immunizations can be given safely during minor illness (eg, URI)

they should be postponed until recovery from moderate or severe illnesses as manfiestations of underlying illness can be incorrectly attribtued to vaccine and vice versa

lichen simplex chronicus

thickened excoriated plaques due to persistent scratching and rubbing assoicated with anxiety disordres occurs in areas that are easy to reach

antibodies in graves disease

thyroid stimulating immunoglobulins

cardiovascular effects of thyrotoxicosis

thyrotoxicosis causes changed via effects of T3 on cardiac myocytes and blood vessels and indirectly by increasing sensitvity to circulating catecholamine increased oxygen demand in thryotoxicosis is due to increased cardiac output and increased systemic oxygen consumption - can lead to anginal symptoms in undlerying coroanry atheroscleoriss

single most effective intervention for slowing progression of diabetic nephropathy

tight BP control: goal BP <140/90 diabetes + elevated serum Cr + proteinuira = diabetic glomerulosclerosis Diabetes is *most common cause of CKD and ESRD* requiring dialysis DN occurs 10-15 years after onset of type 1 and type 2 diabetes hyperglycemia causes microvascular damage (microangiopathy) the advanced glycation end products and other inflammatory mediators damage the glomerulus, resulting in *proteinuria*, over glomerular nephropathy, and ESRD *mild proteinuria (microalbuminuria)* = 30-300mg/d

dermatophyte infeciton ring of erythema and scaling with central clearing

tinea corporis - trichophyton rubrum *risks* athletes who have skin-to-skin contact humid environment contact with infected animals (eg, rodents) *presentation* scaly, erythematous, pruritc patch with centrifugal spread subsequent central clearing with raised annular border *treatment* - continue until lesion is resolved first-line/localized: topical antifungals (eg, clotrimazole, teribinafine) second-line/extensive: oral antifungals (eg, terbinafine, griseofulvin)

clinical features of acute opioid intoxication

titrate naloxone to achieve a RR of >12/min but not to achieve normal mental status

the null hypothesis is the statement of no relationship between the exposure and the outcome

to state the null hypothesis correctly, the study design should be considered

modifiable risk factors for PAC's

tobacco alcohol caffeine stress

first line treatment of genital warts in pregnancy

topical trichloracetic acid causes wart desiccation and eventual regression liquid nitrogen, laser ablation and electrocautery can also be used in pregnacy perinatal transmission may result in juvenile-onset *respiratory papillomatosis*, in which benign warty tumors form on larynx and/or vocal cords, resulting in stridor and chronic hoarseness/cough cesaren delviery is reommended when large condylomata block the introitus or multiple perineal lesions pose a bleeding risk with vaginal birth

mechanism of anthracycline chemo-therapy drugs

topoisomerase II eznyme inhibitors

foodborne botulism

toxins inhibit synpatic acetylcholine release --> constipation, hypotonia, muscle weakness, CN abnormlaities *gold standard dx* = stool assay for C. botulinium toxin

rapid deceleration chest trauma persistent pneumothorax despite chest tube placement and pneumomediastium

trachebronchial perforation secodnary to blunt thoracic trauma right main bronchus most commonly injured in these cases dx confimed with high-resolution CT, bronchoscopy or surgical exploration operative repair indicated *Hamman sign* = audible crepitus on cardiac asucultation

pathophys of normal pressure hydrocephalus

transient increase in intracranial pressure that causes ventricular enlargement as ventricles enlarge, pressure returns to normal initial increase in ventrcular size may be due diminished CSF absorption at arachnoid villi or obstructive hydrocephalus *traid* - abnormal gait, inconteince, dementia no focal signs tx = CSF removal; initally done by serial large volume lumbar punctures; VP shunt can be punt in for refractorysymptoms

treatment of PTSD

trauma focused CBT antidepressants - SSRI, SNRI prazosin for nightmares

79 y/o with fartigue, poor appetite, weight loss. Fourw eeks of cough and SOB. Right sided pleural effusion = 1.5 L of yellow pleural fluid; high lymphocyte count, high protien, low glucose Most likely cause?

tuberculsois exudative effusions characterized by high protien level, lymphocytic leukocytosis, low glucose. latent infection i s common, and reactivation is more likely in elderly patients

CSF: low glucose, elevated protein, lmyphocytic pleoytosis

tuberculsosis meningitis

features of carcinoid syndrome

tumor that scretes - histamine, serotonin, VIP intially they are metbaolized in the liver; patients who have liver metastses will develop carcinoid syndrome

alcohol withdrawal syndrome

tx = lorazepm, dizepman, chlordiazepoxide oxazepmam, lorazepam, temezepam are prefered in liver disease [these lack active metabolites and undergo hepatic metbaolism via phase II glucuronidation instead of phase I] *gamma-glutamyl transpeptidase* is high in alcohol abuse patients DT(48-96h): altered sensorium, agitaiton, tremor, *autonmoic instability* tx = r/o other cases of delirium, e- supplementation, benzo's

indications for surfactant therapy

tx of meconium aspiratin syndrome, respiratory distress due to inhalation of meconium stained amniotic fluid

overview of running injuries of foot & ankle

tx of morton neuron = metatarsal support to decrease pressure on metatarsal head; surgery for refractory treatment

glucose-6-phosphatase deficiency

type 1 glycogen storade disease - Von Gierke disease deficiency G6Pase in liver, kidneys, intesinal muosa results in impaired conversion of glycogen to glucose --> *glycogen accumulation* present at age 3-4 months with hypoglycemia (causing seizures) and lactic acidosis hypuricemia, hyperlipidemia PE: *doll like face* with round cheeks, thin extremities, short stature, protuberant abdomen due to hepatomegaly

thalamic stroke

typically from lacunar stroke - pure sensory strokes stroke in ventral posterolateral (body) and ventral posteromedial (face) transmit sensory information from contralateral side of body and face s/s can be accompanied by transient hemiparesis, athetosis or blassitic movements from disruption of neighobring basal ganglia and CST in posterior limb of internal capsule

how long does it take lactic acidosis following tonic-clonic siezure to resolve

typically within 90 minutes so repeat labs at the 2h mark looking for resoluation

acute diverticulitis

ucomplicated diverticulitis in satble patient can be managed in outpatient setting with bowel rest, oral antibiotics, and observation however, hospitalization and IV abiotics are recommended for patients who are elderly, immunosuprpessed, ahve high fever/signficant leukocytosis, or signficant comorbidities *complicated* refers to diverticulitis associated with *abscess*, perforation, obstruction or fistula fluid collection <3cm can be treatd with IV abx fluid collection >3cm should have *CT guided percutaneous drainage* sigmoid resection is reserved for fistulas, perforation, obstruction, recurrent attacks

approach to hyperbilirubinemia in adults

unconjugated bilirubin --> positive urine urobilinogen assay conjugated bilirubin --> water soluble, excreted in urine; positive urine bilirubin elevated conjugated bili + elevated alk phos --> cholestasis --> get u/s

features of possible child abuse

unexplained or impluasable injuries injuries in different stages of healing malnutrition sudden behavioral or scholastic changes

anticoagulation in renal failure

unfractioned heparin once heparin gets goal PTT>1.5-2x normal; begin wrafrin *renally eliminated options not avaialble* enoxaparin - LMWH fondaparinux - FXa inhibitor [injected] rivaroxaban - FXa inhibitor [po]

pronator drift

upper motor neuron or pyramidal/CST diesease performed by having pt outstretch arms with palms up and eyes closed UMN lesions cause more weakness in supinator muscels compared to pronator muscles of upper limb as a result, affected arm drifts downward and palms turns (pronates) towards floor

initial test in suspecting perforated viscus?

upright xray of chest and abdomen

tophaceous gout

urate crystals may deposit in soft tissues --> forming tophi tophi can ulcerate and drain a chalky material

testing for hpylori w/o alarm symptoms

urea breath testing stool antigen testing

UTI symptoms pH >8 likely cause?

urease proudcing bacterium - Proteus mirablis (most commonly) or Klebsiella pneumonia urease splits urea into ammonia and CO2 ammonia then converts to ammonium and alkalnizes the urine high urine pH reudes solubility of phosphase, raising risk for development of struvite stones (magnesium, ammonium phosphate)

q tip test

urethral hypermobility diagonsed by placing patient in dorsal lithotomy and inserting a ctoon swab in the urethral orifice (qtip test) angle *>30 degrees* from horizontal on increase in intra-abdominal pressure signifies urethral hypermobility

evaluation of blunt genitourianry trauma

urinalysis -if + for hematuria and stable --> contrast enhanced CT -if unstable --> IV pyelography prior to surgical evaluation retrograde cystourethrogram if gross hematuria, difficult urianting, blood at meatus or suprapubic pain (bladder rupture)

how is proteinuria in preeclampsia measured

urine protein/creatinine ratio [>0.3 = proteinuria] or 24h collection for total protein (gold standard) [>300mg]

treatment of *intrahepatic* cholestasis causing pruritis

ursodeoxycholic acid - helps replace hydrophibic bile salts with hydrophilic bile salts

bladder carcinoma

usually a transitional cell carcinoma that recurs after removal *risks*: smoking, radiation, aniline dyes, aromatic amines, diesel exhaust, cyclophosphamide *painless hematuria* frequency, dysuria, urgency are common *diagnosis* = cystoscopy w/ biopsy

physiologic jaundice of newborn

usually benign and resolves on its own by age 1-2 weeks monitor for persistent or worsening jaundice as high levels can cause kernicterus frequent feeding should be encouraged to promote gut colonization and fecal excretion rapidly rising hyperbilirubinemia requires *phototherapy for kernicterus prevention* *exchange tranfusion* is indicated for Tbili >20-25mg/dl *unconjugated hyperbili due to*: 1. high hb turnover [shorter RBC life span] 2. decreased UGT activity [adult levels at 2 weeks] 3. sterile newborn gut cannot break down bilirubin to urobilingen for fecal excreiton --> more bili resorbed in guit and recycled

subconjuctival hemorrhage

usually caused by local trauma or valsalve maneuver (coughing, sneezing, vomiting) well-demarcated patch of extravasated blood beenath the conjuctiva in most cases, the conidtion is from minor burising and does not require any workup at all hemorrhage disappears in 24-48h

liver abscess (description of entamoeba histolytica)

usually entamoeba histolytica (amebic abcess) bacteiral causes can occur in older pt's with medical conditions or following peritonitis hydaits cyst by Echinoccocus (no fever, asymptomatic) - treatment with albdenazole *pyogenic abscess* more common in diabetics or underlying hepatobiliary or pacnreatic disease *risks for e. histolytica* developing nations containminated food/water fecal-oral sexual transmission [rare] *manifestations of e. histolytica* 90% are asymptomatic colitis: diarrhea, bloody stool w/ mucus, abdominal pain liver abscess = RUQ pain, fever; complications - rupture to pleura/peritoneum *diagnosis* stool ova and parasites, stool antigen testing (colitis) E histolytica serolgoy (liver abscess) *serologic testing* confirms diagnosis [stool exame will be sterile by time lvier abscess forms] *tx of e. histolytica* metronidazole and intraluminal antibiotic (eg, paromomycin) do *not* drain abscess

uterine inversion

uterine relaxants (nitro, terbutaline) can be given to aid in reaplcement of uterus if inital attempt is unsuccesful

placenta accreta

uterine villi attach directly to myometrium instead of decidua *risks* prior c-section history of d&c age >35 typically diagnosed by antenatal u/s = irregularity or absence of placental-myometrial itnerface and *intraplacental villous lakes* *antenatally diagnosis --> cesarean hysterectomy* undiagnosed palcenta accreta prestns as difficulty with palcental delivery placenta does not deteach from uterus --> cord avulsion / manual extraction --> placental adherence and severe hemorrhage

anterior uveitis

uvea = tissue layer between cornea/sclera and the retina; the anterior uvea consits of iris and ciliary body and the posterior uvea consits of the choiroid anterior uveitis = inflmmation of anterior uveal tract [iritis or iridoyclitis] exam = *hyperemia concentrated at junction of sclera and cornea (ciliary flush)*, pupilalry constrction, a hazy flare in aqueaous humor, and layering of white cells in anterior chamber (hypopyon) *keratativ precipitates* (mutton fat) and iris nodules may be seen painful, red eye with photophobia, tearing and dimnished visual acuity most often *idiopathic or traumatic* can be associated with systemic inflammatory diseases and infections - HSV, toxo, sarcoid, anklyosing sponlyitis, IBD, reactive arthrtis

immunizations of premature infants

vaccinatiosn for medically stable preterm infants should be administered by *chronologic age* and not gestational age vaccination of premature infants is safe, and antibody production is adeqaute to confer immunity therefore, all stable preterm infants should get first dose of Hepatitis B vaccine at birth (unless infant <2kg)

lochia

vaginal discharge containing blood and mucus normal up to 6-8 weeks postpartum

painless thyroidtis (silent thyroidtis)

variant of chronic autoimmune thyroidistis mild, brief hyperthyroid phase small, *nontender* goiter spontaenous recvoery positive TPO antibody low rardiodine uptake

common causes of erectile dysfunction

vascular neurologic psychogenic - normal nonsexual nocturnal erections endocrine medications hypogonadism

thromboangiitis obliterans (Buergers disease)

vasculitis of small and medium arteries of young patients (age <45) who *smoke* distal extremity ischemia gangrene ulcerations due to nonatherosclerotic occlusion thrombosis patients frequently have normal pulses and normal ABI *evaluation* ischemia on vascular studies (eg, digital plethysomography) segemental occlusion of small and medium sized vessels on angiography *treatment* smoking cessation usually dx after exlcusion of other systemic dsieases (eg, diabetes, autoimmune and hypercoaguable disorders) ESR, serologies, coagulation studies are all *normal*

kawasaki disease (mucocutaneous lymph node syndrome)

vascultitis of small and medium arteries; most commonly in children *<5*; peak incidence of *East asian ethnicity* *fever >5d* with *4 of the following* conjuctivits - bilateral, nonexudative, spares limbus oral mucsaol changes - erythema, fissured lips, strawberry tongue rash extremity changes - erythema, edema, desqumation of hands/feet cervical lymphadenoatphy - >1.5cm node *dx* echo should be done at time of diagnosis; repreated 6-8w later for assessment treatment = aspiring + IG *complicaitons* coronary a. aneursyms MI + icshemia

Angiotensin II effects

vasoconstriction of afferent and efferent glomerular arterioles [Efferent > afferent] - increased renal vascular resistance and net *decrease in renal blood flow* increases efferent preferentially [*increases itnralgomerular pressure to maintain GFR*] and systemic arteriolar resistance --> increases GFR and BP Na/H20 reabsorption - direclty increases proximal tubule sodium reabsorption aldosterone secretion - increased sodium and water reabsorption in distal tubule

overview of subarachnoid hemorrhage

vasospasm occurs in 30% from days 3-10 rebleeding is high in untreated SAH during first 24h, but embolization and tx narrows risk to nearly 0%

most common cuse of arrhytmia after MI

ventricualr fibrilattion --> sudden cardiac test is 50% ofa rrhytmia in 1st hour due to rettant arrhythmia - phae 1a ventricular arrhytmia occur within first 10m of occulsion and are due to reetrant delayed or phase 1b arryhtmias - occur 10-60m after acute infarction are frmo abnormal automaticity

59 y/o with 2 episodes of syncope during last 12h. First episode during breakstfast, second episode whie watching TV. Described as sudden blackouts lasting 1-2m without any confusion aftwaerds. Has recently had diarrhea due to food poisning. BP 130/90, P60 with regular rhytmn. Meds: simvastatin, aspirin, clopidrogen, lisinopril, sotalol Cause?

ventricular arythmia - sudden onset syncope without prodrome is arrhyhtmia torsades de pointes is most likely responsible sotalol has potential side effect of QT prolongation predisposing to torasades diarrhea and hx of CAD can add to this risk

complications of myocardial infarction

ventricular remodeling occurs and gradually causes dilation of LV and thinning of vnetricualr walls; this can cause CHF remodeling occurs in weekns to months following MI *ACE-inhibitors* have been to shown to limit ventricular remodeling; should be intiated within 24 hours of myocardial infarction in all patients without a contraindication

warning signs of colon polyps that suggest malignancy

villous features [particuarly in presence of high-grade dysplasia] large size (>1cm) high number (>3 concurrent adenomas)

most common cause of pharyngitis in peds

viral infection presence of cough + rhinorrhea + absence of exudates = virus

mumps

viral infection that presents with fever and parotitis after a nonspecific prodrome most common in school-age children, who often have mild dsiease or may even by asymptomatic symptoms are more severe the older you get in general, self-limited, but serious complications are possible *aseptic meningitis* is most common complication: fever, headache, nuchael rigidity *orchitis* - postpubertal males and can impair fertility

common causes of esophagitis in HIV

viral is more likely than candidal when: severe odynophagia, no dysphgia, no thrush HSV, CMV are most common viruses

clinical features of hypothermia

warming rate should be 1-2C/hr core temp may initially fall due to incresed return of blood from cold extremities

patient has history of GERD. has new onset, evere, retrosternal chest pain. Cxr = widended meidastinum, some mediastinal air. Next step?

water-soluble contrast esophagography - esophageal perforation management requires IMMEDAITE broad spectrum abx, parenteral nutrition, surgical repair

if patient is on a ventilator. Has stable gasses (high end normal of oxygen). And FiO2 is >60%. next step?

wean the FiO2 to <60% to prevent oxygen toxicity to lungs tidal volume should be set at *6ml/kg* of ideal body weight

when is cholestasis seen in parenteral nutritoin

when PN is for >2 weeks

when is cesaren delviery indicated for labor arrest

when patient i >6cm dilated and has no cervical change for 4-6 hours

clinical features of cystic fibrosis

when pt presents with meconium ileus - and has operative treatment. *add pancreatic enzymes to formula feeds* from this point on about 7% are diagnosed at age >18 about 20% of patients with CF develop sensorineural hearing loss due to freqeunt treatment with aminoglycosides for gram-negative infections (eg, pseudomonas) pseudomonas in sputum in a younger individual is highly suspcious of CF growth chart typically shows normal birth measurements with subsequent deceleration in weight (>2 major percentiles) followed by deceleration in elngth in addition to malabsoprtion, recurrent sinopulmonary infections impair growth due to poor appetite and increased metabolic needs during illness

leukoplakia

white granular patch/plaque over buccal mucosa in patient with hx of alocohol and tobacco use cannot be scraped off reactive precancerous lesion that represents hyperplasia of squamous epithelium smokeless tobacco and alcohol use account for most cases 1-20% progress to squamous carcinoma in 10 years most resole within weeks after cessation of tobacco use

calcium-phosphorus product

with permanent post-op hypoparathyroidism, lifelong therapy and close monitoring are requred to maintain normal serum calcium and phosphorus levels *calcium-phosphorus product* (serum calcium x serum phosphorus) >55 increases risk of *soft tissue calcifcation* deposition of calcium in the basal ganglia, a coplication assoicted with chronic hypoparathyroidism, can lead to extrapyramidal amnifesataions

effects of anovulatory cycles on the endometrium

without ovulation, there is persitent endometrial proliferaiton that results in heavy menses when ovulation does occur heavy menses is caused by exaggerated necrosis of the superficial layer of the endometrium, whih eventually becomes denuded and conitnues to bleed due tol ack of tissue stability during first year after menarche, adolsecnts often have anovulatory cycles with heavy, irregular menstrual bleeding due to immature Hypothalamic-Pituitary axis in ovulatory cycles, the corpus luteum products progesterone after ovulation; progesterone differeniates the proliferative endometrium into secretory endometirum as corpus luteum degnerates, the decrease in progesterone leads to ormal menses through a decrease in endometrial blood supply and sheddling of lining in *anovulatory* - do not porudce progesterone (eg, no corpus luteum involvement) and there is no differenitation into secretory endoemitrum *unpposed estrogen stimulation* resulting in proliferation of endoemtrium *bleeding occurs when endomtrial lining becoems too thickened and unstable* (eg, breakthough bleeding) *PROGESTERONE* treatment helps stabilzie this uncontrolled proliferation due to estrogen by causing differentiation into secretory endometrium

are ppl with Turner syndrome at increased risk for osteoperosis?

yes because ovaries normally produce estrogen, patients with TS are *estrogen deficient*, which leads to amenorrhea and minimal breast development estrogen also inhibits osteoclast-mediated bone resorption; therefore, patients with TS have icnreased bone resorption, decreased bone mineral density, and increased risk of *osteoperotic fracture* estrogen replacement is given to girls with TS to promote normal sexual maturaiton and reduce risk of osteoperotic fractures

is singleton breech fetus contraindicated vaginally?

yes do cesarean delivery *breech presentation* frank breech is most common - presenting part is fetal buttocks with lower extremities flexed at hips, extended at knees single footling - one fetal LE is presentnig double footling - both feet are presenting complete breech - LE flexed at hips and knees

are Howell-Jolly bodies seen in sickle cell?

yes - after autoinfarcation of spleen single, round, blue inclusions on Wright stain basophilic remnants of nulceus functional spleen removes nuclear remnants of red blood cells

are anti-thyroid peroxidase titers associated with miscarriage?

yes - all pts with elevated levels even if euthyroid should be treated with leovhtyroxine to decrease risk of future msicarriage

should a urianry cather be placed in suspected spinal cord injury?

yes - allows for assessment of urianry retnetion and prvent acute bladder distention and damage

can the MMR vaccine be given during breasfeeding?

yes - although it is a live vaccine, it is *safe* for breastfeeding mothers

are physician ethically and legally obligated to report impaired colelgaues?

yes - commonly to the *physician health program (hospital ommittee)* if this body does not exist, then state liscensing board should be contact

is yellow fever a live virus?

yes - do not give to a patient on a biologic, immunosuppressed

is obesity a common cause of amenorrhea?

yes - due to anovulation FSH, LH are normal progesterone withdrawal at menses does not occur

can clonic jerks occur during a syncop episode?

yes - one that is prolonged and associated with cerebral hypoxia, regardless of etiology

can oral contraceptives cause elevations in blood pressure?

yes - up to 5% of chronic OCP users probably due to esotrgen mediated increase in hepatic angiotensinogen synthesis or other effects on RAAS try discontinuing the OCP, and seeing if the HTN resolves if it does not, then proceed with diet and lifestyle modifications if pt is obese next step would be low-dose thiaizde

is eye deviation in first 4 months of life potentially normal

yes - weakness of EOM

persistent depressive disorder (dysthymia)

you can have episodes of MDD within dysthmia - it just becomes a different subtype