ROSH 2
Weakness, fatigue, anorexia, weight loss Hyperpigmentation Hyponatremia and hyperkalemia
Addison disease Corticoadrenal Insufficiency
Administering ___ which is often used to medically induce an abortion, would not be efficacious if the pregnancy is located outside of the uterus. For medical management of an ectopic pregnancy, ___ is preferred.
Administering misoprostol (B), which is often used to medically induce an abortion, would not be efficacious if the pregnancy is located outside of the uterus. For medical management of an ectopic pregnancy, methotrexate is preferred.
Neisseria gonorrhoeae Conjunctivitis treatment
Admission Topical + IV antibiotics
___ typically occur in the setting of constipation or frequent bowel movements and develop secondary to local ischemia caused by hypertonia of the internal sphincter. Patients will complain of a tearing pain. It is the most commonly encountered anorectal problem in children and infants. They will cry during defecation and parents may see blood associated with bowel movements or bleeding that continues after a bowel movement.
Anal fissures
Ankylosing spondylosis is an extraintestinal manifestation of inflammatory bowel disease (IBD), specifically __
Ankylosing spondylosis (A) is an extraintestinal manifestation of inflammatory bowel disease (IBD), specifically HLA-B27.
___is an extraintestinal manifestation of inflammatory bowel disease (IBD), specifically HLA-B27.
Ankylosing spondylosis (A) is an extraintestinal manifestation of inflammatory bowel disease (IBD), specifically HLA-B27.
Question: What blood product may be used to reverse warfarin?
Answer: Fresh frozen plasma.
Question: Which hand joints are most commonly affected in rheumatoid arthritis?
Answer: Metacarpophalangeal and proximal interphalangeal joints.
Ischemic Stroke __cerebral artery: frontal lobe dysfunction, apraxia, contralateral paralysis (lower > upper) __ cerebral artery: contralateral paralysis (upper > lower), aphasia __ cerebral artery and VBI: LOC, nausea or vomiting, CN dysfunction, ataxia, visual agnosia
Anterior Middle Posterior
Endocarditis treatment
Antibiotic therapy should include coverage for Staphylococcus and Streptococcus species. Vancomycin plus gentamicin is a reasonable regimen. Rifampin should be added for patients with prosthetic heart valves.
Bartonella henselae may cause osteomyelitis in children with ___
Bartonella henselae (A) may cause osteomyelitis in children with cat scratch disease
What laboratory test is essential in patients presenting with symptoms concerning for ovarian torsion?
Beta human chorionic gonadotropin level.
A 60-year-old woman presents to the emergency department for progressive, bilateral hand and finger pain. While evaluating her, which of the following would be most suggestive of a diagnosis of osteoarthritis? Bony, hard swelling of the distal interphalangeal joints Pain and swelling localized to the metacarpophalangeal joints Periarticular bone loss on X-ray Stiffness that is worse in the morning and improves with movement
Bony, hard swelling of the distal interphalangeal joints
Guillain-Barré syndrome Most commonly caused by __
Campylobacter jejuni
A 4-day-old neonate born at 38 weeks gestation following an uncomplicated pregnancy and delivery presents to the emergency department with his father due to bilateral eye redness and discharge. On exam, the patient has bilateral conjunctivitis and copious amounts of purulent discharge from both eyes. What is the treatment for the most likely diagnosis? Cefotaxime Cephalexin Ciprofloxacin Erythromycin
Cefotaxime
A 38-year-old woman presents to the emergency department with nausea and vomiting. She estimates her last menstrual period was about 8 weeks ago and is concerned that she is pregnant. Her bedside transabdominal pelvic ultrasound is shown above. Which of the following can arise as a complication of this patient's condition? Calcium oxalate nephrolithiasis Choriocarcinoma Hypothyroidism Pelvic inflammatory disease
Choriocarcinoma
A positive ___ sign may be present, which is characterized by a twitch at the corner of the mouth when the examiner taps over the facial nerve just in front of the ear. Another examination finding in hypocalcemia is the __ sign, which is described as a carpal spasm produced when the examiner applies a blood pressure cuff to the upper arm and maintains a pressure above systolic for 2-3 minutes.
Chvostek Trousseau
Atypical, chest wall pain Tietze syndrome: pain + presence of swelling May be related to repeated minor trauma, rheumatological causes Pain is reproducible with palpation
Costochondritis
Pain is often made worse with breathing, movement, and particularly, horizontal arm flexion (e.g., crowing rooster maneuver). The pain may be intermittently sharp or dull. localized muscle tension, stinging pain, lack of cough, and pain reproduced by palpation.
Costochondritis
Gestational trophoblastic disease treatment
Definitive management is dilation and curettage
__ is a direct manifestation of celiac disease that causes vesicobullous, pruritic lesions on the elbows, knees, and buttocks.
Dermatitis herpetiformis
A 45-year-old man presents with diarrhea. He reports he has had diarrhea for the past 2 months. Additionally, he reports bloating and notes that the diarrhea is pale, foul smelling, and voluminous. Chart review reveals a weight loss of 10 pounds since his last visit 6 months ago. He reports no recent fevers, bloody bowel movements, nausea, or vomiting. A tissue transglutaminase antibody test is positive. Which of the following extraintestinal manifestations might be seen in a patient with the most likely diagnosis? Ankylosing spondylitis Decreased prothrombin time Dermatitis herpetiformis Leukocytosis
Dermatitis herpetiformis This patient has celiac diseas
osteomyelitis diagnosis is made with
Diagnosis is made by bone scan or MRI
septic bursitis diagnosis
Diagnosis: Bursal fluid aspiration
A 55-year-old man presents to the emergency department for rectal bleeding. The patient states he has noticed blood in his stool for the past week, but it has been increasing in volume. This morning, he noticed a large amount of red blood in one of his bowel movements. The patient has a medical history of obesity, gastroparesis, constipation, and diabetes. He has a 40 pack-year smoking history and drinks three alcoholic beverages every night. His temperature is 99.5°F (37.5°C), blood pressure is 167/108 mm Hg, heart rate is 90 bpm, respiratory rate is 15/min, and oxygen saturation is 99% on room air. Rectal exam reveals bright red blood. There is no tenderness upon palpation of the patient's abdomen. Which of the following is the most likely diagnosis? Colon cancer Dieulafoy lesion Diverticulitis Diverticulosis
Diverticulosis
This patient is presenting with a history of constipation and bright red blood per rectum without systemic symptoms or fever, suggesting a diagnosis of
Diverticulosis
painless bright red blood per rectum.
Diverticulosis
pheochromocytoma diagnosis
Dx: ↑ 24h urinary catecholamines and metanephrines, or ↑ plasma metanephrine levels, adrenal CT or MRI
Symptoms include vaginal bleeding in the first or second trimester, hyperemesis, and pelvic pain or pressure. Gestational hypertension before 20 weeks of gestation is highly suggestive
Gestational trophoblastic disease
The classic ultrasound finding is the sonographic "snowstorm" or "bag of grapes," which describes the appearance of multiple cystic structures in the uterus.
Gestational trophoblastic disease
What condition can present with headache, vision loss, jaw pain, and temporal tenderness?
Giant cell temporal arteritis.
A 23-year-old woman presents to the ED with severe chest pain. She is pale and diaphoretic. Her vital signs are T 103.2°F (39.6°C), HR 124 bpm, RR 22/minute, BP 93/57 mm Hg, and SpO2 96% on room air. She has painful nodules on her fingertips and multiple track marks on her arms. Bedside cardiac ultrasound reveals hyperdynamic activity, no pericardial effusion, and an oscillating right ventricular mass. Blood cultures are most likely to grow which of the following? Gram-negative diplococci Gram-negative rods Gram-positive cocci in clusters Gram-positive cocci in pairs
Gram-positive cocci in clusters
Lumbar puncture: increased CSF protein but a normal cell count
Guillain-Barré syndrome
Risk Factors: recent minor respiratory or GI illness Sx: Symmetric, progressive ascending muscle weakness, can lead to respiratory failure, often associated with dysautonomia PE: lack of deep tendon reflexes, symmetric weakness
Guillain-Barré syndrome
The classic clinical features include progressive and symmetric muscle weakness that is accompanied by decreased or absent deep tendon reflexes. Weakness ranges from being mild, with only minor walking difficulties, to full-blown paralysis. The weakness can ascend to affect the facial, respiratory, and bulbar muscles. Weakness generally starts in the lower extremities and ascends
Guillain-Barré syndrome
__(chronic autoimmune) most common thyroiditis in the US Nontender goiter, hypothyroidism, elevated anti-TPO Abs
Hashimoto
__ should be given as the patient is presenting in adrenal crisis.
Hydrocortisone should be given as the patient is presenting in adrenal crisis.
Lithium Toxicity treatment
IV fluids (mild-moderate) Avoid diuretics Hemodialysis (serious)
osteoarthritis It most commonly affects the __ joints, the thumb, knees, and hips.
It most commonly affects the distal interphalangeal (DIP) joints, the thumb, knees, and hips.
__epicondylitis is more common and typically affects tennis players. __epicondylitis occurs more often in those who golf.
Lateral Medial
pheochromocytoma associated with
MEN2 (medullary thyroid cancer)
septic bursitis treatment
Management: Antibiotics +/- bursa drainage if mass effect
unilateral, pulsatile or throbbing headache that can begin with an aura that can include vision changes, changes in the sense of smell, or even weakness
Migraine headaches
OSTEOMYELITIS Most common organism General: __ Sickle cell: __ Cat or dog bites: ___ Children <4, no culture growth: __ Infants < 3 mo: __
Most common organism General: S. aureus Sickle cell: Salmonella, S. aureus Cat or dog bites: Pasteurella multocida Children <4, no culture growth: Kingella Kingae Infants < 3 mo: Group B streptococcus (Streptococcus agalactiae)
A 40-year-old woman presents to the ED complaining of neck pain. For the past three days, she has had a fever, myalgias, and increasing fatigue. Vital signs are BP 130/90 mm Hg, HR 100 beats per minute, RR 14 breaths per minute, oxygen saturation of 97% on room air, and T 100.4°F. On physical exam, she has tenderness over her anterior, midline neck. Which of the following is the most appropriate treatment? Levothyroxine Methimazole Nonsteroidal anti-inflammatory drugs Propranolol
Nonsteroidal anti-inflammatory drugs
A 70-year-old man with atrial fibrillation on warfarin daily and dementia presents to the emergency department after being referred from a coagulation clinic for elevated international normalized ratio. He is asymptomatic and reports no bleeding, bruising, or melena but states he may have unintentionally taken extra doses of warfarin. His vital signs are significant for an irregular heart rate of 88 bpm and a blood pressure of 150/80 mm Hg. His laboratory values are significant for an international normalized ratio of 11, and his hemoglobin is unchanged from baseline. Which of the following is the best next step in the management of this patient? No treatment and repeat labs in 24-48 hours Oral vitamin K, hold next warfarin dose, and repeat labs in 24-48 hours Reversal with four-factor prothrombin complex concentrate Reversal with protamine sulfate
Oral vitamin K, hold next warfarin dose, and repeat labs in 24-48 hours
A 27-year-old woman presents with acute onset of right pelvic pain and nausea that started 6 hours ago. She reports two prior episodes that were similar, but symptoms with those episodes resolved within 1 hour. On examination, she appears uncomfortable and has mild tachycardia without fever. She has tenderness to palpation of the right adnexa. Her pregnancy test is negative. A transvaginal ultrasound is ordered. What is the most common ultrasound finding in the most likely diagnosis? Complete arterial obstruction Heterogeneous appearance of the ovarian stroma Ovarian enlargement Whirlpool sign
Ovarian enlargement Ovarian torsion
Patients present with acute onset of unilateral pelvic pain often accompanied by nausea and vomiting.
Ovarian torsion
Bouchard nodes affect which joint Heberden nodes affect which joint
PIP joint DIP joint
A 44-year-old man presents to the emergency department with a severe headache and sweating. Although his symptoms are already beginning to improve, he is concerned because similar episodes have occurred in the past several weeks during which he feels anxious, sweaty, and experiences flushing. The patient is a current smoker and drinks alcohol every night. His temperature is 99.5°F (37.5°C), blood pressure is 167/94 mm Hg, pulse is 90/min, and respiratory rate is 15/min. Which of the following is the best initial diagnostic test for this patient? Head CT scan without contrast Plasma fractionated metanephrine levels Renal artery ultrasound with Doppler flow Serum renin and aldosterone levels
Plasma fractionated metanephrine levels'' pheochromocytoma
Where are the majority of anal fissures located? Anterior midline External sphincter muscle Lateral position Posterior midline
Posterior midline
__ is the reversal agent for heparin.
Protamine sulfate (D) is the reversal agent for heparin.
Patient will be a child 1-4 years old History of being pulled up by the wrist PE will show the affected arm held close to the body in a flexed and pronated position Most commonly caused by longitudinal traction on a pronated forearm while the elbow is extended
Pulled Elbow (Radial Head Subluxation, Nursemaid Elbow)
A 32-year-old man presents with right-sided elbow swelling and pain. He works as a plumber and has no specific injuries. The elbow pain and swelling developed rapidly and became worse over the last 2 days despite applying ice and using over-the-counter anti-inflammatory medications. His vital signs are HR 104 bpm, BP 110/60 mm Hg, RR 18/min, and T 100.2°F (37.9°C). On physical exam, his right elbow is swollen and tender to touch, with redness and fluctuance isolated to the posterior tip of the elbow. He refuses full flexion of the elbow on exam due to pain but allows passive pronation and supination. What is the most likely diagnosis? Lateral epicondylitis Medial epicondylitis Olecranon bursitis Septic bursitis
Septic bursitis
Patients present with fluctuance, erythema, warmth, and tenderness of the overlying area. More specific features include the rapid onset of pain and swelling, as well as fevers and limited joint mobility.
Septic bursitis
Endocarditis In the United States and Europe, __ is the most common cause overall, and it is the most common organism cultured in those who use IV drugs. it is seen as __on microscopy.
Staphylococcus aureus gram-positive cocci in clusters
A 4-year-old boy presents to the emergency department with a limp and fever. His parent states that he began limping 2 days ago, and it has gotten progressively worse. He will no longer walk. His fever started today. His parent reports no known injuries. On physical examination, his temperature is 39°C with a heart rate of 130 beats per minute. His right hip is warm to the touch with overlying erythema present. He has limited range of motion of the right hip due to pain. Laboratory analysis reveals a leukocytosis with elevated erythrocyte sedimentation rate and C-reactive protein. X-ray of his right hip reveals periosteal thickening. An ultrasound of the right hip reveals a hip effusion. Which of the following is the most common cause of the patient's presentation? Bartonella henselae Pseudomonas aeruginosa Staphylococcus aureus Streptococcus pyogenes
Staphylococcus aureus osteomyelitis
___ is the most common cause of osteomyelitis in children
Staphylococcus aureus (S. aureus) is the most common cause of osteomyelitis in children
A 40-year-old man presents to the emergency department with sudden-onset back pain after lifting a box. The pain radiates down to the mid-thigh and is worse with bending and walking. Physical exam reveals left para-lumbar muscular tenderness without spasm. Which of the following exam maneuver(s) has the highest sensitivity and specificity for sciatica, respectively? Crossed straight leg alone Crossed straight leg raise, straight leg raise Straight leg raise alone Straight leg raise, crossed straight leg raise
Straight leg raise, crossed straight leg raise
Preceded by viral URI Anterior neck pain Suppressed TSH, elevated ESR Low uptake on thyroid scan
Subacute (de Quervain) thyroiditis
A 33-year-old woman with a history of peptic ulcer disease presents to the emergency department with a unilateral, pulsatile headache that is 8 out of 10 in severity. She has had similar headaches previously. This time, she was unable to control her symptoms at home with acetaminophen. Her neurological exam is within normal limits. Which of the following is the best treatment for this patient's headache? Ibuprofen Morphine Oxygen Sumatriptan
Sumatriptan
A 3-year-old boy presents to the emergency department due to a refusal to move his left arm. His symptoms started after his parent grabbed him by the arm to stop him from running into the street. On examination, he is holding the left elbow in flexion with pronation of the forearm. He resists any attempts to move the arm. There is no noted swelling or obvious deformity. What method can be used to reduce the most likely injury? Pronation of the forearm with extension of the elbow Pronation of the forearm with flexion of the elbow Supination of the forearm with extension of the elbow Supination of the forearm with flexion of the elbow
Supination of the forearm with flexion of the elbow
The treatment for most cases subacute thyroiditis is __
The treatment for most cases subacute thyroiditis is nonsteroidal anti-inflammatory drugs (NSAIDs).
Migraine headaches Abortive Rx: Prophylaxis:
Treatment Abortive Rx: triptans, DHE, antiemetics, NSAIDs Prophylaxis: TCAs, beta-blockers, anticonvulsants (valproic acid, topiramate), CCBs
Anal fissures Treatment
Treatment includes encouraging a high fiber diet, softening stool to prevent recurrent trauma, and normalization of bowel movements. In cases that do not respond to conservative treatment, topical nitroglycerin or diltiazem ointment may help to relax the internal sphincter. Surgical intervention may be required in refractory cases. Treatment is stool softeners, protective ointments, sitz baths, topical nitroglycerin or nifedipine
Guillain-Barré syndrome treatment
Treatment is supportive, IVIG, or plasmapheresis
Treatment of diverticulosis with bleeding includes
Treatment of diverticulosis with bleeding includes avoiding oral intake (bowel rest), administering IV fluids, and monitoring their CBC to track for anemia secondary to bleeding. Most cases resolve spontaneously.
osteoarthritis treatment
Tx options: weight management, physical therapy, NSAIDs, acetaminophen (lack of benefit), corticosteroid joint injections, joint replacement
Pernicious anemia is a type of selective malabsorption leading to a deficiency in what vitamin?
Vitamin B12 (cobalamin).
It is characterized by oculomotor dysfunction, mental status change, and gait disturbances
Wernicke encephalopathy
is caused by inflammation of the pericardium, the sac surrounding the heart. The associated pain is typically substernal, sharp, constant, improved with leaning forward, and worsened with laying back. The exam may reveal a pericardial friction rub, and ECG will sometimes show diffuse ST segment elevation with PR depression.
acute pericarditis
pheochromocytoma treatment
alpha-blocker (phentolamine, phenoxybenzamine) prior to beta-blockade to prevent unopposed alpha-agonism surgical resection
Symptoms of __ include pale, foul smelling, and voluminous stool. Celiac disease also often leads to weight loss due to malabsorption of nutrients.
celiac disease
severe pain, photophobia, and foreign body sensation. Patients are typically able to easily identify a known trauma or foreign body. Diagnosis is by visualization of an abrasion under a Wood lamp or slit lamp using fluorescein staining.
corneal abrasion
Pregnant patient, The patient is presenting with a pseudosac with surrounding free fluid, which is concerning for an __
ectopic pregnancy
Ibuprofen is an appropriate NSAID that can be given in a migraine headache, however, it may not be the best medication in a patient with __
gastritis or peptic ulcer disease
Patients present with copious bilateral purulent discharge, severe chemosis, and lid edema within the first 5 days of life.
gonococcal ophthalmia neonatorum
Subacute (de Quervain) thyroiditis treatment
high-dose ASA or NSAID
decreased TSH and elevated T3/T4 Elevated TSH and decreased T3/T4
hyperthyroid hypothyroid
Chvostek and Trousseau signs are seen in
hypocalcemia
Sx: seizures, paresthesias electrolytes
hypocalcemia
Lithium can cause a variety of endocrine abnormalities, either in therapeutic usage or overdose. Subclinical or overt ___is relatively common.
hypothyroidism
Ovarian torsion treatment
laparoscopic detorsion
Hashimoto treatment
levothyroxine
endocarditis The most common valve involved is the ___ valve, and The__ valve is most commonly involved in those who use IV drugs.
mitral tricuspid
Management of simple corneal abrasions includes __ antibiotics for contact wearers antibiotics for noncontact wearers
oral pain control, prophylactic topical antibiotics (as needed for larger abrasions), and topical nonsteroidal anti-inflammatory medications for analgesia. In contact lens wearers, antibiotics should be chosen that cover Pseudomonas, including ciprofloxacin ophthalmic solution. Erythromycin ophthalmic ointment is an appropriate first-line antibiotic for a large corneal abrasion in a patient who does not wear contact lenses.
Heberden nodes, or bony, hard swelling of the distal interphalangeal joints, are nearly pathognomonic for this disease process.
osteoarthritis
It most commonly presents as symmetric, polyarticular, mild joint pain, and stiffness that worsens with use and ultimately leads to joint deformity and loss of locomotion in advanced disease.
osteoarthritis
Sx: pain worse with activity, improves with rest
osteoarthritis
X-ray will show periosteal elevation or bony erosions
osteomyelitis
Catecholamine-secreting tumor located in the adrenal glands Sx: paroxysmal headaches, diaphoresis, palpitations, tremors, and vision changes PE: hypertension, orthostasis
pheochromocytoma
Episodic release of catecholamines leads to severe episodes of hypertension, headaches, sweating, flushing, anxiety, and palpitations.
pheochromocytoma
episodic headache, diaphoresis, tachycardic and HTN triad for
pheochromocytoma
also presents with sharp chest pain made worse with inspiration, it often presents with other signs and symptoms such as dyspnea, hypoxemia, syncope, shock, fever, cough, hemoptysis, tachycardia, and tachypnea.
pulmonary embolism
What bacteria may cause osteomyelitis in patients who have a history of sickle cell disease?
salmonella
Inflammation of bursa due to infection (most commonly Staph aureus) Risk factors: Trauma, Gout, Rheumatoid arthritis, impaired immune system (e.g. diabetes, chronic steroid), atopic dermatitis, psoriasis Presentation: acute onset erythema, warmth, pain, swelling fullness, diminished range of motion
septic bursitis
Test for sciatica Patient is supine Raise symptomatic leg passively Do not bend the knee Test is (+) if pain radiates below the knee upon raising it
straight leg raise (SLR)
The __is a good screening test for sciatica with 92% sensitivity and 28% specificity. The patient's affected leg is extended and passively elevated. Pain elicited in a sciatic nerve distribution past the knee indicates a positive test. Pain elicited in the back alone is not considered positive.
straight leg raise (SLR)
caused by a viral infection or a post-viral inflammatory process. Common symptoms include fever, myalgias, fatigue, and malaise. Patients will complain of anterior neck pain, which is often localized over the area of the thyroid but can radiate to the jaw, throat, upper neck, or ears. The pain may be exacerbated by swallowing, coughing, or neck movement. The hallmark physical exam finding is tenderness over the thyroid gland. If tenderness is absent, another diagnosis should be considered
subacute thyroiditis
Gonococcal conjunctivitis is potentially life-threatening, and patients should undergo a full septic workup to evaluate for other sources of infection. Treatment of isolated gonococcal conjunctivitis is with the
third-generation cephalosporin, cefotaxime
