UWORLD-USMLE Step 3 (1)

indicated for treatment of rheumatoid arthritis and psoriatic arthritis

Tumor Necrosis Factor-Alpha Inhibitors (Etanercept, Infliximab) Psoriatic arthritis commonly affects distal interphalangeal joints of fingers and toes with destructive changes on xray

Tumor Lysis Syndrome (TLS)

Tumors with high burden or rapid turnover, Combination chemo/immunotherapy (lyse tumor cells, releasing intracellular potassium, phosphate, and uric acid into circulation, because they exceed renal elimination results in tumor lysis syndrome) Lead to AKI because of uric acid and phosphate as well as cardiac arrhythmia leading to cardiac arrest due to high potassium, Seizures due to neuronal hyperexcitabiliyt by low calcium Severe electrolyte abnormalities (HIGH Phosphorus, Potassium, Uric acid) (LOW Calcium), AKI, Arrhythmias, Seizures. PPX: IVF, XANTHINE OXIDASE INHIBITOR (ALLOPURINOL or FEBUXOSTAT) or RASBURICASE (Urate Oxidase Analogue-Normalizes serum Uric Acid therefore AKI results from Hyperphosphatemia and Renal tubular calcium-phosphate precipitation) TX: IVF + RASBURICASE, Continuous tele, Aggressive electrolyte monitoring

Coarctation or narrowing of the aorta is associated with

Turner syndrome Weak femoral pulses and decreased post ductal oxygen saturation Aortic arch indentation (3 sign) on radiography

prospective cohort study

Two groups a + risk factor and a - risk factor Compare disease incidence Present to future

Antiretroviral therapy (ART)

Two nucleosides and an integrase inhibitor Lamivudine + abacavir + an integrase inhibitor (e.g., raltegravir) Tenofovir + emtricitabine + an integrase inhibitor

Subtypes of DM

Type 1: Absolute Insulin Deficiency ()Autoimmune destruction of pancreatic BETA cells) -Children, Young adults, Normal Weight, FH less common -KETOACIDOSIS (Glucagon forms ketone bodies), polyuria, weight loss, Acute/Severe -Undetectable C-Peptide, + Pancreatic Autoantibodies (Glutamic Acid Decarboxylase 65 Autoantibody) Type 2: Relative Insulin Deficiency, Insulin Resistance -Adults, Overweight, FH -Gradual/asymptomatic, No ketoacidosis -Elevated C-Peptide, No autoantibodies Monogenic Diabetes (Maturity-Onset Diabetes of the Young): Impaired Insulin Secretion, Impaired Glucose Sensing -<30yo, Normal weight, FH (AUTOSOMAL DOMINANCE) -Mild Hyperglycemia, No Ketoacidosis -Detectable C-Peptide, No autoantibodies

Patient with newly diagnosed PE, has thrombocytopenia in setting of recent heparin therapy

Type 2 Heparin Induced thrombocytopenia Immune mediated disorder resulting in platelet aggregation and thrombosis Necrotic skin lesions at heparin injection sites Dx: SEROTONIN RELEASE ASSAY: Gold standard confirmatory test Therapy: Stop all heparin products, Start a direct thrombin inhibitor (argatroban, bivalirudin) or Fondaparinux (synthetic pentasaccharide) warfarin is only started after patient recovers a platelet count >150k (with non heparin anticoagulant continued until INR is therapeutic)

Variable decelerations, abrupt drop in fetal heart that last <2 min, are the result of

Umbilical cord compression. An amnioinfusion placing a catheter inside the uterus to instill fluid, thereby relieving the umbilical cord compressing and resolving variable decelerations

rhinorrhea, oropharyngeal cobblestoning, chronic non productive cough

Upper Airway Cough Syndrome (Post Nasal Drip)

Esophagogastroduodenoscopy (EGD) used to evaluate for

Upper GI Bleed

best test for diagnosing malrotation with midgut volvulus, causing bilious emesis

Upper GI Series

Bright red or maroon-Colored stool, Hemodynamic instability (orthostatic hypotension), chronic ibuprofen use

Upper GI source of bleeding ESOPHAGOGASTRODUODENOSCOPY (EGD) for identification and treatment (hemostatic clipping) if fail to identify source then next best is Colonoscopy

>60, new onset Dyspepsia (Postprandial fullness, early satiety, epigastric pain)

Upper endoscopy to evaluate for H. Pylori

Recurrent UTI in an infant

Ureteropelvic junction obstruction caused by narrowing or kinking of ureter, causing hydronephrosis on affected side

Topical miconazole cream

tx for tines pedis (chronic and progressive pruritic erosions or scales between the toes)

HALOPERIDOL

typical antipsychotic: high potency MOA: block D2 receptors use: schizophrenia and tourette's syndrome Delirium to prevent harm prior to using restrains side effects: -extrapyramidal effects -HIGH RISK tardive dyskinesia -can prolong QT interval→ arrythmia

Oral antifungal medication for scalp (tinea capitis) or nail (onychomycosis)

—Terbinafine: causes increased LFTs —Itraconazole —Griseofulvin always the wrong answer; less effective and more toxic

Caloric Stimulation of the vestibular apparatus

Irrigation of the external auditory canal with cold water -> NORMAL = Transient, conjugate, slow deviation of gaze to the side of the stimulus followed by saccadic correction to the midline. PSYCHOGENIC COMA IF ABNORMAL then Massive stroke or heroin overdose

Pancreatogenic Diabetes

Islet cell damage from end stage chronic pancreatitis Both glucagon secreting alpha and beta cells affected leads to increased risk of hypoglycemia but decreased risk of ketoacidosis Elevation of serum amylase normal in DKA and not specific for pancreatitis

the best initial therapy for allergic bronchopulmonary aspergillosis (ABPA), coccidioides, blastomycosis, histoplasmosis

Itraconazole

Zidovudine

NRTI SE: Anemia

Acute viral or idiopathic pericarditis on ECG diffuse ST elevation and PR depression

NSAID & COLCHICINE

recurrent Chest pain, palpations, SOB, choking, Trembling, sweating, nausea, chills, dizzy, paresthesia, fear of losing control or dying, worry about additional attacks, avoidance of behavior

Panic Disorder SSRI/SNRI & or CBT Acute: BENZODIAZEPINES

Seek to determine whether an intervention works in real-life conditions

Pragmatic Study

longitudinal study

observational study repeat measurements of the same variables are taken over a prolonged period

when trials with significant psitive results are published but trials with negative/null are not

publication bias

Active TB findings

unexplained weight loss, anorexia, night sweats, fever, fatigue, coughing > 3weeks, hemoptysis, chest pain, cavitation or infiltrates on CXR If NO symptoms and Negative CXR then a positive IGRA or TST means they have latent TB, no confirmatory test required. Therefore require tx with ISONIAZID daily for 9 months, or Rifampin for 4 moths, or Rifampin + Isoniazid for 3 months, or Rifapentine + Isoniazid weekly for 3 months If active TB then microbial diagnosis with serial sputum samples for acid-fast bacilli and mycobacterial culture. once microbial diagnosis obtained. tx with 4 drug therapy.

risk factors for pyelonephritis in pregnancy

untreated asymptomatic bacteriuria and pre gestational diabetes

FeNa <1% & Muddy Brown Casts on Urine Microscopy 24-48hrs following arterial contrast administration.

Contrast Associated AKI Prerenal vasoconstriction & Direct tubular Cytotoxicity Prevent with prophylactic IV NS, Holding NSAIDs, Using lowest possible volume of contrast

Hemophilia A, genetics?

Deficit in coagulation factor VIII X-Linked Recessive Dz Affects mainly males, Heterozygous females are silent carriers. If father affected and mother not a carries, children will not be affected, but female children will be carriers.

Intensely pruritis papules and vesicles on the extensor surfaces of the elbows and knees as swell as buttocks and back

Dermatitis Herpetiformis associated with celiac disease tx by gluten free diet

inflammatory myopathy with heliotrope rash, gottron papules. associated with multiple malignancies (lung, colon, ovaries)

Dermatomyositis

Fetal Fibronectin Testing

Determines risk of preterm delivery in patients with preterm contractions.

sensory loss of anterior and medial thigh, medial shin, arch of right foot. Knee jerk decreased. Unable to extend knee against resistance.

Femoral Nerve Injury Medial shin to arch of foot due to saphenous nerve branch of femoral

Adolescent girl <30, Unilateral, firm, rubbery mobile, well circumscribed mass in upper outer quadrant

Fibroadenoma Benign, estrogen sensitive fibroepithelial tumor Cyclic changes with menses Observe and repeat exam over 1 to 2 menstrual cycles , US If persistent

cause of renal artery stenosis in young patients (FEMALES)

Fibromuscular Dysplasia

Snip or shave excision reserved for

Filiform Cutaneous Warts (finger like keratitis projections)

Cephalexin (Keflex)

First Gen Cephalosporin treats Staph and Strep skin infections

Treatment for Candida (not Candida krusei or Candida glabrata), Cryptococcus, oral and vaginal candidiasis as an alternative to topical medications

Fluconazole

Reversal agent for benzodiazepines

Flumazenil

Treatment of complicated cystitis in non pregnant (DM, Pregnancy, renal failure, Urinary tract obstruction, indwelling catheter, Cystoscopy, Immunospuprresion , Hospital acquired

Fluoroquinolones 5-14days Obtain sample of urine cx prior to initiating therapy

Used to treat Hypertriglyceridemia to reduce risk of pancreatitis

GEMFIBROZIL (Fibrates)

HIV management during pregnancy

Antepartum: -HIV RNA Viral Load, every 2-4 weeks after initiate therapy, monthly until undetectable, then every 3 months -CD4 every 3-6 Months -ART initiation as early as possible Intrapartum: -Avoid artificial ROM, fetal scalp electrode, operative vaginal delivery -Viral load <1000 = ART + VAGINAL DELIVERY =>1000= ART + Zidovudine + C-section Postpartum: -Mom continue ART -Infant (mom viral load <1000): Zidovudine -Infant (mom viral load >1000): Multi Drug ART

Type 1 Autoimmune Hepatitis (elevated hepatic transaminases)

Anti-Smooth Muscle Antibodies

medication toxicity. Fever, dry mucus membranes, tachycardia, non reactive mydriasis, skin erythema, anhidrosis, AMS, urinary retention.

Anticholinergic Toxicity (from Tricyclic Antidepressant Intake) Tx: PHYSOSTIGMINE

SLE with kidney involvement

ANA and Anti-DsDNA RENAL BIOPSY to determine extent of disease and guide therapy Tx: Sclerosis only = no tx, Mild, early stage, non proliferative = steroids, severe advanced proliferative = mycophenolate Mofetil

Child with, right upper extremity HTN. Lower extremity Claudication (intermittent pain in legs during exercise), 2/6 continuous murmur over the left inter scapular area.

Aortic Coarctation. Associated with Turner syndrome or male patients as well. Impaired perfusion distal to the coarctation. inadequate lower extremity perfusion causes leg pain during exercise (claudication). LV overload due to impaired emptying against increased aortic pressure. -4 extremity BP classically shows upper extremity HTN with lower extremity Hypotension. Weak/delayed distal pulses (brachiofemoral delay) -CXR rib notching from collateral vessels and a figure "3" sign at the site of aortic narrowing. Confirm diagnosis with Echocardiogram.

diastolic heart murmur can be a marker of

Aortic Insufficiency, or mitral stenosis related to cerebrovascular accidents (CVA)

palpable purpura, glomerulonephritis, renal insufficiency, fatigue, normal or elevated complement levels and resp tract symptoms (sinusitis, rhinorrhea)

Granulomatosis with Polyangiitis and Microscopic Polyangiitis dx with antineutrophil cytoplasmic antibodies

Treatment for Anogenital Warts, superficial basal cell carcinoma, actinic keratosis

Imiquimod

Active pulmonary TB Tx (Cough >3m, weight loss, fever), CXR (Cavitation, Infiltrate)

Isoniazid, Rifampin, Pyrazinamide, Ethambutol for 2months followed by isoniazid and rifampin for 4 months. + TB Screening usually have + testing for life Sputum (or gastric lavage) acid -fast bacilli testing and mcobacterial culture are required for active TB only.

Systemic Vasculitis with involvement of every organ except the lung. Fever, Weight loss, Fatigue. Multiple motor and sensory neuropathy with pain.

Polyarteritis Nodosa Dx: ESR, Biopsy of Sural nerve or kidney, Test for Hep B & C, Angiography showing "beading" Tx: Cyclophosphamide & Steroids

disseminated gonorrhea

Polyarticular disease, Petechial rash, Tenosynovitis

Serum Anti-Citrullinated Peptide Antibodies

Polyarticular juvenile idiopathic arthritis Inflammatory arthritis involving multiple symmetrical joints Synovial fluid white count 2-20K recurrent and requires NSAIDS

congenital hypo pigmented maculae (ash-Leaf-Spots), glial proliferation, several organ hamartomas/cysts.

Tuberous Sclerosis

infant with seizure, hypo pigmented lesion

Tuberous Sclerosis Mutation in TSC1 (Hamartin) or TSC2 gene (Tuberin), Autosomal Dominant epilepsy, Intellectual disability, Autism and Behavior disorder BENIGN tumors throughout the body like skin (Ash-Leaf Spots, Angiofibromas, Shagreen patches), CNS (Glioneuronal Hamartomas, Subependymal tumors), Heart (Rhabdomyomas), Kidney (angiomyolipoma) Regular skin and eye exams, Serial MRI of brain and kidney, Baseline Echo and Serial ECG, Baseline electroencephalogram, Neuropsychiatric screening. Neuro impairment is the leading cause of death, significant developmental delays and seizures. Either death from mass effect from subependymal tumors or from impairment caused by tumors (status epileptics, aspiration pneumonia). To prolong life span MUST control seizures therefore brain MRI and Electroencephalogram should be obtained when TSC is initially diagnosed Renal involvement obstructive renal angiomyolipoma, renal failure is the seance most common cause of death therefore need abdominal imaging.

Weeks to months after acute MI. ST elevation and deep Q waves

Ventricular Aneurysm (progressive LV enlargement causing HF, refractory angina, ventricular arrhythmias or systemic arterial embolization fue to mural thrombus )

Harsh Holosytolic murmur with maximal intensity over left third and fourth intercostal space with a palpable thrill.

Ventricular Septal defect

Type of bias that occurs when a study uses gold standard testing selectively in order to confirm a positive or negative result of preliminary testing resulting in overestimates or underestimates of sensitivity or specificity

Verification Bias Reduce it by performing gold standard testing in a random sample of participants with negative results.

Acute back pain and decreased spinal mobility, pain increase with standing, walking, lying on back, in an elderly with point tenderness along midline at lumbar vertebrae

Vertebral Compression Fracture -Trauma, Osteoporosis (MOST COMMON due to decreased bone density increased risk in postmenopausal women and men >65), Osteomalacia, Bone metastases, Hyperparathyroid, Paget Hyperkyphosis: Protuberant abdomen, early satiety, Weight loss, Decreased respiratory capacity Dx: Plain xray of spine, studies for hyperthyroid, hyperparathyroid, But D deficiency. DXA scan.

Dysuria, postvoid dribbling, dyspareunia, anterior vaginal mass Hematuria, recurrent UTI, stress urinary incontinence

Urethral Diverticulum Urethral mucosa herniated into surrounding tissue Dx: Urinalysis, Urine Cx, MRI of pelvis, Trans Vag US Tx: Manual decompression, needle aspiration, surgical repair

Intrinsic Sphincter Deficiency (ISD)

Urethral Sphincter Weakness prevents urethra from closing completely, result of neuromuscular damage during pelvic surgery or vaginal delivery

Sudden overwhelming or frequent need to urinate

Urge incontinence Over active Bladder. Tx: Lifestyle modification, Bladder training, Antimuscarinic medications

Sudden, overwhelming urge to urinate

Urge incontinence Tx with lifestyle modification, bladder training, antimuscarinic medications

Thyroglobulin levels

Useful in follow-up management of patients with differentiated thyroid cancers and those with suspected factitious thyrotoxicosis

postmenopausal women describing sex as no longer pleasurable

Vaginal Dryness, Dyspareunia, Vaginal Atrophy SSRI and SNRI (Venlafaxine) relieve vasomotor symptoms Low dose vaginal estrogen therapy can treat vaginal atrophy

Antioconvulsant mood stabilizer used to treat mania and depression in bipolar disorder

Valproate Avoid in pregnancy due to increased risk of neural tube defects, craniofacial abnormalities, microcephaly, growth retardation, cleft lip and palate, limb defects, genital anomalies

Tertiary Prevention

When the disease process has advanced beyond early stages. Taking all actions available to limit impairment and disabilities. Ex: Patient with significant CV disease include cardiac rehab and revascularization procedures.

Time to event data

When the elapsed time before an event occurs is of significant interest. accounts for total number of events in both groups but also for the timing of the events. When assessing treatment benefits. Used in survival analysis where the event of interest is death.

Misclassification of exposure bias

When the exposure is not assessed correctly. In observational studies in which there is no control over the exposure (exposure observed instead of controlled)

Absent an-cutaneous reflex. Sensory loss of perineum, Weakness in urinary or fecal incontinecne, sexual dysfunction

S2-S4

Renal cysts

Simple: Thin wall, Unilocular, No solid components, NO CONTRAST ENHANCEMENT MALIGNANT: Irregular walls, Multilocular, Hetergenous (Solid & cystic) CONTRAST ENHANCEMENT

risk factors for breech presentation

structural uterine abnormalities (fibroids, septate uterus), Placenta previa, multiple gestation, polyhydramnios, advanced maternal age (>35)

elderly with sudden headache, nausea, nuchal rigidity with one sided ptosis and anisocoria

subarachnoid Hemorrhage with cranial nerve III palsy due to ptosis and anisocoria this is due to POSTERIOR COMMUNICATING ARTERY ANEURYSM

Hx of abdominal surgery, swinging fever, leukocytosis, cough and shoulder tip pain.Best Diagnostic test

subphrenic abscess develops 14-21 days after abdominal surgery ABDOMINAL US best diagnostic test.

Spider Angiomas

bright central papules surrounded by several outwardly radiating vessels Due to dilated central arterioles and associated superficial capillary networks. ESTROGEN dependent found in patients with CIRRHOSIS

Hazard Ratio

measure of risk that described chance of events occurring in one study arm compared to another (tx vs control group) Can be calculated at multiple time intervals throughout a study period. Analyze survival or time to event data HR >1 = Increased risk HR < 1 = Decreased risk HR =1= No change in risk

dementia, gait disturbance, Urinary Incontinence, in 60yo

normal pressure hydrocephalus

Hematochezia

"Frank" blood (bright red) in the stool HD STABLE -> COLONOSCOPY -> Source not found? -> EGD -> Source not found -> Capsule endoscopy, repeat EGD/Colonoscopy HD UNSTABLE or UGIB suspected -> Resuscitate, Surgery and IR consult, EGD -> Source not found? Angiography if not stable, but if stable then colonoscopy

Protease inhibitors

"Navir tease a protease" atazanavir or darunavir MOA: stops cleavage of HIV polypeptide into functional parts, thus preventing maturation of new viruses Toxicity: hyperglycemia, GI intolerance, lipodystrophy (buffalo hump); nephropathy, hematuria (indinavir) -Ritonavir inhibits P450 enzymes

Standard deviation of a normal distribution

1 SD: 68% 2 SD: 95% 3 SD: 99.7%

Management options for PE

1. Anticoagulation for all 2. Inferior Vena Cava Filter when anticoagulation contraindicated and have low cardiopulmonary reserve 3. Thrombolysis: PE with Hypotension SBP <90 AND low bleeding risk 4. Embolectomy: Shock likely to cause death within hours OR Failed thrombolysis with persistent hypotension

lead exposure screening

1-2 yo or patients at increased risk for accidental ingestion (developmental delay)

Criteria for diagnosis of giant cell arteritis

1->50yo (GREATEST RISK FACTOR) 2-New onset localized headaches with fever and visual disturbance 3-ESR>50 4-Tenderness or decreased pulse of temporal artery 5-Temporal artery biopsy showing necrotizing arteritis with mononuclear cells 3 out of 5 = GIANT CELL ARTERITIS TEMPORAL ARTERY BIOPSY -> HIGH DOSE GLUCOCORTICOIDS (Prednisone 40-60mg daily)

Esophageal Carcinoma two types

1. Adenocarcinoma-Distal to mid-esophagus associated with chronic GERD and Barrett Esophagus 2. SCC-Upper esophageal lesions-Chronic alcohol and tobacco

Walking is acquired around

12 months but normal 9-16 months if no other delays and normal PE then close followup until 16 months

Developmental Milestones of Toddlers

12M: pulls to stand, cruises, Pincer grasp, says mama or dada, understands no, Plays pat-a-cake, looks for hidden objects 15M: takes a few steps, stacks two blocks, says 1-2 words, follows 1 step command, points to get something, shows affection 18M: walks, climbs, scribbles, feeds with fingers, says >3 words, Follows 1 step command, imitates 2yrs: Runs, Kicks ball, walks up stairs, Uses spoon, says 2 word phrases, knows 2 body parts, parallel play 2.5yrs: jumps, removes clothes, turns pages, says >50 words, follows 2 step command, knows 1 color 3yrs: walks up stairs alternating feet, rides tricycle, dresses with help, uses fork, copies circle, says >3 word sentences, speech 75% intelligible, knows age/sex, plays with other children

Multiple Sclerosis (MS)

15-50yo optic neuritis (monocular visual loss accompanied by eye pain worsens with eye movement), Transverse myelitis presenting with upper motor neuron signs And sensory loss below the level of spinal involvement. Lhermitte sign, internuclear ophthalmoplegia, fatigue, uhthoff phenomenon (heat sensitivity), numbness, paresthesia, paraparesis, spasticity, bowel/bladder dysfunction Relapsing remitting DX: T2 MRI lesions disseminated in time and space (periventricular, juxtacortical, infratentorial, spinal cord), oligocolonal IgG bands on CSF analysis Ovoid-shaped periventricular white matter lesions Neurologic recovery between episodes of acute exacerbation Tx: Oral and IV Corticosteroids are considered equally efficacious in hastening recovery. IV preferred over oral when optic neuritis involved Chronic maintenance therapy to decrease frequency of relapse and reduce ability to develop brain lesions: BETA INTERFERON, GLATIRAMER ACETATE (disease modifying drugs) Pregnant women with MS have a higher risk of C section and or assisted delivery (vacuum, forceps), preferred tx in exacerbation in pregnant patients is short term IV glucocorticoids as there are generally well tolerated and not associated with teratogenicity. Avoid disease modifying drugs during pregnancy. Infants born to mom with MS have an increased risk of developing MS and can be born with lower birth weight.

one time screening for Hep C

18-79 and those high risk for infection (injection drug use, blood transfusion prior to 1992)

Acute HIV Infection

2-4 weeks post exposure Mono like syndrome (Fever, LAD, sore throat, arthralgia) Generalized macular rash GI symptoms HIGH viral load HIV Ab testing may be NEGATIVE CD4 may be normal ****PAINFUL MUCOCUTANEOUS ULCER (Shallow, discrete, white base) and GENERALIZED MACULOPAPULAR RASH include palms, and soles. LEUKOPENIA AND THROMBOCYTOPENIA Tx: Combo antiretroviral therapy partner notification and secondary prophylaxis

post-op atelectasis

2-5 days post op especially after thoracoabdominal surgeries, results from decreased lung compliance, as well as post op pain leading to hypoventilation, reduced coughs impaired mucus clearance. Smoking, obesity, lung or Neuro disease increases risk of post op atelectasis Increased work of breathing or hypoxemia. Increased alveolar-arterial gradient due to intrapulmonary shunting. CXR shows linear opacification in the bilateral lung bases If minimal respiratory secretions administer continuous positive airway pressure those with copious secretions more appropriately managed with aggressive pulmonary hygiene such as chest physiotherapy and suctioning.

congenital adrenal hyperplasia

21 Hydroxylase: Salt wasting in first week of life (VOMIT, DEHYDRATION, HYPOTENSION), Ambiguous genitalia (46XX) in girls, precocious puberty in boys LOW mineralocorticoids, Glucocorticoids (Hypoglycemia from lack of cortisol), Na (lack aldosterone), Aldosterone, cortisol HIGH Androgens, Potassium, 17-hydroxyprogesterone, Testosterone Tx: Glucocorticoids (HYDROCORTISONE) & mineralocorticoids (FLUDROCORTISONE), HIGH Salt diet, Psychosocial support 11b-Hydroxylase: HTN, Ambiguous genitalia in girls HIGH Mineralcorticoids, androgens, 11-deoxycorticosterone and 11 deoxycortisol, Sodium LOW Glucocorticoids, Potassium 17a-Hydroxylase: HTN, Ambiguous genitalia in boys, absent puberty. HIGH Mineralcorticoids, Glucocorticoids LOW Androgens, Potassium Autosomal Recessive

Gestational diabetes is checked for at what gestational age and with what screening test?

24 weeks, 1-hr 50 g OGTT The placenta secretes human chorionic somatomammotropin (HCS), similar in structure to growth hormone, and decreases maternal insulin sensitivity. Secretion of HCS peaks at 24-28 weeks, which is the optimal time to screen for gestational diabetes. A 1-hr 50 g oral glucose tolerance test is the best screening test. A positive 1-hr 50 g OGTT should be confirmed with a 3-hr 100 g OGTT.

Screening & Diagnosis gestational DM

24-48 weeks gestation -> Step 1: Administer 50g oral glucose load, check serum glucose 1 hr later -> If less than 140 then Gestation DM unlikely, BUT if >140 then need to check fasting serum glucose, administer 100g oral glucose load check each hour up to 3 hrs. Human Placental Lactogen Secretion Management: 1st line: Diet, 2nd Line: Insulin, Glyburide, Metformin Target: Fasting <95, 1hr: <140, 2hr: <120 Postpartum management: Fasting glucose at 24-72hr, 2hr 75g GTT at 6-12 week visit.

Prophylactic Administration of Anti-D Immunoglobulin for Rh (D)-Negative Patients

28-32 weeks <72hrs after delivery of Rh (D) + Infant <72hrs after spont abortion Ectopic Pregnancy Threatened abortion Hydatidiform Mole Chorionic Villus Sampling, Amniocentesis Abdominal Trauma 2nd & 3rd Tri bleeding External Cephalic Version Antepartum prophylaxis is NOT indicated if father is Rh (D) - because no risk as mom is also -, only give if parental status is unknown. POSITIVE antibody screening indicates that alloimmunization has already occurred and anti D immune globulin is not administered IF NEGATIVE Ab screen confirms lack of antigen exposure and is indication to proceed with immune globulin prophylaxis at 28 weeks gestation, this will neutralize any occult Rh (D) antigen exposure that may occur between the third trimester and delivery, the postpartum dose of anti-d immune globulin administered <72hrs after delivery reduces the risk of alloimmunization from fetomaternal hemorrhage associated with delivery. SHORT half life of 8 weeks so when given early in pregnancy still need to give another dose between 28 weeks and delivery

prenantal screening for Neural tube defect

2nd tri US, & Maternal Serum Alpha-Fetoprotein

Gestational thrombocytopenia

2nd-3rd trimester of pregnancy platelet count 70-150K no hx of previous thrombocytopenia resolves after delivery Due to hemodilution, and accelerated destruction of platelets Management: Serial Complete blood counts, repeat eval postpartum to ensure resolution

Prostate Cancer Screening

<55 = NOT recommended 55-69 = Consider screening with prostate specific antigen >70 or Life expectancy <10yrs = Not recommended Indolent, long preclinical phase. Most men who develop prostate cancer die from other causes. PSA (prostate Specific Antigen) commonly detects slow growing tumors, half of all screening detected cancers are over diagnosed.

confirmatory test for diabetes in pregnancy

3 hour OGTT —>95 mg/dL fasting —>180 mg/dL at 1 hr —>155 mg/dL at 2 hr —>140 mg/dL at 3 hr If one is abnormal, impaired glucose tolerance If two are abnormal, gestational diabetes

Palpable breast mass

<30yo: US +/- Mammogram (INCREASED BREAST DENSITY REDUCES SENSITIVITY)-> SIMPLE CYST: Needle Aspiration, COMPLEX CYST/MASS (SOLID): Image-guided core biopsy >30yo: Mammogram +/- US -> Suspicious for malignancy (ill defined borders, immobile, LAD, nipple discharge, skin changes, nipple inversion) -> Core biopsy

Prophylactic antibiotic treatment and Tympanostomy tide to reduce number of Acute Otitis Media Recurrences

> 3 episodes in 6 months or > 4 in 12

Screening for Diabetic Retinopathy

5 years after the original diagnosis of Type 1 DM at the time of diagnosis of Type 2 DM

Reversible causes of asystole/pulseless electrical activity

5Hs: 1. Hypovolemia 2. Hypoxia 3. Hydrogen Ions (acidosis) 4. Hypokalemia or Hyperkalemia 5. Hypothermia 5Ts: 1. Tension Pneumo 2. Tamponade 3. Toxins (narcotics, Benzo) 4. Thrombosis 5. Trauma

rolling over by

6 months

Adequate trial period for antidepressant

6 weeks

Full trial of antidepressants is

6 weeks and encourage him to continue taking the medications.

Medicare Program Coverage

65 & older, and those with permanent disability, End stage renal dz, neurodegenerative disorders (ALS) Part A: -Inpatient hospital services -Skilled nursing facilities -Hospice & Home Health Part B: -Outpatient services -Preventive care -Outpatient diagnostics (labs, Xrays) -Outpatient surgery Part C: -Allows private health insurance companies to provide medicare benefits Part D: -Prescription drug coverage

Lower Extremity Alignment

6M: Genu Varum 2Y: Straight 4Y: Genu Valgum (Knock-Knees; Valgus) >7Y: Straight Physiologic findings, reassurance and observation. Spont correction by age 7

Tetanus Prophylaxis

> 3 tetanus toxoid doses: -Clean or minor wound: Tetanus toxoid containing vaccine ONLY if last dose >10years ago, NO TIG -Dirty or severe wound: Tetanus toxoid vaccine ONLY if last dose >5years ago, NO TIG Unimmunized, uncertain, <3 tetanus toxoid doses: -Clean or minor wound: Tetanus toxoid vaccine only, NO TIG -Dirty or severe wound: Tetanus toxoid vaccine + TIG TIG provides passive and immediate but temporary immunity Tetanus toxoid containing vaccines provide active and prolonged but delayed immunity

risk of progression to chronic Hep C

75-85%

initial management of ischemic stroke

<4.5 hrs: Administer Thrombolysis >4.5-24hrs: NO Thrombolysis >24hrs: Not eligible for thrombolysis Obtain CTA of head and neck: -If Large Vessel Occlusion: Mechanical thrombectomy -Laerge Vessel occlusion ABSENT: Standard postischemic stroke management (antiplatelet therapy with aspirin, investigate for embolic source) Stroke patients develop abnormalities in swallowing lead to oropharyngeal dysphagia, aspiration to avoid dysphagia screening at bedside to determine optimal route of administration of meds. DVT and PE common causes of morbidity and mortality in stroke, especially with hemiparesis. DVT prophylaxis with intermittent pneumatic compression and Sub Q prophylactic dose of Heparin

chronic cough in children

> 4 weeks Initial evaluation SPIROMTERY (simple pulmonary function test performed in as cooperative child to detect obstructive airway disease (asthma), CXR is also useful

92% of all skin tissue samples with a positive test results were cancerous, 99% of all skin tissue samples with a negative test result were normal

92% is the PPV, and 99% is the NPV PPV describes the percentage of all tissue samples with a positive test results are cancerous NPV describes the percentage of all tissue samples with a negative test results that are normal Sensitivity describes the proportion of cancerous tissue samples for which the test is positive Specificity describes the proportion of normal tissue samples for which the test result is negative. Negative likelihood ratio describes the probability of a negative test result occurring in a cancerous tissue sample compared to a normal tissue sample Positive likelihood ratio describes the probability of a positive test result occurring in a cancerous tissue sample compared to a normal tissue sample

fever in returning traveler

<10 days: Typhoid fever, Dengue fever, Chikungunya, Influenza, Legionellosis 1-3 weeks: Malaria, Typhoid Fever, Leptospirosis, Schistosomiasis, Rickettsial disease >3 weeks: TB, Leishmaniasis

Common causes of secondary HTN by Age

<20: Renal Parenchymal Disease, Coarctation of Aorta 21-39: Hyperthyroid or Hypothyroid, Fibromuscular Dysplasia, Renal Parenchymal disease 40-64: Hyperaldosteronism, Hyperthyroid or Hypothyroid, OSA >65: Atherosclerotic renal artery stenosis, CKD

Pediatric Septic Arthritis

<3 months old: Staph Aureus, Group B Strep, Gram - bacilli >3months old: Staph aureus, Group A strep Acute on set joint pain, swelling, limited motion, refusal to bear weight, fever HIGH WBC, ESR, CRP Blood Culture Joint aspiration Effusion on US Tx: Joint drainage & debridement, IV Antibiotics (IV VANC=Gram + Coverage), reasons to add CEFOTAXIME or CEFTRIAXONE for Gram - coverage is if <3 months due to gram - bacilli, Unimmunized children due to H. Influenza Type B, Sexually active adults due to N. Gonorrhoeae

Central line associated blood stream infection is greatest when left in place

> 6days

Solitary Pulmonary Nodule (SPN)

>2cm independently correlates with >50% malignant probability If >0.8cm requires additional management or surveillance (Repeat CT in 3 m months) Factors increasing malignant probability: >2cm, Advanced age, Female, Smoker, FH, Upper lobe, Speculated radiographic appearance. Refer for biopsy or surgical excision. Thoracotomy or video assisted thoracoscopy (VATS) can be diagnostic and curative.

aortic atherosclerotic plaques can cause thromboembolic but greatest risk when

>4mm, ulcerated

MEN 2 A Vs B

A medullary thyroid cancer, pheochromocytoma, primary HyperPTH B Medullary thyroid cancer, pheochromocytoma, mucosal neuromas/marfanoid

Interpretation of areas under the ROC Curve

A Receiver Operating Characteristic Curve for a given diagnostic test plots sensitivity on the y-axis (1-specificity). The curve can help determine the best cutoff threshold (the value that determines if a given test result is positive or negative) to use depending on the optimal desired parameters for sensitivity and specificity. The Area under the curve of an ROC curve is the measure of the ability of a diagnostic test to discriminate between two patient states POSITIVE & NEGATIVE. The greater the area under the curve the closer the to 1 and better diagnostic performance of the test. Diagnostic tests with higher AUC perform better than tests with lower AUC

Anticoagulation management of preop Afib

A fib = high risk for HF, MI, Stroke, Death Direct Oral Anticoagulant (RIVAROXABAN): 1. Minimal surgical bleeding risk: STOP day of surgery, NO bridge 2. Low/Moderate/High risk: Stop 1-3 days prior, No bridge Vitamin K Antag (Warfarin): 1. Minimal: Continue, No bridge 2. Low/Mod/High: Thromboembolic risk low? Stop 3-5 days prior, no bridge .... BUT if mod/high risk of thromboembolic risk then stop 3-5 days prior and BRIDGE with Heparin

severe symptomatic anemia in ventilator weaning

A hemoglobin target >7 (restrictive strategy) reduces volume overload and lung inflammation exacerbated by blood products leading to improved outcomes.

catscratch disease

Bartonella Henselae (gram - Bacilli) Papule at scratch site, regional adenopathy, Fever Tx: Generally self limited, AZITHROMYCIN +/- CLINDAMYCIN (Anti staph and strep coverage)

Measles (Rubeola) - FEVER & RASH

Airborne Cough, Coryza, Conjunctivitis, fever, koplik spots, maculopapular rash spread from face to trunk and proximal extremities spares palms and soles Prevent with Live-Attenuated measles vaccine Tx: Supportive, Vit A for hospitalized patients

Smooth area of hair loss

Alopecia Areata Immune mediated tx with topical or intralesional corticosteroids (triamcinolone)

Terazosin

Alpha-1 Antag indicated in the treatment of benign prostatic hypertrophy

clonidine, guanfacine, methyldopa

Alpha-2 Adrenergic agonists treat ADHD in children and adolescents

Congenital problem with eye and ear, deafness, renal failure.

Alport Syndrome

Treating uncontrolled HTN in patients with Gout

AVOID Diuretics (HCTZ, Furosemide) because they decrease the fractional excretion of rate Angiotensin Receptor Blocker LOSARTAN has a mild uricosuric effect and is effective as first line tx for HTN with gout.

Lead Poisoning

Ab pain/constipation, Cognitive impair/behavior problems, Encephalopathy Obtain venous samples, Notify public health department, nutritional counseling, CHELATION IF >45 Levels as low as 10-20 are associated with cognitive impairment and behavior porbelmes (ADHD). Chelation therapy does not improve neuropsychiatric outcomes therefore primary prevention is critical in avoiding long term complications. >100 leadsa to acute encephalopathy (AMS, seizures) >70 leads to hemolytic anemia Chelating agents like Succimer and Edetate Calcium Disodium (EDTA) can lead to hepatotoxicity

Evaluating an acute abdomen when concerned for gallbladder disease or ruptured abdominal aortic aneurysm.

Abdominal Ultrasound

Osmotic Fragility testing

Abnormal in hereditary spherocytosis a genetic hemolytic anemia with spherocytes on peripheral smear and splenomegaly on exam.

maternal hypertension, abdominal trauma, cocaine or tobacco use, result in

Abruptio Placentae (Premature placental separation from the uterus prior to delivery)

Myasthenia Gravis is an autoimmune, postsynaptic, neuromuscular junction disorder caused by

Abs giants Acetylcholine receptors

Environmental risk factors for Acute Otitis Media

Absence of breastfeeding, Day care attendance, Pacifier use, expsoure to second hand smoke Even if smoking is restricted to outdoors, particulate matter will be brought indoors after accumulating in the hair and clothing. Breastfeeding first 6-12 months is PROTECTIVE

Young individual with darkening and thickening of the skin over neck and groin areas, feel itchy.

Acanthosis Nigricans Benign: Insulin resistant states (DM, Obesity, Polycystic Ovarian Syndrome) increased level of insulin and or insulin like growth factors stimulate epidermal and dermal proliferation. Malignant: GI or GU underlying neoplasm. Not obese, uncommon areas like mucus membranes, palms, soles.

HCV antibody testing, Positive test

Active, ongoing infection (chronic or acute), past infection that has resolved, False positive result Further testing required to document HCV RNA in blood. using HCV Nucelic Acid Testing (NAT) if positive than candidate for treatment with antiviral therapy

Botulinum toxin

Acts at Peripheral Nerve endings to inhibit release of Acetylcholine into the Synaptic Cleft Leads to inability to achieve a threshold end-plate post synaptic potential (action potential) Lead to neuromuscular junction failure and weakness, autonomic dysfunction with blurry vision and impaired pupillary response

Azithromycin + Ceftriaxone Treats

Acute Cervicitis Spotting, friable cervix, Mucopurulent discharge

Abdominal pain, leukocytosis, fever, nausea, vomiting, non bloody diarrhea

Acute diverticulitis

depressive symptoms develop in response to a psychosocial stressor (Not grief) and dont meet full criteria for a major depressive episode.

Adjustment Disorder

Hep B vaccine and Hep B Immune Globulin

Administered as post exposure prophylaxis to health care workers exposed to contaminated blood or body fluids within 12-24hrs of exposure NOT hrelfopul in established HBV infection

Streptococcal Pharyngitis (Strep Throat)

Age 5-15 Sudden onset sore throat, fever, ab pain, headaches No though, rhinorrhea or congestion TOnsilar erythema & exudate tender anterior cervical LAD palatal petechiae No oropharyngeal vesicles or ulcers Dx: Rapid strep antigen test if negative them throat culture necessary Tx: Penicillin or Amoxicillin Pen allergic: Cephalosporin (Azithromycin or Clindamycin) Complications: Peritonsillar abscess, cervical lymphadenitis, post strep glomerulonephritis, rheumatic fever

Slipped Capital Femoral Epiphysis

Adolescence and obesity (weightless helps prevent but not treat) Dull hip pain, referred knee pain, altered gait, limited internal rotation of hip. Posteriorly displaced femoral head on Xray Tx: Non weight bearing, Surgical splinting immediate delay in tx >24hrs can lead to Avascular necrosis, and future Osteoarthritis

proximal muscle weakness, facial plethora, easy bruising, purple abdominal striae

Adrenal Hyperplasia can cause Cushing syndrome (wasting of extremities and increased central fat)

Post-Op Hypoxemia

Airway obstruction/Edema: Immediate post op, Stridor, due to endotracheal intubation or pharyngeal muscle laxity Residual Anesthetic Effect: Immediate post op, Anesthetic agents, benzodiazepines, opiates, Diminished respiratory drive (Dec rate or tidal volume) Bronchospasm: Early post op, wheezing (Scheduled nebulizer bronchodilators) Pneumonia: 1-5 days post op, fever, elevated XBC, purulent secretions, infiltrate on CXR Atelectasis: 2-5 days post op, thoracoabdominal surgeries. Splinting, reduced cough, retained secretions. Pulmonary Embolism (thromboembolic or fat): UNCOMMON before 3 days, chest pain, tachycardia, little improvement on supplemental oxygen

Patients with chronic heavy alcohol and Insufficient Nutrition can develop

Alcoholic Ketoacidosis due to increased production of Ketoacids. Cause metabolic Acidosis Wirth an elevated anion gap due to ketoacids

cross-sectional study

An observation of all of a population, or a representative subset, at one specific point in time, used to describe risk and prevalence. ie: measuring efficacy of new test: use participants disease pos and neg subject them to both gold standard test and new test and measure efficacy of new test. Aims to describe relationships b/w a disease or condition and factors of interest that exist in a specified population at a given time. These studies can describe the prevalence of disease or condition and demonstrate association Cannot distingush b/w newly occurring and long -established conditions, nor can they identify causal relationships about what may have precipitated the disease or condition.

blood streaked stool in a well appearing infant <6months due to?

Anal fissures or food protein-induced allergic proctocolitis

dry skin, flushing, fever, mydriasis, AMS, urinary retention, decreased bowel sounds, autonomic instability, tremor on Diphenhydramine

Anticholinergic Toxicity

sudden onset right leg pain associated with diminished pulses, coolness to the touch and normal capillary refill = Viable acute leg ischemia. Also new-onset thrombocytopenia in the setting of heparin administration

Arterial thrombus due to type 2 heparin induced thrombocytopenia Risk greatest with unfractioned heparin, when used in periop setting. Due to autoantibodies against heparin-platelet factor 4 complexes leads to thrombocytopenia (platelet removal by reticuloendothelial system) and arterial/venous thrombosis (due to platelet activation) Type 2: Thrombocytopenia, Onset 5-10 days after heparin administration, New thrombosis. Type 1 is due to non immune mediated caused by heparin induced platelet clumping. Within 2 days of exposure, resolves spont over several days without intervention.

"Snapshot" Cross-Sectional Study

Assessment of a defined population at a particular time is used to estimate the prevalence of risk factors and disease simultaneously.

HPV vaccine

Associated with Cervical cancer, Vulvar & vaginal cancer, anal cancer, penile cancer, oropharyngeal cancer, anogenital warts, recurrent respiratory papillomatosis ALL FEMALES & MALES 11-26 (even if had genital warts, abnormal pap, or + HPV test) Not indicated in pregnancy targets 6& 11 for genital warts nd 16 &18 for cancer in girls prevents cervical cancer, in boys prevents anogenital and oropharyngeal cancers as well as herd immunity against cervical cancer in women.

3 days of cough, wheezing, SOB, whitish thin sputum, peak expiratory flow is 30% lower than baseline, in asthmatic

Asthma exacerbation Most common trigger is a viral upper respiratory infection. Tx: Systemic corticosteroid (prednisone 40-60mg daily for 5-10 days

Detection of Left to Right Shunt

Atrial: Superior/Inferior Vena Cava to Right Atrium: ATRIAL SEPTAL DEFECT (wide and fixed splitting of second heart sound), partial anomalous pulmonary venous drainage, ruptured sinus of valsalva, VSD with tricuspid regurgitation, Coronary fistula to right atrium Ventricular: Right atrium to Right Ventricle: VSD (HARSH-HOLOSYSTOLIC MURMUR with maximal intensity over LEFT THIRD or FOURTH INTERCOSTAL SPACES, PALPABLE THRILL), PDA with pulmonic regurgitation, Coronary fistula to right ventricle Great Vessels: Right ventricle to Pulmonary artery: PDA (Continuous murmur heard best in left infraclavicular area), aorta-pulmonary window

Renovascular HTN

Atrophic Kidney, Recurrent flash pulmonary edema, abdominal bruit, initial onset of severe HTN (>180/>110) at age >55 in setting of diffuse atherosclerosis NEED RENAL US

Reversal for cholinergic toxicity

Atropine Seen in organophosphate exposure from pesticides. Diarrhea, Urination, Miosis, Bradycardia, emesis, lacrimation, and salivation (DUMBELS)

Treatment for chlamydia

Azithromycin Asymptomatic cervicitis dx via nucleic acid amplification testing NOT evident on microscopy or Pap test

Tourette syndrome treatment

Behavioral therapy, Anti-DOPAMINERGIC Agents (Tetrabenazine (dopamine depleter), Antipsychotics (Risperidone, Aripiprazole), Alpha-2 Adrenergic receptor agonists (Clonidine, Guanfacine)

vertigo provoked by a change in position WITHOUT hearing loss

Benign Paroxysmal Positional Vertigo (BPPV)

calcium debris within the posterior semicircular canal

Benign paroxysmal positional vertigo nystagmus commonly seen

Treat extrapyramidal symptoms (dystonic reactions, Parkinsonism caused by high potency antipsychotic medications.

Benztropine

Breast discharge evaluation

Bilateral: Pregnancy Test, Galactorrhea Eval Unilateral: -<30yo: US +/- Mammogram ->30yo: US + Mammogram Most common cause of pathologic nipple discharge is a benign papillary tumor (papilloma) from breast duct lining.

Jaundice in first 2 months of life

Biliary Atresia conjugated hyperbilirubinemia from progressive obstruction of the extra hepatic biliary tree.

Hypomanic (>4days), & Depressive episodes (>2weeks)

Bipolar 2

Involuntary eye closure that can be provoked by external stimuli (bright light or irritants). Elderly Female.

Blepharospasm (Focal Dystonia) Tx: Botox injections

Treatment for generalized anxiety

Buspirone

Case Fatality Rate (CFR) Vs Mortality Rate

CFR: Proportion of people with a particular condition who end up dying from the condition Mortality Rate: Probability of dying from a particular disease in the general population

Thyrotoxicosis in older patients

CV: A fib, Tachycardia, HF Neuro: Apathy, confusion, tremor, proximal muscle weakness/wasting Endocrine: Proptosis, lid lag, thyromegaly GI: Decreased appetite, constipation Apathetic Thyrotoxicosis is an atypical presentation of hypothyroid in older patients characterized by lethargy, confusion, depression. Misdiagnosed as dementia. Dx: Thyroid Function Test

Lipid Screening in Children

CVD RISK FACTORS: Obesity, DM, HTN, Cigarette Use, + FH (parent or grandparent with dyslipidemia or premature CVD <55M, <65F) Yes to above: Serial screening (q1-3y starting at age 2) No to above: Universal screening between 9-11 & 17-21 (AVOID IN MIDPUBERTY, natural variations in lipid levels) Abnormal non fasting lipid panel results (Total cholesterol >200m LDL>130, HDL<40) confirmed with a fasting lipid panel. Management begins with counseling on lifestyle changes (low sat fats, daily exercise) Pharmacotherapy with statins considered for patients >10 with persistent dyslipidemia after 6months of lifestyle changes

Thick "cottage cheese" discharge Normal pH (3.8-4.5) Pseudohyphae

Candida Vaginitis Tx: Fluconazole

HIGH TSH, T3, T4, Alpha Subunit

Central Hyperthryoidism, due to TSH Secreting Pituitary Adenoma Pituitary mass on MRI Minimal or no suppression of TSH by exogenous thyroxine Elevated sex hormones binding globulin Normal thyroid hormone-binding globulin Normal thyroid hormone receptor beta gene Tx: Somatostatin Analog, Transsphenoidal surgery

Treatment for moderate skin infections like Cellulitis

Cephalexin

Subperiosteal bleed that does not cross suture lines

Cephalohematoma common ion instrumental delivery and resolves spontaneously without sequelae.

Sharp pain at base of the thumb. pain reproduced by ulnar deviation at wrist, especially when the thumb is held in opposition across the palm (Finkelstein test)

DeQuervain Tenosynovitis Overuse of the extensor policies breves and abductor pollicis longs tendon,

stress urinary incontinence (SUI)

Decrease urethral sphincter tone &/or Urethral hyper mobility Tx: pelvic floor exercise, caffeine restriction, weight loss, smoking cessation, limit water intake , mid urethral sling if all other conservative measures fail

Patients with Hypoalbuminemia can have

Decreased total plasma calcium Ionized serum calcium (physiologic active form) is hormonally regulated and remains stable. Asymptomatic, measured total plasma calcium does NOT correlate with there physiologically active calcium. Serum calcium decreases by 0.8 for every 1g/dl decrease in serum albumin. Calcium hemostasis: albumin-bound (45%), Ionized (40%), bound to inorganic and organic anions (15%)

Side effect of phenytoin

Decreases folate levels

embolization of cholesterol crystals from an atherosclerotic plaque (atheroemboli)

Digital ischemia and ischemia of the arterioles of the skin (livedo reticularis)

Contrasinidated in treatment of Hypertrophic cardiomyopathy with LVOT obstruction

Dihydropyridine Calcium channel Blockers (Amlodipine) & ACE-I because they reduce the LV blood volume. Venous dilation reduces LV preload and arterial dilation reduces after load. both reduce LV blood volume and can worsen LVOT obstruction and symptoms in HCM.

Preop management of anticoagulants

Direct Oral Anticoagulants (DOACs) discontinued 1-3 days before surgery and DO NOT require bridging anticoagulation. Bridging therapy with low molecular wight heparin necessary for patients on WARFARIN

PPV & NPV depend on

Disease prevalence

Acute angle glaucoma confirmed by

Elevated Intraocular pressure

HTN Stages and Treatment

Elevated: 120-129/<80: Lifestyle changes: Weight loss, exercise, dietary changes (reduced salt, alcohol in moderation, DASH Diet) Stage 1: 130-139/80-89: Lifestyle changes + 1 AntiHTN med Stage 2: >140/>90: Lifestyle changes + 2 AntiHTN meds

In patients with sickle cell disease, are at increased risk for bacteremia from

Encapsulated organisms due to functional asplenia bacteria covered with a polysaccharide capsule. Examples of such bacteria include Streptococcus pneumoniae, Klebsiella, Haemophilus influenzae, Neisseria meningitidis, and Pseudomonas aeruginosa. All SCD patients with fever should have blood cultures drawn and be started on antibiotics.

first step in evaluation of postmenopausal bleeding

Endometrial biopsy, to exclude malignancy

Heavier menstrual bleeding, new onset, prolonged >8days and increased frequency with an inter menstrual interval of <21 days

Endometrial hyperplasia or cancer Risk factors: BMI>30, Age >45, Immediate IUD placement that can mask bleeding symptoms Eval: Endometrial biopsy, pelvic ultrasound, Pap testing, sexually transmitted infection testing, FSH, TSH, and prolactin levels.

Chronic pelvic pain, immobile uterus, pelvic nodularity

Endometriosis

Deep dyspareunia, dysmenorrhea, dyschezia, immobile uterus, tender adnexal mass and nodularity along the posterior cul-de-sac

Endometriosis Dx: Diagnostic Laparoscopy

Pelvic pain with exacerbation by bowel movements (Dyschezia), rectovaginal modularity on pelvic exam.

Endometriosis Ectopic implantation of endometrial glands (extrauterine-Ovaries, cut-de-sac, broad ligament, uterosacral ligaments, Fallopian tubes, sigmoid colon Dyspareunia, Sysmenorrhea, Chronic pelvic pain, Infertility, dyschezia, cyclic dysuria, hematuria Immobile uterus, cervical motion tender, adnexal mass, rectovaginal septum, posterior cul-de-sac, uterosacral ligament nodules Dx: Direct visualization and biopsy Tx: OCP, NSAIDs, GnRH agonists, Surgical resection CAUSES PELVIC ADHESIONS AND INFLAMMATION WHICH LEADS TO INFERTILITY AND CHRONIC PELVIC PAIN

Corneal Abrasion Management

Eye pain & foreign body sensation: -Ocular perforation? corneal infiltrate? Corneal Ulcer? Irregular pupil? 1. YES? -Urgent Opthamology consult 2. NO? -Traumatic or foreign body abrasion? irrigate, topical antibiotics (erythromycin, Polymyxin/Trimethoprim) -Contact Lens Abrasion? Topical antipseudomonal antibiotics (ofloxacin, Ciprofloxacin, Tobramycin), no eye patch, follow up in 24hrs to ensure no ulcer eye shield or patching can press foreign bodies against the cornea and should be avoided

Risk Factors for Colorectal Cancer (CRC)

FH, Polyposis Syndromes (Familial Adenomatous Polyposis), IBS, African American Alcohol, Tobacco (>30years), Obesity EVEN moderate alcohol 2-3 drinks/day = Inc risk, highest risk in heavy drinkers >4 drinks /day

Hyperthyroid meds for Graves while pregnant

FIRST TRIMESTER: PROPYLTHIOURACIL (liver failure so switch back to methimazole after first trimester) SECOND/THIRD TRIMESTER: METHIMAZOLE (Teratogenic in first trimester; scalp defects, tracheoesophageal fistula, choanal atresia)

Most sensitive examination finding for scoliosis

Forward bend test To estimate the severity of curvature a scoliometer is placed along spine measuring the angle of trunk rotation. If >7 degrees = clinicaly significant scoliosis, therefore require further eval with Cobb angle measures which is the gold standard to determine diagnosis and tx. Cobb angle <10 degrees = normal so no follow up needed, if >10 degrees = SCOLIODID = use of back brace, >49 is severe and therefore needs surgical eval for possible spinal fusion Once puberty and skeletal maturity complete progression is typically minimal and tx not required. Abnormal scoliometry or obvious deformity on exam requires a PA and Lateral Xray of the spine

Gestational DM

Human Placental Lactogen Secretion Screen: 24-28 weeks gestation with 1hr 50g GCT, 3hr 100g GTT 1st line: DIET, 2nd Line: Insulin, Glyburide, Metformin Goals: Fasting <95, 1hr postprandial <140, 2hr postprandial <120 Postpartum management: Fasting glucose 24-72, 2hr 75g GTT at 6-12 week visit

Excess secretion of PTH-related peptide causes

Humoral Hypercalcemia of Malignancy Severe hypercalcemia and suppressed PTH

chorea, depression, psychosis, suicide, abnormal eye movements, slow cognitive decline

Huntington Disease

Melasma (hyperpigmentation disorder that presents with irregular brown macula's and patches symmetrically on the face) Tx?

Hydroquinone

Reduce frequency of vas0-occlusive episodes in patients with Sickle Cell Disease

Hydroxyurea takes several months.

Focal Radioiodine Uptake (HOT NODULE)

Hyperfunctioning adenoma

Myosin gene mutation

Hypertrophic Cardiomyopathy

most common caused of sudden cardiac death in young athletes in the US, with a systolic murmur that increases with standing

Hypertrophic Cardiomyopathy

Conditions that alter Thyroxine Binding Globulin Concentration

INCREASED TBG: Estrogens (Pregnancy, OCP, Hormone replacement therapy), Acute Hepatitis DECREASED TBG: Androgenic hormones, High dose glucocorticoids/hypercortisolism, Hypoproteinemia (nephrotic, starvation), Chronic liver dz T4 & T3 are circulating bound to TBG. Active free thyroid hormone is cleared by kidneys and binding proteins ensure adequate availability for delivery to peripheral tissues. HIGH Estrogen (Pregnancy & OCP) stimulate hepatic synthesis of TBG. Patients with normal thyroid function can increase thyroid hormone production to saturate the additional binding proteins but those with primary hypothyroid are unable to increase thyroid hormones, and therefore OCP use in these patients can induce a hypothyroid state. Therefore need an increased dose of levothyroxine when starting OCP or becoming pregnant. Check serum TSH weeks after starting. And in pregnant increase 30% and TSH checked every 4-6 weeks.

acute symptomatic hypocalcemia (Oral paresthesia, carpopedal spasm, tetany, seizures) treat with

IV Calcium Gluconate

Treatment for Von Willebrand Disease

IV Desmopressin (synthetic analog of ADH that increases circulating levels of factor VIII and Von Willebrand Factor.

Management of Diabetic Ketoacidosis

IV Fluids: Rapid infusion of 0.9% NS, ADD Dextrose 5% when serum glucose <200 INSULIN: Start IV Insulin Infusion (HOLD If K <3.3), Switch to SQ (Basal Bolus) once able to eat, glucose <200. Overlap SQ & IV by 1-2hrs POTASSIUM: Add IV K if serum K <5.3, HOLD If >5.3 BICARB: pH <6.9 PHOSPHATE: <1, cardiac dysfunction or respiratory depression Short Acting Insulin (Lispro, Aspart, Glulisine) alone not sufficient in hospitalized patient, BASAL insulin-Long acting Insulin- (Detemir, Glargine) should be added

Advanced HIV started on tx for active pulmonary TB and HIV Infection. Six weeks later develops recurrent fever, cough, worsened pulmonary infiltrate suggesting

Immune Reconstitution Inflammatory Syndrome (IRIS) post immune recovery that quickly occurs after the initiation of antiretroviral therapy. Self limited and requires no alteration top ongoing treatment. anti inflammatory medications are added if symptoms bothersome.

recent viral infection. Asymptomatic petechiae and purpora. mucus membrane bleeding. Platelet count <100,000.

Immune Thrombocytopenia Autoimmune platelet specific autoantibodies Tx: Mild (asymptomatic or cutaneous bleeding (petechiae, Purpura)-No bleeding: Observe Moderate-Severe bleeding (mucosal bleeding, gingival bleeding, epistaxis, internal hemorrhage, hematochezia, intracranial hemorrhage): IV Immune Globulin. if not responsive to tx then splenectomy

petechiae and ecchymoses, Epistaxis, Hematuria, Preceding a viral infection. Isolated Thrombocytopenia.

Immune Thrombocytopenia. Anti-Platelet Autoantibodies (Against GPIIb/IIIa) Tx: Glucocorticoids, IVIG, or Anti-Rh (D) if bleeding or platelets.

Serum Sickness Like Reaction

Immune complex mediated hypersensitivity rx (TYPE III) when circulating Antibodies combine with antigen in blood and tissues and overload normal clearance mechanisms. This then activates complement and causes disease. Antibiotics (Beta Lactam, Sulfa), Acute Hep B (prodromal, preicteric phase of acute infection and resolves with onset of jaundice) 1-2 weeks after exposure, fever, skin rash, polyarthralgia Remove/avoid offending agent, supportive care, steroids or plasmapheresis if severe

Ginseng

Impoved mental performance SE: Bleeding

Primary Nocturnal Enuresis

Inability to achieve nighttime dryness >5yo first step in manasgemtn is enuresis alarm

Infertility

Inability to conceive after >12months Male: Semen Analysis (Variococele, Klinefelter) Ovulatory function: Midluteal Phase (day 21) Progesterone Level Ovarian Reserve: Day 3 FSH & Estradiol Levels, Clomiphene Citrate Challenge test, Antral Follicle count, Antimullerian hormone Fallopian tube Potency: Hysterosalpingogram Uterine Cavity Evaluation: Sonohysterogram

Pediatric Immunizations in the US

Inactivated (Killed): Polio, Hep A, Influenza (injection) Toxoid (inactivated toxin): Diphtheria, Tetanus Live Attenuated: Rotavirus, Measles, Mumps, Rubella, Varicella Subunit/Conjugate: Hep B, Pertusis, H. Influenza B, Pneumococcal, Meningococcal, HPV

Hand Grip: Inc LV afterload

Inc AR, MR, VSD Dec MVP and HCM, AS

Fever, Arthralgia, Murmur

Infective Endocarditis

Pharmacotherapy for chronic HF with Reduced Ejection Fraction

Initial: Angiotensin receptor or ACE-I, Beta Blocker (Metoprolol, Carvedilol, Bisoprolol), Diuretics (Loop +/- Metolazone) Step 2: Aldosterone Antag (Spironolactone) Step 3: SGLT-2 Inhibitor-in proximal convoluted tubule to promote renal excretion of glucose-osmotic diuresis and natriuresis-symptomatic relief in HF (Dapagliflozin) Supplemental: Isosorbide Denitrate + Hydral, Digoxin

Heat stroke

Initiation of rapid cooling, naked patient sprayed with tepid water mist or covered with a wet sheet while large fans circulate air to maximize evaporative heat loss. Patients core temp should be dropped by 0.2C/min

Intolerable side effects of the SSRI (Fluoxetine)

Insomnia and Jitteriness an alternative would be ESCITALOPRAM for SSRI responders otherwise switch classes

tx for cutaneous T cell Lymphoma and mycosis fungoides

Interferon Alpha

internal vs external validity

Internal: Describes Causality (Increased as study is more tightly controlled, Dec as study becomes more like the real world). Biased by confounders, history, maturation, measurement, regression towards mean, repeated testing, selection External: Describes Generalizability (Dec as study becomes more tightly controlled, Inc as study becomes more like real world). Biased due to artificial research environment, measurement, non representative samples

treat allergic rhinitis

Intranasal Glucocorticoids (fluticasone) associated with upper airway cough syndrome

Hgb <11, LOW MCV, HIGH RDW

Iron deficiency anemia

A nonsignificant result (Confidence interval that cross the null) does not imply

Lack of power

Lateral Upper eyelid laceration can predispose to injury of

Lacrimal gland

Metformin can result in

Lactic Acidosis particularly in acute renal failure

maintenance therapy for bipolar disorder

Lamotrigine takes many weeks to titrate to effect

Consolidated Omnibus Budget Reconciliation Act (COBRA)

Legal framework in which patients who have left their employer may continue to receive benefits on their previous employers group health insurance. provided for a limited period under certain circumstances (transition between jobs, death, divorce)

Boys 3-12 yo with mild hip pain and a limp

Legg-Calve-Perthes disease or idiopathic avascular necrosis of the femoral head

chest pain, hemoptysis, lobar or interstitial infiltrate, Fever, GI (N, V, Diarrhea) prior to onset of pulmonary symptoms

Legionella Prophylaxis with levofloxacin

heavy menstrual bleeding & dysmenorrhea, irregular uterus shape on exam

Leiomyomas Uterine fibroids (intramural, Submucosal, Subserosal, intracavitary)

Prostate cancer screening. Benefits of new screening tool will be overestimated due to detection of a disproportionate number of slowly progressive, benign cases. Which bias?

Length Time Bias Increased detection of less aggressive cases giving a false increase in survival Slowly progressive cases asymptomatic for a longer time likely to be diagnosed based on screening rather than clinical symptoms.

When subjects with a rapidly progressive form of disease are less likely to be detected by screening compared to those with slowly progressive disease

Length time bias Patients with slowly progressive disease tend to be asymptomatic for a longer period increasing the likelihood that they will be diagnosed based on screening rather than clinical symptoms. Gives impression that screening improves disease survival whereas in actually it only identifies more benign cases

subjects with a rapidly progressive form of disease are less likely to be detected by screening compared to those with slowly progressive disease

Length time bias overstate the benefit of screening on length of survival and mortality.

Rheumatoid pleural effusion

Leukocytes <5000, Glucose <60, pH <7.3, HIGH LDH

Excellent pneumococcal drugs

Levofloxacin, gemifloxacin, and moxifloxacin

skin lesions are shiny, discrete, intensely pruritic, polygonal-shaped violaceous plaques and papules on flexural surfaces of the extremities. Wrist common site. Whitish, lacy pattern (Wickham Striae) in the mouth tongue and buccal mucosa or as papular atrophic erosive lesions

Lichen Plans (Activated T-Cells directed against basal keratinocytes of the epidermis) In association with liver disease secondary to HEP C infection. Anti Hep C Abs detected in some patients with LP. Mainly a clinical dx but to confirm dx punch biopsy

Upper GI bleed and Lower GI bleed separated by

Ligament of Trietz BRIGHT RED BLOOD from rectum = LOWER GI BLEED Hematemesis & Melena = UPPER GI BLEED (HD unstable, orthostasis, BUN/Cr Ratio >20:1)

angioedema and urticaria associated with what medication

Lisinopril

increased lumbar pain on extension of the spine, improves when sit down or bend forward

Lumbar Spinal Stenosis Dx is best confirmed with MRI of spine (Encroaching of osteophytes at facet joints, hypertrophy of ligamentum flavum, protrusion of intervertebral disk result in narrowing of spinal canal)

Any patient with syphilis who has neurologic symptoms (Headache, blurred vision) requires

Lumbar puncture to evaluate for neurosyphilis HIV + patients at greatest risk for neurosyphilis especially when CD4 <350, and rapid plasma reagin titers are >1:128

Common Primary Sites of origin of brain metastasis

Lung, Breast, Melanoma, Colon Cancer

Major Depression Vs Grief

Major Depression: ->2 weeks, >5 of 9 symptoms: Low mood, Anhedonia, Sleep disturbance, appetite change, low energy, psychomotor changes, guilt/worthlessness, concentration difficulty, suicidal ideation. Grief: -sadness more specific to thoughts of deceased -waves of grief at reminders -self esteem preserved -thouhgt of dying involve wish to Join the deceased

Loss of interest, increased irritability, insomnia, fatigue, impaired concentration, excess guilt for more than 2 weeks, increased irritability,

Major depression Tx: SSRI that treats depression and insomnia = CITALOPRAM

Breast cancer screening

Mammography started in all women age >50

fibrillin gene mutation

Marfan syndrome

Nonejection Click and murmur that vary in timing depending on body position

Mitral Valve Prolapse Nonejection click due to snapping of mitral chord as the valve cusps extend into atrium during systole followed by a systolic murmur of mitral regurgitation Stand, Valsalva (Decreased venous return): LOW LVEDV: critical prolapse point during systole, earlier click and murmur Squat, supine leg raise (Increased venous return): LVEDV HIGH: No click, prolapse doesn't occur

single or multiple non ejection clicks and or mid to late systolic murmur of mitral regurgitation, apical impulse is displaced

Mitral Valve prolapse

accentuated S1 (MV closure) opening snap after S2, low pitched mid diastolic murmur heard at cardiac apex

Mitral stenosis

Effects of Natriuretic Peptides

Myocardial stretch from volume overload leads to increased ANP (atrial natriuretic peptide) & BNP (brain natriuretic peptide) which leads to INC GFR, Diuresis, Renin Inhibition, Decreased Aldosterone, Vasodilation, Increase capillary permeability Neprilysin breaks down ANP and BNP however Sacubitril inhibits Neprilysin and therefore prevents breakdown. Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril-Valsartan) results in BNP accumulation therefore N-terminal proBNP not degraded by neprilysin is a more accurate marker of volume expansion.

Statin medications are infamous for leading to

Myopathy

↑ MS-AFP:

NTD, ventral wall defect, twin pregnancy, placental bleeding, renal disease, sacrococcygeal teratoma, dating error. Dates confirmed by ultrasound: Next step in management: For ↑ MS-AFP: amniocentesis for AF-AFP leveland acetylcholinesterase activity For ↓ MS-AFP:

Hyperkalemia results in

Nausea, Viomiting, Systole and ECG changes

D-Dimer Test

Negative effectively rules out PE

Nuclear acid amplification test (NAAT) is the test of choice for

Neisseria gonorrhoeae

Proteinuria, hypoalbuminemia, hyperlipidemia, hyperlipiduria, edema.

Nephrotic Syndrome

Cafe au lait spots

Neurofibromatosis

Bilateral spillage from Fallopian tubes on Hysterosalpingogram

Normal indicating no tubal obstruction

Cognitive impairment, Urinary Incontinence, Abnormal Gait (Magnetic gait)

Normal-Pressure Hydrocephalus

Zidovudine, Didanosine, Stavudine, Lamivudine, Abacavir, Emtricitabine, Tenofovir: Class of drugs and Side Effects?

Nucleoside Reverse Transcriptase Inhibitors SE: Lactic acidosis

number of people who must be exposed to a treatment to cause harm to 1 person who otherwise would not have been harmed

Number Needed to Harm NNH=1/Absolute Risk Increase(ARI) ARI=Rate of adverse event in tx-Rate of adverse event in placebo

Number needed to treat (NNT)

Number of patients who need to be treated to prevent 1 additional bad outcome. 1/(Absolute Risk Reduction=Control rate-Treatment rate)

HIV positive people with oral thrush need prophylaxis for what at any CD4 count.

PCP with Dapsone

treatment for bleeding esophageal varicose in a pt with cirrhosis

OCTREOTIDE

If hyperthyroidism is diagnosed in FIRST TRIMESTER of pregnancy, preferred medication for tx?

ONLY PTU (Propylthiouracil) if hyperthyroid is diagnosed in FIRST TRIMESTER of pregnancy as Methimazole was teratogenic.

Absence or Petit mal seizures, Therapy

Ethosuximide

Fever, abdominal pain, purulent cervical discharge and cervical motion tenderness classic presentation of

PID Acute complications: Tube-ovarian abscess, pyosalpinx, Perihepatitis (Hugh-Curtis Syndrome)

Positive likelihood ratio Vs Negative

PLR: Probability of an individual with the disease testing positive divided by the probability of an individual without the disease testing positive : LR+ = sensitivity/(1-specificity) LR+ = prob of dz pt testing +/prob of non dz testing + NLR: Probability of an individual with the disease testing negative divided by the probability of an individual without the disease testing negative : LR+ = sensitivity/(1-specificity) LR- = prob of dz pt testing -/prob of non dz testing -

Indications for implantable cardioverter-defibrillator placement in Hypertrophic Cardiomyopathy

PREVENT SUDDEN CARDIAC DEATH Alcohol septal ablation is reserved for persistent symptoms refractory to medical therapy and can increase risk of sudden cardiac death Primary Prevention: -FH of sudden cardiac death -Syncope -Nonsustained VT -Hypotensive BP réponse to exercise -Extreme LV hypertrophy (>3cm) Secondary: -Survivor of cardiac arrest -sustained spont ventricular arrhythmias

Hypercalcemia of malignancy

PTHrP: SCC, Renal & Bladder, Breast & Ovarian. Bone Metastasis: Breast, MM. Increased Osteolysis. Dec PTH,PTHrP,Vit D 1,25-Dihydroxyvitamin D: Lymphoma. High Calcium Absorption. LOW PTH, HIGH Vit D

Xray of bones with thickening of outer cortex, bowing, sclerotic lesions, increased uptake on technetium bone scan. bony pain.

Paget Disease of Bone Osteoclast abnormality leading to increased bone turnover and abnormal remodeling. Normal Calcium, Elevated Alk Phos Tx: WHEN SYMPTOMATIC with BISPHOSPHONATES (Zoledronic Acid, Alendronate, Risedronate), If cant tolerate then switch to CALCITONIN

Management of Vertebral Compression Fracture

Pain worse with sitting or spinal extension, midline spinal tenderness on exam Pain Control: NSAID, Calcitonin (second line), AVOID muscle relaxants Resume normal activity, avoid excess bed rest, order PT for gait training/core strengthening Evaluate and tx underlying osteoporosis with DXA & Bisphosphonates

Brief hyperthyroid phase, Small contender goiter, Sport recovery

Painless Thyroiditis (Silent) + TPO antibody LOW Radioiodine uptake

Test the difference between 2 paired means, patients serve as their own control (Mean BP before and after treatment in the same subjects

Paired T-Test

Awake intubation

Patient independently maintains upper airway tone and spont ventilation while airway visualized. VS Rapid Sequence Intubation Fully anesthetized and paralyzed causing loss of all upper airway tone, protective airway reflexes and respiratory drive. PREFERRED DRUG FOR AWAKE INTUBATION = KETAMINE (phencyclidine Derivative) Provides dissociation, amnesia, and analgesia while maintain upper airway tone, protect airway reflexes and reparatory drive. Also causes sympathetic Surge (by inhibiting reuptake of catecholamines) that increases blood pressure and causes bronchial smooth muscle relaxation.

Autoimmune disease in 2-3 trimester with pruritis that precedes a truncal rash. Periumbilical, urticarial papule and plaques that develop into vesicles and bullae. Rash spreads over entire body but spares the mucus membranes.

Pemphigoid Gestationis Ab reaction to basement membrane 2-3rd tri prodromal pruritis periumbilical papules and plaques rapid eruption of tense bullae spares mucus membranes Dx: Clinical &/or Biopsy Tx: HIGH POTENCY TOPICAL STEROIDS (TRIAMCINOLONE), Antihistamines (LORATIDINE, CETIRIZINE) Obstetric complications: Prematurity, Fetal growth restriction, neonatal pemphigoid gestationis Resolves after delivery

Beta-lactam antibiotics

Penicillins Cephalosporins Carbapenems Monobactams-aztreonam inhibit the cell wall by binding to the penicillin-binding protein

varicella-zoster (shingles) Vaccine

everyone age >50

Diabetic Ketoacidosis in Children

Polyuria/Nocturia, Polydipsia, Polyphagia, vomiting, abdominal pain, weight loss, fatigue, Kussmaul Respirations (deep, rapid breathing), dehydration Glucose >200 Bicarb <15 pH <7.3 Anion gap >14 Serum/Urine Ketones Severe DKA = pH <7.1, Bicarb <5 and AMS. Complications = Cerebral Edema Tx: 10 ml/kg isotonic fluid bolus over 1 hr, Insulin infusion + isotonic fluids with potassium (Insulin moves potassium intracellularly and causes Hypokalemia)

Calcifications within the gallbladder wall

Porcelain Gallbladder due to chronic Cholelithiasis. Increased risk for gallbladder cancer and require prophylactic cholecystectomy.

painless blisters, increased fragility of the skin on dorsal surface of the hands, facial hypertrichosis and hyperpigmentation

Porphyria Cutanea Tarda from deficiency of Uroporphyrinogen Decarboxylase Dx with elevation in Urinary Uroporphyrins tx: Phlebotomy or Hydroxychloroquine, IFN Alpha in those wit Hep C infection

Direct Coombs test

Positive in Autoimmune Hemolytic Anemia, associated with SLE

medical errors

Preventable Adverse Event: Human or system error (wrong diagnosis, wrong drug selection) Negligent Adverse Event: Preventable event caused by clear deviation from standard of care (drug administered to pt with known allergy) Nonpreventable adverse event: Unforeseen event not preventable by following established standards of care (rare adverse effect of appropriately administered drug) Sentinel Event: Serious preventable error causing irreversible patient harm or death (wrong site surgery) Near-Miss Event: Preventable event that is intercepted before harm reaches patient (Nurse catches miscalculated ode of med before administered to partient.

primordial prevention

Prevention of risk factors themselves. Discouraging children from adopting harmful lifestyles.

Amenorrhea <40yo, hot flashes, HIGH FSH, LOW ESTROGEN

Primary Ovarian Insufficiency -idiopathic, Turner syndrome, Fragile X Syndrome (FMR1), Autoimmune oophoritis, anticancer drugs, pelvic radiation, galactosemia Management: Estrogen therapy-Conjugated equine estrogen (with progestin if intact uterus-Medroxyprogesterone acetate)- to reduce risk of endometrial cancer Estrogen therapy can relieve hot flashes, vagina dryness and minimize bone loss and continued until normal menopause age of 50, after that increased risk of venous thromboembolism, coronary heart disease

Indications for Statin Therapy to prevent atherosclerotic cardiovascular disease

Primary Prevention: LDL>190, >40yo with DM, = High intensity Statin

Hyponatremia, Hyperpigmentation, weight loss, hypotension, hyperkalemia.

Primary adrenal insufficiency treat with glucocorticoids

useful in tx of mild to moderate Alzheimer dementia

RIVASTIGMINE (Cholinesterase inhibitor)

Relative Risk (RR)

RR = (Risk of developing a disease in exposed/ Risk of developing same disease in unexposed group) RR<1 = Decreased risk RR=1 =No difference RR>1=Increased risk

Breast cancer treatment for post menopausal women due to estrogenic effects on bone and anti estrogenic effects on breast and uterus.

Raloxifene (INCREASE risk of hot flashes and increased risk of venothromboembolism)

Two Step Serology Testing for Syphilis

Rapid Plasma Reagin + Fluorescent Treponemal Ab Absorption test

steroid 5 alpha reductase deficiency

Rare autosomal recessive disorder that can cause 46 XY individuals to have external female appearing genitalia with clitoromegaly.

Relative Risk (RR)

Ratio of the probability if an event occurring in the treatment group compared to the control group RR=Treatment Rate/Control Rate

Non-REM sleep Arousal Disorders

Recurrent incomplete awakenings from non-REM sleep with: Sleepwalking, and sleep terrors. Little or no dream recall, amnesia for episodes 4-12yo and resolves over 1-2 years. Self limiting Low dose benzo at bedtime if frequent, persistent and distressing

TMP/SMX MOA

folate antagonist

JVD, bibasilar crackles, pulmonary vascular congestion, biatrial enlargement, pulmonary artery HTN

Restrictive Cardiomyopathy

Reduced total lung capacity, FEV1 and FVC decreased. Normal FEV1/FVC ratio,

Restrictive Lung Disease (Interstitial lung disease, obesity, hypoventilation syndrome)

retrospective cohort study

Review past records two groups + and - risk factors Compare disease incidence back in time

Fetal anemia risk factors

Rh Alloimmunization and in utero infection (Parvo B19)

>50yo, fair skinned, single or multiple lesions well-demarcated, pigmented, round or oval, dull or verrucous surface

Seborrheic Keratosis Benign epidermal tumor due to proliferation of immature keratinocytes "STUCK-ON" Appearance Multiple pruritic SKs (LESER-TRELAT SIGN) associated with malignancies (lung and GI tumors) Dx based on appearance, NO treatment symptomatic or cosmetically disfiguring can be treated with cryotherapy or removed by curettage/shave excision or electrodessication

Onset <30, Acute BP increase in pt with previously stable values, Evidence of End-Organ Damage (HF, retinal damage), severe or resistant HTN (uncontrolled despite 3 drug regimen)

Secondary HTN

Sensitivity

Sensitivity = TP / (TP + FN)

Anxiety, Agitation, delirium, diaphoresis, HTN, Tachycardia, Hyperthermia, hyperactive bowel sounds, tremor, myoclonus, hyperreflexia. On SSRI and MAOI

Serotonin Syndrome Drug interactions SSRI (Fluoxetine) and MAOI (Phenelzine). There needs to be a washout period before switching at least 14 days for most SSRI but 5 weeks for Fluoxetine due to long half life. Can also occur if combination of SSRI, TCA and Tramadol, Overdose of serotonergic meds or abuse of serotonergic drugs like MDMA tx: DC all serotonergic meds, Supportive care, sedate with benzodiazepines, Serotonin antagonist (CYPROHEPTADINE)

effusion in the middle ear canal in absence of infection and inflammation. Follows episodes of suppurative otitis media

Serous Otitis Media

Serum marker for Medullary Thyroid Cancer

Serum Calcitonin

most common cause of stroke in pediatric patients

Sickle Cell Disease

Treatment of Helicobacter Pylori Infection

Standard Triple Therapy: PPI + Clarithromycin + Amoxicillin for 10-14 days Modified Triple If allergic to penicillin: PPI + Clarithromycin + Metronidazole for 10-14 days Quad Therapy (If tx failure and macrolide or metronidazole resistant): PPI + Bismuth + Metronidazole + Tetracycline for 10-14 days H. Pylori infection risk factor for PUD, Gastric Cancer, and mucosa-associated lymphoid tissue lymphoma, and GERD

Bacterial Conjunctivitis

Staph aureus, Strep Pneumonia, Moraaxella, H. Influenza. Conjunctival Erythema, mucopurulent discharge Tx: Erythromycin ointment or polymyxin-trimethoprim drops. Topical fluoroquinolone preferred for contact lens wearers due to pseudomonas. CAN PROGRESS TO BACTERIAL KERATITIS-Inflammation of the cornea (especially in contact lens wearer)-photophobia, blurred or impaired vision foreign body sensation, difficulty opening affected eye. URGENT REFErRAL to Ophthalmologist. Diagnose by slit lamp exam showing corneal ulceration, can result in blindness. Empiric therapy with topical combination antibiotic therapy

If AIN does not improve in 48 hours, give

Steroids

Medications that cause increase in Lithium levels when taken simultaneously

Thiazide diuretics, NSAIDs (except aspirin), ACE-I

Standard error of measurement (SEM) error bars of 2 curves overlap

This means that the change was not statistically significant

antibiotics and GBS in pregnancy

Use antibiotics in the following situations: GBS (+) urine culture at any time during pregnancy —Presence of high-risk factors: preterm delivery, Membrane rupture >18 hours with unknown GBS status, Previous baby with GBS sepsis Do not use antibiotics in the following situations: Planned C-section without rupture of membranes

Bronchosopy with biopsy

lung infections that fail to improve or resolve with initial antibiotic therapy obtain tissue sample from central lung tumors

Topical antifungal medication (if no hair or nail involvement):

clotrimazole, miconazole, ketoconazole, econazole, terconazole, nystatin, or ciclopirox

lateralized abdominal pain followed by bloody diarrhea, pain is mild to moderate

colonic ischemia transient reduction in blood flow to the colon due to hypovolemic state or transient ischameia to the bowel.

Positive birefringent rhomboid crystals in

calcium pyrophosphate dihydrate deposition disease, known as pseudo gout Acute monoarticular arthritis in the KNEE

ADHD Diagnosed as child

can persist into adulthood Stimulant meds are first line tx (Methylphenidate, amphetamine), DOES NOT increase risk for substance use or abuse. Non stim alternative (ATOMOXETINE)

Cyclophosphamide causes

hemorrhagic cystitis, not renal failure

best way to minimize ascertainment bias (differential evaluation of outcomes) and increase internal validity of a study

keep individuals involved unaware (participants and researchers)- double blinding

Acute stress disorder vs PTSD

lasts a maximum of 4 weeks

Median Survival Time

length of time that it takes for half of the study population to die

treatment for cough variant asthma

leukotriene inhibitor Montelukast

Hemoglobin A1c levels in pregnant women

levels are lower in pregnant women due to physiologic increase in RBC mass and cell turnover Less sensitive screening test than glucose challenge testing during pregnancy and postpartum period

Hypothyroidism in Pregnancy

stimulation of TSH receptors by BhCG, feedback suppression of TSH, HIGH circulating thyroxine Binding Globulin, HIGH Total T3&T4 INCREASE LEVOTHYROXINE at time of positive pregnancy, measure TSH every 4 weeks and adjust levothyroxine dose to trimester specific TSH norms

Leakage of urine precipitated by increased intraabdominal pressure (cough, Valsalva)

stress incontinence Leakage of urine with cough on exam PESSARY PELVIC FLOOR EXERCISES URETHRAL SLING SURGERY DULOXETINE (Serotonin-Norepinephrine Reuptake Inhibitor)

Standardized mortality ratios

used to determine if the observed number of deaths in a group exceeds what would be expected in a similar group excluding the variable of interest. calculated using mortality rates for the general population to determine the number of expected deaths, which are then compared to the observed number of deaths.

Clonidine

Short acting alpha 2 agonist used for severe HTN episodes Severe rebound HTN if abrupt stop

mid-urethral sling

for stress urinary incontinence due to involuntary leakage associated with intraabdominal pressure.

Hypomagnesium can mimic hypocalcemia but is associated with

heavy alcohol use, prolonged nasogastric suction or diarrhea and diuretic use.

erythrocytosis, elevated serum transaminases and central hypogonadism in a 40 yo with hyperpigmentation and years of arthralgia

hereditary hemochromatosis

Measuring Reverse T3 (rT3)

Hospitalized patient to distinguish euthyroid sick syndrome (HIGH) from Central hypothyroid (LOW)

Dementia, Diarrhea, Dermatitis (symmetric in sun exposed areas forms vesicles and blisters), Stomatitis, Cheilosis

Pellagra

Medial knee pain

pes anserinus pain syndrome. "Pes anserine bursitis" causes medial knee pain. tender diastole to joint line region where the conjoined tendon of semitendinosus, gracilis, and sartorial muscle insert on the tibia.

urinary tract anesthetic for bladder infection and an anesthetic for interstitial nephritis

phenazopyridine is a urinary tract anesthetic for bladder infection pentosan is an anesthetic for interstitial nephritis (both are oral)

COVID-19 infection during pregnancy also increases the risk of

preterm birth and cesarean section. Remdesivir and convalescent plasma are treatment options. Pregnant and lactating patients may be offered the coronavirus vaccine.

hearing impairment in elderly. inability to discriminate speech in a noisy, distracting environment.

presbycusis

changing the age range of participants may

increase external validity results become more generalizable to larger population

ACE Inhibotors can cause cough due to

increased bradykinin levels

Anemia in pregnancy is caused by

increased levels of hepcidin, which inhibits iron transport. Pregnancy increases iron demand, but hepcidin prevents absorption.

HLA Allosensitization

increases risk of graft rejection in patients awaiting organ or bone marrow transplantation and platelet refractoriness in those requiring subsequent platelet transfusion support RBCs DO NOT EXPRESS HLA ANTIGENS

hair loss with moth eaten appearance with scarring

secondary syphilis

Afebrile, descending paralysis starting with cranial nerves.

Clostridium Botulinum Toxin found by serum analysis for bacterial toxin. Tx with Equine Serum Heptavalent Antitoxin

Relative Risk Reduction (RRR)

(Risk (control) - Risk (tx))/Risk (control) relative decrease in the risk of an adverse event in the treatment group compared to a control group

Proximal muscle weakness and cardiomyopathy in a child with delayed ability to walk, cognitive delays.

Duchenne muscular dystrophy X-linked disorder Screen with Creatinine kinase

Acromegaly

- a disorder in adults caused by overproduction of growth hormone Confirm with non-suppression of GH following a glucose load and increased serum IGF1 levels If untreated have increase in CV disease (HTN, LV Dysfunction, asymmetric septal hypertrophy, conduction defects, coronary atherosclerosis and myocardial fibrosis) Early CV disease is reversible following successful treatment of Acromegaly Other problems = DM, Respiratory problems, and malignancy (Colon cancer)

correlation coefficient

-1 or 1 = Stong -0.5 or 0.5 = Moderate 0 = Weak One variable increases as the other variable decreases = negative correlation both variables increase = positive correlation Shows strength but NOT causality

Normal Distribution

-1 to 1 SD=68% -2 to 2SD=95% -3 to 3SD=99.7% 0-1=34% 1-2=13.5% 2-3=2.35% 3-4=0.15% 1-4 SD=16% 2-4SD=2.5% 3-4SD=0.15%

Give Rh(D) immunoglobulin in Rh negative mothers

-28 weeks -Within 72 hours of delivery -After miscarriage/abortion -During amniocentesis or CVS -Heavy vaginal bleeding

when to start therapy in HIV/AIDS

-Any CD4 count if there is any level of detectable viral load -Any stage of pregnancy -Needle-stick, when the patient is known to be HIV-positive

Balloon Valvuloplasty is indicated in symptomatic and asymptomatic (plan to get pregnant or participate in competitive sports) young adults when following criteria met

-Aortic Stenosis -No significant AV calcifications or aortic regurgitation -Peak gradient >50

Postop pulmonary complications

-Atelectasis -Bronchospasm -Chronic lung disease exacerbation -Infection -Prolonged mechanical ventilation & Respiratory failure

A 30-year-old woman comes to the ED with lower abdominal pain and tenderness, fever, leukocytosis, and cervical motion tenderness. What is the next best step in management?

-Best initial test: pregnancy test, then DNA probe (NAAT) for chlamydia and gonorrhea; cervical culture and stain are sometimes done. -Most accurate test is laparoscopy (rarely needed) for recurrent or persistent infection or when diagnosis is not clear.

Health Benefits associated with neonatal circumcision include:

-Decrease UTI in first year of life -Prevent pathologic Phimosis (foreskin constriction preventing retraction) and modest reduction in risk of penile cancer -Reduction in penile inflammatory disorders (balantitis) -reduction in risk of acquiring some sexually transmitted infections like HPV and HIV through penile vaginal sex

Suspect Stroke or TIA. ORDER?

-Echocardiogram. -Start Anticoagulation for clots. -Carotid Doppler/duplex -Endarterectomy for stenosis >70% (only if patient is symptomatic) -EKG and a Holter monitor if EKG is normal -Direct-Acting Oral Anticoagulants (DOACs) are indicated for all stroke/TIA with A-fib or A-flutter (Apixaban (Eliquis®). Dabigatran (Pradaxa®). Rivaroxaban (Xarelto®).

Tx of AKI that develops in hospital setting

-Eliminate or avoid potential nephrotoxic insults: (NSAID, ACE-I, ARBs) should be Dcd and medication should be adjusted for renal function, and contrast media should be avoided -Maintenance of Euvolemic Volume Status: IVF to improve cardiac output and reduce risk of tissue ischemia. Hypervolemnic require diuretics and if anuric (No urine output) then hemodialysis -Management of electrolyte and acid-base imbalances: Potassium, Magnesium, Phosphorus, Calcium, Bicarb

Major risk factors for sudden cardiac death in patients with HCM

-FH of SCD age <50 -personal hx of sustained ventricular arrythmia -massive LV hypertrophy with wall thickness >30 -LVEF <50% -personal hx of syncope In these patients ICD placement is indicated

patients with ischemic stroke undergo initial eval with:

-Head imaging with MRI or CT -Neurovascular imaging including CT or MR angio of head and neck and carotid duplex US to evaluate for stenosis, occlusion, or dissection -ECG to diagnose arrhythmia -Echo to detect intracardiac thrombus or a structural abnormality (patent foramen ovale) Left sided weakness indicates a stroke in the right MCA right sided weakness indicates Left MCA Ambulatory cardiac monitoring can detect an occult arrhythmia such as paroxysmal a fib, monitoring for prolonged period (30 days)

Acute chest pain that may be due to MI, need to rule out Acute Coronary Syndrome

-Normal ECG = Rule out STEMI -Negative Serial Troponin = Rule out NON-STEMI -No hx of exertion chest pain, dyspnea, diaphoresis, T-Wave inversion = Rule out Unstable Angina Once Acute Coronary Syndrome Ruled out then goal is to shift to differentiate cardiac chest pain (stable) vs noncardiac. Stress testing best initial diagnostic intervention. Exercise ECG preferred when possible but if patient cant exercise then Pharmacologic stress testing (ADENOSINE MYOCARDIAL PERFUSION IMAGING, DOBUTAMINE ECHO)

medications are more specific for Streptococcus:

-Penicillin -Ampicillin -Amoxicillin

Preop pulmonary function tests are recommended:

-Prior to lung resection to estimate post lung volumes -to optimize preop COPD control if baseline status cant be determined -Evaluate the cause of dyspnea or exercise intolerance (cardiac disease vs deconditioning)

Carbamazepine side effects

-Severe skin reactions, e.g., Stevens-Johnson (HLA B*1502 testing can predict Stevens-Johnson) -Hyponatremia

Status epilepticus Diagnostic Orders on CCS?

-Sodium, calcium, glucose, oxygen, creatinine, and magnesium levels -Head CT (urgently); if negative, consider MRI later -Urine toxicology screen -Liver and renal function (Electroencephalogram (EEG) only if the other tests do not reveal the etiology)

MECHANISMS OF ORAL HEPATITIS C MEDICATIONS

-Sofosbuvir, dasabuvir: RNA polymerase inhibitor -Glecaprevir/pibrentasvir: Protease inhibitors that prevent viral maturation by inhibiting protein synthesis

Medication induced Hypercalcemia

-Thiazide Diuretics -Lithium -Excessive doses of calcium carbonate or Vit D

Causes of Hypocalcemia

-Vit D Deficiency: LOW Phos, HIGH PTH -HYPOPTH: HIGH Phos, LOW PTH -PSEUDOHYPOPTH: HIGH phos, HIGH PTH -HYPERPHOS: HIGH PHOS, HIGH PTH

Transfusion Reaction Timeline

-sec-min: Anaphylactic -min-hr: Acute Hemolytic -1-6hrs: Febrile non hemolytic, Transfusion associated circulatory overload, Transfusion related acute lung injury, Transfusion transmitted bacterial infection, Urticarial -days: Delayed Hemolytic Irradiated: Bone marrow transplant recipients, Acquired or congenital cellular immunodeficiency, blood components donated by first or second degree relatives Leukoreduction: Chronically transfused patients, CMV at risk patients (AIDS, transplant), potential transplant recipients, Previous febrile non hemolytic reaction Washed: IgA deficiency,. Complement dependent autoimmune hemolytic anemia, continued allergic reactions with red cell transufusion despite antihistamine treatment

Patients with Hypertrophic Cardiomyopathy are at increased risk for cardiac arrhythmias

1. A fib: Increased risk in HCM likely results from LV diastolic Dysfunction leading to Left Atrial Enlargement. Thromboembolic stroke related to A fib cause of morbidity and mortality in HCM 2. Ventricular Tachycardia: Increased risk in HCM related to myocardial disarray and fibrosis as well as chronic myocardial ischemia resulting from myocardial oxygen supply-demand mismatch. Sustained is cause of sudden cardiac arrest most common cause of mortality in HCM Ambulatory ECG monitoring indicated in patients with HCM so that arrhythmic complications can be promptly recognized. Evidence of A fib on ECG monitoring warrants initiation of chronic anticoagulation and evidence of ventricular tachycardia warrant implantable cardioverter defibrillator

FIRST TRIMESTER ROUTINE TESTS

1. Anemia - CBC 2. Blood type, Rh and antibody 3. GU Screening (PAP, UA, Urine Cx) 4. Immunization of Rubella and Hep B 5. Syphilis Status 6. HIV 7. Chlamydia/Gonorrhea 8. US and blood tests to evaluate for Down syndrome

Tx Choice for Graves Hyperthyroid

1. Antithyroid Drugs -Mild hyperthyroid -Older age with limited life expectancy -Prep for radioactive iodine or thyroidectomy -Pregnancy (PTU in 1st trimester) 2. Radioactive Iodine -Mod to severe Hyperthyroid 3. Thyroidectomy -Very large goiter -thyroid cancer -coexisting hyper PTH -Pregnant who cant tolerate meds -Severe opthalmopathy -Retrosternal goiter with obstructive symptoms Lab eval to assess thyroid function performed 4-6 weeks after initiation of antithyroid drug and then every 2-3 months. TOTAL T3 and FREE T4 levels should be used to assess efficacy. Major side effect of antithyroid drugs is Agranulocytosis and Hepatotoxicity. Within 9o days of treatment develop fever, chills, sore throat due to agranulocytosis and therefore obtain CBC. Symptoms of pruritis, jaundice and loss of appetite can signify hepatotoxicity and therefore requires Hepatic markers.

Root Cause Analysis (RCA)

1. Collect Data 2. Create Causal Factor Flow Chart 3. Identify root cause 4. Generate recommendations & implement changes 5. Measure success of changes

Root Cause Analysis (RCA)

1. Collect Data 2. Create Causal Factor Flow Chart 3. Identify root causes 4. Generate recommendations & implement changes 5. Measure success of changes

Lifestyle interventions for HTN

1. DASH DIET 2. Weight Loss 3. Aerobic Exercise 4. Dietary Sodium 5. Alcohol Limitation

CKD can lead to Anemia Due to

1. Decreased renal erythropoietin production->Dec RBC production->managed with Erythropoiesis-Stimulating Agent (ESA) (Darbepoetin) 2. Systemic Inflammation-Anemia of Chronic Dz->Iron sequestration (HIGH FERRITIN), LOW iron absorption->Iron deficiency->Dec RBC production 3. Uremia->INC Bleeding (platelet dysfunction)-> (reduced RBC lifespan)-> INC RBC Loss

Best initial diagnostic test for TIA or Stroke

1. Head CT without contrast. Need 3-5 days before CT can detect nonhemorrhagic stroke 2. MRA (most accurately images the brain for stroke) can be positive within 30-60 minutes of stroke

Contraception Options

1. IUD (>99% efficacy) 2. Implant (>99% efficacy)-effective for 3 years-progesterone induced changes that result in cervical mucus thickening and decreased tubal motility which inhibit sperm migration also causes ovulation suppression via decreased FSH & LH secretion. MOST COMMON SIDE EFFECT = unscheduled bleeding, weight gain, headache. CONTRAINDICATED IN Progesterone receptor positive breast cancer. Ovulation and fertility return within a ,month after removal. 3. Female Sterilization (>99% efficacy) 4. Male Sterilization (>99% efficacy) 5. Depo-Medroxyprogesterone Acetate Injection (94%)-similar mechanism to implant but requires injection every 90 days 6. OCPS (91%)-Pills, patch, ring 7. Condom (82%) 8. Withdrawal (78%)

Quadruple marker screen (testing window is 15-20 weeks gestation)-Second Trimester

1. MS- AFP 2. β- hCG 3. Estriol 4. Inhibin A

Acute gout treatment

1. NSAID 2. COLCHICINE alternative for those with contraindications to NSAIDs like peptic ulcer dz 3. Urate lowering drug (ALLOPURINOL) recommended for those with recurrent attacks or have gouty tophi

Neonatal breast enlargement

1. Neonatal Breast Hypertrophy: Uni or Bilateral: Firm Disc like tissue under areolae, +/- Galactorrhea: REASSURE High level of maternal estrogen crosses the placenta during third trimester, stimulating the neonatal pituitary to produce prolactin. Prolactin stimulation causes unilateral or bilateral breast enlargement. Self limited and resolve within 6 months. In newborn girls maternal estrogen results in labial swelling, leukorrhea, uterine withdrawal bleeding. 2. Mastitis: Unilateral: Focal Erythema, Tenderness, Induration: ABX 3. Abscess: Unilateral: Focal Erythema, Tenderness, Fluctuance +/- Prulent Discharge: ABX +/- Drainage

Coronary revascularization: CABG

1. Patients with refractory angina despite maximal medical therapy 2. Patient whom revascularization will improve long term survival. (Left main coronary stenosis and multi vessel CAD especially the proximal LAD) and LV systolic dysfunction. DM + Mutlivessel CAD CABG IS superior

Management of Generalized Convulsive Status Epilepticus (>5 min of generalized convulsive seizure, or >2 without interval recovery of consciousness)

1. Stabilize circulation, airway, breathing, Gain IV access and administer IV BENZO (Lorazepam, Diazepam, Midazolam) 2. Adjunct IV (Fosphenytoin, Phenytoin, Valproic Acid) 3. Still not terminated then EEG monitoring, initiate infusion of Midazolam, Barbiturates (Pentobarbital, phenobarbital) or propofol Actively seizing trauma patent head CT to rule out intracranial hemorrhage. Otherwise if stable MRI brain to assess underlying structural abnormalities. these are not necessary in a patient with known seizure disorder.

Treatment for C. Diff (>3 stools in 24hrs)

10 days of oral Fidaxomicin or Vancomycin is curative. Recurrence occurs within 30 days of abx cessation Stool testing may remain positive for days to weeks after treatment. Especially in PCR testing for toxin-producing gene, not toxin itself.

postprandial epigastric pain and early satiety

H. Pylori (stool antigen testing)

Erythema Migrans (Rash with central clearing) of Lyme Disease

<8 tx with Amoxicillin >8 tx with Doxycycline

Pelvic US and FSH level ordered to evaluate for primary amenorrhea (Lack of menses)

>15yo with secondary sexual characteristics, or >13 with no secondary sexual characteristics

advanced maternal age

>35 yo increased risk for: 1. Spontaneous abortion 2. Chromosomal abnormalities (e.g., Down syndrome) 3. Birth defects 4. Ectopic pregnancy increased risk for complications (e.g., hypertension, diabetes) during the pregnancy.

Clinical Features of Melanoma

A: Asymmetry: When Bisected, the 2 sides are not identical B: Border irregularities: Uneven edges, pigment fading off C: Color Variegation: Variable picture of brown, tan, black and red D: Diameter: >6mm E: Evolving: Lesion changing in size, shape, color, new lesion

elderly with sudden onset transient visual loss in the eye, has HTN, peripheral vascular disease

AMAUROSIS FUGAX (Ischemic event involving retinal artery). Marker of carotid artery atherosclerotic disease. A carotid bruit on auscultation of the neck is a very frequent finding. indicates significant carotid obstruction.

Treatment regimen for Intrapartum Intraamniotic Infection

AMPICILLIN + GENTAMICIN

Hyponatremia leads to

AMS, seizures Alcohol Use Disorder may place patients at risk of developing osmotic demyelination if serum sodium is corrected too quickly.

Alloimmune hemolytic disease of newborn

ABO or Rh incompatibility between fetus and mother. Maternal blood type O and Negative Rh status

Wolff-Parkinson-White Syndrome (WPW)

Accessory pathway, tachyarrhythmia, conducts faster than the AV node and excites the ventricles prematurely. On ECG: Short PR interval with a delta wave and widened QRS complex Paroxysmal supraventricular tachy; regular narrow complex tachycardia. If develop A fib from like alcohol ingestion can conduct impulse down accessory resulting in syncope. Tx: Catheter Ablation

acute onset epigastric pain radiating to the back, nausea, vomiting, elevated lipase

Acute Pancreatitis No alcohol, Normal TG and Ca. Cholelithiasis with elevation of alkaline phosphatase = GALLSTONE PANCREATITIS If mild no organ failure and local or systemic complications should have Cholecystectomy within 7 days of clinical improvement usually performed on the same hospitalization. Delay if severe which is persistent failure of one or more organs systems. waiting allows for resolution of active inflammation and complications.

Diffuse ST elevation with PR depression

Acute Pericarditis

Most common suppurative complication of acute otitis media

Acute mastoiditis Erythema and tender swelling result in outward vertical displacement of the auricle. Children <2 caused by strep pneumonia, strep pyogenes, staph aureus, pseudomonas IV Abx & Drainage of purulent material Complications = Extra-cranial extension (subperiosteal abscess, facial nerve plays, hearing loss, labyrinthitis), Intracranial extension (brain abscess, meningitis)

Weight loss, fatigue, hypotension, bradycardia, hypoglycemia

Adrenal Insufficiency Iatrogenic occurs when rapidly stop mod-high dose prednisone >3 weeks

mean values of a continuous variable in several groups are being compared (ex: LV wall thickness the continues variable and categorical variable no HCM, Borderline HCM, Definite HCM)

ANalysis Of VAriance (ANOVA) Gives an F statistic (based on variation within and between the different groups) used to obtain a p-value.

With any significant exposure to HIV-positive blood via a needle, scalpel, or penetrating injury

ART for a month. Start within 72 hours of exposure. Use two nucleosides and an integrase inhibitor.

drug combination of dolutegravir and rilpivirine

ART for those on dialysis; this drug combination does not require dose adjustment in end-stage renal disease.

Lower Extremity Proximal DVT

Above the Knee -> Limb threatening? Compartment Syndrome -> YES? THROMBOLYSIS OR THROMBECTOMY (systemic or catheter directed thrombolysis, percutaneous or surgical thrombectomy) NO? Anticoagulant contraindicated? Active/difficutl to treat major bleed, intracranial hemorrhage -> YES? IVC FILTER NO? ANTICOAG IVC filter helpful for patients with acute venous thromboembolism who have absolute contraindication to anticoagulation they lower incidence of Pesticides but increase risk of recurrent DVT If acute DVT DONT use SCDs dye to risk of dislodgment of the clot without therapeutic effect.

Hematuria, Edema, HTN, Urinalysis + protien, + blood, + RBC cast, Low complement C3, weeks after group A strep (pharyngitis)

Acute Poststrep Glomerulonephritis A nephritic syndrome from immune complex deposition between GBM and mesangium as well as from glomerular damage due to complement activation and inflammation. Acute kidney injury with decreased GFR (HIGH Serum Creatinine) and impaired sodium excretion. resulting in sodium and water retention = volume overload with HTN and Edema. + ASO titer TX HTN & Edema with Loop Diuretics = FUROSEMIDE

Older patient recently had MI now with severe abdominal pain out of proportion to benign exam findings

Acute mesenteric ischemia Rapid onset periumbilical pain, pain out of proportion to exam findings, Hematochezia Due to atherosclerosis, Embolic source, Hypercoagulable disorders Lab: Leukocytosis, HIGH Amylase & Phosphate, Elevated Lactate. Dx: CT or MR Angiography Most common cause is superior mesenteric artery occlusion due to embolic disease. Arterial and venous thrombosis due to atherosclerotic disease and watershed infarction of areas with limited collateral vessels

Hemorrhagic exudate in the retina

Acute retinal vein thrombosis

Migratory arthritis, carditis or valvulitis, Sydenham chorea, erythema marginatum, sub q nodules, chronic mitral regurgitation

Acute rheumatic fever following Group A strep Infection

Intrarenal causes of renal failure result in the following:

Acute tubular necrosis (ATN) -Aminoglycosides (gentamicin, tobramycin, or amikacin) (hypomagnesemia is suggestive of aminoglycoside-induced renal failure) -Amphotericin -Contrast agents -Chemotherapy (cisplatin) Dx: BUN to Cr ratio 10:1, Urinary Sodium >40, Urine Osmolality <350 Urinalysis "muddy brown" or granular casts.

3 days of oral TMP-SMX prescribed for

Acute, uncomplicated Cystitis (UTI)

Hyperpigmentation of the skin generalized, more prominent in frction areas like elbows and knees and in light areas like face or dorsal of hand. Vitiligo, Dehydration, Hypotension

Addisons Disease (Primary Adrenal Insufficiency)

>40yo, increasingly heavy menses, chronic pelvic pain, diffuse uterine enlargement (globular uterus)

Adenomyosis abnormal presence of endometrial glands and stroma within the uterine myometrium. The ectopic endometrial tissue induces myometrial hyperplasia and hypertrophy, resulting in a uniformly enlarged uterus. Uniformly enlarges uterus, dysmenorrhea, regular heavy menses, symptomatic anemia (fatigue, tachycardia) secondary to chronic heavy menstrual bleeding. Risk in >40, multiparty, prior uterine surgery (cesarean delivery, myomectomy) dx: MRI & US: Thickened myometrium Tx: hysterectomy but can tx with PROGESTINS (progestin intrauterine device, medroxyprogesterone acetate) for those who have not completed childbearing.

Narrow complex tachy in hemodynamically stable patient with a pulse

Adenosine

Large Sample size & High precision (Narrow Confidence Interval)

Adequate Power

Weight loss, Ab pain, asthenia, amenorrhea, fatigue, weakness, poor appetite, muscle tender, decreased axillary and pubic hair, Increased pigmentation (patchy brown spots on lips and buccal mucosa), Hyponatremia, Hyperkalemia, Hyperchloremic metabolic acidosis

Adrenal Insufficiency dec axillary & pubic hair = decreased adrenal androgen production increased pigmentation = co-secretion of adrenocorticotropic hormone 250mcg Cosyntropin stimulation test with cortisol & ACTH levels -cortisol low, ACTH high, Minimal cortisol response to cosyngtropin - Primary adrenal insufficiency -cortisol low, ACTH low, minimal response - Secondary or tertiary adrenal insufficiency

Viral Gastroenteritis

All Ages: Noro Unvaccinated <2yo: Rotavirus Emesis & watery diarrhea, Abdominal pain, +/- Fever Tx: Fluids, regular diet (limit fats & simple sugars) symptoms can be exacerbated by excess consumption of Hugh fructose.

Adrenal Mass on CT

All adrenal masses require workup for hormone hyper secretion or malignancy. Serum electrolytes, dexamethasone suppression testing, 24hr urine catecholamine, metanephrine, Vanillylmandelic acid and 17-ketosteroid measurement. Surgical resection for all functional tumors, malignant tumors with heterogenous appearance on imaging, and all tumors greater than 4cm. All others can be manages with serial abdominal imaging.

Pneumococcal Polysaccharide Vaccine

All children younger than 2 years old should receive PCV13. Children 2 through 18 years old with certain medical conditions should receive PCV13 and PPSV23. PPSV 23 when under 2 does not elicit an effective immune reposes due to inability to mount a T cell independent immune response.

X-Linked Dominant

All female children of affected males have the condition

Osteoporosis screening

All women should be screened with bone densitometry at age 65.

patient with underlying asthma or CF, develops recurrent exacerbation with fever, malaise, cough with brownish sputum, wheezing, symptoms of bronchial obstruction.

Allergic Bronchopulmonary Aspergillosis Sensitized to Aspergillus antigens resulting in intense IgE and IgG mediated immune response. Dx: Elevated Aspergillus-Specific IgE with elevated total IgE, positive Aspergillus specific IgG, eosinophilia, positive skin test reactivity for aspergillus. CXR: Upper lobe opacities, atelectasis due to. mucus plugging, signs of bronchiectasis (dilated bronchi with wall thickening), tram track sign, ring sign Tx: -Systemic Glucocorticoids (PO PREDNISONE), improve symptoms during acute exacerbation. Speed resolution of lung opacities on radiographic imaging, normalize eosinophil levels and reduce total IgE, serially monitored to assess clinical response. -Antifungal therapy with ITRACONAZOLE or VORICONAZOLE considered as it has been shown to reduce Aspergillus load and antigenic stimulus. -OMALIZUMAB, monoclonal Ab against IgE.

Nasal congestion, itchy watery eyes, clear rhinorhhea, and sneezing in response to an allergen

Allergic Rhinitis Allergic Shiners: Infraorbital edema & darkening, Allergic Salute: Transverse nasal crease, Pale, bluish, enlarged turbinates, Pharyngeal cobblestoning, Allergic Facies: High arched palate open mouth breathing. Tx: Avoid allergen, intranasal corticosteroids (fluticasone spray)

Cirrhosis + Emphysema

Alpha-1 Antitrypsin Deficiency

Impaired cognition and diffuse cortical atrophy on neuroimaging

Alzheimer Dementia

treatment for Ulcerative Colitis (Hematochezia, Urgency, Tenesmus, Crampy lower abdominal pain, weight loss)

Aminosalicylates

First line therapy for outpatient management of community acquired pneumonia

Amoxicillin + Doxycycline if critically ill or risk of MRSA or pseudomonas infection = VANCOMYCIN + CEFEPIME

effective against all Candida, Cryptococcus, and Aspergillus

Amphotericin first-line therapy for Cryptococcus and mucormycosis

Combination third gen penicillin and beta lactase inhibitor used to treat intraabdominal infections

Ampicillin-Sulbactam

Degenerative motor neuron disease manifests with asymmetric limb weakness of the hand or foot, >70 yo

Amyotrophic Lateral Sclerosis (ALS) tx with RILUZOLE and Supportive care

flank pain radiating to the groin, blood in urine, taking ibuprofen and Percocet daily for 10 years, Dilation of the pelvicalyceal system. Cause of renal dysfunction?

Analgesic Nephropathy Chronic tubular injury and tubulointerstitial nephritis that leads to loss of renal function. Ischemic damage to renal papilla may occur due to vasoconstriction of the vasa recta. chronic necrosis of renal papilla and calcifications. Sloughing of papilla cause hematuria. Hematuria, Proteinuria, Pyuria with WBC casts. DC analgesic will cause stabilization or even improvement in renal function

Study compares means of quantitative outcomes between >3 groups.

Analysis of Variance (ANOVA)

Colonoscopy reveals several small, flat, cherry red lesions in the right colon, in a elderly with anemia from occult GI bleed

Angiodysplasia (vascular ectasias or AV malformations) vascular anomalies composed of multiple aberrant blood vessels located in the GI tract. >60yo, Incidental finding on endoscopy, Due to chronic occlusion of submucosal veins, resulting in vascular congestion and formation of dysplastic arteriovenous collaterals. Associated with END STAGE RENAL DISEASE, Aortic stenosis, vWB disease Uremia associated with ESRD causes platelet dysfunction and both aortic stenosis (acquired vWD due to mechanical disruption during valvular flow) and hereditary vWD causes decreased levels of vW factor required for platelet aggregation.

Oppositional Defiant Disorder (ODD)

Angry/Iritable mood, argumentative >6 months characterized by vindictive or deliberately annoying behavior

HLA-B27

Ankylosing Spondylitits

Sudden Cardiac Death in patient <35

Aortic Origin of a coronary Artery Results in ventricular tachyarrhythmia Left main coronary originating from the right aortic sinus and the right coronary originating from the left aortic sinus. The anomalous artery passes between the aorta and pulmonary artery making it susceptible to external compression during exercise. Experience exertion angina, lightheaded, syncope. CT angio or coronary magnetic resonance angio provides the best visualization of coronary anatomy.

An ejection click followed by a crescendo-decrescendo systolic murmur heard in

Aortic or pulmonic valve stenosis the murmur increases in intensity with increased venous return

Ecologic Fallacy

Applying population-level information to an individual level

A study with lower levels of gene expression associated with higher times of B-Lymphocyte repopulation, What is the correlation coefficient

As one variable increases, the other decreases, so r must be NEGATIVE (r<0) and if statistically significant with a p<0.05, so Confidence interval must exclude 0 (IF BOTH VARIABLES INCREASE OR DECREASE TOGETHER< THEN R IS POSITIVE R>0)

Recurrent Pneumonia

Aspiration: -Seizure, Dysphagia (parkinsons), Alcohol Intoxication -Anaerobes, Polymicrobial -Right middle/lower lobe, Dysphagia/Dysarthria, Altered Mentation Bedside swallowing assessment (video fluoroscopic swallowing study)-thickened liquids and modified swallowing techniques COPD: -Chronic bronchitis, emphysema, asthma, bronchiectasis -Strep pneumonia, H. Influenza, Moraxella, Pseudomonas, viral -smoking hx, chronic cough, chronic dyspnea Immunodeficiency: -HIV, primary immune deficiency, Hypoagammaglobulinemia, Hematologic malignancy -S. Pneumonia, H. Influenza, Pneumocystis Post-Obstructive: -Polymicrobial -Hemoptysis, Weight loss/Cachexia TB: -upper lobe/apical, recent immigrant, institutionalized patient, homeless

Olanzapine (Zyprexa)

Atypical Antipsychotics Treat Schizophrenia and Bipolar

Exercise induced bronchoconstriction

Asthma-like respiratory symptoms occurring exclusively during exercise. Hyperventilation -> Incomplete heating & humidification of inspired air -> cooler, dry air triggers mast cell degranulation and bronchospasm Dec exercise tolerance, asthma symptoms appear within 5-10min and improve after 20 min of exercise. Conifer dx with bronchoprovocation testing (spirometry before and after exercise) showing >15% decline in FEV1 Management: Improve control of underlying asthma, premeditate before exercise (ICS-FORMOTEROL), Daily ICSD-Beta Agonist or LTRA for frequent prolonged excersice.

All children with language delay should undergo

Audiology eval to assess for hearing impairment

Recurrence risk is approximately 50% in

Autosomal Dominant Disorders

Recurrence risk is approximately 25% in

Autosomal Recessive Disorders

numerous small renal cysts on US in an infant

Autosomal Recessive Polycystic Kidney Disease, Mutation in PKHD1 Gene

Parathyroid Hormone Related Protein

Cause hypercalcemia elevated in SCC of the lung

chronic abdominal pain, diarrhea, weight loss

Celiac Disease (Tissue Transglutaminase antibody +)

Patients with acute ischemic Stroke who are treated with tissue plasminogen activator should have strict

BP control. Keep <180/105 using IV ANTIHYPERTENSIVE-LABETALOL or NICARDIPINE (to decrease risk of hemorrhagic transformation). AVOID HYPOTENSION to maintain adequate perfusion to the ischemic penumbra. Anti-platelet Therapy (aspirin) administered to stroke patients. NOT until 24-48hrs after tPA (due to increase risk of bleeding) can obtain a con con CT of head to confirm that no interval intracerebral hemorrhage has occurred.

Discontinuation of antiHTN meds

BP under good long term control with single meds Pt adherent to non pharm measures Med tapering: -Long acting meds (Amlodipine) take every other day or reduce dose -short acting meds (Lisinopril) reduce dose and continue taking daily Close BP monitoring over 1-2 months following dose change, resume prior to dose if BP rise over target, DC drug and monitor BP if HTN still controlled with lower dose

Infectious Keratitis

Bacteria (staph aureus, Pseudomonas): Improper contact lens use, Corneal trauma, foreign body: CENTRAL ROUND INFILTRATE, stroll abscess, mucopurulent discharge, Acute: Tx: Topical Antibiotic Therapy HSV: Immunocompromised, HIV: BRANCHED DENDRITIC ULCERATIONS, Dec corneal sensation (V1 branch of trigeminal nerve), watery discharge, recurrent: Tx: Topical or oral antiviral (acyclovir and valacyclovir) Fungi (Candida): Immunocompromised with corneal injury due to contaminated soil (gardening): MULTIPLE ULCERS WITH FEATHERY MARGINS & Satellite lesions, Mucopuruelnt discharge, indolent: TX: Topical or oral antifungals

Thin, off white discharge, fishy odor, pH>4.5, Clue Cells, Positive Whiff test

Bacterial Vaginosis Tx: Metronidazole or Clindamycin

Thin, off-white discharge with fishy odor; No inflammation pH > 4.5; Clue cells; Positive whiff test (Amine odor with KOH)

Bacterial Vaginosis (gardener all Vaginalis) Tx: Metronidazole or Clindamycin

endopthalmitis

Bacterial or fungal infection of the intraocular cavities causes decreased visual acuity, aching of the affected eye and conjunctival injection. Most patient have severe underlying illness or recent eye surgery

ear pain, purulent ear drainage, NO FEVER, pain on manipulation, following water exposure

Bacterial otitis externa, infection of the outer auditory canal caused by pseudomonas aeruginosa

Conjunctivitis Treatment

Bacterial: Erythromycin Ointment, Polymyxin-Trimethoprim Drops, Azithromycin drops. IN CONTACT LENS WEARERS FLUOROQUINOLONE DROPS Viral: Warm or cold compresses, +/- Antihistamine/decongestants Allergic: Antihistamine/decongestants

CSF Analysis

Bacterial: WBC HIGH >1000, GLUCOSE LOW <40, Protein HIGH >250 TB: WBC 100-500, Glucose <45, Protein 100-500 Viral: WBC 10-500, Glucose 40-70, Protein <150 Guillain Barre: WBC 0-5, Glucose 40-70, Protein 45-1000

Balanitis & Balanoposthitis

Balanitis: Inflammation of the glans penis Balanoposthitis: Inflammation of the glans penis + foreskin Thick White Discharge - KOH microscopy for Candida If urethral discharge STI screen Management: Foreskin hygiene, sitz bath, Antifungal or bacterial,

Balanitis and Balanoposthitis

Balanitis: Inflammation of the glans penis Balanoposthitis: Inflammation of glans penis + Foreskin Infection usually due to candida (Thick, white discharge around glans penis) confirm with budding yet on potassium hydroxide microscopy. (KOH). Tx with topical anti fungal (NYSTATIN) A blood glucose level should be checked in a prepubertal child with no risk factor for Candida because BALANITIS CAN BE THE FIRST PRESENTING SIGN OF DIABETES, and new onset bed wetting after period of dry could suggest osmotic diuresis due to glucosuria.

Warfarin

Blocks reduction of Vitamin K (vitamin K recycling) by epoxide Reductase Therefore reduced amounts of Vit K dependent clotting factors II, VII, IX, X Urgent reversal needed in intracranial hemorrhage 1st LINE: PROTHROMBIN COMPLEX CONCENTRATE (Less than 10 min) & VIT K (12-24hrs) 2nd LINE: Fresh Frozen PLASMA

Most common cause of Iron deficiency anemia in the US

Blood loss, males >50yo due to COLON CANCER. Iron studies (LOW Hgb, LOW MCV) & COLONOSCOPY

Meningitis, Cranial nerve palsies, peripheral neuropathies

Borrelia Burgdorferi a spirochete that causes Lyme disease

Postsinusoidal non cirrhotic causes of portal hypertension

Budd-Chiari syndrome caused by thrombosis of the hepatic veins and or supra hepatic inferior vena cava

examine association between risk factor and outcome in a well defined population at one particular time.

Cross-Sectional Study Snapshot of a population and measures frequency of risk factors and outcomes simultaneously

simultaneous measurement of an exposure and outcome within a specific population.

Cross-Sectional Study "SnapShot Study" that frequently uses surveys that make it relatively inexpensive and easy to perform

stridor, respiratory distress, barking cough

Croup (Laryngotracheobronchitis) Racemic Epinephrine and intramuscular corticosteroids

CHA2DS2-VASc

C-CHF H-HTN A2-Age >75 D-DM S2-Stroke V-Vascular Dz A-Age 65-74 Sc-Sex-FEMALE Used in new onset Afib to identify those who need anticoagulation therapy

If arrest of labor (no cervical change in the active phase >4hrs with adequate contractions or >6 hours without adequate contractions)

C-section indicated

Profuse watery diarrhea, recent abx use, advanced age, abdominal bloating, fever, leukocytosis

C. Diff Dx: Stool PCR for C Diff, Stool EIA for C diff toxin & Glutamate Dehydrogenase antigen Control: Hand Hygiene, Contact isolation, Sporicidal disinfectants Lead to Fulminant colitis or toxic megacolon - Intestinal Perforation

recently received antibiotics, low grade fever, abdominal cramp and tenderness, profuse watery diarrhea

C. Diff Infection (>3 loose stools/24hr), recent antibiotic use and recent hospitalization Spore forming, gram positive, anaerobic bacterium transmitted via fecal-oral route. Antibitic resistant spores germinate in the colon to become fully functional bacilli. Normally colonic flora suppress overgrowth of C diff but antibiotics can disrupt normal colonic flora leading to unchecked C diff proliferation. C diff exotoxins (toxin A and B) cause inflammation and mucosal injury.

watery diarrhea, abdominal pain, fever, leukocytosis. Rectosigmoidoscopy with raised yellow/off-white plaques scattered over the colonic mucosa.

C. Diff infection complicated by pseudomembranous colitis.

Wounds that should be left open to heal by secondary intention.

Crush, Bites (hands or feet), immunocompromised Only exception if bites to the face

headache developing over several days. same weakness and speech difficulty seen in stroke. LP normal. most accurate test?

CEREBRAL VENOUS THROMBOSIS. a type of stroke. Magnetic resonance venography (MRV) is the most accurate test. Treat with LMW heparin followed by a direct oral anticoagulant (DOAC) for a few months (e.g., edoxaban, apixaban, rivaroxaban, dabigatran). Oral contraceptives are contraindicated.

Recurrent isolated Angioedema

C1 inhibitor deficiency

High Spinal Anesthesia

C3-C5: Dysphagia, Respiratory paralysis C6-C8: Upper extremity weakness T1-T4: Bradycardia, Hypotension When local anesthetic agent spread to a more cephalic spinal level than intended.

Topical Nystatin is indicated for

CANDIDA (intertrigo)

prevent vertical transmission of syphilis

CANT it happens through the placenta before birth. Treatment is benzathine penicillin IM × 1 for (+) mothers. With penicillin allergy, do oral desensitization followed by full dose benzathine penicillin.

Tx for acute cervicitis in pregnant or breastfeeding patients.

CEFTRIAXONE + AZITHROMYCIN Gonorrhoeae & Chlkamydia

Recurrent pneumonia in the same location in a short period of time, next test?

CHEST CT most concerning possibility is presence of an end-bronchial neoplasm leading to a non resolving pneumonia. also possible to have a lung abscess or empyema that can contribute to failure of symptoms to resolve Treatment resistant pneumonia can also be a cause If Chest CT not helpful, then BRONCHOSCOPY may be needed.

To find in the initial staging workup of lung cancer obtain

CT detect any mediastinal LN metastasis and chest wall invasion, also accurate measure of tumor size, detect small pleural effusions and evaluate liver and adrenal glands for metastasis.

Lipid Screening in Children

CVD Risk Factors: -Obesity, DM, HTN, Cigarette use, Positive FH (parent with dyslipidemia total cholesterol >240, or premature CVD (Male <55, Female <65) If yes to above risk factors then serial screening every 1-3 years starting at age 2 If no then universal screening between age 9-11 and 17-21 Lifestyle changes: Low saturated fats, daily exercise, statin therapy >10yo with persistent dyslipedmia after 6 months of lifestyle changes

Herpangina

Caused by Coxsackievirus no exanthem and presence of oral ulcers affecting POSTERIOR Oropharynx (NOT Anterior like hand-foot-mouth disease)

Alpha Adrenergic Blockers

Causes dialation of peripheral blood vessels. Used for pheochromocytoma, prevention of tissue necrosis and sloughing associated with IV Vasopressors PRAZOSIN

Acute Bloody Diarrhea

Causes: (most are viral non inflammatory watery diarrhea unless there is visible blood then bacterial) -Bacterial (STEC, Shigella, Campylobacter, Salmonella) -Intestinal Amebiasis -IBS -Ischemic Colitis Eval: -Culture, Shiga Toxin Assay, Fecal Leukocytes -Abdominal CT for ischemic colitis (Hypoperfusion) -Endoscopy for suspicion of IBD (progressive, waxing/waning course) Management: -Oral fluid repletion -Empiric Abx for severe disease, elderly, immunocompromised (unless STEC: Shiga toxin producing E. coli) -HOSPITALIZATION NOT required and antibiotics not required, self limited

Oculoplegia, eye redness, bilateral numbness in V1/V2

Cavernous Sinus Thrombosis CN III, IV, V, VI MR venography imagining modality of choice to identify sinus venous thrombosis

Empirical tx for Pelvic inflammatory Disease

Cefoxitin + Doxycycline Covers Gonorrhoeae & Chlamydia

recommended antibiotics for community acquired pneumonia requiring hsopitalization

Ceftriaxone & Azithromycin

treatment of orchitis

Ceftriaxone and Doxycycline age <35 and fluoroquinolone for age >35.

Iron and Vitamin D Deficiency despite a nutritious diet. A young patient with multi-nutrient Malabsorption, most likely explanation

Celiac Disease (gluten sensitive enteropathy) Diarrhea +/- Steatorrhea, weight loss, ab pain, flatulence/bloating, T-Cell Lymphoma Dermatitis herpetiformis, Atrrophic Glossitis Vit D Deficiency, Secondary HyperPTH Osteomalacia/Osteoporosis, Rickets Iron Def Anemia Peripheral Neuropathy, Depression/Anxiety SCREENING: ANTI-ENDOMYSIAL ANTIBODY & ANTI-TISSUE TRANSGLUTAMINASE ANTIBODY GOLD STANDARD = INTESTINAL BIOPSY

Vit D, and calcium deficiency as well as impaired reposes to bisphosphonate therapy

Celiac Disease due to malabsorption LOW calcium

Autoimmune Conditions commonly associated with Type 1 DM

Celiac: -screen with anti-tissue transglutaminase IgA antibodies Autoimmune Thyroiditis: -screen with anti-thyroglobulin and anti-thyroid peroxidase antibodies. TSH levels assessed every 1-2 years.

Hep C, renal involvement, joint pain, purpuric skin lesions.

Cryoglobulinemia Serum cryoglobulin levels (Immunoglobulins and light chains, IgM) Complement levels are LOW Treat Hep C, Rituximab helps with severe disease.

MSK exam of infant with increased tone in bilateral lower extremities, scissoring posture of the legs. sustained clonus in ankles bilaterally.

Cerebral Palsy common complication of prematurity (<37 weeks gestation) risk: premature, low birth weight, intrauterine infection, perinatal asphyxia Clinical: Delayed motor milestones, abnormal tone, hyperrefelxia, seizures, intellectual disability Dx: Clinically by 1-2 yo, BRAIN MRI (Periventricular leukomalacia, basal ganglia lesions) PERMANENT, need PT, OT, ST If promoter dysfunction severe then gastrostomy feeds may be needed and botulinum and baclofen can help reduce spasticity and clonus.

Painless second trimester pregnancy loss

Cervical insufficiency due to inherited collagen defects (Ehlers-Danlos) and prior cervical surgery (cervical ionization) because these conditions cause structural weakness of the cervix.

Second generation minimally sedating antihistamines

Cetirizine treat seasonal allergies

type 1 diabetes mellitus

Children, young adults Thin habitus, Comorbid autoimmune disorders (acquired HYPOthyroid) Polyuria, polydipsia, weight loss, anorexia, ketoacidosis Confirmatory testing: C-peptide low/undetectable, Autoantibodies (Glutamic Acid Decarboxylase Antibody) Management: Frequent glucose monitoring, BASAL PLUS BOLUS INSULIN: long acting & rapid acting insulin combo OR continuous sub q insulin infusion pump Insulin pumps recommended for T1DM with hypoglycemia, suboptimal glycemic control A1c >7%, highly variable blood glucose readings on basal bolus regimen.

Mucopurulent cervical discharge and a friable cervix.

Chlamydia Trachomatis Tx: Doxycycline (NOT recommended during breastfeeding because excreted in breast milk and cause tooth discoloration and enamel hypoplasia in infant)

weight loss combined with bulky, foul smelling stools difficult to flush, high daily alcohol intake. Multiple hospitalizations due to abdominal pain. Epigastric pain that relieved by sitting up or learning forward. Exacerbated by meals.

Chronic Pancreatitis (Fat malabsorption and Steatorrhea) Epigastric Abdominal Pain that radiates to the back relieved by sitting up or learning forward Acute pancreatitis can be diagnosed with Elevated serum lipase or amylase however in chronic pancreatitis there is no elevation of the enzymes and therefore NEED MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) Pancreatic calcifications are the hallmark of chronic pancreatitis. Pancreatic enlargement, ductal dilation, pseudocysts may also be seen. An acceptable alternative would be Abdominal CT.

> 3months of dysuria, pain in GU region, pain during ejaculation Normal prostate exam

Chronic Prostatitis (>20 leukocytes on Urinalysis) Urine Culture can differentiate chronic prostatitis/ chronic pelvic pain syndrome. Urine culture results are aseptic. but chronic bacterial prostatitis-urine culture results show bacteriuria (>10 fold increase after prostate massage) resemble symptoms of UTI, therefore inappropriately treat with antibiotics. May transiently improve symptoms manifestations generally recur within days of antibiotic cessation. Dx: URINALYSIS and URINE CULTURE before and after prostate massage Tx: Medications for prostate enlargement (alpha blockers), antibiotics, anti inflammatories and/or psychotherapy

CXR with upper lobe nodule and lower lobe emphysema

Chronic Silicosis (Miners, Sandblasters, foundry workers, masons)

fever, pharyngitis, sandpaper like rash

Scarlet fever treated by Amoxicillin

Hypocalcemia (seizures, muscle cramps, paresthesias, hyperrefflexia, laryngospasm, bilateral cataracts) basal ganglia calcifications, Hyperphos, High PTH

Chronic hypocalcemia due to PSEUDOHYPOPTH = End Organ RESISTANCE to PTH, resulting in hypocalcemia which signals increased PTH through biofeedback. This is different from Hypoparathyroidism which cause hypocalcemia and hyper phos but is due to impaired PTH production. ALBRIGHT HEREDITARY OSTEODYSTROPHY, a subtype of pseudohypoparathyroid = Short, round facies, short 4th/5th metacarpals. PTH maintains calcium hemostasis by trigger calcium reabsorption and phosphate excretion in kidneys. Also promotes calcium release from bone and increase VIT D to stimulate intestinal absorption of calcium. Tx: Calcium & Vit D

Pathophysiology of Anemia of Chronic Disease

Chronic inflammatory stimulus -> Macrophages release Cytokines (IL-6) -> Act on Liver to release Hepcidin -> Cause decrease in iron export from macrophages (blocks Ferroportin on surgface of macrophages), Decrease iron gut absorption by blocking ferroportin there as well.

Beta-lactamase inhibitors

Clavulanate Sulbactam Tazobactam amoxicillin does not cover Staphylococcus, but amoxicillin-clavulanate does. Ampicillin does not cover Staphylococcus, but ampicillin-sulbactam does. Clavulanate and sulbactam add coverage for resistant Haemophilus to ampicillin and amoxicillin. This makes these two medications a great answer for sinusitis, oral infections including abscess, otitis media, and human or animal bites.

best drug for anaerobic streptococci that are found in the mouth

Clindamycin

Thyroid nodule workup

Clinical Eval, TSH level, US 1. No Cancer risk factor? or suspicious US findings? -Normal or elevated TSH -> FNA -> Tx based on findings -LOW TSH -> Iodine 123 Scintigraphy -> Hyperfunctioning (hot) nodule -> Treat Hyperthyroid If HYPOfunctioning (COLD) Nodule then FNA 2. If cancer risk factors -> FNA

pigmented papules or plaques characterized by a verrucous STUCK ON appearance

Seborrheic Keratoses

unilateral, orbital headaches, male, <180min, 1-8x a day over a period of weeks. ptosis, mitosis, lacrimation, conjunctival injection, rhinorrhea and nasal congestion

Cluster Headache preventative treatment = VERAPAMIL Acute tx = 100% OXYGEN = FIRST LINE then intranasal contralateral to side of headache. Sumatriptan

Brachial to femoral pulse delay

Coarctation of the Aorta

Exposure and Response Prevention Therapy

Cognitive behavioral therapy considered first line psychotherapy for OCD Gradual and repetitive exposure to anxiety provoking stimulus that produce obsessional thoughts. followed by prevention of performing the associated compulsions or ritual

2 groups of individuals are initially identified as exposed or non exposed according to their status with respect to a specific risk factor and then followed over time to assess development of outcome

Cohort Study If compare disease incidence in future = Prospective If compare disease incidence in past = Retrospective

breast engorgement (diffuse, bilateral breast tenderness)

Cold compress, NSAID and breast pumping

Thyroid enlargement in adolescent girls who have normal thyroid function tests and negative antithyroid antibodies

Colloid Goiter

Treatment of acne vulgaris

Comedonal Acne: Closed Or open comedones on forehead, nose, chin Tx: Topical retinoids, salicylic, azelaic, glycolic acid Inflammatory Acne: Inflammatory papules (<5mm) and pustules Tx: Mild: Topical retinoids + Benzoyl Peroxide, Mod: ADD Topical ANTIBIOTICS (Clindamycin, Erythromycin), Severe: Add PO ANTIBIOTICS Nodular (Cystic) Acne:

Hepatotoxicity as a side effect of herbal meds

Comfrey (for joints), ephedra (respiratory symptoms, weight loss, stimulant), Jin Bu Human (Chinese med used as a sedative and analgesic)

Acute foot drop, weak foot dorsiflexion, eversion, paresethesia and or sensory loss over dorsal of foot and lateral shin

Common Perineal Nerve Injury, at the knee on the lateral aspect of the fibular head

Weight Gain After Smoking Cessation

Common. 9-11Ib in the first few months. More likely to gain weight if use Varenicline over Nicotine Replacement Therapy or Bupropion.

fever, consolidation (crackles, focal increased breath sounds) on lung auscultation.

Community acquired pneumonia treat with azithromycin or moxifloxacin

Community Acquired Pneumonia tx vs Hospital Acquired

Community: Ceftriaxone + Azithromycin Hospital: Piperacillin-Tazobactam (Antipseudomonal agents)

One-Way Analysis of Variance (ANOVA)

Compare means of a quantitative dependent variable among >2 group means. Cant adjust for other variables.

Study participants are selected or lost to follow up

Selection bias Randomization in a clinical trial reduces the selection bias

Intention to Treat Analysis

Compares intervention group in a randomized trial by including all subjects as initially allocated after randomization, regardless of what happens during the study period. If subjects are doing so poorly as to switch interventions or to drop out of the study then their outcome should be attributed to that intervention. Therefore Intention to treat analysis conducted to avoid effects of crossover (non compliance to assigned intervention) and attrition (loss to follow up, drop out) which may disrupt the benefit of randomization and introduce bias in the estimation of the effect of the intervention. Leads to more conservative estimate of the effect of the intervention, if attrition or crossover is significant, ITT analysis may be less likely to identify a statistic significant difference between interventions, however results will reflect the real effect of the intervention as intended in the population.

pain out of proportion to injury, Pain increase on passive stretching, rapidly increasing and tense swelling, paresthesia

Compartment Syndrome Compartment pressure >30 or delta pressure (diastolic BP - Compartment Pressure) <20-30 indicates significant compartment syndrome. Fasciotomy

secondary HyperPTH in patients with CKD

Compensatory rise in PTH due to hypocalcemia Diabetic Nephropathy

Oral codeine and tramadol in children <12

Contraindicated because of ultra rapid metabolism of codeine and tramadol causes an unpredictably high concentration of the active drug in the body, result in respiratory depression and death

Provocative Tests for Carpal Tunnel Syndrome

Compression of the median nerve as it passes under the transverse carpal ligament. PHALEN test: Flexion of wrist compresses nerve inside carpal tunnel TINEAL test: Light tapping elicits tingling sensation HAND Elevation test (holding hand over head) Nerve Phalen: Hyperextension of the wrist Worse at night, relived by shaving the hands (flicking sign) or running them under warm water. Initial Tx: Splinting, corticosteroid injection only provides short term relief (risk of tendon rupture) NERVE CONDUCTION STUDIES can confirm the diagnosis and assess severity. by demonstrating slow conduction along the nerve at level of carpal tunnel. Use when chronic or refractory cases in prep for surgery.

Auto-positive end-expiratory pressure (auto-PEEP)

Condition caused by insufficient duration of the expiratory phase resulting in accumulated air pressure in the lungs Temporarily disconnecting the ventilator and providing bag ventilation with long expiration time is the appropriate tx.

Baby with fixed plantar flexion, adduction of foot and inward facing sole. feet resist range of motion assessment

Congenital Clubfoot (talipes Equinovarus) developmental deformity of talus bone. tx: non surgical stretching and serial casting. After treatment complete bracing is required for a few years to prevent recurrence. If not treated then surgical intervention may be considered.

Cryoprecipitate used in life threatening bleeding refractory to first and second line therapies

Contains Fibrinogen, Factor VIII, and XIII and vWF facilitate platelet aggregation and lead to reduced bleeding time

When the control group unintentionally receives the treatment or the intervention

Contamination bias

LOW Radioiodine uptake seen in

Silent (painless) Thyroiditis, Postpartum Thyroiditits, Thyroid hormone abuse, Iodine induced Thyroiditits, Subacute De Quervain Thyroiditis.

minimal change disease tx

Corticosteroid More common in children and worse prognosis in adults Nephrotic Syndrome (heavy proteinuria, edema, HLD)

HIV, extremely elevated CSF pressure, and molluscum contagiosum like skin lesions

Cryptococcal meningoencephalitis HIGH CSF opening pressure >250-300, Low leukocyte count <50, HIGH protein and glucose, Positive India ink or cryptococcal antigen test if develop recurrent symtomps of elevated ICP require serial lumbar punctures Induction-Amphotercin B and Flucytosine > 2 weeks until symptoms resolve and CSF sterilized Consolidation-High dose oral fluconazole for 8 weeks Maintenance: lower dose oral fluconazole for >1 year to prevent recurrence

HIV and <50 CD4 cells with fever and headache. Neck stiff. Photophobia. Diagnosis & Treatment.

Cryptococcus. Lumbar puncture will show an increase in the level of lymphocytes in the CSF. The most accurate test is a cryptococcal antigen test. Treat initially with amphotericin and 5-FC, followed by fluconazole. The fluconazole is continued lifelong unless the CD4 count rises. If the CD4 count rises, all opportunistic infection treatment and prophylaxis can be stopped. The only treatment that cannot be stopped is the antiretrovirals.

contraindication to progestin-releasing IUD

Current breast cancer because some breast cancers are progesterone receptor positive and at risk for tumor progression

patient with HIV, widespread skin papules with central umbilication (some lesions with central necrosis and covered with hemorrhagic crust)

Cutaneous Cryptococcosis Immunocompromised like AIDS with CD4 <100 Dx: Biopsy: Periodic Acid-Schiff, Gomori Methanamine Silver Nitrate) Hyperplasia of ther overlying dermis with underlying granulomas surrounding encapsulated yeast. Tx: >2weeks of IV Amphotericin B & Oral Flucytosine followed by a year of Oral Fluconazole.

HTN, Tachycardia, Tachypnea, Headaches, Confusion, Anxiety, seizures, coma, Cherry red skin, High lactic acid. In patient given Nitroprusside

Cyanide Poisoning Combustion of plastics from structure fires, Mining, Sodium Nitroprusside med release of nitric oxide and cyanide ions. Cyanide converted to thiocyanate renal excreted. But in renal insufficiency can lead to cyanide toxicity. Inhibits mitochondrial oxidative phosphorylation and forces anaerobic metabolism. Management: Decontaminate, Supportive care, tx with hydroxocobalamine +/- Sodium Thiosulfate

recurrent sinopulmonary infections, intestinal obstruction (meconium ileus), pancreatic insufficiency, diabetes, male infertility

Cystic Fibrosis Mutation of CFTR gene Autosomal Recessive Elevated Sweat Chloride Levels CFTR mutation on genetic testing Abnormal nasal potential difference Nutritional support, airway clearance, Abx coverage for staph aureus and pseudomonas (MRSA coverage with VANCOMYCIN PLUS 2 drugs against Pseudomonas CEFEPIME, AMIKACIN)

B Cepacia pneumonia without granuloma, Sinupulmonary infections ONLY

Cystic Fibrosis if with granuloma then Chronic granulomatous disease

Dysuria + white cells in urine + suprapubic tenderness

Cystitis

urinary frequency, urgency, burning, and dysuria in young, otherwise healthy women. Diagnosis & Treatment.

Cystitis (UTI) Best initial test is urinalysis. The most accurate test is urine culture. Uncomplicated cystitis —Fosfomycin, nitrofurantoin (SAFE IN PREGNANCY), or TMP/SMX orally for 3 days if not E. coli resistance (if resistance, use ciprofloxacin or levofloxacin) —Quinolones for more serious infections Complicated cystitis (presence of an anatomic abnormality, i.e., a stone, obstruction): TMP/SMX or ciprofloxacin for 7 days

fever, cough, dyspnea, diffuse ground glass opacities

Cytomegalovirus Pneumonia Prophylaxis with Valganciclovir

Onychomycosis (Tinea Unguium)

DAILY PO TERBINAFINE - 1st line Finger nail - 6 weeks toenail - 12 weeks Itraconazole BID x 1 week/month for 2 months (toenail)

Polydipsia, Polyuria, Dilute Urine (Urine Osmolality <300)

DDX: DI, or Primary Polydipsia Differentiate with water deprivation test. Overnight fast from water elevates serum sodium and osmolality, Cause secretion of ADH (increased renal water reabsorption) and highly concentrated urine (OSm >600) this is normal finding. In DI: Impaired renal concentration due to ADH resistant (Nephrogenic DI) or deficient in ADH production (Central DI). Therefore urine remains dilute In Primary Polydipsia: ADH increases and urine becomes concentrated. Psychiatric or CNS disorder. Excess water intake suppresses ADH and polyuria is appropriate response to excess water load. Alternate test is Desmopressin (ADH ANALOGUE) to assess renal concentrating ability.

Vit D deficiency

DEC Calcium, DEC Phos, INC PTH

Left lower quadrant abdominal pain and low grade fever and hematochezia

DIVERTICULITIS COLONOSCOPY IS CONTRAINDICATED due to risk of perforation.

following renal transplant risk of ____within the first few months?

DM Immunosuppression medication adverse effects: Glucocorticoids cause weight gain, and decreased insulin sensitivity, Calcineurin inhibitors (tacrolimus, cyclosporine) cause reversible toxicity to pancreatic islet cells leading to impaired insulin secretion. Improved renal function: The healthy transplanted kidney causes increased insulin excretion and capable of increased gluconeogenesis Susceptibility increased when >45yo, BMI>30, and + FH

contrast associated acute kidney injury

DM and CKD are risk factors And patients taking metformin could lead to metformin associated lactic acidosis High risk patients = GFR <30, Prophylactic measures (IVF), and metformin held for 48 hrs Low risk patients = GFR >45, no prophylactic measures or stopping of meds required.

DPP4 Inhibitors

DO NOT use in pancreatitis and discontinue in those who develop pancreatitis also can result in hypersensitivity and angioedema.

Tubulointerstitial Mononuclear Cell Infiltration

Dec urine output, elevated serum creatinine = AKI Peripheral esoniphilia and pyuria with WBC casts = ACUTE INTERSTITIAL NEPHRITIS Antigen hypersensitivity that leads to renal tubulointerstitial mononuclear cell infiltration. (T-Lymphocyte, Macrophages) tubular accumulation of WBCs, poretinuria, hematuria caused by tubular damage. Caused by Meds (Antibiotics-Cefazolin, NSAIDs, PPIs), Rheumatologic disease (SLE, Sjogrens, Sarcoidosis), Infections (legionella, TB, CMV) New med exposure, AKI, Arthralgia, malaise, TRIAD OF FEVER,SKIN RASH & EOSINOPHILIA Urinalysis: WBC, WBC Cast, +/- Mild RBCs & Proteinuria, Peripheral Eosinophilia +/- Eosinophils Renal biopsy: Tubulointersititial inflammation & edema

Hypermagnesemia results in

Decreased Deep Tendon Reflexes, and muscle paralysis. Flaccid quadriplegia, decreased respiration, eventual apnea.

low back pain, chronic, worsen with activity, relieved with rest

Degenerative Disc Disease Can lead to acute disc herniation presenting with acute lumbosacral radiculopathy pain radiating to dermatome

Sexual dysfunction due to SSRI

Delayed Orgasm

sleep disturbance, motor impairment, visual hallucinations, fluctuating attention or alertness

Dementia with Lewy bodies

dementia, Fluctuation cognition (Alertness, attention), Visual hallucinations, Parkinsonism, Rapid Eye movement sleep behavior disorder Repeated falls, Syncope, delusions, depression or anxiety

Dementia with Lewy bodies LOW DOPAMINE TRANSPORTER UPTAKE IN THE BASAL GANGLIA

deeply seated painless or sometime painful oblong, firm masses in the trunk/extremity, intraabdominal bowel and mesentery, and abdominal wall. Vague upper abdominal pain and discomfort.

Desmoid Tumor locally aggressive benign tumor arising from Fibroplastic Elements within the muscle or fascial planes with very low potential for metastasis or differentiation. Common in Adenomatosis Polyposis (Gardner Syndrome) due to abnormal wound healing or clonal chromosomal abnormalities causing a neoplastic behavior. Can cause Intestinal obstruction or bowel ischemia, high rate of recurrence. CT or MRI to evaluate size, and biopsy. Surgery is definitive therapy, otherwise radiation therapy if not surgical candidate

used in patients with Von Willebrand Disease to increase levels of von willebrand factor and factor VIII

Desmopressin (ddAVP)

amniocentesis

Determine the fetal karyotype at 15-17 weeks. —A needle introduced transabdominally through the uterus aspirates a sample of amniotic fluid —Risks: fetal loss; maternal bleeding; infection; rupture of membranes; fluid leakage; or direct/indirect injury to fetus

Child with ventriculoperitoneal shunt with fever and irritability

Device related infection (ventriculitis, meningitis) Full neuro exam, Physical exam to evaluate for meningitis (kerning, Brudzinski), Abdominal exam (where VP SHUNT TERMINATES), check for papilledema checking for intracranial pressure. Neuroimaging looking at size of ventricles (Shunt obstruction can lead to noncommunicating hydrocephalus), evaluate CSF if anything above is abnormal, via direct shunt aspiration.

prevent neurologic complications in adults with pneumococcal meningitis

Dexamethasone

Leading cause of blindness in the USA

Diabetes

Stocking-Glove Pattern: distal symmetric polyneuropathy, erectile dysfunction with loss of cremasteric reflex in a diabetic

Diabetic Neuropathy

Painful inguinal nodes, ulcerative genital disease, enlarged nodes, sometimes called buboes, may develop a suppurating, draining sinus tract. Best initial test and treatment

Diagnostic testing is NAAT of a lymph node aspirate or serology for Chlamydia trachomatis. Treatment is aspiration of the bubo, followed by doxycycline or azithromycin.

Form of Cognitive Behavioral Therapy developed to treat borderline personality disorder

Dialectical Behavioral Therapy (CBT)

Diphtheria-Tetanus-Acellular Pertusis Immunization

Diphtheria toxoid, Tetanus toxoid, Conjugated pertussis antigen 5 doses given at ages: 2,4,6 months 15-18 months 4-6 years 2 serious complications that are absolute contraindication to future DTaP immunization: Anaphylaxis immediate after or Encephalopathy within 7 days (due to pertussis components) so instead give Td component only

Diagnosing shingles

Direct fluorescent antibody testing for VZV Shingles = Erythematous papules progressing to grouped vesicles in a dermatomal distribution

Autosomal Dominant

Disorders affect 50% of all children born to an affected parent Consecutive generations, and father to son transmission is common.

Aspirin in High doses (>2g/day)

Displaces thyroid hormone from thyroid hormone-binding proteins, leading to an increased thyroid hormone effect with decreased TSH, Total T3 and Total T4

Tenosynovitis (pain with passive extension and or tenderness over the flexor sheaths of multiple tendons) + Dermatitis (painless pustules on distal extremities) + Migratory Polyarthralgia ()asymmetric joint pain)

Disseminated Gonococcal Infection Detect Neisseria Gonorrhoeae in urine, cervical, or urethral sample Tx: 3rd gen Cephalosporin IV

brisk, painless hematochezia in an elderly

Diverticulosis diagnosed by colonoscopy.

Health Care Worker who do not have immunity to VZV

Documented previous hx of varicella or have received the 2 dose varicella vaccine IF no immunity then postexpsoure prophylaxis with varicella vaccine within 5 days of exposure IF no immunity AND immunocompromised or pregnant, Varicella-Zoster Immune Globulin or Antiviral therapy

Metoclopramide (Reglan)

Dopamine Antagonist, and Serotonin Agonist Promotes gastric emptying and improves nausea and vomiting Can cause Extrapyramidal effects (dystonia-torticollis, akathisia (restlessness) and Parkinsonism. Tx: Diphenhydramine or Benztropine are the drugs of choice for the immediate treatment of Metoclopramide induced acute dystonia

Inhibin A levels are increased in the blood of mothers of fetuses with

Down Syndrome

Post cardiac injury syndrome, several weeks following MI

Dressler Syndrome an immune mediated pericarditis

Sustained muscle contractions resulting in twisting or abnormal postures (torticollis) patient on metoclopramide or Antipsychotics

Drug induced dystonia tx with Benztropine an anticholinergic

FeNa >1%, after antibiotics and NSAIDs. Pyuria. WBC casts and hematuria.

Drug induced interstitial nephritis Inflammatory Hypersensitivity response complete recovery to baseline within 3-7 days.

muscular dystrophies

Duchenne: -XR -Deletion of Dystrophin Gene -2-3yo -Proximal muscle weakness (Gowers sign), Claf pseudo hypertrophy -Cardiomyopathy, arrhythmias, scoliosis -Wheelchair by adolescent, death 20-30yo for respiratory or HF Becker: -XR -Deletion of Dystrophin Gene -5-15yo -proximal weakness -Cardiomyopathy, arrhythmias Death 40-50 HF Classic Myotonic: -AD -Trinucleotide repeat DMPK gene -12-30yo -Facial and distal muscle weakness, grip myotonia (sustained hand contraction after attempted grip release, sustained thumb abduction after thenar eminence percussion) -Cardiomyopathy, arrhythmias, Dysphagia, cataracts, testicular atrophy -Death 45-55 resp or HF

Bell palsy

Due to Stroke, GBS, Sarcoidosis, Otitis Media, Herpes, Lyme dz, Cerebellopoltine angle neoplasm, parotid neoplasm Tx: HIGH DOSE Glucocorticoids, Acyclovir, Eye protection (lubrication, taping of eye at night) >85% complete recovery with steroid tx within weeks to months

PTH independent Hypercalcemia (HIGH calcium, LOW PTH) in setting of critical illness and acute quadriplegia

Due to immobilization Seen in patients with very high bone turnover (adolescents, Paget dz) Bone resorption increased and bone formation decreased leading to release of calcium from bone stores. 25-hydroxy Vit D are normal Tx with bisphosphonates to decrease bone resorption and preserve bone mass

Temporary improvement of epigastric pain after a small meal vs pain exacerbation

Duodenal ulcers = Improvement after meals, but worsening at night -H. Pylori associated with duodenal ulcers -Triple therapy with PPI (Omeporazole), Clarithromycin, Amoxicillin -Confirm eradication with urea breath test or fecal antigen test after 4 weeks of completion of therapy Gastric Ulcers = Exacerbation of pain after meals

Gestational transient thyrotoxicosis

During pregnancy, hCG directly stimulates TSH receptors on thyroid follicles because of homology between TSH and hCG (SHARE ALPHA SUBUNIT) thereby increasing release of thyroid hormone. But normal or only slightly increased free hormone levels. HIGH hCG leading to increase in both total and free thyroid hormone = Gestational transient thyrotoxicosis seen in multiple gestation or hyperemesis gravidarum. Self limited condition and resolves as hCG levels naturally decline by 14-16weeks gestation.

Epigastric pain or burning, postprandial fullness, early satiety, bloating, >1 month

Dyspepsia Functional/Idiopathic, Malignancy (gastric, esophageal), Peptic Ulcer Dz (H pylori, NSAIDs), Drug induced (NSAID, Bisphosphonate) LOW MALIGNANCY RISK: <60, no alarm symptoms -Test & treat for H Pylori (stool antigen, urea breath test) HIGH malignancy risk: >60 & (GI Bleed, weight loss, iron def anemia, LAD< dysphagia, odynophagia, persistent vomiting, palpable mass, FH of upper GI cancer) -Gastroenteroly referral/Upper Endoscopy Trial PPI (Pantoprazole, Omeprazole) if no cause found

upper abdominal pain, epigastric fullness and mild nausea that occurs after eating and at night.

Dyspepsia (Peptic Ulcer Dz, GERD, Malignancy, NSAID Induced Gastritis) Patient >60 considered high risk for malignancy and should undergo upper GI ENDOSCOPY with biopsy. Also indicated in <60 with significant weight loss, GI bleed, palpable mass, vomiting, dysphagia, odynophagia, FH.

UTI abx in pregnancy

E. COLI Get: - Nitrofurantoin (not 1st trimester 2/2 hemolytic anemia) - Amoxicillin - Amoxicillin-clavulanate - Cephalexin - Fosfamycin Contraindicated - Tetracyclines - Fluoroquinolones (cartilage) - TMP-SMX (NTD, cleft palate, kernicterus, cardiac defects) - Aminoglycoside (gentamycin - deafness) Repeat urine cx as bacturia increases risk pyelonephritis and respiratory distress

Infectious Urethritis in older men with enlarged prostates

E. coli tx with Fluoroquinolones (OFLOXACIN)

atrialization of the right ventricle due to malformed tricuspid valve. Tricuspid regurgitation and cyanosis.

Ebstein Anomaly

Excellent for neutropenic fever (better than amphotericin). Have no significant human toxicity. Salvage therapy for aspergillosis

Echinocandins (caspofungin, micafungin, anidulafungin). Have no significant human toxicity because they inhibit the 1,3 glucan synthesis step, which does not exist in humans

Liver cyst with fluid, peripheral calcifications and septation

Echnococcus parasitic infection cause hepatic cyst asymptomatic for years after infection

unexplained grand mal seizures in a hypertensive and/or proteinuric pregnant woman in the last half of pregnancy

Eclampsia = Preeclampsia + Seizures

best Antiretroviral for HIV to use when the patient has TB

Efavirenz

When an external variable differentially modifies the effect of a risk factor on the disease of interest in different groups

Effect Modification

Ehlers-Danlos Vs Marfan

Ehlers-Danlos: -Hyperextensible skin, easy bruising, poor healing, velvety skin with atrophic scarring -Joint hypermobile, Pectus Excavatum, SCOLIOSIS, High arched palate -MVP -Abdominal & Inguinal hernias, uterine prolapse -COL5A1 & COL5A2 mutation -Autosomal Dominant Marfan: -Striae -Joint hypermobile, Pectus excavatum, SCOLIOSIS, Tall with long extremities -Progressive aortic root dilation, MVP -Lens and retinal detachment, spomnt pneumothorax -FBN1 mutation -Autosomal Dominant

Human Bites

Eikenella Corrodens ALpha hemolytic Strep Staph aureus Fusobacterium Prevotella Management: Local wound care & irrigation, No primary closure except face, antibiotics, tetanus booster Tx: Oral amoxicillin/clav (Ampicillin-Sulbactam if IV)

carbon monoxide poisoning

Entrapment during fire results in Hemoglobin binding with high affinity to the toxin and reduces oxygen delivery to tissues. HIGH Levels of Carboxyhemoglobin. Cellular hypoxia, severe metabolic acidosis with elevated lactic acid can result.

Fixed, immobile uterus, rectovaginal modularity and adnexal mass (endometrioma), dysmenorrhea, heavy menstrual bleeding.

Endometriosis Endometrioma, implante and adhesions

Kaposi sarcoma (KS)

Endothelial Tumor Caused by Herpes virus 8 (HHV8) Most common in untreated HIV Violaceous, red, or brown flat lesions grow into papules, most common along skin folds, pruritis, pain, friable, lymphedema distal to lesion. May involve the lungs and GI Tx: ART

Viral Meningoencephalitis (Fever, Headache, Vomiting, AMS, Nuchal Rigidity)

Eneterovirus: COXSACKIE, ECHOVIRUS HSV Arbovirus: WEST NILE transmit by mosquitos (summer and early fall), maculopapular rash and excoriated mosquito bites - detect west nile IgM antibody in CSF and treatmnent is supportive CSF with aseptic pleocytosis Tx: Supportive care, Acyclovir for HSV

Maraviroc

Entry inhibitor: Blocks the CCR5 receptor. Chemokine receptor 5 (CCR5) is the mechanism whereby the HIV virus enters the CD4 cell. CCR5 is the attachment point of the GP120 on the surface of the HIV virus whereby it finds its way into human cells.

extremely painful and tender testicle with a normal position in the scrotum.

Epididymo-Orchitis

Upper Arm adducted and internally rotated, Elbow extended, Forearm pronated, Wrist & fingers flexed

Erb-Duchenne Palsy (waiters tip): C5-Weak deltoid and infraspinatus muscles, C6-Biceps and wrist extensors, C7-Finger Extensors Shoulder dystocia due to high birth weight (advanced maternal age, obesity, multiparity) = fetal macrosomia (>9.9Ib) Management: OBSERVATION & PT, 80% of patients spent recovery in 3 months. Only surgical intervention if no improvement by 3-9 months

Only carbapenem that does NOT cover pseudomonas

Ertapenem

Cohort Study

Estimates and compares the risk of developing disease between exposed and non exposed

Postmenopausal Osteoporosis

Eval: DXA Scan (T-Score <-2.5), Serum chem panel, CBC, 25-Hydroxyvitamin D level Lifestyle measures: Regular weight bearing exercise, Avoid tobacco & excess alcohol intake, Adequate calcium (>1,200 mg/day) and vitamin D (>800 IU/day) Therapy: Bisphosphonate (alendronate, Risedronate), alternatively zoledronic acid or denosumab NORMAL Serum calcium level should be confirmed prior to treatment. In addition Vitamin D deficiency can increase risk of Hypocalcmeia so total body stores should be assessed by measuring 25-hydroxyvitamin D

HIV screening

Everyone age 15-65 should be tested for HIV regardless of risk factors

Criteria for Acute Liver Failure

Evidence of hepatic injury: 1. Elevated Aminotransferases 2. Encephalopathy 3. INR >1.5

Inappropriate pregnancy weight

Excess Weight gain: GDM, Fetal Macrosomia, C-Section Inadequate Weight gain: Fetal growth restriction, preterm delivery Recommendations for weight gain in pregnancy depends on pre pregnancy BMI. If pre pregnancy underweight <18.5 BMI, therefore require greater gestational weight gain 28-40Ib to maintain healthy pregnancy

primary dysmenorrhea

Excess prostaglandin production <30yo, BMI<20, Tobacco, Menarche <12yo, Heavy/Long menstrual periods, Sexual abuse Pain first 2-3 days of menses, N/V/D, normal pelvic exam NSAID + OCPs

adjunctive therapy for DM in patients with difficult to control hyperglycemia

Exenatide, GLP1 Analog

Seek to determine whether an intervention works in optimal conditions

Explanatory Study

Perinatal hepatitis B infection

Exposed infants should receive Hep B vaccine and Immunoglobulin within 12 hours of birth Followed by completion of the normal Hep B series (Age 0, 2, and 6 months) Serology should be obtained at 9 month well child visit. If HBsAg not detected at that time, the infant is uninfected.

Familial Hypocalciuric Hypercalcemia (FHH) Vs Primary Hyperparathyroid (PHPT)

FHH: AUTOSOMAL DOMINANT due to mutation of calcium-sensing receptor (CaSR) that leads to decreased sensitivity to calcium NORMALLY high calcium levels suppress PTH but in FHH, higher calcium concentrations are required, concurrently the defective CaSR causes increased reabsorption of calcium in renal tubules -Normal or mildly high calcium -Noirmal or high PTH -No Sxs -Normal Bone density -Low Urinary Calcium excretion Tx: reassurance PHPT: osteoporosis, nephrolithiasis, CKD -HIGH calcium -HIGH PTH -Symptomatic -LOW bone density -HIGH Urinary calcium Excretion TX: Parathyroidectomy

Most effective Pharma therapy for reducing triglyceride levels and recommended in patients with severe hypertriglyceridemia (>1000) to reduce risk of pancreatitis

FIBRATES (Gemfibrozil) 150-500: Weight loss, Moderate alcohol intake, increase exercise, Known cardiovascular disease or high risk (Add statin therapy) >1000: Prevent pancreatitis by vibrates, fish oil, abstinence from alcohol

More sensitive test for neurosyphilis

FTA is more sensitive than VDRL for neurosyphilis.

Purposeful falsification of symptoms for obvious external benefit

Factitious Disorder

psychiatric condition characterized by feigning or inducing illness to assume the sick role without obvious external benefit

Factitious Disorder

Study design where >2 interventions and all combinations of these interventions

Factorial study design

Trisomy 21: early testing

First trimester screen: β- hCG, pregnancy- associated plasma protein A (PAPP-A), fetal nuchal translucency Cell-free DNA

Octreotide infusion

For bleeding esophageal varies

Ursodeoxycholic acid

For patient with small, noncaclcified gallstones who have mild symptoms of biliary colic.

Macroorchidism, large jaw, intellectual disability

Fragile X (X-linked Dominant)

Autism spectrum disorder often occurs in patient with

Fragile X Syndrome. BOYS, LONG NARROW FACES, LARGE EARS, LARGE TESTICLES

Molluscum contagiosum (poxvirus) widely disseminated and persistent and involve the face

Frequently seen in HIV patients warrant HIV testing Tx requires removal of the lesion via curettage/Cryotherapy or chemical removal with topical agents (podophyllotoxin)

indicated for bleeding due to coagulation factor deficiencies (DIC)

Fresh Frozen Plasma (FFP) High PT, PTT and decreased platelet count

Clinical Microsystems

Frontline Health care settings where patients, families and health care teams interface. May include support staff, equipment, information technology, billing. examples: outapatient primary care clinic, cancer center, hospital emergency department, hospital ICU, nursing home. Patients depend on coordination of different Microsystems for comprehensive care.

Dementia with early personality changes (disinhibition)

Frontotemporal Dementia

carbamazepine can cause

Fulminant hepatic failure with resulting hyeperammonemia, hepatic encephalopathy, seizure

tender, solitary mass in the breast in female 35-50

Simple Breast Cyst Resolution after needle Aspiration

Indicated for exacerbation of Chronic Obstructive Pulmonary Disease

GLUCOCORTICOIDS (METHYLPREDNISOLONE)

Dyspareunia, Vulvar Irritation, Pelvic Organ prolapse, Urinary symptoms due to vulvovaginal atrophy

Genitourinary syndrome of menopause

Vagina Bleeding, Pelvic pain/pressure, HIGH b-hcg (positive pregnancy test), Dark irregular lesion on the posterior fornix that bleeds after contact.

Gestational Trophoblastic Neoplasia: Choriocarcinoma Metastasis to lungs, vagina, CNS and liver Malignant transformation of the chorionic villi or trophoblast Risk factors: Hydatidiform mole, Maternal age >40 Eval: Pelvic US, CXR, Thyroid function test, hepatic function test, renal function test Tx: Chemo, Hysterectomy After tx b-hCG used as a marker for disease remission or progression

Tall, excess weight gain, coarse facial features, frontal bossing

Gigantism-GH is elevated

impaired hepatic conjugation of billirubin

Gilbert Syndrome

adolescent with asymptomatic jaundice

Gilbert Syndrome. Periodic asymptomatic jaundice from unconjugated hyperbilirubinemia.

What is the best method to prevent contrast-induced renal failure?

Give hydration with normal saline.

referred Otalgia (ear pain)

Glossopharyngeal Nerve CN IX from tongue converge with Vagus Nerve CN X from posterior pharyngeal wall at the jugular Foramen resulting in referred pain felt in external auditory canal

Avascular necrosis of the humerus most often seen in patients with a hx of

Glucocorticoid use, lupus, sickle

Diffuse iodine uptake on scintigraphy

Graves disease Due to Thyrotropin receptor autoantibodies that stimulate iodine uptake and thyroid hormone synthesis Tx: Radioiodine Thyroid Ablation

Goiter, Exophthalmos, Myxedema

Graves disease due to Thyroid Receptor Autoantibodies.

Serum phosphorous

HYPOcalcemia in HYPOPTH is associated with INC phosphorous

Painful ulcerative genital disease, Best initial test and treatment

Haemophilus ducreyi (Chancroid) The best initial tests are a swab for Gram stain (gram-negative coccobacilli) and culture (will require specialized medium: Nairobi medium or Mueller-Hinton agar). Treatment is a single IM shot of ceftriaxone or a single oral dose of azithromycin.

<7yo, summer/fall, painful vesicles/ulcers oral mucosa, macules/pupules/vesicles on palms, soles, buttocks, NOT pruritic fever, malaise

Hand-Foot-Mouth Disease COXSACKIE VIRUS Complications: Myopericarditis, Aseptic Meningitis, Nail Dystrophy (1-2 months later) Tx: Supportive (pain control hydration)

Athletes Heart

Heightened Vagal Tone - Resting bradycardia with or without first degree AV block, left ventricular wall thickness (LVH) NON PATHOLOGIC Condition No additional cardiac eval needed other than ECG

Men, hyperpigmentation, DM, Cardiomyopathy, elevation in transaminases

Hemochromatosis Serum ferritin and transferrin saturation

DM and hyperpigmentation of the skin are features of

Hemochromatosis (Bronze Diabetes) brownish or bronze at times slate gray on sun exposed skin like face

Highest NPV is based on test with

Highest Sensitivity

Highest PPV is based on test with

Highest Specificity (A good confirmatory test must have a HIGH specificity)

Single Item Screening for Alcohol Use

How many times in the past year have you had 5 (4 women) or more drink in a day?

HIGH GLUCOSE, LOW BP, HIGH PULSE, Dry mucus membranes, absent JVD, Confusion, lethargy. Disoriented to time and place. Negative serum ketones.

Hyperosmolar Hyperglycemic State (HHS) HHS and Diabetic Ketoacidosis occur in patients with poorly controlled diabetes. TYPE 2 DM tend to develop HHS and Type 1 ketoacidosis. In HHS Dehydration (dry mucus membranes and tachycardia) occurs from an osmotic diuresis caused by Hyperglycemia. Mild acute renal failure. Markelfy high serum osmolality results in neurologic symptoms. Hypernatremia exacerbate his AMS. Hyperkalemic due to insulin insufficiency and hyperosmolality, (overall body potassium deficit caused by increased urinary excretion) FIRST STEP: Aggressive Fluid Resuscitation (Isotonic Saline).

first step in evaluation of premenopausal bleeding while on Tamoxifen

Hysteroscopy

Dynamic Left Ventricular outflow tract obstruction

Hypertrophic Cardiomyopathy (enlarged inter ventricular septum in combo with systolic anterior motion of the mitral valve), the lower the LV blood volume the worse the obstruction, therefore goal is to maintain high LV blood volume Standing & Valsalva Strain Decreases LV volume (worsens obstruction, accentuates the murmur) Squatting, Supine leg raise, Handgrip Increases LV volume (lessens obstruction, decreases murmur) Tx: 1st line = Beta Blockers (metoprolol-non selective beta 1 and beta 2 blocker resulting in asthma exacerbation) increase LV blood volume to reduce LVOT; by 1. Negative Chronotropy: Inc diastolic filling time to increase LV end diastolic volume , 2. Negative Inotropy decrease contractility to cause blood ejection to complete at a higher LV end systolic volume IF INTOLERANT TO BETA BLOCKERS 2nd line= NONDIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS: VERAPAMIL 3rd line once failed medical therapy = Alcohol Septal Ablation

Causes of Tongue Enlargement

Hypothyroid, Amyloidosis, Acromegaly, Mucopolysaccharidosis, MEN 2B

Decreased solute intake can result in

Hypovolemic Hyponatremia with Low urine sodium <40

Reversal for anticoagulant Dabigatran (Direct Thrombin Inhibitor)

IV Idarucizumab (monoclonal Ab)

Status epilepticus therapy on CCS

IV MEDS 1. Benzodiazepines (lorazepam) 2. If seizure persists after moving the clock forward 10-20 minutes, add fosphenytoin 3. If seizure persists after moving the clock forward another 10-20 minutes, add levetiracetam, valproic acid, or phenobarbital 4. If seizure persists after moving the clock forward another 10-20 minutes, add general anesthesia (e.g., pentobarbital, thiopental, midazolam, propofol)

Tx for Torsades De Pointes

IV Magnesium

Petechiae or purpora that develop in any skin area following a viral URI

Idiopathic Thrombocytopenic Purpura (ITP)

isolated pubic hair development Normal bone age and no additional signs of adrenarche (acne)

Idiopathic premature pubarche

Management of anaphylaxis

Immediate: -Epinephrine (beta-2, Alpha-1 agonist causes bronchial smooth muscle relaxation and vasoconstriction (inc BP and dec Edema) IM x3 doses if severe/refractory then IV -IVF & Trendelenburg for hypotension -Albuterol for bronchospasm -Early intubation for upper airway obstruction Adjunct: -H1/H2 Antihistamines -Glucocorticoids -Glucagon for patient on beta blockers -hospital admission if shock

most superficial of the bacterial skin infections is and caused by

Impetigo caused by Streptococcus pyogenes or Staph epidermal layer of the skin. Because it is so superficial, there is weeping, crusting, and oozing of the skin.

Hip fracture in elderly

In elderly patient who are stable and ambulatory prior to fracture, surgery within 48 hours is associated with lower mortality and lower risk of pressure ulcer and pneumonia.

Labor protraction in the active phase due to

Inadequate (Hypotonic) uterine contractions Contractions have to occur every 2-3min If no cervical change over 2hrs, inadequate contractions >3min, In there active phase of labor (cervix >6cm) therefore in labor protraction and need labor augmentation to increase contraction frequency and intensity OXYTOCIN and an AMNIOTOMY (artificial rupture of membranes are first line treatment

Rate Ratio

Incidence rate of an event in the intervention group divided by the incidence rate of the same event in the control group RR<1=The incidence rate of the event is lower in the intervention group than the control group (INTERVENTION IS PROTECTIVE) RR=1=Incidence rate of the event is the same in both groups RR>1=Incidence rate of the event is greater in the intervention group than in the control group (INTERVENTION IS RISKY)

Lower the measurement variability of an outcome the more likely the statistical test will detect an effect when such an effect exist.

Increase in statistical power. (probability of detecting a true difference) Type II Error represents the probability of failing to detect a true difference. An increase in statistical power produces a decrease in type 2 error.

Increased risk of death from antipsychotics in patients with dementia

Increased cardiac events, stroke, falls, aspiration, pneumonia

Phototoxic dermatitis

Induced by Diuretics, Abx, NSAIDs Erythema with or without bull and gesticulation over sun exposed areas (dorsal hands, upper chest, face)

Positive TB Skin test and Prior BCG Vaccines

Induration from BCG rarely exceeds 15mm and decreases 15 years after it is received. Interferon Gamma release assays can be used to distinguish a true positive skin test from BCG vaccination. Upper lobe fibrosis on CXR is strongly suggestive of Latent TB. Latent TB tx = Rifampin x 4months or Isoniazid + Rifampin x 3 months.

Indirect Hyperbilirubinemia in a patient with Vit B 12 deficiency

Ineffective Erythropoiesis Defective DNA synthesis with megaloblastic transformation and intramedullary hemolysis HEMOLYTIC ANEMIA: HIGH LACTATE DEHYDROGENASE, LOW HAPTOGLOBIN, INDIRECT HYPERBILI

non bilious, projectile emesis in 3-6 week infant. vomit immediately after oral intake. Vomit color of milk. On adbodem exam there is waves of peristalsis.

Infantile Hypertrophic Pyloric Stenosis (thickened Pylorus)-OLIVE SHAPED ABDOMINAL MASS Risk: Firstborn male, macrolide antibiotic exposure 3-6 weeks Prominent peristaltic waves represent exaggerated gastric contractions attempting to move food beyond the obstruction. Hypochloremic, Hypokalemic Metabolic Alkalosis Confirm Dx with abdominal ultrasound (Thickened elongated pylorus muscle) Tx: IVF, and surgical pyloromyotomy

Infant with symmetric spasms, developmental delay

Infantile Spasms epileptic disorder of infancy Dx: Electroencephalogram: Hypsarrhythmia Tx: Corticotropin (ACTH), Vigabatrin

Young, Fever, Tonsillitis/Pharyngitis, LAD, fatigue, Hepatosplenomegaly,

Infectious Mononucleosis (EBV) + Heterophile Antibody (monospot) test (screen for IgM antibodies called heterophile antibodies, produced in response to EBV infection and agglutinate with erythrocytes from unrelated species (horse in the mono spot test, or sheep in Paul-Bunnell Test) Avoid sports for >3weeks, contact sports >4 weeks due to risk of Splenic Rupture Self limited treated with supportive care and NSAID IF GIVE PENICILLIN CAN TRIGGER APPEARANCE OF A MACULOPAPULAR RASH Corticosteroids are warranted in rare cases when airway obstruction appears imminent.

Low back pain, decreased spinal motion, X-rays reveal sacroiliitis and bridging syndesmophytes

Inflammatory Spondyloarthropathy (Ankylosing Spondylitis)

mild abdominal pain, tenderness, slightly elevated serum lipase in a setting of recent acute pancreatitis likely has

Inflammatory fluid collection (Pancreatic Pseudocyst) mass effect and location causing abdominal pain, biliary and pancreatic duct obstruction or fistulization into adjacent organs. Erode into adjacent blood vessels result in pseudo aneurysm and gestational hemorrhage. Supportive if significant symptoms then surgical or endoscopic drainage.

Abdominal Aortic Aneurysm (AAA)

Infrarenal Aorta >3cm RISK: SMOKING, Male, Older, White, FH, Atherosclerotic dz SCREEN: Abdominal US in men 65-75 who ever smoked Management: SMOKING CESSATION, Aspirin & Statin therapy, Repair if >5.5cm FU: 4-5.4cm US q6-12m, Smaller US q2-3y

organophosphate poisoning

Inhibition of Acetylcholineesterase -> Cholinergic Toxicity MUSCARINIC EFFECTS: DUMBELS Defecation Urination Miosis Bronchospasm/Brady Emesis Lacrimation Salivation Nicotinic effects: Muscle weakness, paralysis, fasciculations CNS: Resp failure, seizure, coma Tx: Resuscitation: O2, Fluids, Intubation -ATROPINE (competitive antagonist of the acetylcholine muscarinic receptor and decreases cholinergic activity) -PRALIDOXIME (acetylcholinesterase reactivator) -ACTIVATED CHARCOAL if within 1 hr of exposure

Modafinil

Inhibits dopamine transporters to increase arousal and is used to treat ADHD off label potential for abuse

Trazodone

Inhibits ser reuptake. Antidepressant Use: insomnia Toxicity: sedation, nausea, priapism, postural hypotension

Postpartum Endometritis

Inoculation and infection of the endometrial cavity by vaginal flora during labor or delivery Risk: MOST SIGNIFICANT RISK IS ****C-Section, Intraamniotic Infection, Group B Strep, Prolonged rupture of membranes, Operative vaginal delivery, preterm (<37), posterm (>42 weeks) Fever for >24hrs postpartum, uterine fundal tenderness, purulent lochia Polymicrobial infection Tx: Clindamycin + Gentamicin

Bupropion Side effects

Insomnia, Jitteriness, anxiety

Management of Type 1 DM

Insulin Replacement: Dec with "honeymoon" phase, vigorous exercise, Inc with puberty/rapid growth Urine ketone checks Avoid alcohol to decrease hypoglycemia risk Hemoglobin A1c every 3 months Initial eval: Lipid panel, Screen for other autoimmune condition (thyroiditis, celiac disease), depression/eating disorder >10yo and DM>5 years: Yrine albumin/Cfreatine ratio annually (nephropathy), Foot inspection & vibration testing annually (Polyneuropathy), Dilated eye exam every 2 years (retinopathy)

Non-alcoholic fatty liver disease (NAFLD) Pathogenesis

Insulin Resistance leads to: 1. Increased Lipolysis -> Increased free fatty acids -> Hepatocyte fat accumulation -> Dec Oxidation -> Dec Metabolism and Decreased VLDL -> Decrease export to circulation 2. Hyperinsulinemia -> Increase Lipogenesis -> Hepatocyte fat accumulation -> Rest as above

Per-Protocol Vs Intention to Treat Analysis

Intention to Treat Analysis: Compares treatment groups in a randomized trial by including all subjects as initially allocated after randomization, regardless of what happens during the study period. This helps avoid effects of attrition (loss to follow up, dropout) and crossover (switching to another assigned intervention) which may disrupt the benefit of randomization and introduce bias in the estimation of the effect of the intervention. Lead to conservative estimates of the effect off interventions. If attrition or crossover is significant, ITT analysis may be less likely to identify a statistically significant difference between treatments. However, results will reflect the expected effect of the intervention in a practical clinical setting. Per-Protocol Analysis: ONLY those patients who strictly adhere to a research protocol, excluding all non adherent and drop off patients are included in the final data analysis. Therefore benefit of randomization is lost. Overestimate the effect of the intervention in a practical clinical setting.

Sudden intermittent abdominal pain and vomiting, sausage shaped mass in right abdomen, CURRANT JELLY STOOLS. 6 months to 3yo

Intussusception Telescoping of one bowel segment into adjacent segment resulting in bowel edema -. Ischemia and Necrosis ILEOCECAL related to recent viral illness resulting in hypertrophy of intestinal Peyer patches, pathological lead points (Meckle diverticulum (Technetium 99m scan + = ectopic gastric mucosa), HSP, intestinal tumor) US: Target Sign AIR OR SALINE ENEMA Surgical intervention for failed enema reduction or signs of peritonitis IF AFTER AIR ENEMA tachycardia, severe abdominal pain and abdominal distention = Intestinal perforation. First get an abdominal Xray, presence of free air confirms diagnosis.

transplant patients, prolonges neutropenia, chronic corticosteroid use, AIDS with the class triad of cough, chest pain, hemoptysis. CT Chest with Nodules with Ground Glass Opacity, cavitation with air fluid levels.

Invasive Pulmonary Aspergillosis Serum Biomarkers: Galactomannan, Beta-D-Glucan Tx: Voriconazole, Reduction of immunosuppressive regimen, surgery

Microcytic/Hypochromic anemia with anisocytosis, Serum ferritin <15,

Iron Def Anemia GI tract major source of blood loss leading to iron def anemia in MALES, Fecal occult blood test needed followed by colonoscopy

Low MCV, High RDW, LOW RBCs, Microcytic, Hypochromic, LOW IRON & FERRITIN, HIGH TIBC, LOW Hgb

Iron Deficiency Anemia Vegetarians are at increased risk, especially during pregnancy

Acute febrile syndrome within 24hrs of initial treatment for spirochete infection (Syphilis, Leptospirosis, tick-borne spirochete) Fever, malaise, chills, headache, myalgia

Jarisch-Herxheimer Reaction. due to rapid lysis of spirochetes, released bacterial proteins into the blood stream and triggers an innate immunologic response. NO effective prevention, self limited and resolve within 48hrs. If severe treat with acetaminophen.

fever, headache, and myalgia developing 24 hours after treatment for early stage syphilis

Jarisch-Herxheimer reaction It is a benign, self-limited reaction caused by the release of pyrogens from dying treponemal spirochetes. Treat with aspirin and continue the treatment.

Left axis deviation on ECG

LV Hypertrophy

Vertigo, tinnitus, nausea, loss of balance follows a viral illness (influenza), trauma, bacterial infection, allergies, benign tumor, certain meds

Labyrinthitis

Elderly with impaired executive function (planning or carrying out tasks, processing new information), impaired memory and recall. Difficulties with focus and concentration.

Late-Life Depression - Reversible cognitive impairment - Pseudodementia Assess and treat depression RISK FACTOR for Major Neurocognitive Disorder (Dementia) in the years that follow.

Instability with medial movement of knee, VARUS LAXITY

Lateral Collateral Ligament (LCL)

Treatment of infertility in PCOS (acne, hirsutism, irregular menses)

Letrozole or Clomiphene LETROZOLE: Acts on ovaries. Ovarian Theca Cells produce Androgen, which are converted to estrogen by Aromatase within ovarian granuloma cells. PCOS patients have increased ovarian androgen production which leads to increased ovarian estrogen production and inhibit GnRH, FSH, LH Inhibits Aromatase therefore decrease androgen to estrogen conversion, lead to low estrogen which feedback to increase GnRH and which rincreases pituitary FSH release to stimulate dominant follicle and ovulation. CLOMIPHENE: Acts on Hypothalamus. Depletes hypothalamic estrogen receptors, leading to hypothalamus to perceive low estrogen levels, the hypothalamus now increases GnRH released which increases FSH and LH and induced Ovulation..

Older adult with back pain worsened by extension

Ligamentum Flavum Hypertrophy lead to lumbar spinal stenosis Spondylosis (degeneration)

Hazard Ratio

Likelihood of an event occurring in a treatment group relative to the control group HR <1 - event is less likely to occur in tx group than control similar to RR except that RR is calculated at the end of a study to convey the risk of an event occurring within that time frame in contrast to HRs a measure of the instantaneous risk of an event occurring during a subset of totally study period

Linear Regression Models

Linear relationship between a dependent variable and one or more independent variables. Multiple linear regression could be used to quantify the effects of alcohol use, tobacco smoking and charred food consumption (independent variables) on the incidence of gastric cancer (dependent variable)

Medication that requires evaluation of thyroid and kidney function before initiation of therapy. Due to hypothyroid and renal toxicity.

Lithium

First line tx for Bipolar manic episodes

Lithium (AVOID IN PREGNANCY - Ebstein Anomaly) Anticonvulsant mood stabilizers (Carbamazepine, Valproate - AVOID IN PREGNANCY-Neural Tube Defects) Antipsychotics (Haloperidol - SAFE IN PREGNANCY) Elcetroconvulsive therapy ONLY if unresponsive to meds

First line tx for Bipolar I Disorder

Lithium (Avoid in renal dz) & Valproate (Avoid in liver dz) (anticonvulsant mood stabilizer) Immediate management of acutely manic patient with escalating agitation and psychosis requires antipsychotic (RISPERIDONE)-Quick onset administered IM

Patients treated with anticonvulsant mood stabilizer Valproate should have baseline and periodic monitoring of

Liver function tests

Inhibiting Na-K-2C symporter in thick ascending limb of the loop of henle.

Loop Diuretics to promote diuresis to remove volume overload symptoms

Adverse effects of SGLT-2 Inhibitors: Cana-GLIFLOZIN

Lower blood glucose by reducing reabsorption of glucose in the kidney GU Infections: Vulvovaginal candidiasis, UTI, Fournier Gangrene Osmotic Diuresis: Volume deplete, Symptomatic Hypotension, AKI Metabolic: Euglycemic Diabetic KETOACIDOSIS Orthopedic: Fracture, Foot Ulcer Tx: Hydration, DC med, Insulin

Canagliflozin

Lower blood glucose by reducing the reabsorption of glucose in the proximal renal tubule.

lower extremity edema, renal dysfunction, proteinuria (>500mg/day), urinalysis with active sediment (Hematuria, RBC cast) in SLE

Lupus Nephritis (Immune complex mediated glomerular injury) Immune complexes composed of ANTI dsDNA Abs & LOW Complement levels Renal biopsy indicated prior to tx Tx: Immunosuppression with Glucocorticoids (Methylprednisone, prednisone), and cyclophosphamide or mycophenolate mofetil

+ Antinuclear Ab, Low Serum Complement (C3, C4)

Lupus nephritis

Peripheral precocity (excess sex hormones (androgen) from the gonads, adrenal glands, or exogenous source resulting in precocious puberty. As well as testicular assymtery or a palpable testicular mass

Lydia Cell Tumor.

Mean vs mode as a valid choice for central location

MEAN is the most valid choice for central location for a normally distributed continuous data A perfect bell shaped curve Asymmetrical, do not follow a normal distribution, positive or negative skewed; MEDIAN is a more representative and valid measure of central location MODE is used to describe Categorical variables (Qualitative)

Anti malaria chemoprophylaxis in a pregnant patient

MEFLOQUINE

Ginkgo Biloba Leaf Extract

MEMORY BOOSTER due to increased cerebral blood flow somewhat effective in treatment of intermittent claudication and Alzheimer Disease SE: Seizures, Headaches, Irritability, restlessness, diarrhea, nausea, vomiting, INCREASE RISK OF BLEEDING inhibits platelet activating factor. resulting in intracerebral bleeding.

Mutation in the RET proto-Oncogene most common cause of

MEN 2A and 2B Autosomal Dominant MEN2A associated with Primary Hyperparathyroid due to parathyroid Hyperplasia with increased urinary calcium excretion

CNS Anterior Brainstem

MIDBRAIN -Optic II -Oculomotor III -Trochlear IV PONS -Trigeminal V -Abducens VI -Facial VII -Vestibulocochlear VIII MEDULLA -Glossopharyngeal IX -Vagus X -Accessory XI -Hypoglossal XII

treatment for orthostatic hypotension

MIDODRINE (alpha-Adrenergic agonist)

Bone pain, anemia, Hypercalcemia (cause constipation), Fatigue, Fractures (osteolytic lesions), congestion of glomerulus with immunoglobulins results in renal insufficiency. HIGH ESR. High protein on urine dipstick.

MULTIPLE MYELOMA Evaluate by serum or urine protein electrophoresis looking for monoclonal immunoglobulin spike (M-Spike)

Inadequate folate and Vitamin B12 in pregnancy secondary to inadequate maternal intake due to persistent nausea and vomiting or lack of prenatal vitamins.

Macrocytic Anemia with hyperhsegmented neutrophils

Effect of intensive glycemic control in type 2 diabetes

Macrovascular complications: Acute MI, stroke: No change (short term) Instead of tight glycemic control need BP control, lipid lowering therapy, low dose aspirin, smoking cessation Microvascular complications (nephropathy, retinopathy): Improve Mortality: No change or increased TIGHT glycemic control can reduce the risk of microvascular complications of diabetes especially nephropathy (proteinuria, CKD) and retinopathy. Target A1c <7%. DM with chronic hyperglycemia is associated with increased risk of cognitive decline and dementia.

loss of vision in the center of the visual field

Macular degeneration Dry: Cellular debris (drusen) accumulates between the retina and choroid. Wet: blood vessels growing up from chord behind the retina.

Congenital Syphilis

Maculopapular or vesicular rash involving palms, soles, buttocks. NO ORAL MUCOUS patches. Neonatal Period associated with hepatomegaly and lymphadenopathy

Thick and thin smears used to diagnose

Malaria causes anemia from hemolysis of parasitized RBCs Cyclical high fever and malaise, headaches, abdominal pain.

X-Linked Recessive

Male offspring of a female carrier have a 50% chance of being affected, where as female offspring have a 50% chance of being carriers

high risk for urinary tract malignancy (renal, bladder, prostate)

Male, >40yo, Smoking, Gross hematuria, pelvic radiation or exposure to aniline dyes Upper and lower tract need to be evaluated. Lower with Cystoscopy, Upper with CT Urogram, if CKD alternate would be US

Cough, dyspnea, chest pain, night sweats, weight loss, Pleural effusion. Pleural calcifications, thickening and mass. Worked as a shipbuilder

Malignant Mesothelioma Asbestos exposure (cement, tile, automobile brake pad, shipbuilding industry). Tumor arise 15-30yrs after exposure. Pleural effusion: exudative effusion, LOW pH & Glucose. Dx: Thoracentesis with cytology Tx: Palliative, Surgery, chemo, radiation. 9-13months survival

Infants of mothers with diabetes experience HYPOglycemia

Maternal Hyperglycemia in utero triggers fetal beta-cell hyperplasia and subsequent hyperinsulinemia

Peripheral precocity (excess sex hormones (androgen) from the gonads, adrenal glands, or exogenous source resulting in precocious puberty. As well as fibrous dysplasia and numerous cafe-au-lait macula's with irregular borders.

McCune-Albright Syndrome More common in females

comparing the difference between 2 paired proportions, patients serve as their own control (Success/Failure before and after treatment in the same subjects)

McNemar Test

2 year old, Painless rectal bleeding, soft, non tender slightly distended abdomen. Technetium-99 nuclear scan shows increased uptake in RLQ abdomen.

Meckels Diverticulum Persistent Vitelline (Omphalomesenteric) Duct, Ectopic gastric mucosa (failure of vitelline duct to obliterate during the first 8 weeks of gestation, leaving behind a blind pouch containing ectopic gastric tissue)-> Intestinal ulceration & bleeding Rule of 2s: By age 2, <2 inches, Within 2 feet of ileocecal valve. Acute abdominal pain due to complications: -Intussusception: Recurrent, atypical -Diverticulitis (mimis appendicitis) -Bower obstruction, perforation (Peritoneal signs) Technetium-99 pertechnetate (meckel) scan detects gastric mucosa (concentrates in the parietal cells of the diverticulum and stomach) If symptomatic and + scan then surgical resection

common causes of vertigo (sensation of spinning)

Meniere Disease: recurrent lasting 20 min to several hours, sensorineural hearing loss, tinnitus or feeling of fullness in ear, tx with diuretics due to increased volume/pressure of endolymph in semicircular canals (end-lymphatic hydros) BPPV: Benign Paroxysmal Positional Vertigo: brief episodes triggered by head movement, Dix-Hallpike maneuver causes nystagmus Vestibular Neuritis: acute single episode that can last days, follows viral syndrome, abnormal head thrust test, tx with corticosteroids Migraine: vertigo associated with headache Brainstem/Cerebellar Stroke: sudden-onset persistent vertigo, other Neuro symptoms

Periodic vertigo, unilateral hearing loss, tinnitus

Menieres Disease

small effusion, LOCKING sensation with extension, Inability to fully extend, joint line tenderness, positive McMurray test at the knee

Meniscus Injury

Localize the lesion. Profound upper extremity weakness (contralateral in the case of unilateral arterial occlusion). Aphasia. Apraxia/neglect. The eyes deviate toward the side of the lesion. Contralateral homonymous hemianopsia.

Middle cerebral artery

selective phosphodiesterase-3 inhibitor that causes positive isotropy as well as reduction in preload and afterload

Milrinone

nausea, skin rash (mild b/l lower extremity pitting edema, and palpable nonblanchin purpuric rash), fatigue, tingling in hands and feet, joint pain, bilateral ankle reflex absent. High Cr, LOW C3,C4,CH50, 2+ protein on urinalysis, + Rheumatoid factor. Hx of IVDU

Mixed Cryoglobulinemia Syndrome: Triad = 1. palpable purpura, 2. Weakness, 3. Arthralgia Vasculitis due to deposition of immune complexes (IgG and IgM rheumatoid factor) within the vascular wall of small & medium size vessels. Arise in those with chronic Hep C (hx of IVDU) Dx: Serum Cryoglobulin levels , Elevated rheumatoid factor, Hypocomplementemia, Glomerulonephritis Tx: 1. Initial immunosuppressive therapy - Stabilize end organ damage using RITUXIMAB plus PREDNISONE 2. Tx underlying dz-targeted therapy if Hep c tx with antiviral therapy

bradycardia, on ECG Intermittent nonsonducted P waves and regular PR interval

Mobitz type II AV Block High rate of progression to complete AV third degree block. In the absence of reversible causes (Ischemia, electrolyte abnormalities, medications-Beta blockers, Nondihydropyridine calcium channel blockers), infiltrative disease (sarcoidosis) or age related fibrosis) requires PACEMAKER

Phenelzine (Nardil)

Monoamine Oxidase Inbibitors (MAOIs) Contraindicated with SSRI because of serotonin syndrome Need 2 week washout period (5 weeks for fluoxetine due to longer half life) due to risk of hypertensive crisis or serotonin syndrome.

Diagnostic Criteria for Multiple Myeloma

Monoclonal Protein in Serum Urine >10% clonal plasma cells in bone marrow or soft tissue/bone pasmacytoma End organ damage (CRAB) Calcium elevation, Renal insufficiency, Anemia, Bone pain (lytic lesions) Whole Body Low Dose CT scan without contrast is the preferred screening modality used to evaluate skeletal system.

Major depression in an independent risk factor for increased

Morbidity and mortality in Cardiovascular Dz. Increased inflammation, Endothelial cell dysfunction, abnormal platelet activation, increased cortisol and sympathetic tone. No interaction with cardiac meds.

A 29-year-old multigravida was found on routine prenatal laboratory testing to be positive for hepatitis B surface antigen. She is an intensive care unit nurse. She received 2 units of packed red blood cells 2 years ago after experiencing postpartum hemorrhage with her last pregnancy. Which of the following indicates the greatest risk of transmission?

Mothers who are (+) for HBsAg, anti-HBe antibody, and IgM anti-HBc are acutely infected. Mothers who are also (+) for HBeAg have an 80% risk of transmission to fetus. Anti-HBs (antibody to surface antigen) indicates immunity to infection from previous immunization. Hepatitis B surface antibody is an IgG antibody that can cross the placenta. Hepatitis B infection is not an indication for cesarean delivery. Treatment is hepatitis immunization and HBIG in the neonate. Chronic HBV can be treated with interferon or lamivudine.

Pituitary Adenomas + Primary Hyperparathyroid + Pancreatic/Gastrointestinal neuroendocrine tumors

Multiple Endocrine Neoplasia Type 1 Pituitary Adenoma (Prolactinoma): Secrete prolactin, GH, ACTH cause headaches and visual field defects Primary HyperPTH: Parathyroid hyperplasia, Hypercalcemia TX: PARATHYROIDECTOMY: due to symptomatic hypercalcemia, osteoporosis, CKD, nephrolithiasis. pancreatic/ GI neuroendocrine tumors: Gastrinoma: recurrent peptic ulcers, Insulinoma: Hypoglycemia, VIPoma: Secretory diarrhea, Hypokalemia, Hypochlorhydia, Glucagonoma: Weight loss, Necrolytic migratory erythema, Hyperglycemia Multiple cutaneous lipomas

Highest increased risk for PID

Multiple sexual partners

Hypocalcemia can cause

Muscle spasms due to tetany, perioral paresthesia Tx with Calcium Chloride

episodes of double vision, intermittent difficulty swallowing, occur at end of the day and go away after a short nap. mild ptosis.

Myasthenia Gravis (Neuromuscular Junction Disease)-Autoantibodies against acetylcholine receptor. Fluctuating muscle weakness that worsens throughout the course of the day. First notice with double vision and ptosis due to weakness in extra ocular muscles. next most common muscles are the bulbar muscles resulting in dysphagia dn dysarthria. ASSOCIATED WITH THYMOMA

wound infection with papular and ulcerative lesions that develop over several days from salt and fresh water

Mycobacterium Marinum

T-Cell Lymphoma with slow progressive skin lesions that appear as patches, plaques, tumors, erythroderma.

Mycosis Fungoides Tx: skin-directed corticosteroids, chemo, phototherapy and/or radiation

Post seizure urinalysis evidence of blood with minimal red blood cells raising suspicion for

Myoglobinuria due to rhabdomyolysis Release of intracellular muscle components into the circulation after muscular injury due to trauma, compression injury, Infection, drug use like PCP, toxin exposure. HIGH Creatine Kinase and urinalysis with blood but no RBCs = Myoglobinuria Major complication is acute kidney injury so need IVF to increase renal perfusion and prevent intratubular cast formation

middle aged woman with flat affect, bilateral ptosis, weak hand grip, atrophy of small muscles of hands, difficulty releasing grip after grasping examiners hand.

Myotonic Dystrophy AD: CTG Trinucleotide Repeat Expansion in DMPK gene (transcribed to mRNA but not translated) Longer repeat length correlates with earlier and more severe disease Adult: Myotonia (delay in muscle relaxation-cant release hand grip), weakness Child: Cognitive and behavioral difficulties Infant: Hypotonia, Respiratory failure, Inverted V shaped upper lip Arrhythmias, cardiomyopathy, dysphagia, constipation, pharyngeal weakness, hypoventilation, insulin resistance, hypogonadism, cataracts, frontal balding, excess daytime sleepiness Dx&Tx: Genetic testing, supportive management. life expectancy reduced due to CV and Resp Disease

Treatment for acetaminophen toxicity

N-Acetylcysteine

Single best test for both gonorrhea and chlamydia

NAAT urine sample In men blind vaginal swab in women

Primary Enuresis

NEVER established nocturnal continence Enuresis alarm to condition child to wake before voiding or DESMOPRESSIN at bedtime decreases nocturnal polyuria

Recurrent lapses into sleep or napping multiple times a day, 3x weekly, for 3 months. Hypnagogic hallucinations.

Narcolepsy Conscious brief episodes of sudden bilateral muscle tone loss precipitated by emotions such as laughter, spont abnormal facial movements without emotional triggers (Cataplexy) HYPOCRETIN-1 DEFICIENCY by CSF analysis Rapid Eye Movement sleep latency <15min Dx via Polysomnography (sleep study) Tx: Reduce daytime sleepiness; MODAFINIL (a stimulant, first line) SNRI (Venlafaxine) or SSRI and TCA can treat cataplexy Sodium Oxybate (salt form of gamma-hydroxybutyrate) improve nocturnal sleep, relieve excess daytime sleepiness and has anti-cataplectic properties (due to abuse potential not used as often)

Early Side Effects of SSRIs

Nausea, Anxiety, Insomnia Common at start of SSRI, tolerance develops over several weeks. Continue SSRIs for the duration of the adequate trial period of 6 weeks and reassess then.

fever, pain, purulent drainage from ear, in an elderly with diabetes and immunocompromised individuals

Necrotizing (MALIGNANT) Otitis Externa Aggressive Pseudomonas Infection

Patient who experiences sexual assault should be offered emergency contraception to prevent pregnancy

Negative pregnancy test does not exclude the possibility of pregnancy, because only positive after implantation (4 weeks after last menstrual period) Oral emergency contraceptive pills prevent pregnancy by delaying ovulation ULIPRISTAL (Antiprogestin) = most effective oral EM contraceptive pill may be taken up to 5 days after unprotected intercourse.

congenital deafness (most common sequelae), congenital heart disease (e.g., patent ductus arteriosus, or PDA), cataracts, intellectual disability, hepatosplenomegaly, thrombocytopenia, and "blueberry muffin" rash

Neonates with congenital rubella Rubella is a single-stranded RNA virus of the family Togaviridae.

Hyperproteinuria, Hypoproteinemia, Hyperlipidemia, Edema, HTN

Nephrotic Syndrome loss >3.5 g per day of protein in the urine; when that happens, albumin level in the blood falls and there is edema Hyperlipidemia is a part of nephrotic syndrome; be sure to use statins Thrombosis can occur because of loss of antithrombin III, protein C, and protein S in the urine Dx: UA with HIGH protein, 24hrs urine protein shows >3.5g, Spot urine for protein to Cr ratio >3.5:1, Renal biopsy

Retrospective observational study in which subsets of controls are matched to cases and analyzed for the variables of interest

Nested (case-control study)

observational study in which subsets of cases and controls identified and selected from a follow up study are compared with regard to the distribution of risk factors

Nested Case-Control Study

Child with abdominal mass, weight loss, signs of excess catecholamine secretion (High BP, Flushing, sweating)

Neuroblastoma : Neural Crest Origin, Involves Adrenal Medulla <2yo, Abdominal mass, Periorbital Ecchymoses (Orbital Metastases), Spinal Cord Compression from epidural invasion, Opsoclonus-Myoclonus Syndrome Painless mass originating in the adrenal medulla or along the sympathetic chain. Derived from cells of primitive sympathetic ganglia and secrete catecholamines (epi, norepinephrine) Dx: Elevated Catecholamine metabolites, small round blue cells on histology, N-myc gene amplification

Dopamine antagonists can cause AMS, fever, rigidity

Neuroleptic Malignant Syndrome Tx with DANTROLENE a peripheral muscle relaxant

Carbamazepine (Tegretol) side effects

Neutropenia aplastic anemia, thrombocytopenia: BONE MARROW SUPPRESSION (Fever, mouth ulcers, easy bruising or petechiae) Hyponatremia SIADH

high billirubin in infants

Newborns have elevated bilirubin due to liver immaturity, lack of intestinal bacteria to break down bilirubin and high hemoglobin turnover. Pathologic unconjugated hyperbilirubinemia caused by increased red blood cell turnover from a cephalohematoma after vaccum assisted delivery. Also can be caused by prematurity (<37 weeks), exclusive breast feeding, sibling requiring phototherapy, east asian race. >20-25 associated with kernicterus, bilirubin encephalopathy, results in severe neurologic dyfunction (movement disorder, sensorineural haring loss) Phototherapy converts bilirubin into water soluble form that can be excreted in the urine and stool. phototherapy should be continued with interval bilirubin monitoring. Direct bilirubin Level that is high is conjugated hyperbilirubinemia that does not respond to phototherapy and is always pathologic

Photosensitive dermatitis, erythematous tongue, diarrhea, vomiting, insomnia, dementia, confusion

Niacin Deficiency (pellagra)

Treatment of uncomplicated cystitis in non pregnant

Nitrofurantoin for 5 days TMP-SMX for 3 days Fosfomycin single dose

Peripheral precocity (excess sex hormones (androgen) from the gonads, adrenal glands, or exogenous source resulting in precocious puberty

Non Classic Congenital Adrenal Hyperplasia (AUTOSOMAL RECESSIVE) Reduced 21-hydroxylase activity -> Excess androgen production (acne, early pubic hair, BUT normal sized testes and girls hirsutism and menstrual irregularities, advanced bone age) no salt wasting, not identified by newborn screen Dx: Elevated 17-hydroxyprogesterone on ACTH stimulation test. Tx: HYDROCORTISONE Classic Congenital Adrenal Hyperplasia COMPLETE 21-hydroxylase deficiency Salt wasting, identified by newborn screen

Nontunneled Centrally inserted central catheter vs peripherally inserted central catheter

Nontunneled Centrally inserted central catheter are commonly used for short durations in hospitals BUT hasve as higher rate of infection (bacteremia) therefore PICC is preferred for long term use PICC also has fewer procedural complications and increased patient comfort. DISADVANTAGE OF PICC = higher risk of THROMBOTIC EVENTS (upper extremity venous thrombosis (PE) ) Due to longer catheter length which increases vascular endothelial cell contact and risk of endothelial damage which can initiate coagulation cascade. Higher catheter to vein diameter ratio which decreases the venous cross sectional area available for blood flow leading to venous stasis and increased likelihood of thrombus formation. Can reduce risk by choosing smaller diameter. AVOID PICC IN CKD due to thrombosis can induce vessel stenosis and reduce available sites for future hemodialysis access.

Congenital pulmonary valve stenosis, obstruction of the pulmonary valve is associated with

Noonan Syndrome

Number needed to treat (NNT)

Number of patients who need to be treated to prevent one additional bad outcome. Calculation is the INVERSE of Absolute Risk Reduction (ARR) ARR = Control group event rate - Experimental group event rate NNT = 1/ARR =

Number needed to treat (NNT)

Number of patients who need to be treated with a specific drug to prevent 1 additional negative event. Inverse of Absolute Risk Reduction 1/ (risk (control) - Risk (tx))

irritability, poor concentration and decreased short term memory in an elderly, who doesn't sleep well at nights complains of headaches

OSA increased risk when >50yo, Male, Neck circumference >17in, elevated BP

pain, weakness in leg adduction and sensory loss over a small area in the medial thigh

Obturator Nerve Injury secondary to pelvic trauma or surgery

Epithelial Keratitis marked by linear branching lesions on the cornea with conjunctival injection.

Ocular Herpes Simplex Tx: Acyclovir

Calculated in case-control studies to compare the exposure of participants with the disease to the exposure of those without.

Odds Ratio

Odds Ratio (OR)

Odds of an outcome given an exposure / odds of an outcome in absence of exposure

dilation of cecum and right colon in absence of mechanical obstruction to the flow of intestinal contents, involve the right side of colon.

Ogilvie's Syndrome (acute colonic pseudo-obstruction)

Abdominal Aortic Aneurysm screening

One-time ultrasound screening in men 65-75 years who have ever smoked.

Mother who screens positive for chlamydia or infant who acquires it treated with

Oral Macrolide therapy (oral azithromycin, or Erythromycin)

Treatment for nodulocystic acne

Oral Retinoids (Isotretinoin)

Low Fecal Elastase-1

Pancreatic Exocrine Insufficiency Need pancreatic enzyme supplementation seen in chronic pancreatitis

manicure, nail biting, thumb sucking resulting in pain, erythema, edema of nail fold

Paronychia (localized bacterial infection of the nail fold or cuticle) Gram + skin flora Tx: Warm Soaks, Burow Solution (aluminum acetate), 1% acetic acid, Antiseptic (chlorhexidine) soaks or topical antibiotics (mupirocin) If abscess should be drained with hypodermic needle or small scalpel.

in a patient with opioid use disorder but requires opioid can give

Partial opioid agonist buprenorphine (limits opioid induced euphoria, may reduce the relapse risk

CASE-CONTROL STUDY

Particioasnts are identified as CASES or CONTROLS according to an OUTCOME STATUS One group is cases where they have the disease and one group is the control without the disease, then assess for past exposure to risk factor of interest.

Pediatric patient with acute onset joint pain, swelling, limited motion (hip flexed, abducted and externally rotated), refusal to bear weight, Fever. HIGH WBC, ESR, CRP. Effusion on US/MRI

Pediatric Septic Arthritis <3months: Staph Aureus, Group B Strep, Gram - Bacilli >3months: Staph aureus, Group A strep Tx: Joint drain & debride, IV Abx

Risk factors for postop pulmonary complications

Patient Risk Factors: -Age >50 -Severe COPD -Current smoking -OSA -Pulmonary HTN -CHF -ASA>2 -Serum Albumin <3 Procedural Risk Factors: ->3hrs -Emergency surgery -Head/Neck Surgery -Thoracic/Upper Abdominal surgery -Neurosurgery -Use of long acting neuromuscular blockade (pancuronium)

Exercise during pregnancy contraindicated with

Patients with cerclage and hx of cervical insufficiency should avoid exercise during pregnancy to minimize risk of preterm delivery Those at risk for preterm delivery: Cervical insufficiency, preterm labor during current pregnancy, preterm premature of membranes those at risk for antepartum bleeding: Plecenta previa, persistent 2nd or 3rd trimester bleeding Those with severe anemia, HTN of pregnancy (preeclampsia), restrictive lung disease, severe heart disease

erythema in the central face associated with flushing, telangiectasia. Adults 30-60yo. Light skinned, hair and eye color. Triggered by hot or spicy foods, alcohol, temperature extremes, emotional distress

Paulopustular Rosacea May experience ocular symptoms (burning or foreing body sensations, blepharitis, keratitis, conjunctivitis, corneal ulcers, and recurrent chalazion) NEED OPTHO CONSULT TOPICAL METRONIDAZOLE can also use oral antibiotics like metronidazole, tetracycline, doxycycline, minocycline, erythromycin

Sharp chest pain, diffuse ST elevation

Pericardial effusion occurs with acute pericarditis

heavy menstrual bleeding, fatigue, sleep disturbance. regular menses, well rugged vagina.

Perimenopause

patient with pyelonephritis who does not respond to treatment after 5-7 days. The patient remains febrile and still shows white cells on urinalysis. Diagnosis & Treatment.

Perinephric Abscess Perform a sonogram or kidney CT to find the collection. best diagnostic test is biopsy Treatment is a quinolone + staphylococcal coverage such as oxacillin nafcillin, or vancomycin

erectile dysfunction in patient with DM, HLD, Cigarette Smoking, and buttock and thigh pain

Peripheral Artery Disease due to atherosclerosis Bilateral aortoiliac PAD can lead to not only the buttock and thigh pain but as well as the erectile dysfunction. Obtain ANKLE-BRACHIAL INDEX (ABI) to screen for PAD. If <0.9 = Normal.

paroxysmal HTN, diaphoresis, headaches, sinus tachycardia

Pheochromocytoma Urine and Plasma metanephrine testing

Cilostazol

Phosphodiesterase-3 inhibitor that provides symptomatic relief some patients with claudication due to PAD

Bitemporal hemianopsia

Pituitary tumor

all patients with painless third trimester vaginal bleeding.

Placenta previa is implantation of the placenta that extends over the internal cervical os. Previous placenta previa, Previous C-section, Previous multiple-gestation pregnancy, Previous abortion, Advanced maternal age, Maternal smoking or cocaine use. best initial test is a transabdominal ultrasound Treatment begins with ultrasound monitoring. At 32 weeks, if the placenta is >2 cm away from the os, the patient may deliver vaginally; if <2 cm, repeat ultrasound at 36 weeks. At 36 weeks, a placenta that is >2 cm away from the os permits vaginal delivery.

most important risk factor for placenta accreta

Placenta previa with a prior C-section Treatment is a peripartum hysterectomy.

Plan-Do-Study-Act (PDSA)

Plan: Collect background info, identify specific goal and intervention Do: Implement Plan, Collect Data Study: Analyze Data, Assess whether intervention met goal Act: Determine Lessons Learned, Modify plan for next cycle

Positive overnight dexamethasone suppression test for Cushing syndrome secondary test

Plasma ACTH levels

pulmonary disease in patients with CD4 <200, fever, dyspnea, cough, interstitial pulmonary infiltrates

Pneumocystis Pneumonia

Acne, Male pattern baldness, hirsutism, menstrual irregularities, polycystic ovaries on Ultrasound

Polycystic Ovary Syndrome HIGH Testosterone, Estrogen, Imbalance in LH/FSH chronic elevated estrogen due to peripheral conversion of androgens to estrone in adipose tissue which contributes to chronic anovulation and infertility. DM, HTN, OSA, Nonalcoholic Steatohepatitis, Endometrial Hyperplasia Tx: Weight loss FIRST LINE to improve ovulation by decrease adipose and decrease estrogen, OCP for menstrual regulation, Letrozole for ovulation induction if unable to lose weight

3 days Post laparoscopic cholecystectomy, patient complains of abdominal pain, fever, guarding, ileus (diminished bowel sounds, small and large bowel distension) and leukocytosis.

Possible bowel injury therefore need CT with contrast

Localize the lesion. Prosopagnosia (inability to recognize faces).

Posterior cerebral artery

spontaneous abortion (miscarriage)

Pregnancy Loss <20weeks Advanced Maternal Age, Previous Spontaneous Abortion, Substance use disorder, extremes in BMI MOST COMMON CAUSE : FETAL CHROMOSOMAL ABNORMALITY (Aneuploidy, Trisomy 16) Tx: Expectant, Medical induction with Misoprostol, suction curettage if infection or HD unstable Rho (D) immunoglobulin, Pathology exam Complications: Hemorrhage, retained products of conception, septic abortion, uterine perforation, intrauterine adhesions.

In women of childbearing age with pulmonary hypertension

Pregnancy carries an extremely high mortality risk and should be avoided Non estrogen based contraception (lower risk for venous thrombosis)

SLE risk factor development of

Premature coronary atherosclerosis and coronary artery disease leads to premature death due to MI Common cardiac complication is Pericarditis (positional substernal chest pain with friction rub) Coronary vasculitis rare Non Hodgkin lymphoma, diffuse large B cell Lymphoma

depression, anxiety, irritability, bloating, breast tenderness +/- anger irritability that resolves with onset of menses

Premenstrual Syndrome (PMS), & Premenstrual Dysphoric Disorder (PMDD) Due to SEROTONIN Risk for DEPRESSION SSRI are first line (FLUOXETINE, CITALOPRAM) If the first SSRI doesn't work then try another otherwise can opt in for OCPs

Hyperthyroid due to graves disease see

Pretibial myxedema causing patchy nonpitting edema

Deep Q waves in leads V1-V4 consistent with

Previous Anterior MI

Females 30-65 yo. Fatigue, Pruritis, Arthritis, Hyperpigmented skin, RUQ pain, Xanthelasmata, Xanthomata, HIGH Alk Phos,

Primary Biliary Cholangitis (PBC) - Fibrosis and obliteration of the intrahepatic bile ducts, leading to cirrhosis + AntiMitochondrial Ab (AMA) Liver biopsy if AMA - Tx: Ursodeoxycholic Acid (Slow progression of disease), liver transplant in advanced cirrhosis (ONLY CURATIVE TREATMENT) COMPLICATION = Osteopenia and Osteoporosis. As the dz progresses cholestasis may cause toxic accumulation of substances that inhibit bone turnover. VIT D levels are normal. Screen regularly for osteoporosis using bone densitometry. Calcium and Vitamin D supplements are recommended and bisphosphonates in those with established osteoporosis. If Vitamin D deficiency can result in Osteomalacia (decreased bone mineralization)

HIGH FSH, LOW Estradiol, <40yo, Turner dz or chemoradiation. Oligomenorrhea or amenorrhea and Hypoestrogenism

Primary Ovarian Insufficiency

Syphilis Treatment by Stage

Primary, Secondary, and early latent (<12 months of infection) = BENZATHINE PEN G IM Single Dose Late Latent (>12months), unknown duration, Gummatous/CV syphilis = BENZATHINE PEN G IM WEEKLY for 3 weeks Neurosyphilis = Aqueous PEN G IV Q4hr for 10-14 days Congenital Syphilis = Aqueous PEN G IV q8-12hrs for 10 days Tertiary syphilis or anaphylactic reaction to penicillin = CEFTRIAXONE x2weeks If latent syphilis or unknown duration and anaphylactic reaction to penicillin then alternative would be DOXYCYCLINE for 28days

Primary Vs Secondary Mitral Valve Regurgitation

Primary: Intrinsic defect of the mitral valve apparatus (Leaflets, Chordae Tendineae), Myxomatous degeneration of the mitral valve leading to mitral valve prolapse (systolic click). Mitral valve repair or replacement indicated Secondary (or functional) refers to that occurring due to a disease process involving the left ventricle (myocardial ischemia, dilated cardiomyopathy. Management involves optimizing the LV function (medication, cardiac resynchronization therapy)

Risk factor for placenta previa

Prior C-Section, Placentia previa in a prior pregnancy, multiple gestation, advanced maternal age.

Most common risk factor for placenta previa

Prior C-section

Dyspnea during Hemodialysis

Prior to initiation of hemodialysis: Volume Overload After initiation of Hemodialysis: Acute Coronary Syndrome, Anaphylaxis

Attack Rate

Proportion of people in whom an illness develops out of the total population at risk for the disease

Relative Risk Reduction (RRR)

Proportion of risk reduction attributable to a specific intervention or exposure as compared to a control Risk for disease in exposed/intervention group and the unexposed/control group RRR = (Risk in unexposed-Risk in exposed)/Risk in Unexposed RRR = 1 - RR RR = (Risk of developing a disease in exposed/ Risk of developing same disease in unexposed group)

Misoprostol

Prostaglandin E1 Analog Used for Cervical Ripening and Labor induction

Small, painful papules in beard area?

Pseudofolliculitis Barbae penetration of hair shaft into the interfollicular skin (through lateral wall of follicle-transfollicular penetration or curving back into the skin-extra follicular penetration) Most prevalent in Black men with tightly curved facial hair, shaving with multi blade razor cutting hair below skin surface increases risk. Tx: DC Shaving, adjust shaving to single blade warm compresses, hair clippers

erythematous plaques, surrounded by sterile pustules that spread outward ion flexural regions (axilla, Inflammatory region) NO PRURITIS

Pustular Psoriasis of Pregnancy

Dysuria + white cells in urine + flank pain + fever

Pyelonephritis

3-6 weeks old with projectile vomiting with feeds

Pyloric Stenosis dx with Abdominal US

Dysphagia, drool, Exploring Caves

Rabies US: Bats, Raccoons, Skunks, Foxes Developing world: Dogs Hydrophobia (Pathognomonic for rabies, water triggers pharyngeal spasms that cause patient to be frightened of drinking), Aerophobia (pharyngeal Spasm), Autonomic Instability, Spasticity, Agitation, AMS, Ascending flaccid paralysis Post Exposure Prophylaxis: Rabies Immunoglobulin, Rabies Vaccine Series, is effective only in preventing disease prior to manifestation of symptoms, after disease onset tx is primarily palliative and most patients suffer from coma and death within weeks of illness onset. Long term Neuro defects if patient does survive. Coma, Resp Failure & death within weeks

diarrhea, fecal incontinence, mucus discharge, painful urge to go but only pass a small amount of mucus: tenesmus (ineffectual/painful straining on defecation) during or within 6 weeks of pelvic radiation. Guaiac-Positive Brown Stool. Colonoscopy Pale rectal mucosa, several serpiginous telangiectasia and small area of mucosal hemorrhage.

Radiation Proctitis Tx: Fluids, antidiarrheal agents if chronic then sucralfate or glucocorticoid enemas.

Diagnostic criteria for anaphylaxis

Rapid symptom onset and any one of the following 1: Skin/mucosa (Hives, lip/tongue swelling), Hypotension, Resp Distress 2: wheezing, stridor, dyspnea, tacky, syncope, abdominal pain, vomit, diarrhea

unilateral vocal cord paralysis, change in voice quality

Recurrent laryngeal nerve

infant with poor feeding, hypotonia, congenital cataracts, jaundice, hepatomegaly

Red blood cell galactose 1-phosphate uridylyltransferase (GALT) deficient in GALACTOSEMIA

Gottrons papules

Red/Purple Papules or plaques associated with Dermatomyosisits dorsal and radial surfaces of the metacarpophalangeal joints, proximal interphalangeal joints, proximal phalanx

First Stage of Labor: 2 phases

Regular, painful contractions and ends at complete (10cm) cervical dilation. 1. Latent Phase: From beginning of regular contractions to 6cm cervical dilation 2. Active Phase: From 6cm to 10cm, rapid >1cm/2hr

Sensitivity Analysis

Repeating primary analysis calculations after modifying certain criteria or variable ranges, goal is to determine whether such modifications significantly affect the results initially obtained. If results of sensitivity analyses conducted with slight changes in certain variables are similar to the initial results, the investigators can be confident of the robustness of their results.

Calculated in cohort studies

Relative Risk Ratio of the probability of an outcome occurring in the exposed group compared to the probability of it occurring in the non-exposed group.

hematuria (moderate blood and RBC on Urinalysis), Chronic Cigarette use.

Renal Cell Carcinoma Associated with smoking, obesity, HTN. Can have hematuria, abdominal mass, flank pain. Paraneoplastic syndrome (erythropoietin secretion) Dx requires a CT of the abdomen. (Enhancing mass of kidney with thickened irregular septa) Tx: Nephrectomy is curative

Laboratory Evaluation of HTN

Renal Function: Electrolytes, Creatinine, Urinalysis, Urine Albumin/Creatinine ratio Endocrine: Fasting glucose, Hgb A1c, Lipid profile, TSH Cardiac:ECG, Echo Other: CBC, Uric Acid

Calcitriol (1,25-DihydroxyVitamin D)-Active metabolite of Vit D

Renal Osteodystrophy & Hypoparathyroid

Common cause of secondary HTN in young adults

Renal Parenchymal Disease (Glomerulonephritis, Vesicoureteral Reflux) HTN caused by increased renal sodium absorption due to resistance to atrial natriuretic peptide and elevated activity of collecting tubule sodium-potassium pumps.

Tenofovir side effects

Renal Tubular Acidosis and Fanconi syndrome; it also causes decreased bone mineral density.

Most common secondary cause of HTN

Renovascular Disease -Atherosclerotic Dz = (carotid bruit, popliteal and post tibias pulses barely palpable) -Elevated Cr -Unilateral renal atrophy -Recurrent flash pulmonary edema -Abdominal bruit Dx: MRA, CTA, or Doppler US

Renovascular disease

Resistant HTN (uncontrolled despite 3 drug) Malignant HTN (End Organ Damage) Severe HTN (>180/120) after 55yo Severe HTN with diffuse Atherosclerosis Recurrent flash pulmonary edema with severe HTN Abdominal bruit, Rise in serum creatinine after starting ACE-I or ARBs, Unexplained atrophic Kidney Renal Artery stenosis should be assessed by Renal Duplex Doppler US or CT/MR angiography

patient with Diabetic ketoacidosis with fever, nasal congestion, purulent nasal discharge, headache, sinus pain, black eschar on inferior nasal turbinate, perioribital swelling

Rhino-Orbital-Cerebral Mucormycosis due to Rhizopus Species (Fungus) This organism possesses ketone reductase enzyme that catalyzes growth in high-glucose, acidic environments. In DM (ketoacidosis), Hematologic Malignancy, Solid organ or stem cell transplant. Dx: Sinus Endoscopy with biopsy & culture Tx: Surgical Debridement, IV Liposomal Amphotericin B, Elimination of risk factors (HIGH glucose, Acidosis)

Treatment for respiratory syncytial virus

Ribavirin SE: causes anemia

fever, headache, maculopapular or petechial rash originating on ankles/wrists

Rickettsial Disease (Rocky Mountain spotted fever) from a tick bite. Tx with Doxycycline.

TB meds

Rifampin: Inhibition of bacterial DNA dependent RNA Polymerase : GI effects, Rash, Red-Orange Body Fluids, Cytopenia Isoniazid: Inhibition of mycolic acid synthesis : Neurotoxicity-Peripheral Neuropathy, ataxia, paresthesias due to compete with pyridoxine/Vit B6 - cofactor in synthesis of synaptic neurotransmitters (GIVE VIT B6/PYRIDOXINE), Hepatotoxicity (NEED Baseline transaminase level and monitoring q3m) Pyrazinamide: Unclear : Hepatotoxicity, Hyperuricemia Ethambutol: Inhibition of Arabinosyl Transferase : Optic Neuropathy

An R prime wave (second R wave) in V1 and a widened S wave in V6 describes a

Right Bundle Branch Block. Benign or in setting of pulmonary HTN or acute pulmonary embolism

parasternal heave

Right Ventricular Hypertrophy

scuba diving is not recommended during pregnancy due to

Risk of fetal decompression sickness from air embolus formation

fever, headache, macular or petechial rash that begins on wrists/ankles and spreads to the trunk after a tick bite

Rocky Mountain Spotted Fever treated with Doxycycline

Alcohol has been show to worsen what skin condition

Rosacea

End-Of-Life Medication Management

STOP: Insulin, Anti HTN, Statins, Aspirin CONT: Pain meds, Antiemetics, Laxatives, Antidepressants, Seizure prophylaxis

Schizophrenia: Delusions, Hallucinations, Disorganized speech, disorganized or catatonic behavior. Manic: Grandiosity, pressured speech, decreased need for sleep. Psychotic: Delusions and auditory hallucinations

Schizoaffective Disorder, Bipolar Type persistent auditory hallucinations even when the mood is stable = Psychotic symptoms lasting > 2 weeks in the absence of a major depressive or manic episode

social withdrawal, decline in academic functioning, progression to paranoid delusions, auditory hallucinations, and blunted affect and asociality

Schizophrenia Tx: Anti psychotic - ARIPIPRAZOLE - Low risk of side effects (weight gain, Extrapyramidal, prolonged QT)

Decreased hearing, subcutaneous nodules, Hypopigmented spots on back, MRI of head shows bilateral cerebellopontine angle masses

Schwannoma (Schwann Cells)-Acoustic neuromas in Neurofibromatosis

T12 vertebral compression fracture (fragility fracture) in a elderly, despite treatment for osteoporosis with calcium, vitamin D, Bisphosphonate.

Secondary causes of Osteoporosis should be identified. Endocrine: -Hyperthyroid, HyperPTH, Hyper cortisol, Hypogonad Metabolic/Nutritional: -Calcium, Vit D Deficiency, Eating disorder GI/Hepatic: -Malabsorption (Celiac, Crohns), Chronic Liver Disease Renal: -Glucocorticoids, Phenytoin, Carbamazepine, PPI Other: -Rheumatoid, Multiple Myeloma, Alcohol, Immobilization

Progesterone

Secreted by corpus luteum during luteal phase of menstrual cycle (following ovulation) to prepare endometrium fro possible pregnancy implantation.

Trazodone side effects

Sedation, dry mouth, orthostatic hypotension, priapism

Patients with a history of anaphylaxis should be prescribed

Self-injectable Epinephrine Anaphylaxis a severe IgE mediated Type 1 Hypersensitivity reaction. Serum IgE levels are elevated in allergic conditions but nonspecific, Tryptase released by mast cells during anaphylaxis, normal between episodes, falsely low in food induced anaphylaxis

An unexpected occurrence involving actual or risk of death or serious injury that requires investigation to determine wether the event could have been prevented and how to prevent in future.

Sentinel Event

Valve Replacement in Aortic Stenosis

Severe AS criteria: -Aortic Jet Velocity >4 or mean transvalvualr pressure gradient >40, valve area <1 Indications for valve replacement: -Severe AS + onset of symptoms (Angina, syncope), LVEF <50%, Undergoing other cardiac surgery like CABG Percutaneous balloon aortic valvulotmy is considered only as a bridge to surgical trans catheter aortic valve replacement in severe AS. associated with high rates of procedural complications and does not improve long term prognosis Aortic Valve Replacement is the ONLY effective treatment for severe symptomatic AS

Infected pancreatic necrosis

Severe cases of Acute pancreatitis can lead to pancreatic necrosis. Initially sterile but can become secondarily infected (Gram - Enteric Bacteria), >7 days after initial presentation. Suspected in patients with persistent abdominal pain, in those who's condition initially improves but then deteriorates (Leukocytosis, fever, unstable vital signs). ABDOMINAL CT with Contrast can show gas within pancreatic necrosis IV antibiotics (Meropenem, Fluoroquinolone + Metronidazole)

First few months of life. Diarrhea, severe bacterial, fungal (pneumocystis jirovecii, candida), viral (HSV, CMV, EBV)

Severe combine immunodeficiency due to Adenosine Deaminase Activity reduced

Fentanyl

Short acting opioid analgesic used for pain management during short procedures Can cause reparatory depression and exacerbate hypotension

Glucocorticoid Cessation

Short term (<3 weeks) unlikely to cause suppression of the Hypothalamic-Pituitary-Adrenal Axis and therefore can be STOPPED ABRUPTLY with no risk for adrenal insufficiency.

HBcAg

Should never be detected in serum as it presents in infected hepatocytes only.

HbA: 60% HbS: 40%

Sickle Cell Trait

Dactylitis (painful swelling of the hands or feet)

Sickle cell disease Autosomal Recessive Hgb Beta Globin Chain Mutation When exposed to triggers (cold, dehydration, overexertion) RBCs sickle and destroy erythrocyte. Children <4yo common sequestration site is small bones of hands and feet results in bone infraction and a vast-occlusive pain crisis (Dactylitis) RBC destruction due to intravascular hemolysis results in chronic hemolytic anemia (Scleral Icterus, Jaundice) Dx: Hemoglobin Electrophoresis, predominant HbS with absent HbA. Acute management includes hydration and pain control. HYDROXYUREA can prevent future vaso-occlusive episodes.

HIGH Serum iron with HIGH Transferrin

Sideroblastic anemia due to Vit B6 deficiency (Cofactor in heme synthesis)

single, closed loop of dilated bowel on CT scan

Sigmoid Volvulus Tx: Colonoscopic Decompression

Dry Mouth (xerostomia), dry eyes (keratoconjunctivits sicca),

Sjogren Syndrome Opthalmologic eval (Schirmer Test: Slit-lamp exam to assess tear break up time), autoantibody screening with anti-Ro/SSA, anti-La/SSB, Antinuclear Abs, and Rheumatoid factor. Gold standard for confirming the test is labial salivary gland biopsy Tx salivary flow stimulation and artificial saliva

Common cutaneous signs of insulin

Skin tags, Acanthosis Nigricans, Xanthelasma

decreased urine output, 2-3 days post op with nausea, vomiting, abdominal pain and obstipation (severe constipation)

Small bowel obstruction

patient with prior hx of abdominal or pelvic surgery returns years later with abdominal distension, nausea, vomiting, intermittent abdominal pain and multiple air fluid levels in the small intestine

Small bowel obstruction (post op adhesions formation in the peritoneal cavity)

Levothyroxine treatment for Papillary & Follicular Thyroid Cancer

Small, Low risk of recurrence tumors: Target TSH 0.1-0.5 for 6-12m, then low normal range Intermediate risk tumors: target TSH 0.1-0.5 Large, Agressive distant metastasis Tumors: Target TSH <0.1, continue for several years Suppressing TSH with Levothyroxine prevents recurrence to not allow stimulation of growth of residual thyroid cancer cells. Take on empty stomach

Cross-Sectional Study

Snapshot of a population to estimate prevalence of risk factors and disease simultaneously

Fever, focal/severe back pain, neurologic findings (motor/sensory, bowel/bladder dysfunction, paralysis), HIGH ESR

Spinal Epidural Abscess (bacterial fluid collection in the epidural space) Staph Aureus, Immunosuppresion (HIV, Alcohol, Old age) Distant infection, spinal procedures, injection drug use MRI OF SPINE WITH CONTRAST, BLOOD AND ASPIRATE CULTURES Borad spec abx: Vancomycin + Ceftriaxone Urgent aspiration/surgica; decompression

Anti-Aldosterone and Anti-Testosterone effects. Reduce Androgen-related symptoms such as acne and hirsutism

Spironolactone

used to treat hyperandrogenic symptoms (acne, Hirsutism) associated with PCOS

Spironolactone by blocking peripheral androgen receptors

Low back pain that worsen by extension, in a gymnast or diver

Spondylolisthesis Bilateral pars interarticularis fracture -> Ant slippage of vertebral body (L5 Slips over S1) Due to repetitive back extension and rotation (Gymnast, Diver), Adolescent growth spurt Palpable step off may be present. Tenderness with deep palpation. Confirm diagnosis With lateral xrays Avoid the enticing sport, obtain MRI of spine and surgical consult if Neuro defects and symptoms >90 days

Sporotrichosis

Sporothrix Schenxkii (Dimorphic fungus) Ulcerations With NONpuruelnt odorless drainage. form along lymphatic chain Dx: Tissue Biopsy and Cultures of a nodule (aspirate fluid or Biopsy) -> Cigar-Shaped Yeast with narrow based budding Tx: Prolonged course of Itraconazole

most common cause of osteomyelitis

Staphylococcus aureus

Cause of cellulitis

Staphylococcus aureus and Streptococcus pyogenes

Childhood Absence Epilepsy

Staring spell, Unresponsive to stimulation, <20 sec, Simple automatisms frequent, provoked by hyperventilation, many episodes per day Dx: EEG with 3 Hz Spike & wave Discharges Associated with ADHD, anxiety, depression TX: ETHOSUXIMIDE Often spont remit by early puberty with no major long term sequelae MONITOR Granulocyte count due to Agranulocytosis

Adult Cardiac Arrest

Start CPR, given Oxygen, Attach monitor/defibrillator 1. VF/Pulseless VT ->Shock ->CPR x2min, Airway, IV/IO access, Epinephrine q3-5min 2. PEA/Asystole (Sinus, Brady, A fib) -> CPR x2min, Airway, IV/IO access, Epinephrine q3-5min

Cervical cancer screening

Start Pap testing at age 21, regardless of the onset of sexual activity. Continue Pap smears every 3 years until age 29. From 30 to 65, Pap smear combined with HPV testing is done every 5 years until age 65, when it can be stopped.

Receding Syndrome

Starvation -> DEC Insulin, INC Glucagon, INC Cortisol -> INC Ketone bodies -> INC Glycogenolysis, Lipolysis, Protein catabolism -> Depletion of fat, protein, vitamins, minerals and intracellular electrolytes START REFEEDING INC Insulin -> INC Glycogen Synthesis, protein synthesis, intracellular uptake of phosphorus, potassium, magnesium, thiamine -> DEC serum phosphorous, potassium, magnesium, serum thiamine, INC sodium, and water retention LEADS TO ARRHYTHMIA CHF (pulmonary and peripheral edema) SEIZURES WERNICKE ENCEPHALOPATHY Management begins with empiric thiamine repletion, correction of electrolyte abnormalities, esp hypophosphatemia, prior to starting feeds Oral Phosphate therapy preferred over IV because of lrifethrestning Hyperphosphatemia (hypocalcemia, Acute renal injury, Arrhythmia)

Fosphenytoin (Cerebyx) can be used to treat

Status epilepticus (Seizures lasting >5-10min) or serail seizures without return to baseline conciseness between episodes

Furosemide can cause

Steven Johnson Syndrome

Chest pain, On ECG (ST elevation, T wave inversion in the anterior precordial leads and QTc prolongation. Elevated serum troponin. Absence of obstructive coronary artery disease on coronary angio

Stress Induced (Takotsubo) Cardiomyopathy catecholamine surge brought on by acute physical or emotional stress (traumatic event, illness of loved one) segmental left ventricular dysfunction with mid and apical hypokinesis and basilar hyperkinesis. Balloon shape on echo.

urine Leak with coughing, sneezing, laughing, lifting

Stress Urinary Incontinence Intrinsic Sphincter Deficiency and Urethral Hypermobility Tx: Lifestyle modification, pelvic floor exercise, pessary, Urethral Sling Surgery

Facial Port-Wine Stain and Leptomeningeal Angiomatosis

Sturge-Weber Syndrome

Elevated TSH, Normal T4, Non specific symptoms of Fatigue, Weight loss followed by weight gain

Subclinical Hypothyroidism: HIGH TSH, Normal Free Thyroxine most common cause is Chronic Lymphocytic (Hashimoto's) Thyroiditis = HIGH Anti-Thyroid Peroxidase (anti-TPO) Check for Anti-Thyroid Peroxidase (Anti-TPO) antibodies, associated with progression to overt Hypothyroidism and can identify patients likely benefit from treatment. Indications to tx: -TSH>10 -TSH 7-9.9 (<70yo, and if >70 symptomatic) -TSH 6.9: <70 if symptomatic, >70 DONT TREAT Associate with RECURRENT MISCARRIAGES, severe preeclampsia, preterm birth, low birth weight and placental abruption. And Anti-TPO is associated with increased risk for pregnancy loss even in those who are euthyroid

Management of Hydatidiform Mole

Suction curettage -> Weekly BhCG levels until detectable -> Increasing = Trophoblastic neoplasia -> Decreasing -> monthly BhCG levels x6months Once undetectable surveillance is complete can attempt pregnancy

can't intubate, can't oxygenate due to upper airway obstruction

Surgical airway = CRICOTHYROTOMY Tracheostomy not done in emergency situation because technically more difficult and higher risk of hemorrhage

Type of selection bias where experimental and control groups differ from a prognostic standpoint, due to unforeseen confounding variables

Susceptibility Bias

Supraventricular tachycardia (A fib with rapid ventricular response in Hemodynamically unstable patient with a pulse

Synchronized cardioversion when becomes pulseless management shift toward CPR for PEA cardiac arrest

Severe hyponatremia resulting in seizures post surgery and can be worsened by IVF (5% dextrose with 0.45% saline) leading to water retention.

Syndrome of Inappropriate Antidiuretic Hormone Post op common due to prominent non osmotic stimuli for ADH secretion (Pain, nausea, physical and emotional stress) Mild-Moderate Hyponatremia: Nausea, Forgetfulness Severe: Seizures, Coma Tx: increase in serum sodium concentration best accomplished with Hypertonic saline, of asymptomatic then fluid restriction would be appropriate

Left Ventricular Hypertrophy in CKD

Systemic HTN present with CKD is contributor to concentric hypertrophy. and anemia in CKD (Chronic inflammation, impaired erythropoietin production, and iron deficiency) contributes to eccentric hypertrophy Unmet oxygen demand in the tissues leads to vasodilation and reduction in systemic vascular resistance, encourage high output HF (volume overload) and LV Dilation Myocardial hypoxia and loss of the cardioprotective effects of Erythropoietin on myocardium can facilitate myocardial apoptosis and necrosis leading to myocardial fibrosis with reduced contractile function and LV dilation. Erythropoiesis-stimulating Agents (Epoetin, Darbepoetin) mimic endogenous erythropoietin and useful in treating anemia of CKD and reduced LVH when Hgb is below 10, but if Hgb >13 then Inc risk for Ischemic stroke, venous thrombosis and inc mortality

generalized urticarial rash, rubbing the edge produces wheals and erythema

Systemic Mastocytosis and wheals and erythema from rubbing edge is called Dariers Sign. 50% of these patients have hepatosplenomegaly

syncope, flushing, hypotension, vomiting, abdominal pain

Systemic mastocytosis Dx: TRYPTASE biomarker for mast cells

Contact dermatitis

T cell mediated hypersensitivity (Type IV reaction)

Pleural effusion with lymphocyte predominant, exudative, elevated adenosine deaminase, no orgnaism on smear, Rapid HIV test is +

TB Pleural Effusion HIV increases risk of TB. Fever, cough, pleurisy and weight loss. HIGH ADENOSINE DEAMINASE = TB Pleural Biopsy required for diagnosis see pleural Granulomas Antiretroviral Therapy is delayed 1-2 weeks after initiating TB tx to reduce risk of immune reconstitution inflammatory syndrome

Evaluation of hyperthyroidism

TSH LOW, Free T3 & T4 HIGH = Primary Hyperthyroid If primary then is there signs of Graves disease? (goiter, opthalmopathy) -> YES? Graves Disease -> NO? Radioactive Iodine Uptake -> LOW? Measure serum Thyroglobulin -> HIGH? Thyroiditis, Iodide Exposure LOW?->Exogenous Hormone

Diabetic with bilateral foot numbness and burning sensation. Best initial screening test for neuropathy?

TUNING FORK TEST

Occupational HIV Postexposure Prophylaxi

TWO Nucleotide/Nucleoside Reverse Transcriptase Inhibitors (TENOFOVIR, EMTRICITABINE) + Integrase Strand transfer inhibitor (RALTEGRAVIR), protease inhibitor, non nucleoside reverse transcriptase inhibitor Start within first few hours of exposure and continued for 4 weeks.

Used in tx of Seborrheic Dermatitis

Tar-based creams and shampoos

dyspnea, hypotension, diminished breath sounds on affected side, tracheal deviation toward unaffected side

Tension Pneumothorax Tx: Needle Thoracostomy to decompress

Hepatitis C screening

Test everyone age 18 and over.

15-35yo Male, unilateral, firm ovoid mass painless testicular nodule or swelling, dull lower abdomen ache. Does not transilluminate.

Testicular Cancer High risk in cryptorchidism or HIV. Dx: Scrotal US, Tumor Markers (AFP, b-hCG), CT scan and CXR for staging Tx: radical orchiectomy, chemotherapy, 95% cure rate Trans-scrotal biopsy can increase risk of lymphatic spread and recurrence.

extremely painful and tender testicle with an elevated testicle in an abnormal transverse position.

Testicular torsion is different in that it presents with an elevated testicle in an abnormal transverse position.

Decreased Libido and erectile dysfunction with preserved nocturnal penile erections

Testosterone Deficiency

Anemia due to hemoglobinopathy and requires further eval with hemoglobin electrophoresis

Thalassemia, the peripheral blood smear shows Target Cells

A man comes to the clinic having had a painless, firm genital lesion for the last several days. The inguinal adenopathy is painless. What is the most accurate diagnostic test?

The most accurate test in primary syphilis (Treponema Pallidum) is darkfield microscopy. It is far more sensitive than VDRL and RPR, which are only 75% sensitive and have false negative rates of 25%.

A 23-year-old woman (G3 P1 Abortion 1) is seen at 17 weeks gestation. She recently underwent a triple marker screen with the maternal serum alpha fetoprotein (normal <2.2 MoM). Her test showed an elevation in maternal serum alpha fetoprotein. On examination her uterus is at the umbilicus. What is the next step in management?

The most common cause of an abnormal MS-AFP is gestational dating error. The first step is to get an obstetric ultrasound to confirm the gestational age. A first trimester ultrasound is the most accurate way to date a pregnancy.

A 34-year-old multigravida presents for prenatal care in the second trimester. She reports a history of substance abuse but states she has been clean for 6 months. With her second pregnancy, she experienced a preterm delivery at 34 weeks' gestation of a male neonate who died within the first day of life. At that delivery, the baby was swollen, with skin lesions, and the placenta was very large. She was treated with antibiotics but she can't remember what they were. On a routine prenatal panel with this current pregnancy, she is found to have a positive VDRL test. What is the next step in management?

The next step after any positive screening test is the confirmatory test before starting therapy. FTA-ABS or MHA-TP is the confirmatory tests for syphilis. Once syphilis is confirmed, give intramuscular penicillin.

Tattooting

The pigment is taken up by macrophages in the dermis which allows it to remain in the skin permanently Dermabrasion involves removal of superficial layer of the epidermis thereby allowing pigment to leach out of the skin. Laser removal breaks up the pigments into smaller molecules taken up and cleared by macrophages in skin. Can lead to scar marks and cause skin hypo- or hyper pigmentation.

Right ventricle and inferoposterior walls of the left ventricle, coronary artery?

The right coronary artery

A 24-year-old childcare worker is 29 weeks pregnant and is currently working. One of the children she cares for was diagnosed with rubella last week. Rubella antigen testing is performed and her IgG titer is negative. What is the next step in management?

There is no postexposure prophylaxis available, and immunization during pregnancy is contraindicated (live vaccine). The only correct management is to await normal delivery and give vaccination to the mother after delivery.

Patients with anaphylaxis requiring hospital admission

Those with symptoms lasting hours to days despite treatment Severe symptoms such as hypotension, upper airway edema, respiratory distress multiple doses of epinephrine THESE patients are higher risk for BIPHASIC ANAPHYLAXIS (recurrence of symptoms after an initial period of resolution)

<20 weeks gestation, vaginal bleeding, closed cervix, normal fetal heartbeat on US

Threatened Abortion

Contraindications to epidural (neuraxial analgesia)

Thrombocytopenia (<70K) or rapidly dropping platelet count associated with preeclampsia with severe features. Increased risk of spinal epidural hematoma. Intravenous Labor analgesia is an option for those who have contraindications to neuraxial analgesia or prefer less invasive intervention Platelet transfusion is only indicated for <10k, active bleeding <50k, or planned major surgery with <50k

AMS, petechial rash, renal failure, thrombocytopenia, microangiopathic hemolytic anemia (hyperbili, Scleral icterus)

Thrombotic Thrombocytopenia Purpura Fever, seizures, coma, GI (N,Abdominal pain) Hemolytic Anemia (HIGH LDH, LOW HAPTOGLOBIN, Schistocytes) Deficiency in ADAMTS13 life threatening requires emergency tx with plasma exchange

Pentad of Fever, Microangiopathic hemolytic anemia (pallor), thrombocytopenia, renal failure, Neuro impairment (confusion)

Thrombotic Thrombocytopenic Purpura

used to treat severe atopic dermatitis or psoriasis

Topical High potency corticosteroids (clobetasol)

Treatment for glaucoma: red eye, pain, vision loss acutely

Topical Prostaglandins

Podophyllotoxin & Imiquimod

Topical medications used to treat condylomata acuminate, genital warts caused by Human Papillomavirus Skin colored veracious and filiform papules in anal/perianal area, penile shaft, vulvovaginal and cervical areas.

Useful as prophylactic treatment for migraines or seizures

Topiramate

Isolated Anti-HBc +

Total Core Ab (IgM & IgG) NEED TO obtain IgM anti-HBc to determine if infection recent. Liver function test should also be performed as an elevation in transaminase levels suggest active infection. If liver enzymes are abnormal with negative IgM anti-HBc or if evidence of chronic liver disease, HBV DNA should be obtained to evaluate for chronic HBV infection. 1. Window Period: Acute HBV infection when HBsAg fallen but anti-HBs has not yet risen. IgM anti-HBc is positive, liver enzymes are elevated 2. Years after recovery from acute HBV infection once anti-HBs has waned off. Liver enzymes are normal and IgM anti-HBc is usually negative. 3. after many years of chronic HBV infection when HBsAg has fallen to an undetectable level. Chronic liver disease and HBV DNA is detectable.

Fever, Hypotension, Tachycardia, Abdominal distension, Leukocytosis, Large bowel dilation on imaging

Toxic Megacolon Surgical consult for colectomy if develop peritonitis or colonic necrosis/perforation

Pregnant patient handling cat feces or litter boxes, drinking raw goat milk, eating raw meat, or possibly gardening

Toxoplasma gondii classic triad 1. Chorioretinitis 2. Intracranial calcifications 3. Hydrocephalus Fetal growth restriction may be seen on ultrasound. Testing includes Toxoplasma IgG (past exposure and are protective) and IgM levels (recent exposure and risk of exposure to the fetus). Tx: pyrimethamine and sulfadiazine. Treat pregnant patients with spiramycin.

multiple ring enhancing lesions on brain imaging

Toxoplasmosis Infection

headache, nausea, vomiting, and focal neurologic findings. Diagnosis & Treatment?

Toxoplasmosis. best initial test is a head CT with contrast showing "ring" or contrast-enhancing lesions. Treat with pyrimethamine and sulfadiazine for 2 weeks and repeat the CT scan. If the lesions are unchanged in size, then perform a brain biopsy, since this is most likely lymphoma.

psychodynamic psychotherapy

Traces problems back to their origins in childhood.

coughing, SOB, stridor

Tracheomalacia (Weakness of the walls of the trachea leading to expiratory airway collapse)

A 28-year-old woman at 31 weeks' gestation with her first child wakes in the middle of the night to find that she has vaginal bleeding. She is not experiencing any pain or fluid leakage. What is the next step in management?

Transabdominal ultrasound placenta previa. Cervical exam should be deferred until placenta previa is ruled out.

periodic monitoring while on Valproic Acid

Transaminases due to risk of hepatotoxicity

Causes of Elevated Prostate Specific Antigen

Transient: -Urine retention -Mild acute prostate infection/inflammation -Urologic procedure (cystoscopy) -Digital Rectal Exam -Recent Ejaculation Persistent: (repeat in 6-8 weeks) -BPH -Prostate Cancer -Severe or chronic Prostatitis

Diagnostic testing for Infective Endocarditis

Transthoracic Echocardiogram (TTE), if negative then proceed to Transesophageal Echocardiogram (TEE)

Rapidly progressive weakness of the lower extremities following an upper respiratory infection, accompanied by sensory loss and urinary retention

Transverse Myelitis Dull back pain may be present. On Neuro exam muscle flaccidity and hyporefelxia

segmental spinal cord inflammation that can result in extremity weakness. A clear sensory level is often seen. and no focal vertebral tenderness.

Transverse Myelitis in patients with HIV

Echinacea

Treat & Prevent Cold & Flu SE: Allergic Rxns, Dyspepsia

Saw Palmetto

Treat BPH Increased risk of bleeding, GI Distress

Patient with acute kidney injury, in the setting of high grade lymphoma and electrolyte abnormalities (Hyperphosphatemia, Hypocalcemia, Hyperkalemia)

Tumor Lysis Syndrome Excessive release of intracellular contents (potassium, Phosphate, and purine nucleic acids metabolized to uric acid) Commonly occurs following initiation of chemotherapy also can occur spontaneously in patients with malignancies with rapid cell turnover such as Non Hodgkin lymphoma, acute leukemia Calcium phosphate stones and uric acid stones cause AKI, Hyperkalmia causes cardiac arrhythmia, and seizures Tx: IVF + Uric Acid Reducing Therapy (Urate Oxidase Analogue = RASBURICASE (Metabolizes uric acid that has already accumulated) or Xanthine Oxidase Inhibitor = ALLOPURINOL, FEBUXOSTAT (Prevent production of additional uric acid, leaving the existing elevated unaffected), continue Tele, Aggressive electrolyte monitoring and treatment RASBURICASE is contraindicated in pts with G6PD deficiency due to risk for methemoglobinemia and hemolysis. URATE OXIDASE ANALOGUE (RASBURICASE) PREFERRED OVER A XANTHINE OXIDASE INHIBITOR (ALLOPURINOL, FEBUXOSTAT) BECAUSE IT METABOLIZES EXISITING ELEVATED LEVELS OF URIC ACID RATHER THAN PREVENTING FORMATION OF ADDITIONAL URIC ACID.

Poison Ivy Contact Dermatitis

Type IV (Cell-Mediated) Hypersensitivity reaction linear papules and clear fluid filled vesicles pain and intense pruritis are typical immediate removal of contaminated clothing and gentle cleansing of exposed areas Tx is supportive (cool compress, topical corticosteroids)

Antibasement membrane antibody

Type of immune mediated glomerulonephritis. Ab against type IV collagen in GBM --> complement fixation --> PMN chemotaxis. Pulmonary lesions lead to type IV collagen in lung BMs. Signs: hemoptysis (coughing up blood), oliguria (reduced urine output) with hematuria (Goodpasture's syndrome).

STEMI treatment

URGENT REVASCULARIZATION with Percutaneous Coronary Intervention within 90 min of first medical contact or within 120 min for those needing transfer to PCI capable facility. If cant have PCI in enough time consider Fibrinolytic Therapy.

nipple discharge

US +/- Mammogram if abnormal then percutaneous biopsy if normal then Galactorrhea eval (Prolactin level and thyroid studies) Benign (physiologic) nipple discharge typically bilateral, multi ductal, nonbloody, expressed only with manipulation of the breast. Due to Hyperprolactinemia, Thyroid disease, Antipsychotics, Gastric motility agents, stress, excess breast/nipple stimulation however it can be a sign of breast cancer

Fetal growth restriction (FGR)

US estimates fetal weight <10th% or birth weight <3rd% Risk for Stillbirths Symmetric: -1st tri -chromosomal abnormalities -congenital infection (Toxoplasmosis, CMV) -global growth lag Asymmetric: Smaller abdominal circumference <1st%: Inadequate fetal nutrition and oxygenation -2/3rd tri -Uteroplacental insufficiecny (due to HTN) -Maternal malnutrition -Head sparing growth lag *Regular non stress test, non invasive fetal heart rate monitoring a stable baseline 120-160 with periodic acceleration and normal beat to beat variability indicates a well oxygenated fetus with normal acid base status *weekly biophysical profile, US eval of amniotic fluid and fetal activity indications of fetal renal perfusion, acid base status and oxygenation *serial umbilical artery doppler sonography (monitor for decreased umbilical artery blood flow and increased vascular resistance, indicates deteriorating placental function and decreased fetal oxygenation. *serial growth US Normal testing suggests low risk of stillbirths within one week of test date if abnormal immediate delivery to prevent fetal acidosis and stillbirth

Dysfunction of the bowel and bladder is an important risk factor for

UTI in toddlers who are toilet training Fecal retention causes rectal distention which can obstruct bladder emptying, incomplete dysfunctional voiding results in stagnant urine which promotes microbial growth increasing the risk for UTI increase dietary fiber and water intake as well as titrate laxative use (polyethylene glycol) to produce soft regular bowel movements

Erythema nodosum, pyoderma gangrenosum, bloody diarrhea

Ulcerative Colitis

prolonged diarrhea, abdominal pain, weight loss, and colonoscopy reveals focal ulcerations alongside normal mucosa

Ulcerative Colitis Cobblestone with skip lesions

Subacute onset of bloody diarrhea, abdominal pain, urgency, tenesmus, incontinence, mucosal edema, loss of vascular markings, exudates and spont hemorrhages

Ulcerative colitis

Cryptorchidism in infants

Undescended Testicle -> <6 months old monitor for spont descent >6 months refer for orchiopexy If completed by 1yo optimizes fertility potential and testicular growth and surgical fixation decrease risk of testicular torsion. Family education should include the increased risk of cancer IF BILATERAL -> Karyotype analysis, Pelvic US, adrenal/gonadal hormones

causes of lower extremity edema

Unilateral: -DVT --> DIPPLER US to confirm dx, tx with Factor Xa inhibitors -Muscle strain -Lymphedema -Paralyzed limb -Cellulitis Bilateral: -HF -Venous insufficiency -Medication effect (Dihydropyridine calcium-channel blockers-amlodipine)

Eelectroconvulsive Therapy (ECT)

Unipolar & Bipolar Depression Catatonia Bipolar Mania for treatment resistance, psychotic features, refusal to eat or drink, risk of suicide, pharmacotherapy contraindicated due to comorbid medical illness or poor tolerability, pregnancy when pharmacotherapy undesirable or ineffective Increased risk for severe CV dz, recent MI, space occupying brain lesion, recent stroke, unstable aneurysm

Involuntary urine leakage that occurs after a strong urge to urinate

Urgency Incontinence Caused by bladder detrusor muscle overactivity caused by neurological disease (MS) or bladder abnormalities Risk factors is increasing age, stroke, depression, DM, obesity, caffeine, tobacco TX: TIMED VOIDS AND BLADDER TRAINING, WEIGHT LOSS, SMOKING CESSATION, AVOID CAFFEINE AND ALCOHOL, ANTIMUSCARINIC (TOLTERODINE, SOLIFENACIN, OXYBUTYNIN)-improve bladder capacity and inhibit detrusor muscle contractions during bladder filling by blocking acetylcholine release in the bladder SE: dry mouth, constipation, drowsy, blurry vision. if still no improvement consider Botox injections or percutaenous tibial nerve stimulation

tumor lysis syndrome, often after chemotherapy for lymphoma.

Uric acid crystals Treatment is hydration, allopurinol, and rasburicase (breaks down uric acid)

Liothyronine (T3)

Used in place of Levothyroxine for a short period to prevent symptoms of hypothyroid in patients with thyroid cancer who are holding levothyroxine in prep for radioactive iodine uptake and scan

Radionuclide Thyroid Scan

Used in the evaluation of Hyperthyroid and can distinguish between Graves (diffuse uptake) and Nodular disease (focal uptake)

multiple linear regression model

Used to evaluate association between 1 quantitative dependent variable (primary outcome) and >2 independent variables that can be either quantitative or qualitative. Effect of main independent variables of interest LDL on the primary outcome of renal frame count is adjusted to account for the effects of other independent variables int the model BMI, platelet count, Cr clearance.

Common Drugs Affecting Lithium Levels

Used to tx bipolar. Eliminated by kidney. Can be reabsorbed by transport proteins in proximal tubule that normally handles sodium and potassium. Drugs that affect glomerular filtration or renal reabsorption can alter serum levels. INCREASE: -Thiazide Diuretics (Inhibit reabsorption of sodium in distal convoluted tubule causing compensatory increase in reabsorption of sodium and concurrently lithium in proximal tubule -NSAIDS -ACE-I (Lisinopril), ARBs (Losartan) (Reduce glomerular filtration and therefore clearance of lithium) -Tetracycline, Metronidazole DECREASE: Osmotic Diuretics (Mannitol), Theophylline MINIMAL TO NO EFFECT: Calcium Channel Blockers (Amlodipine), Loop Diuretics

Screening for diabetic nephropathy

Using micro album,in beggining 5 years after oroiginal diagnosis, and at time of diagnosis for Type 2 DM. If evidence of diabetic nepropathy then treat with ACE-I

Hx of pelvic radiation and Tamoxifen use leads to

Uterine Sarcoma (leiomyosarcoma) postmenopausal or abnormal uterine bleeding and irregularly shaped rapidly enlarging uterus

abnormal/postmenopausal bleeding, pelvic pain or pressure, uterine mass

Uterine Sarcoma - Malignancy originating from Myometrium or Endometrial CT Post menopause, pelvic pressure, uterine mass, ascites (free fluid in post cup-de-sac), uterine bleeding, abdominal distension. Most common site of metastasis is the LUNGS (pleural effusion) Risk from Pelvic radiation, Tamoxifen use, Post menopausal Dx: US, Endeometrial biopsy TX: Hysterectomy

Indomethacin (Indocin)

Uterine Tocolytic used at <32 weeks gestation to inhibit contractions and delay delivery up to 48 hrs. >32 weeks AVOID results in premature closure of ductus arteriosus

Angular Cheilosis & Stomatitis in Vit Deficiency

VITAMIN B2 (RIBOFLAVIN)

pruritic generalized vesicular rash (SPARES palms and soles) Fever in a child

VZV-Chicken Pox

Attacks of dizziness, nauseated, cant walk or speak during these episodes, tingling sensation in hips, double vision.

Vertebrobasilar Insufficiency Reduced blood flow in the base of the brain, secondary to emboli, thrombi, or arterial dissection. Labyrinth and brainstem affected. Dizzy, vertigo, dysarthria, diplopia, numbness Risk factors: DM, HTN, HLD, Arrhythmia, CAD, Smoking

Antithrombotic Therapy in patients with Mechanical Heart Valves

WARFARIN (Vit K Antag) is the ONLY acceptable oral anticoagulant for mechanical prosthetic valve to prevent thrombotic valve dysfunction and thromboembolic events Warfarin (Goal INR 2-3): Aortic valve replacement if no risk factors (Afib, LV systolic dysfunction, prior thromboembolism, hyper coagulable state) Warfarin (Goal 2.5-3.5): Mitral Valve Replacement, Aortic valve replacement with >1 risk factor, Aortic valve replacement with an old generation valve LOW DOSE ASPIRIN: ONLY in patients with another strong indication (severe CAD)

Dilated cardiomyopathy, polyneuropathy, Neurocognitive impairment, oculomotor dysfunction, ataxia, encephalopathy, amnesia

WET BERIBERI & WERNICKE_KORSAKOFF SYNDROME THIMAINE (VIT B1)

<35yo, hepatomegaly, high transmaniases, neuropsychiatric symptoms (Depression, movement disorders), low ceruplasmin levels

WILSON DISEASE Abnormal transport and metabolism of copper

Antithrombotic Therapy in patients with mechanical heart valves

Warfarin (INR 2-3): Aortic Valve replacement if no risk factors present Warfarin (INR 2.5-3.5): MV replacement (Higher thrombotic risk in mitral valve therefore higher INR target), Aortic valve replacement with >1 risk factor Low Dose Aspirin: Only in patients with another strong indication (Severe CAD) Risk factors = A fib, LV systolic dysfunction, Prior thromboembolism, Hyper coagulable state Vitamin K Antag (WARFARIN) ONLY acceptable oral anticoagulant agent to prevent thrombotic complications in mechanical prosthetic valve.

Risk factors for extubation failure

Weak cough, frequent suctioning, poor mental status, positive fluid balance, pneumonia as initial cause, >65yo, comorbid conditions

Second Generation Antipsychotic Side Effects

Weight gain-Extrapyramidal side effects-Prolonged QT Aripiprazole: Low-Low-LOw Clozapine: Very high-Low-Med (Used in tx resistant schizophrenia if failed >2 antipsychotics, Cause NEUTROPENIA) Lurasidone: Low-Medium-Low Olanzapine: Very high-Low-Med Quetiapine:High-Low-Med Risperidone: High-High-Med Ziprasidone: Low-Low-High

Patients with symptomatic pelvic organ prolapse can be treated with

Weight loss, Pelvic floor exercises, Vaginal PESSARY and or surgical repair

AMS, Oculomotor dysfunction (Nystagmus)m Gait Ataxia

Wernicke Encephalopathy

Type I Errors (False Positive)

When a study incorrectly rejects a null hypothesis that is true. The rate of type I errors is denoted by a a and usually reflects the significance level of a test. A higher a increases the likelihood of a type I error and decreases the likelihood of a type II error.

Autoimmune Hemolytic Anemia

When circulating cytotoxic autoantibodies (Type II Reaction) are directed against the patients own red blood cells. Symptoms of anemia (dyspnea on exertion)

Most common dyslipidemia treatment used in patients with HIV are?

When on ART can cause dylipedmia including increased total cholesterol, LDL and TGs, and reduced high density lipoprotein USE STATINS: Rosuvastatin, Atorvastatin, Pravastatin

Contamination bias

When participants in one trial group receive treatment or intervention meant for participations from another group.

<5yo, with unilateral painful abdominal ,ass, HTN, Hematuria

Wilms Tumor (most common renal malignancy in children)

Hepatic, Psychiatric (DEPRESSION), neurologic dysfunction. Dysarthria, Dystonia, Tremor, Parkinsonism

Wilson Disease Disorder of copper transport in which copper accumulates A slit lamp eye exam can be used to look for copper deposits inc the cornea (Kayser-Fleischer Rings)

mineral metabolism abnormality

Wilson Disease, Copper accumulation in the brain and present with cognitive dysfunction 5-35yo with DYSARTHRIA (Slurred speech)

Thrombolytics for Acute Ischemic Stroke

Within 4.5 hours of symptom onset

Amputated body parts should be __________ to assist in preserving tissue.

Wrapped in sterile gauze, moistened with saline and placed in a sealed, sterile plastic bag. Bag should then be placed in a chilled container; Ice should be mixed with saline or sterile water (50/50 mixture).

fever, rash, headache, joint pain, and body aches.

Zika Virus screened with RNA nucleic acid testing (NAT) and Zika virus IgM testing. spread by the bite of an infected Aedes mosquito, and can also be sexually transmitted by exposed individuals. Zika can then be passed from mother to fetus during pregnancy, leading to birth defects such as microcephaly.

Elevated Serum Gastrin level

Zollinger Ellison Syndrome

CASE SERIES

a small group of patients with a similar diagnosis or treatment is described at a point in time or followed over a certain period. NO COMPARISON GROUP CANT establish Associations between risk factors and outcome.

woman in her third trimester with severe abdominal pain, sudden vaginal bleeding, and uterine contractions.

abruptio placentae secondary to the premature separation of the placenta from the uterine walls. Always test for DIC in these patients. transabdominal ultrasound, CBC, and fibrinogen level. Abdominal trauma (auto accidents), Maternal cocaine use, Polyhydramnios, Chronic hypertension, Preeclampsia/eclampsia, Maternal smoking Treatment depends on If either mom or fetus is unstable, C-section delivery is the answer

specific test; it must catch all the people that

actually have the disease.

Careful cross-matching of blood prevents

acute hemolytic reactions fever, chills, flank pain, and hemoglobinuria within an hour of transfusion. can progress to renal failure and disseminated intravascular coagulation. the direct anti globulin test (Coombs) is positive and plasma free hemoglobin >25mg/dl

Treatment for chronic hepatitis B

adefovir, lamivudine, telbivudine, entecavir, tenofovir, interferon Interferon is used only in those coinfected with hepatitis D.

Cell-free fetal DNA testing

advanced maternal age >35yo, Abnomral maternal serum screening test, risk of fetal aneuploidy per sono, prior pregnancy with aneuploidy, robertosnian translocation Screening for Trisomy 21,18,13,aneuploidies, and fetal sex determination If + then diagnostic testing (Chorionic Villus Sampling, Amniocentesis)

HPV vaccine

all females age 13-45 boys to age 21

Hypotension, elevated peak pressure (bronchospasm) and decreased end-tidal CO2 (decreased CO and CO2 delivery to the lungs) shortly after anesthetic induction are concerning for

anaphylaxis Caused by an acute IgE-mediated release of inflammatory mediators (histamine) MOST COMMON rocuronium, antibiotics, skin antisepsis products (chlorhexidine, Iodine) and blood products Inspect the skin under the drapes and once diagnosis made administer epinephrine

External validity (or generalizability)

applicability of a study result beyond the group that was initially assessed

Hepatopulmonary syndrome

arteriovenous shunting in the lungs and can occur after years of liver disease Platypnea (Induced dyspnea in upright position) Orthodeoxia (Hypoxia in upright position)

ODDS RATIO (OR)

association between an exposure to a risk factor and an outcome, defined as odds of an exposure in cases divided by odds of same exposure in controls. OR>1 indicates the exposure is associated with an increase in odds of an outcome

smoking cessation prior to surgery

at least 4 weeks

A 28-year-old woman presents at 36 weeks' gestation with rupture of membranes. On examination she is found to have 7 cm cervical dilatation. She received all of her prenatal care, and her only complication was a course of antibiotics for asymptomatic bacteriuria. GBS screening was negative. Her first baby was hospitalized for 10 days after delivery for GBS pneumonia and sepsis. What is the most appropriate management?

because the patient's previous birth was complicated with neonatal GBS sepsis. Treatment for GBS is intrapartum IV penicillin. With penicillin allergy, use IV erythromycin or clindamycin if sensitivities are available (if not available, use vancomycin).

Integrase inhibitors

bictegravir, dolutegravir, elvitegravir, or raltegravir combine with two nucleosides

exertional dyspnea

can be cardiac (HF) or Pulmonary (Chronic lung disease) HF exacerbation would cause exertion dyspnea with orthopnea, paroxysmal nocturnal dyspnea, JVD, peripheral edema. Vs COPD with hx of smoking, prolonged expiration on lung exam, PFTs to evaluate.

GnRH agonists

cause Amenorrhea and decrease Leiomyoma Size in patients with leiomyomas that are causing heavy bleeding. If failed medical management then myomectomy and uterine artery embolization are indicated.

Antipsychotic meds (haloperidol, Risperidone) can cause

central hypogonadism, due to antidopaminergic effect, leads to hyperprolactinemia.

painless, acute monocular vision loss. Tortuous and dilated veins, diffuse hemorrhages, disk swelling, cotton wool spots

central retinal vein occlusion

common benign vascular tumor in adults

cherry angioma sharp circumscribed areas of congested capillaries and post capillary venues in the papillary dermis. multiple small vascular bright red dome shaped papules. Only in skin not deep tissues or mucosa. blanch with pressure. increase in number as the patient ages. bleed if disturbed otherwise asymptomatic and do not need treatment. Eelectrocauterization under local anesthesia can treat small lesions while shave excision with electrocauterization is required for large lesions.

Inhaled Long Acting Muscarinic Antagonists (LAMAs) TIOOTROPIUM

chronic controller agents for asthma step up therapy when inadequate response to a scheduled inhaled corticosteroid and beta agonist MONOtherapy as initial tx for COPD

chronic lead poisoning can lead to

chronic kidney disease

reduced ankle brachial index and symptoms of calf pain with walking

claudication due to peripheral artery disease (PAD). CV risk factors like advancing age, DM, smoking, HTN can increase risk of developing PAD. PAD represents atherosclerotic cardiovascular disease and denotes an increased risk of future CV events (MI, Stroke). Initiate Aspirin + High intensity statin to lower risk of CV events

impetigo

common infectious complication of atopic dermatitis and presents with erythematous papoules, pustules, vesicles with honey-colored crusts. caused by Staph aureus or Group A Strep.

Carbapenems

cover streptococci and all sensitive staphylococcus (MSSA). Use for ESBL (Extended Spectrum Beta-Lactamases).

L1-L2

cremasteric reflex, hip flexion and adduction

observational study where a specific population or group is studied at one specific point in time

cross-sectional study

When there is a painless genital ulcer, order

darkfield microscopy to diagnose primary syphilis. VDRL or RPR screening in first trimester; confirm (+) screen with FTA-ABS.

persistent false beliefs

delusional disorder

Succinylcholine

depolarizing agent used in rapid-sequence intubation. Metabolized by acetylcholinesterase and leads to prolonged apnea and blockade at NMJ.

In treating syphilis in the penicillin allergic patient

desensitization is the answer for: Neurosyphilis Pregnant women

IgA deficiency

develop antibodies against IgA. can react with Ig A containing donor products and induce a anaphylactic reaction (Angioedema, hypotension, and respiratory distress) progress to shock. Reduce this risk by washing to remove as much plasma as possible for IgA deficiency and prior allergic transfusion reaction.

Osteomyelitis in adults almost always presents in a patient with

diabetes, peripheral arterial disease, or both with an ulcer or soft tissue infection.

dysphagia

difficulty swallowing 1. Oropharyngeal-difficulty initiating a swallow-cough, drool, aspiration 2. Esophageal-food sticking in upper or lower chest first step is evaluating with NASOPHARYNGEAL LARYNGOSCOPY Esophagogastroduodenoscopy most helpful when have lower esophageal symptoms, NOT for upper esophagus

Medication Related Hair Loss

diffuse non-scarring thinning, not a discrete bald patch Hair loss via a telogen or anlagen effluvium Meds: Beta Blockers, Anticoagulants, Systemic retinoids, Anticonvulsants, Anti thyroid meds, and chemo meds (Antimetabolites, alkylating agents, mitotic inhibitors).

chorionic villus sampling (CVS)

done at 10-14 weeks' gestation a sample of the placenta (chorionic villi) is removed and tested for chromosomal abnormalities. —Indications: Advanced maternal age; Abnormal cfDNA test; parents who are carriers of chromosomal disorders; mother with a sex-linked disorder; previous child with chromosomal disorder —Risks: Fetal loss; maternal bleeding; infection; rupture of membranes

L5-S2

dorsiflexion and plantar flexion

Hypothyroidism effect on skin

dry, thick, inelastic skin independent of exposure to UV light

Granulomatous Disorders (Sarcoidosis, TB) can cause hypercalcemia

due to extra renal production of 1,25-dihydroxyvit D.

burn center deaths

due to inhalation injuries. SUPRAGLOTTIC DAMAGE is one of the most alarming types of inhalation injuries and stems from inhaling hot air steam or smoke. resulting in edema and significant narrowing of airway.

Stratified Analysis

evaluate the presence of potential confounding and effect modification at the analysis stage of a study

child treated for otitis media now presenting with retracted tympanic membrane with yellow fluid and decreased mobility

effusion in the middle ear = Serous otitis media or otitis media with effusion After tx of otitis media effusion can persist for up to 3 months. if otherwise asymptomatic watchful waiting is indicated, as spont resolution is likely to occur. Otherwise if there is symptoms of fever, pain purulent effusion or if its bilateral then treat with amoxicillin-clav.

Streptozyme test

evaluate for streptococcal infection can cause post strep glomerulonephritisdue to immune complex deposition. Renal insufficiency, nephritis, low C3

chlorpheniramine

first gen H1 Antihistamine with Anticholinergic properties that can relieve postnasal drip and rhinorrhea. It is sedating and not used as first line

Head Circumference Measurement

from birth to 2-3 years. Macrocephaly HC>97th percentile. Neuroimaging is required to evaluate for pathologic intracranial process: Rapidly expanding (>2cm in infants <6months), seizures, developmental delay HEAD US best study in infants with an open anterior fontanelle

Exercise during pregnancy associated with decrease risk of

gestational diabetes, preeclampsia, C-Section

infantile strawberry hemangiomas

grow rapidly but spontaneously regress by 5-8 yo. PROPRANOLOL is a tx for it if ulcerating lesion

potassium hydroxide prep of skin scrapings to identify

hyphae and yeast forms of malassezia species in patients with tines versicolor

topical imiquimod

immunomodulator that induces local cytokines, used for anogenital warts but can be as an alternative to plantar warts that dont respond to salicylic acid or liquid nitrogen therapy

JVP

increase during expiration Decrease during inspiration due to increased compliance of the right ventricle Kussmaul Sign = abnormal increase in JVP during inspiration -> seen in constrictive pericarditis or restrictive cardiomyopathy

17-hydroxyprogesterone

intermediate in adrenal cortical cortisol and androstenedione production. HIGH in Congenital Adrenal Hyperplasia, due to 21-hydroxylase & 11b-Hydroxylase deficiency LOW in Congenital Adrenal Hyperplasia due to 17a-hydroxylase deficiency

Upper GI Series in an infant is used for

intestinal malrotastionand volvulus severe constant abdominal pain and bloody tools bilious vomiting

Unlike PPV, Sensitivity and Specificity are

intrinsic characteristics of the test and are NOT affected by disease prevalence

Overflow incontinence

involuntary loss of urine associated with overdistention and overflow of the bladder -common in those with bladder outlet obstruction (men with bph, pts with urethral stricture) and those with neurogenic bladders -also common after getting anesthesia Impaired detrusor contractility

Iron Deficiency is uncommon in infancy because

iron reserves obtained in utero from maternal blood, lasts 4-6 months in term infants.

LDL and VLDL are removed from serum by lipoprotein signals. If the lipoprotein is lost in the urine with nephrotic syndrome

lipid levels in the blood rise.

ALL azoles can cause:

liver toxicity

A patient with a DVT develops a stroke. What study would most likely identify the underlying etiology of the stroke?

lower extremity DVT alone would NOT put a patient at risk for an embolic stroke unless the patient had a intracardiac communication. Therefore the best study would be a Transothoracic Echo. Intracardiac communication like a patent Foramen Ovale or Atrial Septal Defect is present and allows a dislodged venous clot travel into the arterial circulation, parodoxical emboli lead to embolic stroke in younger patients.

If presented with a case of cellulitis in a leg, make sure you order

lower extremity Doppler to exclude a blood clot Both clotting and cellulitis can cause a fever

Two-sample t-test compares

mean of quantitative variable between 2 groups, as in a study comparing mean construct scores between 2 intervention groups.

sensitive test; it must catch all patients that

may have the disease.

pooling data from several studies to perform an analysis is called

meta-analysis Epidemiologic tool used to increase the power of a study (increase sample size) Especially when outcome is rare or if the difference in outcome between groups is small, difficult for a single study to detect the difference. DISADVANTAGE: "pooling" of the biases and limitations of individual studies into one analysis.

Trastuzumab

monoclonal Ab that targets Human Epidermal Growth Factor Receptor 2 (HER2) Causes a decline in LVEF. Loss of myocardial contractility (myocardial Hibernation) leading to decreased LVEF. Trastuzumab-associated cardiotoxicity is reversible. Complete recovery of cardiac function after tx DC Can treat the HF with Beta blocker and ACE-I

Most dangerous and safest anti seizure meds in pregnancy

most dangerous is valproic acid while safest is levetiracetam or lamotrigine OCPs/estrogen increase metabolism of lamotrigine to ineffective levels

Daptomycin side effects

myopathy and a rising CPK not effective for lungs

Adverse Effects of Daptomycin

myopathy, rhabdomyolysis

Abacavir should be used only in those who are

negative for the HLA- B*5701 mutation.

side effects of foscarnet

nephrotoxicity

Bradykinesia and generalized "lead pipe" muscular rigidity

neuroleptic malignant syndrome due to dopamine antag

Mental status change, high fever, autonomic instability, diffuse muscle rigidity

neuroleptic malignant syndrome tx with DANTROLENE

Rocuronium and Succinylcholine

neuromuscular blocking agents used in rapid sequence intubation to cause paralysis, loss of upper airway tone and cessation of all reparatory effort.

Every HIV- positive pregnant woman

on HIV medications regardless of the stage of her pregnancy or her CD4 count. If the mother's viral load is undetectable at the time of delivery, there is no need for intrapartum zidovudine for the mother. The baby will receive oral zidovudine for several weeks even if the mother is undetectable.

per protocol analysis

only data from subjects who completed the intervention originally allocated at randomization are analyzed. Overestimate the real effect of the intervention on the outcome. VS The subtype "As-Treated Analysis" subjects are evaluated based on the intervention they received rather than the intervention to which they were randomized. therefore benefit of randomization is lost.

diagnosis of ADHD

onset of symptoms before age 12 with a duration >6months

hour to days monocular vision loss associated with eye pain that worsens with eye movement with afferent pupillary defect

optic neuritis

most effective way to stop smoking

oral medication, such as bupropion or varenicline. Less effective therapies that can be tried first are nicotine patches and gum.

Excess water ingestion (psychogenic Polydipsia)

overwhelm the capacity of the kidneys to excrete free water and lead to euvolemic hyponatremia Urine Osm is low <100 as kidneys attempt to excrete large amounts of free water

child with abdominal symptoms (diarrhea, Ab pain, distension), poor growth, eosinophilia, iron deficiency anemia, from tropical nation

parasitic infection by Hookworm Intestinal Nematodes (Ancylostoma Duodenale, Nacator Americanus) Antiparasitic treatment: Albendazole, Nitazoxanide

Case-control study

participants are initially identified as cases based on disease status or controls and then presence of past exposure to >1 risk factor of interest is determined in each group. IDENTIFY POTENTIAL RISK FACTORS FOR UNCOMMON DISEASES

Recall bias results from inaccurate recall of

past exposure = misclassification of exposure

Tilt Table Testing

patients with recurrent episodes of syncope but no evidence of structural heart disease

Relative Risk Reduction (RRR)

percentage indicating relative reduction in the treatment event rate compared to the control group RRR=ARR/CONTROL RATE

When there is fever and a new murmur or change in a murmur, the best next step in management

perform 3 sets of blood cultures first. If the blood cultures are positive, then perform an echocardiogram to look for vegetations. Fever + murmur means possible endocarditis. Do blood cultures. If you get positive blood cultures + positive echo, you have endocarditis.

onset of secondary sex characteristics in boys <9yo and girls <8yo

precocious puberty True central precocious puberty is due to early maturation of the hypothalamic-pituitary-gonadal axis. VS peripheral precocity due to excess sex hormones (androgens) production from the gonads, adrenal glands, or an exogenous source.

integrase inhibitor raltegravir

prevent the integration of the genetic material of the HIV virus from being integrated into the CD4 cell chromosome. HIV is an RNA virus. Reverse transcriptase turns it into DNA, and this viral DNA must be integrated into human DNA in order to be reproduced. This is the step blocked by the integrase inhibitor

Low tidal volume ventilation is important for

preventing risk of barotrauma in acute respiratory distress syndrome due to diffuse inflammatory changes in the lungs

correlation coefficient

r describes the direction (negative or positive), and the strength (values closer to -1 or 1 indicates stronger relationship) r<0 one variable increases the other variable decreases r>0 both values increase or decrease together -1 or +1 = strong -1 to 0 or 0 to 1 = Weak relationship 0 = No relationship

pyloric sphincter bypass or resection (distal gastrectomy)

rapid emptying of gastric contents (hyperosmolar chyme) into the small intestine. Fluid shifts intravascular to intraluminal; can cause dumping syndrome cramps and diarrhea. Occur shortly after meals and include vasomotor manifestations (diaphoresis, palpitations) Injury to the vagus nerve can cause gastroparesis. delayed gastric emptying causing abdominal pain, distention, early satiety, nausea, vomiting

Propofol

rapid onset sedation and amnesia Deep sedation, respiratory depression, loss of airway reflexes

An inadequate sample size can lead to

reduced statistical power to control for all confounders. The statistical significance of the result lost due to lack of sufficient power to adjust for confounders.

using standardized testing

reduces likelihood of measurement bias

Posterior shoulder pain

referred pain from cervical spine (nerve impingement due to disc herniation and spinal stenosis at the cervical spine level)

Screening for renal artery stenosis using doppler US is helpful in patients with

reistant HTN refractory to Antihypertensive therapy

Transurethral Resection of the Prostate (TURP)

relieve symptoms of bladder outlet obstruction but are indicated ONLY for chronically persistent obstructive symptoms. ONLY if failed trial of medications to relieve symptoms.

Metformin is contraindicated for patients with

renal insufficiency, Hepatic Dysfunction, Alcohol abuse, Sepsis, CHF Increase the risk of lactic acidosis when combined with large dose IV Iodine contrast (during coronary angio) HOLD on day contrast is given and restart 48hrs later

Extensive tubular epithelial necrosis

renal ischemia (hypotension, sepsis) and found in Acute Tubular Necrosis, occurs during hospital admission. associated with Muddy Brown Casts

PCI with bare metal or drug eluting stent

revascularization option for patients with refractory angina due to severe single or two vessel CAD not involving the proximal LAD

RR (Relative Risk)

risk ratio comparing risk of an outcome among exposed to that among the unexposed. When given as 1:1000 in exposed and 0.5:1000 among non exposed then. 1:1000 = 0.1 & 0.5:1000 = 0.05 0.1/0.05 = 2

pediatric constipation

risk: Intiation of solid food, cows milk, toilet training, school entry Clinical features: Painful/hard bowel movements, stool withholding, encopresis Complications: Anal fissures, hemorrhoids, enuresis/UTI Tx: High Diet Fiber, water intake, Limit cows milk intake to <24oz, laxatives, suppositories, enemas OSMOTIC LAXATIVES (LACTULOSE)cause retention of fluid in the gut lumen and stool resulting in softer bowel movements. Acute and long term use of osmotic laxative is considered safe. Stimulant laxatives is an adjunct it increases peristalsis to promote defecation but has side effects of abdominal cramp, diarrhea, nausea

Meningococcal vaccination

routine at age 10-18 Children at especially high risk, who should be vaccinated even earlier, are those with functional anatomic asplenia, HIV positive, or terminal complement deficiency. Group B vaccination is also given. If the question says the patient is to receive the medication with eculizumab and ocrelizumab, choose the answer "Vaccinate against meningococcus."

Diabetes screening

routine only in those with hypertension or who are obese.

paranoia, delusions, social withdrawal

schizophreniform Early cannabis use may be a causal factor in developing schizophrenia in those with susceptibility

Adverse Effects of Imipenem

seizures

Quaternary Prevention

set of health activities that mitigate and/or limit the consequences of unnecessary or excessive intervention by health system. ex: Use of a shared electronic medical record to limit unnecessary, repeat cardiac Cath procedures

A large V wave in jugular venous pulsation seen in patients with

severe tricuspid regurgitation

Alopecia Areata

smooth discrete areas of compete hair loss, no scaling, scarring or inflammation. Most will have regrowth in the involved area over time. T-cell infiltration around hair follicles and association of other autoimmune conditions (pernicious anemia, vitiligo, thyroid disease) Even after successful treatment can recur Tx is with topical or intralesional corticosteroids can restore normal hair growth but doe not cure the disease. new hair growth is seen in 4-6 weeks post injection.

Mini-Mental State Examination (MMSE)

test for dementia score <24 = Dementia or Delirium

absent cremasteric reflex

testicular torsion Emergent surgical detorsion and orchiopexy

vaginal bleeding, closed cervix, intrauterine pregnancy with normal fetal cardiac activity

threatened abortion

Adverse Effects of Linezolid

thrombocytopenia (Low Platelets) optic neuropathy stocking-glove peripheral neuropathy (i.e. peripheral neuropathy) serotonin syndrome (inhibitor of MAO)

Linezolid side effects

thrombocytopenia and interferes with MAO inhibitors.

Patients with active TB and close contacts

transmit to close contacts via aerosolized droplets for up to 3 months, prior to onset of symptoms. If initial screening with TB skin test is negative, repeat testing at 8-10 weeks to confirm. If positive should be further evaluated with CXR and symptom review to differentiate between latent and active TB. When CXR or symptom review is positive, testing for acid-fast bacilli in sputum can confirm the diagnosis of active TB. If positive but negative CXR and symptoms negative then have latent TB and therefore treat with RIFAMPIN DAILY for 4months or RIFAMPIN + ISONIAZID for 3months, OR ISONIAZID for 6-9 months (only in those who cant tolerate rifampin due to drug interaction or hypersensitivity)

A holosystolic murmur at lower sternum that increases with inspiration

tricuspid regurgitation

ART in uninfected persons before high-risk events occur, such as needle-sharing or sexual contact.

two-drug combination of tenofovir and emtricitabine before exposure. This two-drug treatment is continued daily for a month after the last exposure.

Empiric treatment for infective endocarditis

vancomycin and gentamicin (or ceftriaxone), treat for 4-6 weeks. Add rifampin if there is prosthetic valve endocarditis.

Dual eligible enrollees (Medicare-Medicaid or Medicare-Medi)

very low income seniors or disabled individuals who qualify for both

Years lived with disability vs years of life lost

years of life lost due to premature mortality (standard tables of life expectancy based on age) Years lived with disability, with a standard disability weight for the disability

Lung cancer screening

yearly in long-term smokers age 50-80 with 20 pack-years. Use a low-dose chest CT to do the screening. Stop if it has been >15 years since the patient quit smoking.

Albuterol

β2-agonist. Relaxes bronchial smooth muscle, relieves bronchoconstriction (wheezing) Use: acute exacerbation of asthma (rescue inhaler)

Fetal Growth Restriction (estimated fetal weight (EFW) is <10th percentile or the abdominal circumference is <10th percentile for gestational age): Fetal Causes

—Aneuploidy —Infection (e.g., TORCH) —Structural anomalies (e.g., congenital heart disease, NTD, ventral wall defects) —Detailed sonogram —Karyotype —Screen for fetal infections

Third Trimester Bleeding Management on CCS

—Get the patient's vitals —Place external fetal monitor —Start IV fluids with normal saline Order: —CBC —DIC workup (platelets, PT, PTT, fibrinogen, and D-dimer) —Type and cross-match —Obstetric ultrasound to rule out placenta previa —Give blood transfusion for large volume loss —Place Foley catheter and measure urine output —Perform vaginal exam to rule out lacerations —Cesarean delivery if maternal or fetal instability Do not perform a digital vaginal exam —placenta previa must be ruled out first with an ultrasound.

Sensitive staph (MSSA)

—IV: oxacillin/nafcillin, or cefazolin (first-generation cephalosporin) —Oral: dicloxacillin or cephalexin (first-generation cephalosporin)

Penicillin allergy

—Rash: cephalosporins —Anaphylaxis: clindamycin or linezolid —Severe infection: vancomycin, linezolid, daptomycin, telavancin — Minor infection: clindamycin, TMP/SMX, delafloxacin

Resistant staph (MRSA)

—Severe infection: vancomycin, daptomycin, linezolid, ceftaroline, tigecycline, or telavancin —Minor infection (skin): trimethoprim/sulfamethoxazole (TMP/SMX), clindamycin, doxycycline

↓ MS-AFP:

—Trisomy 21 (Down syndrome) ↓ MS-AFP ↓ Estriol ↑ β-hCG ↑ Inhibin A — —Trisomy 18 (Edward syndrome) ↓ MS-AFP ↓ Estriol ↓ β-hCG ↓ Inhibin A amniocentesis for karyotyping Elevated amniotic fluid- acetylcholinesterase activity is specific to open NT D.

Adenosine

↑ K out of cells → hyperpolarizes cell and ↓Ca intracell. Use: Antiarrhythmic. drug of choice for dx/tx of supraventricular tachy. AV Nodal Reentrant Tachy (Dual AV Node conduction creating a reentrant circuit, triggered by premature atrial contraction, regular R-R intervals, P waves buried within the QRS complexes, Narrow QRS complexes) short acting (~15 sec). Toxicity: flusshing, hypotension, chest pain. Effects are blocked by theophylline and caffeine.

Vancomycin in combination with piperacillin/tazobactam is associated with an increased risk of

AKI

A 24-year-old HIV-positive woman (G2 P1) presents in her 16th week of pregnancy. Her previous child was diagnosed HIV positive after vaginal delivery. What is the most effective method to decrease the risk of vertical transmission?

triple ART is indicated for more effective management of HIV in the mother to drive the viral load to <1,000. Elective C-Section is of most benefit in women with low CD4 count and high RNA viral load (>1,000). All neonates of HIV-positive women will have positive HIV tests from transplacental passive IgG passage. Triple-drug therapy: —Start triple therapy immediately —IV intrapartum ZDV at time of delivery if viral load not fully suppressed —Combination ZDV-based ART for 6 weeks after delivery Give the infant prophylaxis against HIV, with 6 weeks of ZDV -Vaginal delivery is preferred unless maternal viral load >1,000 viral copies/mL -Advise mother not to breastfeed (breast milk transmits the virus) Avoid invasive procedures (e.g., fetal scalp electrodes)

iron deficiency anemia in children (universal screening 1yo)

>24 oz of cows milk per day if >1 yo Hgb<11 Empiric trial of ferrous sulfate, give with juice between meals as vitamin C facilitates iron absorption Limit milk intake <20oz per day Increase iron rich foods (meats, fortified cereals) Hypochromic, microcytic RBCs and decreased reticulocyte count. once initiated on supplementation with ferrous sulfate the RETICULOCYTE COUNT increases rapidly, however in moderate to severe iron deficiency takes about a month for the hematocrit and hemoglobin to increase and few months to regular values. After a month of empiric treatment increase in Hgb supports diagnosis and should be maintained on treatment for 2-3 months after normalization of Hgb to replenish iron stores. Ferritin reflects iron stores and does not begin to rise until after Hgb normalizes Mentzer index refers to ratio of MCV to total RBC count. Before tx patients with iron deficiency anemia have low MCV and total RBC count with HIGH mentor index >13.

postop urinary retention

>50yo, surgery >2hrs, >750ml intraop fluids, regional anesthesia, neurologic disease, underlying bladder dysfunction, previous pelvic surgery DEC urine output, abdominal distension, suprapubic pressure/pain Indwelling catheter, clean intermittent catherization Due to combination of anesthesia and administration of large volume of IVF, anesthesia causes bladder stretch receptor dysfunction and decreased detrusor contractility which along with large fluid volumes results in rapid overdistension, this causes suprapubic tender and ab distension

asymptomatic, firm, smooth, annular plaque with raised borders

Localized granuloma Annulare

Octreotide

Somatostatin Analogue used in AIDS related diarrhea and diarrhea due to neuroendocrine tumors (VIPomas)

Specificity

Specificity = TN / (TN + FP)

S2-S4

Sphincter tone

Abrasion to the cheek from a tree branch, developed nodular, ulcerative lesion at the site of injury and similar lesion along the proximal lymphatic chain

Sporotrichosis Nodular Lymphangitis can occur from Mycobacterium Marinum, Nocardia, Leishmania, Sporothrix shenckii) Painless papule, ulcerates and drains nonpuruelnt, odorless fluid over days more lesions develop along the lymphatic chain. NO FEVER. Cultures: Aspirate fluid or biopsy: Cigar-Shaped Yeast with Narrow-Based Budding at 37C Tx: Itraconazole for 3-6m

Pressure Ulcers Staged by depth of involvement

Stage I: Non blanch able erythema of intact skin Stage II: Superficial ulcers causing a partial thickness loss of the epidermis, dermis, or both Stage III: Deep ulcer causing full thickness loss with damage to SubQ tissue that may extend to but not through fascia Stage IV: Very deep ulcers full thickness loss with extensive tissue destruction that may damage adjacent muscle, bone, or supporting structures Full thickness wounds stage III, IV require debridement of devitalized necrotic tissue and specialized wound dressing

Pharmacologic rate control of Afib

Start with beta blockers or Nondihydropyridine CCB (Verapamil, Diltiazem) (Contraindicated in HFrEF Additional rate control needed add another first line drug from a different class, Consider DIGOXIN in pts with HFrEF If still not adequate then add AMIODARONE (Contraindicated in COPD), Consider ablation

Treatment of Symptomatic Peripheral Artery Disease

Step 1A: Smoking cessation, BP & DM control, Anti-platelet & statin Therapy Step 1B: Supervised Exercise Therapy Step 2: Cilostazol Step 3: Revascularization: Angioplasty +/- stent placement, Bypass graft

Insomnia, Decreased appetite, Irritability, Dilated pupils, Tachycardia, HTN, Diaphoresis

Stimulant Toxicity

ADHD treatment

Stimulant: -Methylphenidate & Amphetamine: weight loss, decreased appetite, insomnia, abdominal pain, tachycardia, HTN, addiction potential Non-Stimulant: -Clonidine, Guanfacine: sedation, dry mouth, constipation, irritability, anxiety, hypotension, Ab pain, sleep disturbances (nightmares) -Atomoxetine: Dry mouth, decreased appetite, insomnia, hyperhidrosis, erectile dysfunction

Imiquimod

Stimulates the release of cytokines such as interferon, TNF- alpha, and interleukin-6. It also stimulates natural killer cells to get rid of HPV-infected cells and malignant cells that are not melanoma. Imiquimod is indicated for basal cell cancer, actinic keratosis, and minor squamous cell cancer, in addition to venereal warts.

Patchy uptake of iodine on scintigraphy

Toxic multi nodular goiter

abdominal pain, sweating, shaking, fever, chills, headache, irritability, anxiety, insomnia, decreased appetite, restlessness, depressed mood. In a cannabis smoker

Cannabis Withdrawal

Situs inversus, Chronic Sinusitis, Airway disease leading to bronchiectasis

Kartagener Syndrome AR congenital mucociliary disorder known as primary ciliary dyskinesia.

Indicated in evaluating Turner syndrome

Karyotype analysis

treatment of cellulitis

- Minor: dicloxacillin, cephalexin, or amoxicillin/clavulanate orally - Severe disease: oxacillin, nafcillin, cefazolin, or ampicillin/sulbactam IV - Penicillin allergy (Rash: cephalosporin, e.g., cefazolin or ceftaroline, Anaphylaxis: vancomycin, linezolid, or daptomycin, Minor infections: clindamycin, TMP/SMX)

Screening guidelines for STDs

- Women age <25 should be screened yearly for gonorrhea and chlamydia - Men who have sex with men should be screened yearly for gonorrhea, chlamydia, and syphilis - Everyone, regardless of risk factors, should be tested for HIV

Pharmacologic Interventions for Neuropsychiatric symptoms of Dementia

-Apathy/Hallucinations: Cholinesterase Inhibitors -Agitation/Paranoia: SSRIs -Severe aggression/Psychosis: Antipsychotics -AVOID Benzos due to adverse effects (delirium, paradoxical agitation)

MECHANISM OF ERYTHROMYCIN ADVERSE EFFECTS

-Causes severe nausea, vomiting, and diarrhea. -Increases the release of motilin, a hormone that increases GI motility between meals to the point of excess GI motility (which is why it works for hypomotility disorders such as diabetic gastroparesis)

Threaten viability of potential donated organs

-Central Diabetes Insipidus (increase UOP >1000 ml/h and cause volume depletion -Systemic Hypotension due to loss of sympathetic tone and volume depletion -Hypothermia Important to maintain EUVOLEMIC, NORMOTENSIVE, NORMOTHERMIC state achieved by administering IVF and Desmopressin to reduce the diuretic impact of central diabetes insidious, inotropic or pressor support to maintain BP and warm air blankets to maintain temperature.

Tetanus prophylaxis

-Clean or minor wound: >3 toxoid doses: Tetanus toxoid vaccine only if >10yrs, NO TIG Unimmunized, uncertain, or <3: Vaccine only, NO TIG -Dirty or severe wound: >3 toxoid doses: Tetanus toxoid vaccine only if >5yrs, NO TIG Unimmunized, uncertain, or <3: Vaccine + TIG UP TO DATE ON IMMUNIZATION: 4 Tetanus Toxoid-containing Vaccines (Diphtheria, Tetanus Toxoid, acellular Pertusis (DTaP) at ages 2,4,6 months and additional DTaP at 4 years.

HFpEF

-LV diastolic dysfunction due to impaired relaxation -Chronic HTN results in concentric LV hypertrophy -Obesity & sedentary lifestyle leads to Myocardial interstitial fibrosis that leads to diastolic dysfunction and decompensated volume overload. -CAD, DM Dx: Dyspnea, Orthopnea, paroxysmal nocturnal dyspnea (dry cough, worse when lying down), JVD, Lower extremity edema, S3. CXR: Interstitial edema (Kerley B Lines) progress to alveolar edema (Alveolar opacification) Tx: Mineralcorticoid Antag:Spironolocatone, SGLT2 inhibitors: Dapagliflozin, Loop diuretics for volume overload, Anti HTN to reduce after load, Exercise and cardiac rehab

Biventricular pacing devices for

-LV ejection fraction <35% -HF symptoms -Left Bundle Branch Block with QRS >150msec Implantable cardioverter-defibrillator (ICD) to prevent sudden cardiac death

Reducing the risk of recurrence of C. Diff

-Minimize Abx use (Especially Fluoroquinolones, Clindamycin, Broad spec Penicillins/Cephalosporins) -Avoid Gastric Acid Suppression: Proton pump inhibitors and H2 blockers alter colonic microbiome -Avoid Hospitalization: Nosocomial exposure accounts for most C. Diff Transmissions -Advanced Age: Older individuals have diminished colonic immunity and greater exposure to antibiotics, proton pump inhibitors and hospital environments

Management of Asthma Exacerbation During Pregnancy

-O2: Maintain SaO2>95% -Bronchodilators: Nebulized or inhaled albuterol, Inhaled Ipratropium -Systemic Corticosteroids: If incomplete response to bronchodilators, PREDNISONE -Additional Therapy: MgSO4 or Terbutaline if severe, Epinephrine Contraindicated, Intubate for resp failure UNTREATED -> Maternal & Fetal mortality, Premature birth, low birth weight

Postmenopausal Osteoporosis: Osteopenia Vs Osteoporosis

-Osteopenia: T score on DXA -1 to -2.5 -Osteoporosis: T score <-2.5 or confirmed Osteoporotic Fracture Eval: Serum Chem Panel, CBC, Serum 25-Hydroxyvit D AVOID SMOKING and excess alcohol, Regular weight bearing exercises. Calcium >1200 mg/day, Vitamin D >800 IU/day CALCULATE 10 year risk of hip fracture Oral bisphosphonate (Alendronate) for Osteoporosis or high risk osteopenia (10 yr risk of hip fracture >3% or combined major fracture >20%)

Treatment for Osteomyelitis

-To treat osteomyelitis appropriately, perform a bone biopsy/culture. -IV oxacillin or nafcillin for 4-6 weeks; oral therapy cannot be used = Staph -vancomycin, dalbavancin, oritavancin, linezolid, ceftaroline, or daptomycin = MRSA -If Chronic: debridement (no urgency to treat; get the biopsy, move the clock forward, and treat what is found on the culture) -Gram-negative bacilli (Salmonella and Pseudomonas): oral antibiotics (only time they will be effective)

Third Trimester Routine Tests

1. Diabetes - 1 hr 50 g OGTT between 24-28 weeks 2. Anemia - CBC- Hgb <11 - most common cause is iron deficiency 3. Atypical antibodies - Indirect coombs test. For Rh - to look for Anti-D Abs before RhoGAM (Dont give if have Anti-D Abs) 4. GBS Screening - vaginal and rectal cx at 35-37 weeks - IV penicillin, if allergic then IV Clindamycin or Erythromycin if sensitivities available if not then IV Vancomycin

3 main subtypes of Basal Cell Carcinoma (BCC)

1. Nodular: MOST COMMON, shiny, pearly, skin colored nodule with telangiectasia, or rolled raised border and ulceration 2. Superficial: SECOND Most Common, pink or red macules, patches, thin plaques, atrophic appearing centers and peripheral small, pearly, papules. 3. Morpheaform/Infiltratitive: LEAST Common, Shiny, Pale, scar like indentations In general, chronic >3 weeks non healing ulcerated lesions suggest malignancy and warrant biopsy

Hyperkalemia ECG signs

1. Prolonged PR, Tall Peaked T Waves 2. Loss of P waves, ST Elevation 3. Widened QRS (Sine Wave Pattern) 4. Systole

Greater than 5 days of fever + Conjunctivitis, mucosal changes, LAD, rash, Extremity changes

Kawasaki Disease

One of the criteria to determine causality

A dose response relationship between an increased Level of exposure to a risk factor and an increased probability of disease assumes that the more intense the exposure the greater the risk of disease.

Preferred treatment for HTN in patients with CKD

ACE-I & ARBs improve Proteinuria and slow kidney disease progression monitor renal function as they can cause hyperkalemia and acute drop in GFR.

First Line Anti HTN drug classes

ACE-I, ARBs, Calcium Channel Blockers, Thiazide Diuretics ACE-I & ARBs should never be combined because of the risk of HYPERKALEMIA & NEPHROTOXICITY GOOD COMBO = ACE-I & Calcium Channel Blocker and the ACE-I can minimize the edema associated with calcium channel blockers.

treating proteinuria due to glomerular damage from diabetic nephropathy, glomerulonephritis, nephrotic syndrome

ACE-Inhibitors (lisinopril), Angiotensin II Receptor Blockers (Losartan) reduce proteinuria and slow progression of CKD by blocking angiotensin II mediated renal efferent arteriole vasoconstriction. Therefore reduce glomerular hydrostatic pressure, decelerating development of glomerular capillary sclerosis.

Acute "pop" with rapid onset of large effusion at the knee

ACL: Anterior Drawer and Lachman Test PCL: Posterior drawer test

Tourette syndrome associated with and treated with

ADHD and OCD Tx: Anti-Dopaminergic Agents: -Tetrabenazine (Dopamine Depleter) -Antipsychotics Alpha 2 Agonists

Levothyroxine replacement therapy for Hypothyroid

AFTER Radioiodine therapy for Graves patients are left with residual hypothyroid state requiring lifelong levothyroxine replacement Initial: standard dose 75-125 and 25-50 if elderly/heart disease Adjustment: Increase every 6 weeks until TSH within normal range Maintenance: Monitoire TSH every 6-12 months CONDITIONS REQUIRING HIGHER DOSES: Malabsorption (Celiac Dz-HIGH prevalence in pts with autoimmune thyroid disease-Test with Anti-Transglutaminase IgA or Anti-Endomysial IgA Antibodies if + then Endoscopy. Manage by gluten free diet), Drugs that interfere with absorption (iron, Calcium), Drugs that increase thyroxine metabolism (Phenytoin, Carbamazepine, Rifampin), Obesity, Pregnancy, Overt proteinuria

Single most important risk factor for Osteoporosis

AGE Medications that predispose: glucocorticoids, anti androgens, anticonvulsants Caucasian > African FH, Smoking, Alcohol

Colon Cancer Screening

AGE 45 (Colonoscopy every 10yrs) First Degreee relative with colorectal cancer or high risk adenomatous polyp (>10mm high grade dysplasia, villous): Colonoscopy at age 40 or 10 years prior to age of diagnosis of family member, whichever comes first), repeat every 5 Years. Patients with Ulcerative Colitis: Start screening 8-10 years after diagnosis., Colonoscopy every 1-3 years.

Uric Acid-Reducing Agents

ALLOPURINOL, FEBUXOSTAT -> Inhibits Production of Uric Acid by blocking Xanthine Oxidase RASBURICASE (recombinant Urate Oxidase) -> Acts on Uric Acid by converting it to Allantoin to increase clearance

sudden onset vaginal bleed, abdominal or back pain, high frequency low intensity contractions, rigid, tender uterus.

Abruptio Placentae Placental detachment from the uterus before fetal delivery Typically accompanied by vaginal bleeding but a concealed abruption trapped in between placenta and uterine wall can occur Risk: HTN, Preeclampsia, Abdominal Trauma, Prior abruption placentae, Cocaine and tobacco US: Retrplacental hematoma otherwise clinical finding Complications: Fetal Hypoxia, Preterm birth, Mortality, Maternal hemorrhage, DIC Fetomaternal hemorrhage in Rh(D)-Negative mothers is more serious as it can result in Alloimmunization therefore a KLEIHAUER-BETKE TEST indicated to detect and quantify the amount of fetomaternal hemorrhage by calculating percentage of fetal blood cells in the maternal circulation this can determine the amount of Rho(D) immune globulin administered to decrease risk of alloimmunization.

Cardiac Syncope

Absence of autonomic prodromal symptoms (nausea, diaphoresis, feeling warm) usually present prior to benign syncope, suggest cardiac. Admit and undergo telemetry monitoring, and echo depending on findings may need amiodarone, catheter ablation or implantable cardiac defibrillator Aortic Stenosis or HCM: Exertion Syncope, Systolic Murmur Ventricular Tachycardia: No preceding symptoms, Cardiomyopathy or previous MI (Q waves suggesting ischemic scarring from previous MI) Sick Sinus Syndrome: Preceding fatigue or dizziness, Sinus pauses on ECG Advanced AV Block: Bifascicular block or Increased PR interval on ECG, Dropped QRS complexes Torsades de Pointes: No preceding symptoms, Meds that prolong QT, hypokalemia , Hypomagnesemia

Absolute & Functional Iron Deficiency

Absolute: Depleted Iron Stores: LOW FERRITIN Functional from (Erythropoiesis-Stimulating Agent: Darbepoetin) use: Insufficient Iron to accommodate accelerated erythropoiesis: HIGH FERRITIN, LOW Transferrin --> Iron supplementation should be given to optimize benefit of ESA therapy. Functional from anemia of chronic disease: Iron sequestered in macrophages and cannot be mobilized: HIGH FERRITIN

Skin conditions & associated diseases

Acanthosis Nigricans: Insulin resistance, GI Malignancy Multiple Skin tags: Insulin resistance, Pregnancy, Crohns Porphyria cutanea tarda, cutaneous leukocytoclastic vasculitis secondary to cryoglobulinemia: Hep C Dermatitis herpetiformis: Celiac Dz Sudden onset severe psoriasis, recurrent herpes, disseminated molluscum contagiosum: HIV Severe seborrheic dermatitis (pruritic, erythematous plaques with greasy scales): HIV, Parkinson Explosive onset multiple, itchy seborrheic keratoses: GI Malignancy Pyoderma Gangrenosum: IBS

first line SYMPTOMATIC Tx for dementia related cognitive impairment

Acetylcholineesterase Inhibitors (Donepezil, Rivastigmine, Galantamine) &/or MEMANTINE (NMDA Antag) Inhibit Acetylcholineesterase at synaptic cleft, thereby increase cholinergic transmission and result in symptomatic improvement

Donepezil

Acetylcholinesterase inhibitor. ↑ endogenous ACh. CNS penetration. Use: Alzheimer's disease Improve cognitive function ands activities of daily living in various forms of dementia.

Doxycycline used in a variety of dermatologic conditions

Acne, Rosacea, Hidradenitis Suppurativa

Anterior shoulder pain

Acromioclavicular or glenohumeral joint osteoarthritis and bicep tendonitis

Erythematous, Scaly Papules; rough plaques, sun exposed areas

Actinic Keratosis Biopsy for possible SCC (>1cm, rapid growth, ulceration, tender) Tx: Isolated: Cryotherapy, Diffuse: Topical Fluorouracil, Imiquimod, Tirbanibulin

Erythematous, Scaly papules, rough plaques, sun exposed areas, elderly.

Actinic Keratosis precursor to SCC. Hypertrophic: Thick Scales on erythematous base Atrophic: Soft, red macules that lack scales Cutaneous horn Isolated? LIQUID NITROGEN CRYOTHERAPY Diffuse? Topical Fluorouracil, Imiquimod, Tirbanibulin

Topical 5-FU and Cryotherapy with topical liquid nitrogen

Actinic keratosis (premalignant SCC condition) or 5-FU can be for SCC in Situ (Bowen Disease) malignancy limited to epidermis

Secondary Prevention

Action that attempts to halt the progression of a disease at its initial stage before irreversible pathological changes take place, thus preventing complications. Ex: If have existing MI and start a statin

Primary Prevention

Action undertaken BEFORE the patient develops the disease and prevents occurrence of the disease itself.

A 21-year-old multipara is admitted to the birthing unit at 39 weeks gestation in active labor at 6 cm dilation. Membranes are intact. She has a history of genital herpes preceding the pregnancy. Her last outbreak was 8 weeks ago. She now complains of pain and pruritus. On examination she has localized, painful, ulcerative lesions on the right vaginal wall. Which of the following is the next step in management? (fever, malaise, and diffuse genital lesions during pregnancy)

Active genital herpes is an indication for C-Section. Contact with maternal genital lesions during an active HSV episode is the most common cause of transmission. Transplacental infection can also occur with primary infection during pregnancy Surviving infants develop meningoencephalitis, intellectual disability, pneumonia, hepatosplenomegaly, jaundice, and petechiae. -C-section for women with lesions suspicious for active genital HSV at the time of labor -Acyclovir to patient for primary infection during pregnancy

vision loss, severe eye pain, headaches, nausea, vomiting. Light halos seen. Conjunctival redness and dilated poorly reactive pupil.

Acute Angle Closure Glaucoma

pregnant patient with fever, right sided abdominal pain and leukocytosis

Acute Appendicitis Due to upward displacement of the appendix there is no peritoneal sign and no McBurney point tenderness Dx: GRADED COMPRESSION ABDOMINAL ULTRASOUND, if inconclusive get abdominal MRI (IF NON PREGNANT ABDOMINAL CT) If ruptured appendix can result in spont abortion, preterm labor, preterm delivery COMPLICATION: PYLEPHLEBITIS, infective suppurative portal vein thrombosis, from intrabdominal or pelvic infections, fever, RUQ pain, jaundice, hepatomegaly. Elevation in Alk phos and gamma-glutamyl transferase, and imaging (CT, US). Tx with prolonged broad spec antibiotics

Fever, Nasal congestion/obstruction, purulent nasal discharge, maxillary tooth discomfort, facial pain/pressure worsen with bending forward

Acute Bacterial Rhinosinusitis Tx: 1st line = PO Amox-Clav x 5-7 days Alternate = Doxycycline or Fluoroquinolones Supportive = Analgesics, Decongestants, Saline irrigation, topical glucocorticoids Most are viral URI (influenza, Rhino, Aden) resolve in 10 days However others develop secondary bacterial infection (Strep pneumonia, H. Influenza, Moraxella) this is evident with persistent symptoms post URI >10days, High fever, purulent nasal discharge, facial pain.

cough lasting >5days and up to 3 weeks, post viral respiratory infection. purulent yellow or green sputum during cough. No fever. Wheezing, bronchi and chest wall tenderness

Acute Bronchitis mild dyspnea and chest wall discomfort and crackles that clear with cough suggesting secretions that are easily mobilized unlike pneumonia Fever not present and if was then think pneumonia Dx: Clinical, CXR only when pneumonia suspected, symptomatic treatment (NSAID or bronchodilators), antibiotics not recommended

persistent RUQ pain, fever, leukocytosis, N, V especially after a large meal

Acute Calculous Cholecystitis When gallstone obstructs cystic duct and results in gallbladder wall inflammation Dx: RUQ US reveals Choleliths with gallbladder wall thickening or sonographic Murphy sign (Increased pain Teheran transducer compresses gallbladder) If US is negative or inconclusive then do HEPATOBILIARY IMINODIACETIC ACID (HIDA) SCAN (Cholescintigraphy) After confirming diagnosis then emergency Laparoscopic Cholecystectomy within 72hrs of symptom onset.

Pulmonary complication of Sickle Cell Disease

Acute Chest Syndrome Vasoocclusion of pulmonary vasculature, triggered by fat embolus (adults), or infection (children) CXR: Pulmonary infiltrates Increased work of breathing, cough, tachypnea, wheezing, fever, hypoxemia, chest pain Tx: Ceftriaxone (Third gen cephalosporin) & Azithromycin (macrolide) These will cover strep pneumo & Mycoplasma pneumoniae, IVF to prevent dehydration and further sickling, Pain control to prevent hypoventilation and atelectasis

fever, jaundice, RUQ pain (Charcot Triad) +/- Hypotension and AMS (Reynolds Pentad) HIGH Direct bili, Alk Phos, Amonotransferases

Acute Cholangitis Ascending infection due to biliary obstruction Biliary dilation on Ab US or CT scan Tx: Abx for enteric bacteria, Biliary drainage by ERCP within 24-48hrs

Fever, Jaundice, RUQ pain (Charcot Triad) +/- Hypotension, Altered Mental Status (confused, lethargic) (Reynolds Pentad)

Acute Cholangitis Ascending infection due to biliary obstruction (gall stone disease most common cause, however if undergone cholecystectomy then at risk due to biliary stricture, malignant biliary obstruction, poschole migration of biliary clip) HIGH Direct bill and all phos HIGH Aminotransferases Ab US or CT with biliary duct and common bile duct dilation Tx: Abx coverage of enteric bacteria, Biliary drainage by ERCP within 24-48hrs

Fever, Jaundice, RUQ pain, - Charcot Triad - Hypotension, AMS (Reynolds Pentad)

Acute Cholangitis (Ascending infection due to biliary obstruction-gallstones, bile duct stenosis, cholangiocarcinoma) disrupt normal bile flow and allow bacteria from the duodenum to ascend the biliary tract, causing infection. Increased direct bile & Alk phos, High Aminotransferases US with biliary dilation on Abdominal US or CT scan Tx: Abx for enteric organisms (Piperacillin/Tazobactam, Ciprofloxacin with metronidazole) & BILIARY DRAINAGE BY ERCP WITHIN 24-48HRS for gallstone removal and stent placement

active smoker, father died suddenly in sleep, substernal chest pain, inferior lead T- Wave abnormalities

Acute Coronary Syndrome GIVE aspirin 325mg, if active chest pain Sublingual nitroglycerine. Then get a Troponin I level and if ongoing chest pain serial ECGs every 30min. Collect at least two troponin levels three hours apart. takes about 6-12hrs from symptom onset to become detectable. HIGH TROPONIN = NONSTEMI NORM TROPONIN but with CHEST PAIN = Non cardiac chest pain and undergo stress testing for further eval

chronic HTN, medication non adherence, ECG evidence of LV hypertrophy (increased voltage in precordial leads), several weeks of cough, SOB, sensation of choking.

Acute Decompensated HF results from critical elevation in intracardiac filing pressures due to LV systolic and or diastolic dysfunction (coronary ischemia, HTN cardiomyopathy) also vascular disease and marked elevation in preload (excess volume resuscitation) or afterload (severe HTN) Pulmonary edema (bilateral crackles, vascular congestion on CXR, tachypnea, hypoxia), JVD, TX: Hemodynamic stabilization, improve oxygenation, optimize volume status with IV DIURETICS (FUROSEMIDE) they reduce intravascular volume, lower intracardiac filling pressures and improve pulmonary edema AVOID BetA BLOCKERS in Acute Decompoensated HF due to negative isotropy and chronotropy causing potential worsening of pulmonary edema. Addition of IV VASODILATION after inadequate response to initial therapy. NITROGLYCERINE (venous dilator) leads to rapid decrease in cardiac preload resulting in reduced intracardiac filling pressure and improvement in Pulmonary edema Transthoracic Echo performed if uncertain etiology. Confirm suspected LV dysfunction (HTN Cardiomyopathy) and provide assessment for valvular abnormalities (mitral regurgitation)

LLQ abdominal pain, Fever, Nausea, Vomiting, Ileus (peritoneal Irritation)

Acute Diverticulitis CT SCAN of ABDOMEN with Contrast Management: Bowel Rest, Abx (Ciprofloxacin, Metronidazole) Complications: Abscess, Obstruction, Fistula, Perforation If dont improve in 2-3 days of tx should receive a repeat CT of abdomen and pelvis to evaluate for complications. MOST COMMON COMPLICATION = Colonic Abscess (see localized fluid collection on CT) require percutaneous drainage and IV abx followed by elective partial colectomy several weeks later. Emergency Laparotomy and Colectomy if diverticulitis leads to perforation. Colonoscopy performed 6-8 weeks after complete resolution of symptoms to rule out colon cancer

Antipsychotic Extrapyramidal Effects

Acute Dystonia: Sudden, sustained contraction of the neck, mouth, tongue and eye muscles: BENZTROPINE or DIPHENHYDRAMINE (Antihistamine and anticholinergic activity) Akathisia: Subjective restlessness, inability to sit still: BETA BLOCKER (PROPRANOLOL), BENZODIAZEPINE (LORAZAPAM), BENZTROPINE Parkinsonism: Gradual onset tremor, rigidity, bradykinesia: BENZTROPINE, AMANTADINE (dopamine agonist) Tardive Dyskinesia:mDyskinesia of mouth, face, trunk, extremities: VALBENAZINE, DEUTETRABENAZINE

Third Trimester with N, V, epigastric pain, malaise, elevated transaminases

Acute Fatty Liver of pregnancy

HIGH creatinine, HTN, Hematuria with dysmorphic RBC, RBC cast, proteinuria, arthralgia, rash.

Acute Glomerulonephritis

Elevated Aminotransferases, + Hep B Surface Antigen, + Hep B IgM Core Ab, + Hep B e antigen (Indicator of high infectivity) and detectable Hep B DNA.

Acute Hep B Virus Infection. Very low risk of acute liver failure and therefore resolve spontaneously and can be managed with outpatient supportive care and close follow up. Antiviral therapy ONLY in those with immunosuppression, concurrent hep C, severe hepatitis, fulminant hepatic failure.

abdominal pain, vomiting, diarrhea, agitation, paresthesia, confusion, in females.

Acute Intermittent Porphyria

Straight keg raising test is positive in 90% of

Acute Lumbar Herniation

Sudden onset of severe periumbilical pain with nausea and vomiting, pain out of proportion to exam (subjective pain with normal abdominal exam), in person with A fib.

Acute Mesenteric Ischemia Due to Afib leading to embolic phenomenon. Arterial occlusion of superior mesenteric artery (cardiac emboli or thrombotic), non occlusive ischemia due to hypo perfusion (low cardiac output) to splanchnic circulation, Superior mesenteric vein occlusion. METABOLIC ALKALOSIS (elevated lactate), leukocytosis, hemoconcentration (high hematocrit), CT of abdomen & CT angio show focal or segmental bowel wall thickening, mesenteric stranding and porto menseteric thrombosis CT abdomen with focal or segmental bowel wall thickening, intestinal pneumatosis with portal vein gas, dilated bowel, mesenteric stranding) Best study is CT ANGIO Tx: Fluid resuscitation, correction of metabolic acidosis, broad spec antibiotics, nasogastric tube for decompression. Surgical consult required.

sudden onset hypotension, hyper dynamic precordium, decrescendo holosystolic murmur at cardiac apex, tachycardia, pulmonary crackles, JVD, hyper dynamic cardiac impulse, diaphoresis

Acute Mitral Regurgitation due to mitral chord tendineae from mitral valve prolapse (CT DISEASES LIKE MARFAN OR EHLERS-DANLOS SYNDROME), infective endocarditis, rheumatic heart disease, trauma or papillary muscle rupture due to MI Dx: Bedside ECHO EMERGENCY SURGICAL INTERVENTION

Bulging TM, Middle ear effusion Plus TM inflammation (fever otalgia, erythema)

Acute Otitis Media Strep pneumonia, NON TYPEABLE H. Influenza, Moraxella Initial: AMOXICILLIN (10 day course) 2nd line: AMOX-CLAV - Beta-Lactamase Inhibitor (repeat infection within a month of initial treatment concerning for beta-lactamase-producing strains of nontyeable H. Influenza, strep pneumonia, Moraxella) Penicillin allergic: CLINDA or AZITHRO Complications: TM perforation, conductive hearing loss, mastoiditis, meningitis recurrent infection within 2 weeks of treatment is caused by same pathogen as the initial infection due to resistant strains, if greater than 2 weeks then different pathogen CONCURRENT otitis media & Puruelnt Conjunctivitis + Otitis-Conjunctivitis Syndrome = Nontypeable H. Influenza

RV dilation and Hypokinesis seen with, and hypoxemia

Acute PE, which OCP is a risk factor for.

acute severe epigastric pain radiating to the back associated with N, V. Relieved by leaning forward, and worsened by eating.

Acute Pancreatitis Gallstones & Alcohol account for >65% of cases Hypertriglyceridemia 14% of cases (Triglyceride >1000)-LIPID PANEL to assess Hypercalcemia, Drugs (valproic Acid, Diuretics, furosemide, didanosine), Infections (CMV, HIV, Ascariasis), Trauma, Ischemia, Post ERCP Dx requires characteristic pain, serum amylase or lipase >3x normal, Imaging consistent with pancreatitis (Contrast CT or MRI) Establishing diagnosis with lab markers is preferred over imaging due to cost, faster, lack of exposure to radiation. Also CT has low sensitivity in first 72hrs Tx: Volume resuscitation, pain control, Oral feeding within 24hrs as tolerates, gallstone pancreatitis, ERCP if common bile duct stone present, cholecystectomy to prevent recurrence, Hypertriglyceridemia pancreatitis, Apheresis or IV Insulin, Fibrate (fenofibrate) to prevent recurrence

Pleuritic chest pain worsens with deep inspiration and improves with sitting up, retrosternal and radiates post to bilateral trapezius, PERICARDIAL FRICTION RUB (scratchy sound heard during ventricular systole along left sternal border). Fever, ECG with diffuse ST elevation and PR depression.

Acute Pericarditis On Echo pericardial effusion Caused by viral or idiopathic, SLE, Uremia, POST MI (Early (<4days post MI) = peri-infarct pericarditis, Late = Dressler Syndrome) Tx: HIGH DOSE ASPIRIN if persistent then narcotics & Colchicine for viral or idiopathic Friction rub is TRIPHASIC (Atrial systole, Ventricular Systole, Early ventricular diastole)

Mitochondrial Encephalomyopathy with Lactic Acidosis & Stroke Like episodes (MELAS)

Age <40, stroke like episodes (hemiparesis, vision abnormalities), seizures, muscle weakness, hearing loss, lactic acidosis (due to mitochondrial dysfunction) Maternal inheritance, condition passed from affected mother to male and female offsprings HOWEVER males do not further transmit the disease

Several weeks after Group A Strep (pharyngitis, Impetigo), Gross hematuria (tea or cola colored urine), Edema (periorbital), HTN

Acute Poststrep Glomerulonephritis Nephritic Syndrome (Renal failure, HTN, Hematuria, RBC casts) 2-4 weeks after infection Urinalysis: + protein, + blood, +/- RBC casts, HIGH Creatinine, LOW C3, LOW CH50, Positive Streptozyme test: Antistreptolysin ), Anti-DNAse B, Antihyaluronidase, Anti-Nicotinamide adenine Dinucleotides, Antistreptokinase management: Supportive care, volume overload with loop diuretics, treat HTN, Hemodialysis if refractory. Children recover in a few weeks, adults more likely to develop CKD -> End Stage Renal Dz

Elevated Serum Potassium

Acute Renal Failure, NSAID, Lisinopril Peaked T waves, prolongation of PR interval and QRS, Disappearance of P waves, and eventual sine wave. Bradycardia. Tx: IV CALCIUM GLUCONATE (short acting) then need to lower potassium by Glucose and Insulin combo to drive potassium intracellularly.

Urgent Coronary Revascularization indicated for

Acute ST elevation MI (STEMI): ST Elevation in leads I and aVL with reciprocal ST depression in II, III, aVF -New ST elevation at J point (Point where QRS meets ST segment) >2 anatomic contiguous leads (>1mm in all leads except V2,V3), > 1.5mm in F, >2mm in M >40, >2.5mm Men <40 in V2, V3 -New Left bundle branch block with clinical presentation consistent with acute coronary syndrome Optimal therapy is with percutaneous coronary intervention (PCI) within 90 minutes of first medical contact or within 120 minutes for patients who require rapid transfer to PCI capable facility. If PCI not possible then Fibrinolytic therapy (tenecteplase, Alteplase, Reteplase) indicated within 30 minutes of hospital arrival.

BUN/Cr <20. FeNa > 2%. Urine osmolarity < 350 mOsm/kg. UA shows muddy/granular casts

Acute Tubular Necrosis AKI +/- RBCs/protein in ATN. +/- eosinophils if AIN from antibiotics. Supportive care, tx underlying cause, remove offending agent

fever, dysuria, leukocytosis, lower abdominal pain, pyuria and bacteriuria on urinalysis, tender swollen prostate

Acute bacterial prostatitis complication of acute urinary retention due to urethral impingement from prostate swelling. Inability to void, suprapubic full/discomfort, renal insufficiency, Bladder scan with >300ml residual volume. Tx: Urgent bladder decompression with suprapubic catheterization & Empiric Abx (TMP-SMX, Ciprofloxacin)

mucopurulent discharge, postcoital/intermenstrual bleeding, friable cervix

Acute cervicitis Chlamydia, Gonorrhoeae Nucelic Acid Amplification testing, Wet mount microscopy Tx: EMPIRIC TX CEFTRIAXONE + DOXYCYCLINE DO NOT WAITY FOR CULTURE ALSO TREAT PARTNER And both patient and partner need to abstain from sex for a week after completion of treatment.

Treatment for Herpes in pregnancy

Acyclovir is safe in pregnancy. Use acyclovir in pregnancy if there is evidence of active lesions at 36 weeks.

Antiviral agents for herpes simplex, varicella zoster

Acyclovir, valacyclovir, and famciclovir

Type 1 diabetic with weight loss, fatigued, eosinophilia, low sodium, hyperkalemia, pre renal azotemia, low blood glucose, decreased insulin requirements

Adrenal failure Dx: Cosyntropin Stimulation Test

HTN associated with episodic Headaches, flushing, sweating, tachycardia

Adrenal medullary tumor = pheochromocytoma secretes catecholamines

Risk of Nondisjunction resulting in Trisomy 21 or Klinefelter syndrome (XXY) increases with

Advanced Maternal Age

amniotic fluid embolism (acute onset Hypoxemia, Hypotension, DIC (hematuria, hemorrhage) during labor or immediate post partum

Advanced maternal age, >5 live or still births, C section or instrumental delivery, placenta previa or abruption, preeclampsia Amniotic fluid enters maternal circulation through endocervical veins, the placental implantation site or areas of uterine trauma (cesarean incision site). The amniotic fluid triggers a massive anaphylactoid reaction resulting in vasospasm, obstructive shock, pulmonary edema, respiratory failure, seizures and DIC. Shock, Hypoxemia respiratory failure, DIC, Coma or seizure Tx: Respiratory and hemodynamic support, +/- Transfusion

Autosomal Recessive

Affects about 25% of all children with 2 carrier parents Offspring of a single affected parent are carriers for but do not have the disorder, disease skips generations.

Risk of Reactive Arthritis

After chlamydia infection 4-8% however 20% if HLA-B27 + Defective antigen presentation through class I HLA molecules ONLY 30-50% of patients with reactive arthritis are HLA-B27 +

adolescent pregnancy

Age <19 Maternal Complications: Hydatidiform mole, Preeclampsia, Anemia, Operative Vaginal Delivery, Postpartum Depression Fetal Complications: Gastroschisis, Omphalocele, Preterm Birth, Low Birth Weight, Perinatal Death

A man is admitted for pneumonia from a nursing home. He is placed on piperacillin-tazobactam, and he becomes afebrile. Two days later, his BUN and creatinine start to rise. He develops a new fever and a rash. What is the most likely diagnosis, and what is the most accurate diagnostic test?

Allergic interstitial nephritis is a hypersensitivity reaction to medications such as penicillin or sulfa drugs. Other common culprits are phenytoin, allopurinol, cyclosporine, quinidine, quinolones, or rifampin. The clue to diagnosis is the fever and rash. The best initial test is urinalysis (UA) that shows white cells. However, the UA is not capable of distinguishing between neutrophils and eosinophils. The most accurate test is a Wright stain or Hansel stain of the urine that will show eosinophils. This is more sensitive than either the blood eosinophil level or elevated IgE level. There is no specific therapy generally given for allergic interstitial nephritis; it resolves on its own.

Subjects not randomly assigned to the treatment group

Allocation bias DIFFERENT from selection bias because which occurs when studied sample does not represent the target population

well-demarcated, round, non scattered patches of complete hair loss. (tapered hair near the insertion into the scalp especially at the periphery of the plaque. Nail pitting.

Alopecia Areata at risk for other autoimmune diseases: Thyroid, Vitiligo, Pernicious Anemia

LOW MCV, NORM RDW, TARGET CELLS, NORMAL-HIGH IRON & FERRITIN

Alpha Vs Beta Thalassemia Mild microcytic, hypo chromic anemia with LOW MCV & MCH, Elevated Ferritin due to inc RBC turnover Mediterranean, Middle Eastern, Southeast Asia, African, Indian Alpha has normal electrophoresis, Beta has elevated Hgb A2

Stratified Analysis

Analyzing subjects based on the presence or absence of a certain variable Used to control confounding factors.

Infant or child with coughing, choking, tachypnea, wheezing, Hypotension, syncope, spitting up, vomiting, crampy abdominal pain, hypotonia, lethargy, crying spells, angioedema, flushing, urticaria, pruritis

Anaphylaxis severe type 1 hypersensitivity diagnosed when acute allergic symptoms are present >2 systems. Tx: IM Epinephrine (0.01 mg/kg), early airway management for upper airway edema, volume resuscitation for hypotension, antihistamines, B2 adrenergic agonists and glucocorticoids Children with anaphylaxis should be discharged with an epinephrine autoinjector

Primary amenorrhea (absence of menarche by 15), Normal breast development. NO pubic or axillary hair.

Androgen Insensitivity Syndrome Phenotypical Female with a Male 46XY Genotype X-Linked Recessive Mutation of Androgen receptor gene, makes peripheral tissue unresponsive to androgens despite normal concentrations produced by intact testes. Free testosterone is aromatized to estrogen, resulting in breast development. Cryptorchid testes often reside in inguinal canal or abdomen as testicular descent is an androgen dependent process. Uterus and Fallopian tubes are absent and vagina ends with a blind pouch. Dx: Pelvic US, Karyotype, testosterone levels

Young patient with back pain with morning stiffness which improves throughout the day or with exercise, reduced range of forward flexion of the lumbar spine and reduced chest expansion

Ankylosing Spondylitis - HLA-B 27 positive Xray of the Sacroiliac Joint - Must have sacroiliitis earliest change seen on X-ray to diagnose (other findings; Erosion of the ischial tuberosity and iliac crest) Aerobic exercise (swimming, Walking, Bicycling) improve joint stability, muscle strength. Monitoring Dz: Xray after 3 months if MILD DZ 1. Anteroposterior and lateral views of lumbar spine 2. Lateral view of cervical spine 3. Pelvic radiograph RESTRICTIVE LUNG DZ due to limited costovertebral joint motion and development of apical pulmonary fibrosis. COUNSEL on smoking cessation. Acute anterior Uveitis, cataracts, cystoid macula edema (acute onset unilateral eye pain, photophobia, blurring of vision) Aortic Regurgitation and Mitral Valve Prolapse, Varicocele, Ileal and colonic mucosal ulceration, Atlanto-axial subluxation causing spinal cord compression, caudal equine syndrome, IgA nephropathy, secondary amyloidosis.

pityriasis Rosea

Annular pink herald patch on trunk, Christmas tree pattern, Pruritis Common in adolescent and young adults. Begins with solitary herald patch annular erythematous scaly lesion on neck or trunk and as it increases in size and fades centrally, m multiple smaller oval lesions appear in clusters in a Christmas Tree pattern on the back. Spares the face, palms, and soles. Rapid Plasma Reagin Test indicated in sexually active patients to exclude syphillis, involves palms nd soles but mimics rosea. NO TX NECESSARY FOR ROSEA because rash resolves spontaneously over several weeks to months.

Anovulatory Uterine bleeding in menopausal transition

Anovulatory bleeding due to Oocyte depletion and abnormal follicular development and Failure of ovary to secrete progesterone. However endometrium may continue to proliferate due to unopposed estrogen secretion and progress into endometrial hyperplasia or cancer. Median age 51yo, dx made after >1 year of amenorrhea. Most women experience symptoms of menopause (hot flashes, irregular menses, sleeping difficulties) over several years prior to cessation of menses. periods of amenorrhea followed by irregular unpredictable bleeding Menopause dx is clinical and FSH level NOT required Endometrial biopsy for: ->45yo with anovulatory bleeding -<45 yo with risk factors for unopposed estrogen (obesity, PCOS), or persistent abnomnral bleeding Tx: Cyclic progestin therapy, low dose OCP, Levonorgestrel intrauterine device, Cyclic hormonal therapy

Clozapine

Anripsychotic for treatment of refractory schizophrenia and schizoaffective disorder. SE: Neutropenia/Agranulocytosis. MUST monitor the absolute neutrophil count. Weight gain, metabolic syndrome, seizures, PE, myocarditis, excess salivation, constipation, ileus.

pain, redness, variable visual loss, constricted and irregular pupil. Leukocytes on in anterior segment seen with slit lamp.

Anterior Uveitis (Iritis) May also see a hazy "flare" indicative of protein accumulation secondary to a damaged blood aqueous barrier. Tx: Antimicrobial therapy for viral or bacterial causes and topical corticosteroids for non infectious causes.

Localize the lesion. Profound lower extremity weakness (contralateral in the case of unilateral arterial occlusion). Mild upper extremity weakness (contralateral in the case of unilateral arterial occlusion). Personality changes or psychiatric disturbance. Urinary incontinence

Anterior cerebral artery

Doxorubicin

Anthrcycline MOA: topoisomerase II inhib→double strand breaks + DNA intercalation, also releases free O2 radicals→single strand breaks side effects: CARDIOTOX (from free O2 radicals)→acute arrythmias + myocarditis

Amiodarone Induced Pulmonary Toxicity

Antiarrhythmic drug for treatment of Ventricular and Supraventircular tachyarrhythmias Prolonged treatment with amiodarone result in photosensitivity, skin discoloration, bone marrow suppression, thyroid dysfunction, abnormal liver function tests, and pulmonary toxicity Death related to amiodarone use is due to pulmonary toxicity Chronic interstitial pneumonitis, organizing pneumonia, acute respiratory distress syndrome have non productive cough, fever, pleuritic chest pain, weight loss, dyspnea on exertion and focal or diffuse interstitial opacity on CXR Cumulative dose effect and serum amiodarone levels are usually within normal range. DC AMIODARONE AND GIVE CORTICOSTerOIDS

Rifaximine

Antibiotic used to treat small intestine bacterial overgrowth. Malabsorption syndrome due to anatomic (surgically created blind loops) our motility (diabetes, sclerosis) disorders that presents with abdominal bloating, flatulence and diarrhea. Also used to avoid recurrence of hepatic encephalopathy and treat C diff.

Dry skin and mucosal surfaces, dilated pupils seen in overdose of

Anticholinergic agents TCAs, Datura Stramonium Plant, Mushrooms

TCAs second line treatment due to side effect of

Anticholinergic, orthostasis, cardiotoxicity

Pyridostigmine

Anticholinesterase used to tx myasthenia gravis

contraindicated in acute mania

Antidepressants because they can worsen the the manic symptoms

Aspirin is indicated as prophylaxis for thrombosis in patient with recurrent pregnancy loss

Antiphospholipid Syndrome

Oseltamivir, zanamivir, and peramivir

Antiviral: inhibits viral neuraminidase *influenza A & B* - give within first 2 days of sx Side fx: GI, cough/bronchospasm, skin

cardiac syncope

Aortic Stenosis or HCM: Exertional Syncope, systolic murmur on examination Ventricular Tachycardia: No preceding symptoms, Cardiomyopathy or previous MI (Scarring evidenced by Q waves on ECG, and wall motion abnormalities on Echo), lasts 1-2 min then recovery with no residual symptoms Sick Sinus Syndrome: preceding fatigue or dizzy, Sinus pauses on ECG Advanced AV Block: Bifascicular block or increase PR interval on ECG, Dropped QRS complexes on ECG Torsades De Pointes: No preceding symptoms, meds that prolong QT interval, Hypokalemia or Hypomagnesemia

oropharyngeal lesions in children

Aphthous Stomatitis (Canker Sore): Recurrent Ulcers on Anterior oral mucosa (lips, cheeks, mouth floor, venture of tongue), no fever, no systemic symptoms Herpangina (Coxsackie Group A): Veiscles & ulcers on POSTERIOR pharynx, fever. HAND WASHING to prevent spread. Herpes Gingivostomatitis: Vesicles & Ulcers on ANTERIOR oral mucosa and around mouth, fever Group A Strep Pharyngitis: Tonsillar exudates, fever, anterior Cervical LAD Infectious Mono: Tonsillar exudates, fever, diffuse cervical LAD, +/- Hepatosplenomegaly

Acute Severe Anemia in Sickle Cell Disease

Aplastic Crisis: LOW Retic Count: Transient arrest of erythropoiesis, secondary to infection (Parvo B19) Splenic Sequestration Crisis: HIGH Retic Count: Splenic Vasoocclusion -> Rapidly enlarging spleen, Children prior to autosplenectomy Sickle cell disease patients compensate for the chronic anemia with increased erythropoiesis and elevated reticulocyte count.

Selection Bias

Ascertainment: study population differs from a target population due to nonrandom selection methods Nonresponse: High nonresponse rate to surveys/questionaiires can cause errors if non responders differ from responders Berkson: disease studied using only hospital based patients may lead to results not applicable to target population Prevalence (Neyman): Exposures that happen long before disease assessment can cause study to miss diseased patients that die early or recover Attrition: significant loss of study participants may cause bias if those lost to follow up differ significantly from remaining subjects

Asymptomatic bacteriuria

Asymptomatic bacteriuria is treated in pregnancy to prevent progression to pyelonephritis with nitrofurantoin.

Chlamydia & Gonorrhea screening in Sexual active Women <25 &/or >25 with High risk sexual behavior

Asymptomatic most common Cervicitis Urethritis Perihepatitis (Fitz-Hugh-Curtis Syndrome) Dx: Nucleic Acid Amplification Testing Empiric Tx: Ceftriaxone + Doxycycline (AZITHROMYCIN INSTEAD IF PREGNANT) Confirmed Chlamydia: Doxy + Ceftriaxone Confirmed Gonorrhea: Ceftriaxone Complications: PID, Ectopic Pregnancy, Infertility, Pharyngitis

Bone density screening

At age 65 in women without risk factors. Postmenopausal women <65 if risk factors such as body weight <58kg, chronic steroid use, smoking, malabsorption disorders (pancreatic insufficiency in CF), hip or low impact fractures.

DVT secondary to reversible or time limited risk factors (Surgery, Pregnancy, OCP, trauma) should be treated for

At least 3 months but no longer than 6 months. Risk of recurrent DVT after 6 months is really low. No further tx after 6 months of successful warfarin tx and without symptoms.

Treatment of lead toxicity

At risk < 5 should repeat testing in 1 year Mild: 5-44: No meds: repeat venous blood level within 1 month Mod: 45-69: Meso-2,3-dimercaptosuccinic acid (DMSA, Succimer), lead lines on xray Severe:>70: Dimercaprol + Calcium disodium Edetate (EDTA) A child with an elevated capillary (finger stick) lead level requires confirmatory venous sampling

intense abdominal pain after eating (intestinal angina) and unintentional weight loss from food aversion.

Atherosclerotic narrowing of the mesenteric vasculature.

acute pruritic erythematous patches and papules (extensor surfaces, trunk, face, flexural creases)

Atopic Dermatitis FH of atopy (eczema, asthma, allergic rhinitis) Mutation in FILAGGRIN GENE Tx: Topical Emollients, First line = Topical Corticosteroids, Second Line = Topical Calcineurin Inhibitors (Pimecrolimus) complications secondary infection with impetigo (staph aureus) and eczema herpeticum (HSV) Chronic With intermittent flares in early childhood and resolves by adulthood

Chronic pruritic rash with excoriations and lichenification

Atopic Dermatitis Mutation in epidermal barrier proteins (Filaggrin) leads to DEC water content, HIGH permeability, HIGH inflammation Immune dysfunction (Th2 skewed response) Associated with Allergic rhinitis, asthma, and food allergy HIGH IgE and Eosinophilia Tx: AVOID Hot or dry environments and harsh soaps and detergents, oral antihistamines are useful, regular use of emollients to maintain skin hydration can relieve pruritis TOPICAL GLUCOCROTICOIDS (hydrocortisone=low potency, Triamcinolone or Betamethasone=mod to high potency) For face, eyelid or flexural areas consider CALCINEURIN INHIBITORS (TACROLIMUS) SEVERE FORM OF DISEASE MAY REQUIRE UV PHOTOTHERAPY OR SYSTEMIC IMMUNOSUPPRESANTS

Narrow QRS Tachycardia, Absence of organized P waves, Irregularly Irregular Rhythm, varying R-R intervals

Atrial Fibrillation First step in management is rate control with BETA BLOCKER (Metoprolol, Atenolol) or Nondihydropyridine Calcium Channel Blockers (Diltiazem, Verapamil)

mid-systolic ejection murmur and wide and fixed splitting of second heart sound.

Atrial Septal Defect and moderate to large left to right shunt

Displaced point of maximal impulse (LVH), Bilateral flank pain/fullness. HTN. Hematuria, proteinuria, flank pain.

Autosomal Dominant Polycystic Kidney Dz Screen with renal US. Presence of enlarged kidneys with multiple bilateral cyst is diagnostic. Extrarenal features: cerebral aneurysm, hepatic & pancreatic cysts, MVP, Aortic regurgitation, Colonic diverticulosis, ventral/inguinal hernia. Management: Rigorous BP control with ACE-I, Hemodialysis, Renal transplant for ESRD >18yo with + FHshould be screened with renal US. Autosomal dominant so offspring of single affected parent have a 50% chance of getting dz, if both parents affected then 75% chance.

Marfan syndrome

Autosomal Dominant mutation in FBN1 gene encoding the protein Fibrillin-1 Tall, increased arm span to heigh ratio, myopia MAIN CAUSE OF MORBIDITY AND MORTALITY = AORTIC ROOT DISEASE (aneurysmal dilation, aortic regurgitation, dissection) NEED AN ECHO prior to sports participation.

Colon Cancer Screening

Average Risk: START age 45 yo: -Colonoscopy every 10 years -gFOBT (Guaiac fecal occult blood test) or FIT (Fecal Immunochemical test) every year -FIT-DNA (stool DNA test) every 1-3 years -CT Colonography every 5 years -Flexible Sigmoidoscopy very 5 years or event 10 years with annual FIT Patients with First Degree Relatives with Colorectal Cancer or High risk adenomatous polyp: -Colonoscopy at age 40 or 10 years prior to diagnosis in first degree relative whichever comes first -Repeat every 5 years (every 10 years if first degree relative diagnosed >60yo) Patients with Ulcerative Colitis: -Screen 8-10 years after diagnosis -Colonoscopy every 1-3 years

Menopausal Transitioin

Average age 51, occurs over years. Menstrual bleeding gradually decreases, however cycles can become unpredictable, inter menstrual intervals typically lengthen.

to prevent neural tube defect

Average risk: 0.4mg Folic Acid Daily High risk: 4mg Folic Acid Daily (Antiepileptic use, prior pregnancy with NTD) >1 month prior to conception If on low carb diet may not be getting enough fortified food to meet minimum daily folate requirements.

Insulin therapy for DM2

Basal Insulin (intended to work continuously throughout the day) added first and safe to use with other antidiabtic meds. NPH & Long-Acting insulin analogs (deter, Glargine, Degludec) effective in lowering A1c. HOWEVER, NPH is associated with higher risk of HYPOGLYCEMIA compared with long acting insulin analogs Good glycemic control regardless of type of therapy decrease risk of microvascular complications (retinopathy, neuropathy, neuropathy) there is NO conclusive evidence that glycemic control with insulin reduces risk of microvascular events (MI, stroke) or all cause mortality.

adrenal insufficiency workup

Baseline ACTH levels and ACTH Stimulation Test 1. Subnormal Cortisol Response: -HIGH ACTH - Primary Adrenal Insufficiency -LOW ACTH - Central Adrenal Insufficiency 2. Normal Cortisol Response: -High clinical suspicion of central adrenal insufficiency - Metyraspone or insulin hypoglycemia test -Low clinical suspicion - Adrenal insufficiency ruled out

Like histrionic where they have attention seeking, manipulative behavior and rapidly shifting emotions they also have suicidal behavior, intense anger, chronic feeling of emptiness

Borderline Personality Disorder

Constitutional delay of puberty

Boys, short, delayed bone age, FH of late onset puberty diagnosis of exclusion in girls

palpable breast mass in a 30-50 yo smooth mobile well circumscribed without malignant features (LAD, nipple Discharge)

Breast Cyst Mammogram to evaluate. Simple breast cyst with smooth border, thin wall and no separations or solid components are benign A Fine needle aspiration should be done to relieve pain if symptomatic. If fluid is bloody and mass persistent than increased risk of breast cancer then need core needle biopsy but if non bloody such as clear, green straw colored etc and both mass and symptoms resolve then low risk for cancer and require no additional management. If it was an abscess or cellulitis then would have fever, erythema, induration, fluctuant then place on abx.

jaundice in forst 3-5 days of life peaks about age 2 weeks in breast fed infant

Breast Milk Jaundice Unconjugated hyperbilirubinemia in excessively breast fed infant. High beta-glucuronidase activity in breast milk that deconjugates intestinal bilirubin and allows for increased intestinal absorption and enterohepatic circulation of bile. Management: CONTINUE BREASTFEEDING EXCLUSIVELY spontaneous resolution by 3 months.

first sign of puberty in girls

Breast development If >12yo with short stature and no breast development = Constitutional delay of puberty, characterized by a delayed bone age. Therefore need Bone age test.

First week of life. Jaundice. High serum bilirubin.

Breastfeeding failure jaundice Lactation failure from inadequate milk supply, poor latch, infrequent feeding.

delusions, hallucinations, disorganized speech or behavior <1 month

Brief Psychotic Disorder

SE of Valproic Acid (Depakote)

Broad spec anti seizure med THROMBOCYTOPENIA (CBC with platelets obtained and followed) HEPATOTOXICITY & PANCREATITIS (liver enzymes, and lipase should be monitored) TERATOGEN (neural tube defects)

Tx for parkinsonian symptoms in Parkinson Disease or dementia with Lewy bodies

Bromocriptine (DOPAMINE AGONIST)

Digital Clubbing

Bronchiectasis Pulmonary neoplasms Cyanotic congenital heart disorders: TETRALOGY OF FALLOT: RV outflow tract obstruction, Overriding Aorta, RV Hypertrophy, VSD

Infant in the winter with nasal congestion, rhinorrhea, coarse breath sounds, wheezing, +/- crackles, Fever, increased work of breathing with accessory muscle use (retractions), nasal flaring and grunting.

Bronchiolitis due to Respiratory Syncytial Virus (RSV) <2yo DX CLINICALLY Upper respiratory prodrome of rhinorrhea, nasal congestion and cough followed by 2-3 days later by lower airway signs of wheezing and increased work of breathing. Symptoms peak around day 3-5 of illness. If <2 moths of age then greatest risk of apnea and respiratory failure. Older, full term or healthy infants and young toddlers recover with NO complications. However recurrent wheezing is seen in 30% of patients. AVOID other triggers of airway reactivity, particularly exposure to secondhand cigarette smoke. Hospitalize on contact and droplet precautions. Supportive care with IVF, nasal bulb suctioning and humidify oxygen Palivizumab for <29 weeks gestation, chronic lung disease of prematurity, hemodynamically significant congenital heart disease RIBAVIRIN ONLY FOR IMMUNOCOMPROMISED with SEVERE DZ (VERY EXPENSIVE)

abnormal flow of urine from bladder back into utter dying bladder contraction causing recurrent UTIs

Vesicoureteral reflux

Thick, cottage cheese discharge, vaginal inflammation, Normal pH (3.8-5.5)

Candida Vaginitis Tx: Fluconazole

Treat superficial fungal dermatoses (tines corporis)

CLOTRIMAZOLE

demyelinating plaque (multiple sclerosis) in midbrain can impact

CN III-oclumotor CN IV-Trochlear If demyelinating plaque in the pons then CN V-Trigeminal can cause trigeminal neuralgia

Clinical features and management of TCA overdose

CNS: Mental status change (drowsy, delirium, coma), seizures, respiratory depression CV: sinus tachycardia, hypotension, prolonged PR/QRS/QT, Arrhythmias (V-tach, fibrillation) Anticholinergic: Dry mouth, blurred vision, dilated pupils, urinary retention, flushing, hyperthermia Tx: Oxygen, intubate, IVF, activated charcoal for within 2 hrs of ingestion, IV sodium bicarb for QRS interval widening or Ventricular Arrhythmia TCA inhibits fast sodium channels in his purkinje tissue and the myocardium to decrease conduction speed, increase phase 0 depolarization and prolong refractory period. This can prolong QRS interval (>100msec) and cause arrhythmias (V tach, V fib). TCAs can also decrease calcium influx into myocardium and increase peripheral vasodilation causing hypotension. Can also cause acidemia which can increase serum potassium due to cellular exchange of hydrogen and potassium. MANAGE TCA INDUCED CARDIOTOXIC EFFECT WITH SODIUM BICARB (increases serum pH and extracellular sodium)The increased pH modifies TCAs to their neutral form, making them less available to bind to rapid Na channels. elevated extracellular sodium increases the electrochemical gradient across cardiac cells affect TCA ability to bind fast sodium channels. Can use Magnesium or lidocaine if refractory to sodium bicarb.

Capillary testing of lead levels in children

CONFIRM with venous Lead Level due to risk of contamination of capillary samples. If asymptomatic, mild intoxication (<45) require counseling CHELATION THERAPY (succimer) only when lead level >45 Peripheral blood smear shows Basophilic Stippling (blue cytoplasmic granules within RBCs) Because lead is stored in bone Xray may reveal an increased opacity at growth plates (Lead Lines)

Greatest risk for post pulmonary complications

COPD Cigarette Smoking Sleep Apnea HF Prior to undergoing an elective procedure these conditions should be optimized. Smoking cessation (>4weeks) treatment of any HF or COPD exacerbation.

Reduced FEV1/FVC Ratio, Reduced DLCO

COPD DLCO is also reduced differentiates from Asthma de to emphysematous destruction of the alveolar-pulmonary capillary membrane.

Calcium and Vitamin D for F>50

Calcium: 1200mg (Milk, yogurt, dark green leafy vegetables) Vit D: 600-800 IU (Fortified milk, fatty fish, sunlight) To prevent osteoporosis from menopause is to have good nutrition and exercise. Calcium and VitD Is essential.

Complete rupture of Achilles tendon confirmed by

Calf Squeeze Test: Thompson Test: Normally when squeeze the calf, shortens the gastrocnemius and passively plantar flex. Active plantar flexion is still present its the passive when squeezing the calf that is abnormal.

External Cephalic Version (ECV)

Can cause non reassuring fetal heart rate abnormalities (Abruptio placentae) that necessitates immediate C-Section. If delayed >37 weeks allows time for spontaneous version, and eliminates possible iatrogenic preterm birth. Contraindication to ECV: Active herpes, Placenta Previa, Multifetal gestation, Fetal growth restriction. FOOTLING BREECH PRESENTATION ABSOLUTE CONTRAINIDCATION TO VAGINAL DELIVERY

BPPV (benign paroxysmal positional vertigo)

Canalithiasis, presence of crystalline debris (canaliths) in semicircular canals. disrupt normal flow of fluid in the semicircular canals leading to contradictory signaling from canals Dix-Hallpike Maneuver can help diagnose see vertigo and nystagmus as patient quickly lies back into supine position with head rotated 45 degress tx: Canalith repositioning maneuvers (epley)

Unilateral vision loss, eye pain, funduscopic evidence of vitreous haze and off-white chorioretinal lesions. Hospitalized patients who have an indwelling central catheter. GI surgery/perforation, Immunocompromised and or TPN.

Candida Endophthalmitis Fluffy.yellow white chorioretinal lesions with indistinct borders. Spread to the vitreous c chamber marked by a haze or floating white fungal balls. Tx: Fluconazole or Voriconazole

MOST reliable method for verification of proper endotracheal tube placement

Capnography (Measurement of CO2 concentration over time) Normal: Rectangular wave form with 4 phases, if flat = improper placement Colorimetric EtCO2 detector consists of litmus paper that changes color when exposed to CO2. CO2 exhalation from an ETT properly placed in the trachea will lead to a color change from purple to yellow, but if improperly placed results in no color change.

Headache, nausea and lightheadedness while in a home with older appliances

Carbon Monoxide poisoning CO birds heme with greater affinity than oxygen and interferes with oxygen offloading at the tissue level. Mild: Flu like symptoms (headache, malaise, nausea, dizzy) Severe: seizure, syncope, coma, MI ABG -> HIGH Carboxyhemoglobin (pulse ox cant differentiate difference between carboxy and oxyhemoglobin) Tx: HIGH flow oxygen through nonrebreather face mask (severer cases need hyperbaric oxygen)

Smoke inhalation, headaches, confusion, malaise, dizzy, nausea, seizures, syncope, coma, MI, arrhythmias

Carbon Monoxide poisoning CO binds heme much greater than oxygen, forming carboxyhemoglobin. Pulse Ox normal because cant differentiate between carboxyhemoglobin from oxyhemoglobin. ABG: Carboxyhemoglobin Level ECG +/- Cardiac Enzymes Tx: HIGH flow 100% Oxygen, Intubation/Hyperbaric Oxygen (severe)

Hypotension and neck vein distention

Cardiac Tamponade

Hypotension, JVD, Distant heart sounds, SBP decrease >10mmHg during inspiration

Cardiac Tamponade Blood in pericardial space-increased hydrostatic pressure in pericardial space, impaired diastolic filling of the right heart (LV rupture, Cardiac Surgery) Pericardial Effusion (malignancy, infection, Uremia) ECG: Low Voltage QRS complex, Electrical Alternans CXR: Enlarged Cardiac Silhouette, Clear lungs Echo: MOST SPECIFIC FINDING OF TAMPONADE = Right Atrial & Ventricular Collapse, IVC Plethora Pulsus Paradoxus is an exaggerated drop in systolic BP due to bowing of the right ventricle into the left ventricle during inspiration. (Seen also in severe asthma, or COPD, constrictive pericarditis, obesity) TX: IVF to increase right sided preload, Drainage via pericardiocentesis or pericardial window

Cardiac Death vs. Brain Death

Cardiac: -Irreversible electrical & mechanical asystole (circulatory arrest) -Apnea -Confirmed by observation period (5 min) off life support Brain: -absence of brainstem reflexes -apnea requires formal testing to rule out residual brainstem function

Stroke in a young adult

Cardiac: patent Foramen Ovale, Congenital Heart Dz, Arrhythmia Hematologic: Heparin-Induced Thrombocytopenia, Inherited or acquired hyper coagulable state, Sickle Cell Disease Infectious: Endocarditis, VZV, Syphillis (Meningovascular), Bacterial meningitis, TB meningitis, cryptococcus, coccidiomycosis, Histoplasmosis Other: Inflammatory Arteritis (Takayasu Arteritis), Cocaine, Amphetamine, Cerebral Artery Dissection

Nonselective beta blocker

Carvedilol -Beta 2 blocking can exacerbate asthma symptoms -Beta 1 blocking can cause vasodilation which worsens HCM

patients in a study were initially selected based on their disease status, and then categorized based on past exposure to a risk factor.

Case Control design The Odds Ratio is a measure of association used in case control studies to compare odds of exposure in cases relative to controls OR = Odds of exposure in cases/ Odds of exposure in controls = (a/c)/(b/d)

2 groups of individuals are identified as cases or controls according to an outcome and then assessed on their past exposure to risk factors

Case-Control

selecting patients with a particular disease (cases) and patients without the disease (controls) and then determine their exposure status

Case-Control Study

Hx of schizophrenia, Mutism, Resistance to instruction and movement, Assuming positions against gravity, mimicking speech and movements.

Catatonia occurs in ill patients with psychotic disorders Tx: Benzodiazepines (Lorazepam), Elctroconvulsive therapy

severe low back pain, urinary or bowel incontinence, motor weakness or sensory loss in legs bilaterally and saddle anesthesia

Cauda Equina Syndrome

Low sodium, Borderline low TSH, Low Free T4, borderline low cortisol and glucose

Central Hypothyroid and concomitant Central Adrenal Insufficiency Measure baseline ACTH levels and short ACTH stimulation test to assess adrenal reserve. A low ACTH and subnormal response to ACTH confirms central adrenal insufficiency Levothyroxine tx for hypothyroid in patients with uncorrected adrenal insufficiency may trigger ADRENAL CRISIS by increasing metabolic demand and clearance of glucocorticoids.

>60yo, painless acute vision loss in 1 eye, complete or relative afferent pupillary defect, retinal whitening/cherry red spot in macula on funduscopy

Central Retinal Artery Occlusion Carotid artery atherosclerosis (Most common)-Central retinal artery is branch of ophthalmic artery which comes from internal carotid. , Cardiogenic embolism, small artery disease due to DM or HTN, Carotid artery dissection, Sickle cell or hypercoagulability, Vasculitis (giant cell arteritis) cherry red spot at macula due to preserved circulation via post ciliary arteries. Exclude giant cell arteritis with ESR, and CRP, carotid artery imaging, and cardiac eval Tx: Urgent ophthalmology consult, Ocular massage to lower the intraocular pressure, Possible intra-arterial thrombolytics, Risk factor modification for atherosclerosis. CAN HAVE IRREVRSIBLE RETINAL DAMAGE IN 90-100min.

Postexposure Prophylaxis for Sexual Assault

Chlamydia: Doxycycline Gonorrhea: Ceftriaxone Trichomonas Vaginalis: Metronidazole HIV: Tenofovir-Emtricitabine with Raltegravir Hep B: Hep B Vaccine +/- Hep B Immunoglobulin They should receive all expect for Hep B vaccine as it depends on vaccination status

Acute painless vision loss

Central Retinal Artery Occlusion: Severe vision loss with temporal sparing, Hx of Amaurosis Fugax. Pale fungus with CHERRY RED SPOT. INTRAARTERIAL THROMBOLYTICS, OCULAR MASSAGE, REDUCTION OF INTRAOCULAR PRESSURE (ANTERIO CHAMBER PARACENTESIS) -MOST COMMON CAUSE = Carotid Artery Atherosclerosis, cariogenic embolism, clotting disorders, carotid artery dissection, vasculitis (giant cell) Central Retinal Vein Occlusion: Blurred vision to severe vision loss. fungus with retinal hemorrhages & optic disc edema (blood & thunder), observation +/- intravitreal injection of VEGF inhibitors Retinal Detachment: floaters, photopsia (flashing lights)Fundus wirh vitreous hemorrhage and marked elevation of retina. Surgical correction (retinopexy, vitrectomy) Vitreous Hemorrhage: hazy vision +/- red hue or vision loss, floaters/shadows. Dec or absent red reflex. RBC/Floating debris in vitreous, obscured view of fungus. Bed rest HOB elevation 30-45 degrees. photocoagulation or virectomy

Painless (no uterine contractions) cervical dilation, pelvic pressure when gestation distends the vagina, increase in vaginal discharge due to loss of mucus plug or with light vaginal bleeding. bulging or proposing amniotic membranes can be present.

Cervical Insufficiency risk: Collagen abnormalities (ehlers-Danlos Syndrome), Uterine Anomalies (septate or bicornuate uterus), obstetric trauma, surgical trauma (cold knife cone) Management: CERCLAGE (can also be done prophylactically with patient who has a hx at 12-14 weeks gestation) PROLAPSING AMNIOTIC MEMBRANES are a predictor for IMMINENT DELIVERY and indicate POOR PROGNOSIS prolapse of membranes into vagina causes prolonged exposure to vaginal flora and a high risk for intraamniotic infection (chorioamnionitis), preterm membrane rupture, abruption placentae, pre viable or preterm delivery, and maternal mortality. prolapsed membranes increase complications to corkage placement due to risk of membrane rupture.

Thickened injected conjunctiva, watery or mucopurulent discharge, eyelid swelling, 5-14 days old

Chlamydial Conjunctivitis -> leads to chlamydial pneumonia if not treated (staccato cough and rales) Direct contact with maternal genital secretions during delivery Tx: Oral Macrolide (AZITHROMYCIN or ERYTHROMYCIN) Tx prenatally with macrolide

Abdominal pain, fever, leukocytosis, common bile duct obstruction on US, elevated bili and alk phosphatase levels

Choledocholithiasis dx: Endoscopic Retrograde Cholangiopancreatography

livedo reticularis, low C3 and C4, and increased eosinophils.

Cholesterol embolism

Pharma therapy for Dementia with Lewy bodies

Cholinesterase Inhibitor (Donepezil): Cognitive Impairment-> Cause diarrhea, vomiting, bradycardia Carbidopa-Levodopa: Parkinsonism REM Sleep Behavior Disorder: Melatonin Visual Hallucinations, Delusions: Antipsychotics (Risperidone-Dopamine Receptor Antagonist (POTENT)) and AVOID HALOPERIDOL first gen-> Worsening of confusion, Parkinsonism, Autonomic Dysfunction-> Instead use second gen (Quetiapine)

Indicated for mild to moderate dementia

Cholinesterase inhibitors (Donepezil, Rivastigmine)

Recurrent pregnancy loss > 3 spont abortions

Chromosomal abnormalities Klinefelter 47 XXY MOST COMMON chromosomal cause of male infertility, Gynecomastia, cryptorchidism, long legs, sparse facial/body hair, intellectual disability

bacterial prostatitis

Chronic = >3 months of urinary tract symptoms (frequency, dysuria, urgency) and or pain in perineum Acute = fever, chills, cloudy urine, voiding symotoms 6 week course of TMP-SMX

Hypothyroid, Brady, Cold intolerant, elevated TSH

Chronic Autoimmune (Hashimotos) Thyroiditis

Young endurance athlete with Bilateral leg pain that worsens w/ exertion & improves w/ rest.

Chronic Exertional Compartment Syndrome HIGH intracompartmental pressure during exertion. Compartmental pain that recurs with same time, distance and intensity of exercise. Pain relieved after short rest, Bilateral and involves anterior/lateral lower leg compartments. Exam and Imaging normal at rest, measure compartment pressure after exercise. Manage by decreasing activity level, improve foot wear, definitive tx elective fasciotomy

Recurrent infections with Catalse-Positive Bacteria & fungi (Staph, BURKHOLDERIA CEPACIA, SERRATIA MARCESCENS, Nocardia, Aspergillus) Recurrent Lung Infections & Skin Abcesses, Perirectal infection Granulomas on biopsy

Chronic Granulomatous Disease BOYS-X-Linked Recessive Mutation of NADPH OXIDASE Impaired Neutrophil Respiratory burst (NADPH Oxidase) & Dec reactive Oxygen species -> Inhibit phagocytic intracellular killing (DECREASED SUPEROXIDE KILLING) Dx: Dihydrohodamine Flow Cytometry & Nitroblue Tetrazolium Testing Tx: TMP-SMX, Itraconazole, IF-Gamma Prophylaxis, Hematopoietic cell transplant is curative

Severe bacterial and fungal pneumonias and skin infections.

Chronic Granulomatous Disease X-Linked immune disorder Dihydrorhodamine 123 Oxidation test

Elderly, High Lymphocytes, organomegaly, LAD, anemia, Thrombocytopenia

Chronic Lymphocytic Leukemia (CLL) - Monoclonal B-cell, NOT T-cell Disease. Dx: FLOW CYTOMETRY, Severe lymphocytosis and smudge cells, DONT NEED LN & BONE MARROW biopsy Median survival 10yrs Worse prognosis with multiple chain LAD, Hepatosplenomagealy, anemia, thrombocytopenia Complication: Infection, Autoimmune Hemolytic Anemia Secondary malignancy (Richter Syndrome)

fatigue, poor exercise tolerance, weight loss, splenomegaly, elderly. Translocation of chromosome 9 and 22 (Philadelphia chromosome) bar/abl fusion protein

Chronic Myeloid Leukemia Chromosome translocation of chromosome 9 and 22 which produces the Philadelphia chromosome. results in production of bcr/abl fusion protein that causes unregulated stimulation of tyrosine kinase system. Thus tyrosine kinase inhibitors are treatment of choice. Allow for long term disease control.

Chronic epigastric pain with intermittent pain free intervals, malabsorption with steatorrhea and weight loss, hx of DM

Chronic Pancreatitis Alcohol use, Cystic Fibrosis, Ductal obstruction (malignancy, stones), Autoimmune Amylase and lipase NON DIAGNOSTIC CT SCAN OR MRCP show calcifications, dilated ducts and enlarged pancreas Tx: Pain management, Alcohol and smoking cessation, frequent small low fart meals, pancreatic enzyme supplementation First line tx if lifestyle modification then pancreatic enzyme replacement and analgesics.

Episodic Urticaria >6weeks occurs without apparent triggers (pruritic, confluent round or serpiginous erythematous plaques (wheals)) appear and enlarge over min-hrs then disappear in 24hrs

Chronic Spont Urticaria Eval: CBC, CRP, ESR, LFTs, Urinalysis Skin biopsy to exclude urticarial vasculitis or mastocytosis Tx: Initial therapy 2nd gen H1 antihistamines (Loratadine,Cetirizine) AVOID 1st Gen H1 blocker (Hydroxyzine) only give at bedtime due to high risk of sedation and anticholinergic side effects.

episodic intensity pruritic rash affecting torso and extremities, past 3 months multiple episodes of similar rash that erupted sporadically without triggers and then resolve within 1-2 days.

Chronic Spontaneous Urticaria AVOID HEAT, NSAID TX with 2nd gen H1 Antihistamines (LORATIDINE, CETIRIZINE)

excoriated lichenified plaques at beltline

Chronic allergic dermatitis Topical high potency glucocorticoids (betamethasone, Fluocinonide) useful for treatment of flares in intermittent short courses (<4weeks) Topical tacrolimus is an alternative for areas where glucocorticoids are contraindicated like face.

severe alcohol use disorder who develops weakness

Chronic depletion of Phosphate secondary to decreased Vit D Once patient is fed or received IVF with glucose, insulin secretion is increased which results in shifting of phosphate intracellular and unmasking of the compensated phosphate depletion. Concern for Rhabdomyolysis from Hypophosphotemia and the CPK should be checked.

Chronic hypertension VS Gestational hypertension VS Preeclampsia

Chronic hypertension: a history of elevated blood pressure before pregnancy or before 20 weeks' gestation Gestational hypertension: new onset of hypertension at ≥20 weeks of gestation without proteinuria or signs of end-organ dysfunction Preeclampsia: proteinuria and/or severe features are present

motor or vocal tics

Chronic tic disorder >1yr, Provisional tic disorder <1 year If MOTOR & VOCAL = Tourette syndrome

PostThrombotic Syndrome

Chronic venous insufficiency following acute DVT, within 2 years of thrombus Leg edema, fatigue, pain, superficial venous dilation, venous stasis ulcers, worse at end of day Tx: exercise (ankle flex, walking), compression (bandage and stockings)

Tx for acute uncomplicated pyelonephritis

Ciprofloxacin

25-hydroxyvitamin D & 1,25-Hydroxyvitamin D

Circulating 25-hydroxy is converted to 1,25 by PTH. Vitamin D deficiency confirmed by low 25-hydroxy

Kaposi sarcoma (KS)

Co infection of HIV and Human Herpes Virus Type 8 AIDS defining condition DEEP red, purple or brown macules on trunk, extremities and face. Plaques or nodules that are ovoid and linear in shape along skin tension lines.

Indications for Stress Ulcer Prophylaxis

Coagulopathy (platelet <50K, INR >1.5, PTT >2x normal) Mechanical Ventilation >48hrs GI Bleeding or ulceration in last 12 months Head trauma, spinal cord injury, major burn Glucocorticoid therapy >1 week ICU stay Occult GI bleeding >6days Sepsis Critically ill patients have uremic toxins and reflux of bile salts into the stomach, disrupt the protective glycoprotein layer, lead to increased permeability of gastric mucosa, predispose to ulcer formation. Head trauma causes increased gastrin secretion, parietal cell stimulation and acid secretion. Shock is associated with mucosal ischemia leading to ulcerations. Most of these ulcerations occur within 72hrs and tend to be located in the proximal stomach. later located in duodenum. PROTON PUMP INHIBITORS & H2 ANTAGONISTS used to increase the pH in the stomach by lowering gastric acid formation, preventing gastric injury associated with ulcer formation Both PPI and H2 antagonist may be associated with increased risk of C diff and Pneumonia

in childhood, upper extremity HTN, different from normal BP in lower extremity, headaches epistaxis, lower extremity claudication. unequal upper and lower extremity pulses

Coarctation of the Aorta

Cobicistat

Cobicistat is a mechanism-based inhibitor of cytochrome P450 (CYP) 3A enzymes that is indicated in the EU as a pharmacokinetic enhancer (i.e. booster) of the HIV-1 protease inhibitors (PIs) atazanavir and darunavir in adults. contraindicated in pregnancy.

Acute cramps moderate abdominal pain and tenderness, hematochezia, bloody diarrhea, leukocytosis, lactic acidosis CT: Colonic Wall thickening, fat stranding, pneumatosis (gas in the bowel wall). Endoscopy: Edematous & friable mucosa Abdominal Xray: Dilated transverse colon, mucosal edema on sigmoidoscopy

Colonic Ischemia Non occlusive "watershed" ischemia, underlying atherosclerotic disease (HTN, DM, End stage renal dz), Hypovolemia Mismatch between Oxygen demand and supply results from diffuse mesenteric atherosclerosis combined with a state of low blood flow (hypovolemia during hemodialysis) Splenic flexture, rectosigmoid juction IVF, bowel rest, Abx, colonic resection if necrosis develops

Colon Cancer Screening Alternative

Colonoscopy is most sensitive but due to bowel prep can offer flexible sigmoidoscopy. If normal then repeat at 5 year intervals. If abnormal finding then need to undergo colonoscopy for visualization of entire colon to rule out synchronous polyps in proximal colon.

Brain Death

Coma, Absent felt or extensor pestering, Absent pupillary light or corneal reflexes, no oculovestibular reflex (dolls eyes), No cough (tracheal suctioning), No gag reflex, Absent rooting or sucking reflex SPINAL REFLEXES (JERKING) may be present can have spontaneous movements (finger flex, truncal movement, felt art hip, knee and ankle with foot stimulation, plantar reflexes (babinski), limb movement to painful stimuli and alternating flexion-extension of toes.

after injuring knee intense pain, cant put weight on it, discomfort and insomnia juts by putting clothing or sheets on it, swelling around knee, increased temperature and more sweating of that leg, mottled bluish discoloration.

Complex Regional Pain Syndrome pain out of proportion to the injury Type 1 without nerve lesion Type 2 with a nerve lesion Injury causing increased sensitivity to sympathetic nerves, increased neuropeptide release causing burning pain to light touch (allodynia). Stage 1: Burning pain, edema, vasomotor changes in a limb after injury stage 2: progression of edema, skin thickening, muscle wasting Stage 3: limited range of motion and bone demineralization Dx: Autonomic testing that measures increased resting sweat output or MRI Tx: Regional Sympathetic Nerve Block or IV regional Anesthesia

Hypercalcemia (Constipation, fatigue, nausea, nephrolithiasis), Steps in eval?

Confirm Hypercalcemia with repeat testing, then measure PTH Elevated = PTH Dependent -Primary HyperPTH -Lithium -Familial Hypocalciuric Hypercalcemia Suppressed = PTH Independent -MALIGNANCY -Vit D Toxicity -Granulomatous Dz -Meds like Thiazides -Milk-Alki Syndrome -Thyrotoxicosis -Vit A Toxicity -Immobilization

Conus Medullaris Vs Cauda Equina Syndrome

Conus Medullaris: L1-L2, UMN (lumbosacral cord), Severe LOW back pain, bowel/bladder dysfunction, symmetric motor weakness, Hyperreflexia, UMN signs, symmetric perianal numbness Cauda Equina: L2-Sacrum, LMN (lumbosacral spinal roots), RADICULAR PAIN (radiates from back/hip into your legs), Bowel bladder dysfunction, Assymteric motor weakness, Areflexia/Hyporeflexia, Asymmetric saddle numbness that extend into leg -SADDLE ANESTHESIA - S2-S4 -Bowel, Bladder, Sexual Dysfunction (urinary staining) - S3-S5 -Absent Ankle Reflex - S1-S2

Neonatal Gonococcal Conjunctivitis

Copious exudate & eyelid swelling (2-5yo) Gram - Diplococci Positive culture on modified Thayer-Martin Medium Tx: One dose IM Ceftriaxone or Cefotaxime Prevent with Erythromycin Ointment (within 1 hrs of birth) Gonococcal has a earlier and more severe presentation then chlamydia conjunctivitis

Contraindications to IUD placement

Copper & Progestin: Pregnancy, Endometrial or cervical cancer, unexplained vaginal bleeding, Gestational Trophoblastic disease, Severe uterine cavity distortion, active pelvic infection Progestin: Active liver dz, current breast cancer Copper: Wilson Dz

Chronic Kidney disease independently increases the risk for

Coronary Artery Disease -Altered calcium balance (secondary hyperparathyroid) lead to arterial calcium deposition and accelerated atherosclerosis -Loss of protein in urine facilitating an unfavorable lipid profile -Increased systemic inflammation contribute to accelerates atherosclerosis and instability of atherosclerotic plaques Patients with CKD, especially females are more likely to have atypical symptoms therefore high suspicion exist for stable angina Cardiac stress testing in form of stress echo or treadmill stress testing is most appropriate.

2 disease interventions are compared and one of the interventions diagnoses the disease earlier than the other.

Lead Time Bias Presume effect on outcome but actually intervention only diagnosed the disease sooner and no effect on survival

Overestimation of survival due to earlier disease diagnosis

Lead-Time Bias

Anterior and anterolateral wall of the left ventricle, coronary artery?

Left Anterior Descending Artery

Lateral and posterolateral Wall of the left ventricle, Coronary artery?

Left Circumflex Artery

Neuropsychiatric symptoms associated with SLE

Headache, Seizure, Polyneuropathies, Cognitive dysfunction, anxiety, mood changes, new onset psychosis Treat with antipsychotics or oral steroids Antinuclear Ab (sensitive) Anti-dsDNA & anti-smith (specific)

Fontal Lobe Tumor

Headaches, focal neurological deficit, seizure, loss of inhibition from frontal lobe cause primitive reflexes (glabellar tap, grasp and palmomental reflexes) Foster Kennedy Syndrome (optic atrophy on side of tumor and papilledema on contralateral side)

Excessive emotionality and excitability, attention seeking, sexually provocative, overly concerned with appearance. Considers relationships more intimate that they really are.

Histrionic Personality Disorder

1,25 dihydroxy Vit D can be produced by what tumor

Hodgkin Lymphoma

Risk of renal cell carcinoma of native kidney in renal transplant recipients

Increased due to immunosuppression and may be related to structural changes that occur in the native kidney

menopausal hormone therapy (MHT)

Increased risk of stroke, breast cancer, and venous thromboembolism Alternate treatment = SSRI (Escitalopram) or SNRI (Venlafaxine)

Central venous catheter, chemo induced neutropenia developed rapidly progressive ulcerative skin lesions. PAINLESS red macula's that rapidly progress to pustules/bullae and then quickly evolve into gangrenous ulcers, with raised violaceous margins.

Ecthyma Gangrenosum from Pseudomonas Aeruginosa in immunocompromised patients Tx with IV antibiotics. (Antipseudomonal beta-lactam (Piperacillin-Tazobactam) & Aminoglycoside (Gentamicin)

Immunosuppressant used in Anti GBM disease or Pauci-Immune Vascultiits

Cyclophosphamide

Intravenous Immunoglobulin is the appropriate tx for

KAWASAKI DISEASE Vasculitis of unclear etiology characterized by fever, mucus membrane change, cervical LAD, Conjunctivitis, extremity edema, rash

Painless, Bloody Stools, ill appearing infant with abdominal pain and lethargy

Meckel Diverticulum Ectopic gastric tissue that secretes hydrochloric acid, causing intestinal ulceration and bleeding Complications = Intussusception and Intestinal Obstruction

abdominal pain, amenorrhea, vaginal bleeding, cervical motion, adnexal tenderness, palpable adnexal mass. Positive hCG (above discriminatory zone >3,500). Adnexal mass & empty uterus on transvag US.

Ectopic Pregnancy Commonly at the ampulla of the Fallopian tube Stable: METHOTREXATE Unstable: SURGERY

Prostaglandin that inhibits gastric acid secretion and improves mucosal defense. Used to prevent ulcers associated with use of NSAID.

Misoprostol

myopathy, myalgia, fatigue and exercise intolerance

Mitochondrial disease

Common cause of decreased vision in elderly patients

Cortical cataracts & Macular degeneration Cataracts: slow progressive opacification of lens, progressing to painless blurry vision with intact visual fields. Macular Degeneration: degeneration of the central portion of the retina leading to loss of central vision. DRUSEN (cellular debris-yellowish deposits of lipids and calcium) in dry macular degeneratioin Choroidal Neovascularization in Wet Macular Degeneration. Cataract surgery = lens extraction. BUT can increase risk of macular degeneration progression because opacified lens provided protection

Psychosis as a side effect of what meds

Corticosteroids, appetite suppressants, quinacrine, levodopa, carbidopa, amantadine, isoretinoin

Infection of skin in the intertriginous spaces. Confluence of pruritic, reddish brown finely wrinkled papule. Coral red fluorescence on wood lamp

Corynebacterium Minutissimum

used in evaluation of adrenal insufficiency

Cosyntropin

chronic, nonproductive cough. Chest tightness.

Cough-Variant Asthma Triggered by exercise (cold temps) or forced expiration and commonly occurs at night. Allergens (dust mites, Molds) are common triggers. Positive Methacholine Challange

tender thyroid gland, recent viral infection. LOW TSH, HIGH T4, HIGH THYROGLOBULIN, LOW RAIU

Subacute Granulomatous (De Quervain) Thyroiditis Transient Hyperthyroid due to follicular injury and release of preformed hormone.

Choking child

Coughing, gagging -> Encourage Coughing Complete Obstruction: Unable to cough or speak, respiratory distress, cyanosis -> <1yo: Head down/face down perform 5 back blows, turn face up and perform 5 chest thrusts on sternum with 2-3 fingers. >1yo: Lean child forward abdominal thrusts (just above the naval but well below the sternum) or 5 back blows and 5 abdominal thrusts

Avoid tyramine-containing foods

Counseling point for MAO-B Inhibitors

most common causes of culture-negative endocarditis

Coxiella and Bartonella

Rashes involving the palms and soles seen in what diseases?

Coxsackie, secondary syphilis, scabies, Rocky Mountain spotted fever

tremor in distal upper extremities and becomes much more pronounced with outstretching of the arm. Increase at end of any activity or movement. Head tremor. FH of tremor.

Familial tremor or benign essential tremor NO resting tremor. Does NOT cause disability and can have normal life expectancy. If unable to carry out fine motor tasks due to the tremor then can start Beta-Blocker.

neuropsych signs, upper motor neuron and extrapyramidal signs, startle myoclonus, akinetic mutism. rapidly progressive cognitive decline to death within a year.

Creutzfeldt-Jakob disease

On colonoscopy in a 15-40yo with abdominal pain and bloody diarrhea see aphthous ulcers, cobblestoning, skip lesions.

Crohns Disease

Prevalence at a specific point in time

Cross-Sectional Design

Recurrent sinopulmonary infections (chronic productive cough), Intestinal obstruction (meconium Ileus), Pancreatic insufficiency and Diabetes, Male infertility

Cystic Fibrosis Mutation of CFTR gene AR Elevated sweat chloride levels CFTR mutation (impairs chloride transport, resulting in thick secretions. This allows bacterial colonization (Staph and Pseudomonas). Mucus plugs the airway and leads to hyperinflation from chronic obstruction and bronchiectasis. Thick intestinal secretions leave GI tract dehydrated and prone to constipation. Mucus blocks pancreatic ducts and impairs enzyme secretion, resulting in malabsorption, failure to thrive and CF related Diabetes. SWEAT CHLORIDE TEST (2 elevated sweat chloride levels in a symptomatic patient are diagnostic) CXR: Thickened non tapering bronchial walls, Tram Track Sign, Signet Ring Sign. Tx: Nutritional support, airway clearance, Antibiotic coverage for staph aureus and pseudomonas

most common cause of sensorineural deafness in children. intrauterine growth restriction, prematurity, microcephaly, jaundice, petechiae, hepatosplenomegaly, periventricular calcifications, chorioretinitis, and pneumonitis.

Cytomegalovirus (CMV) HHV-5 IgG (+)/IgM (-) past exposure and no risk for primary infection. IgG (+)/IgM (+) or IgG (-)/IgM (+) indicates recent infection Antiviral therapy with ganciclovir or foscarnet to prevent viral shedding and hearing loss (but does not cure the infection) CMV hyperimmune globulin to potentially reduce the risk of congenital infection in pregnant women with primary CMV infection

HIV with <50 CD4 cells and blurry vision. Diagnosis & Treatment?

Cytomegalovirus (CMV). Dilated ophthalmologic examination. Ganciclovir (Low WBC) or Foscarnet (High Cr) Maintenance therapy is with oral valganciclovir lifelong, unless the CD4 goes up with ART. If the CD4 rises, you can stop the CMV medications.

Asymptomatic Bacteriuria

NO manifestations of UTI has a clean catch urine culture that grows >100,000 E. coli. Transient resolves in 2 weeks. Reassure and observe no treatment or retesting necessary. ONLY tx if pregnant, undergoing urologic procedures, or within 3 months of kidney transplant.

Children >2yo, low grade fever, unilateral acute otitis media can be

Observed with close followup

Treatment for diabetic neuropathy

DULOXETINE (SNRI), Pregabalin, TCAs ,Anticonvulsants (Gabapentin, Lamotrigine, Carbamazepine)

Symmetric swelling and pain of the hands and feet in setting of known sickle cell disease

Dactylitis (Hand-Foot Syndrome) Result from vast-occlusion of the TVs supplying the metacarpals and metatarsals (6m-4yo) triggers include stress, illness, temperature changes, dehydration. Tx: Pain control (NSAIDs) & Oral opioids (Oxycodone)

Mechanism of Low sodium in Rhabdomyolysis

Damaged muscle binds calcium. Each skeletal muscle cell contains sarcoplasmic endoplasmic reticulum for calcium (SERCA). SERCA is the normal mechanism for ending contraction, which it achieves by pulling all the cell calcium out of the cytosol. When the outside covering, or sarcolemma, is damaged, the SERCA can suck up calcium and lower the blood level.

muscular rigidity seen in neuroleptic malignant syndrome, high fever, altered sensorium, autonomic instability, HIGH Creatine kinase, leukocytosis. Treat with?

Dantrolene

SSRI-associated sexual dysfunction

Decreased libido, Anorgasmia, Delayed ejaculation, common cause of non adherence Rule out sexual dysfunction due to depression, medical conditions, primary sexual disorder, stress/relationship issues, substance abuse switch to non-SSRI antidepressant: BUPROPION or MIRTAZAPINE Dose reduction for patient on high dose SSRI monitor for loss of efficacy

dysphagia & gastroparesis (vomit, early satiety, weight loss, positive gastric emptying)

Decreased peristalsis in the esophagus and stomach due to PARASYMPATHETIC UNDERACTIVITY Parasympathetic nervous system primarily promotes motility. Vagus nerve (CN X) originates from dorsal vagal nucleus of medulla carries parasympathetic fibers from medulla to upper GI (esophagus, stomach, small intestine, proximal part of colon) With MULTIPLE SCLEROSIS, can have demyelinating lesions impacting the dorsal vagal; nucleus of the medulla, disrupting parasympathetic innervation.

Fetal Growth Restriction (estimated fetal weight (EFW) is <10th percentile or the abdominal circumference is <10th percentile for gestational age): Maternal Causes

Decreased placental perfusion —Hypertension —Small vessel disease (e.g., SLE) —Malnutrition —Tobacco, alcohol, street drugs —Monitor with serial sonograms, nonstress test, amniotic fluid index (AFI), biophysical profile, and umbilical artery Doppler —AFI is often decreased, especially with severe uteroplacental insufficiency

Fetal Growth Restriction (estimated fetal weight (EFW) is <10th percentile or the abdominal circumference is <10th percentile for gestational age): Placental Causes

Decreased placental perfusion —Infarction —Abruption —T win-twin transfusion —Velamentous cord insertion —Monitor with serial sonograms, nonstress test, amniotic fluid index (AFI), biophysical profile, and umbilical artery Doppler —AFI is often decreased, especially with severe uteroplacental insufficiency

Symptomatic management of common MS findings

Depression: SSRI, SNRI Spasticity-pain/stiff of legs, esp when rise out of bed or chair: PT, Stretch, Massage, Baclofen, Tizanidine Fatigue: Sleep hygiene, regular exercise, Amantadine, Stimulants (Methylphenidate, Modafinil) Neuropathic pain: Gabapentin, Duloxetine Urge Urinary Incontinence: Timed voiding, Fluid restrict, Anticholinergic meds (oxybutynin, tolterodine)

Inducible Urticaria

Dermographism: Scratching Cholinergic: Elevated core. body temp Delayed pressure: sustained mechanical pressure Aquagenic: Water Solar: Sun exposure After trigger is removed, resolves within 1-2 hrs Tx: AVOID Stimulus, H1 Blocker (Cetirizine)

Cause of Urgency urinary incontinence (Overactive Bladder), sudden overwhelming urge to void followed by an involuntary loss of urine

Detrusor Muscle Overactivity

Child with excessive cows milk intake can be at risk for? if not treated

Developmental delay Iron deficiency anemia can be caused by prematurity, Lead exposure, Less than 1 yo Delayed introduction of solids (exclusive breast feeding after 6 months), Cow/soy/goat milk, Greater than 1 yo too much cows milk, less than 3 servings of iron rich foods a day Hgb <11, LOW MCV, HIGH RDW Microcytic, Hypochromic RBC Tx: Oral Ferrous Sulfate. Iron essential for neuronal myelination, migration, and differentiation. Chronic deficiency can lead to psychomotor delay and neurocognitive impairment.

HIV and <50 CD4 cells, plus wasting with weight loss, fever, and fatigue. Anemia. Increased alkaline phosphatase and GGTP with a normal bilirubin are characteristic of hepatic involvement. Diagnosis & Treatment.

Diagnostic testing is blood culture (least sensitive), bone marrow (more sensitive), and liver biopsy (most sensitive). Treatment is azithromycin (or clarithromycin), rifabutin (or rifampin), and ethambutol.

Infant with Hgb <9 at birth and <6 at 2 months. Macrocytic RBCs. Craniofacial abnormalities, ABSENT THUMBS

Diamond-Blackfan Anemia Bone marrow failure (anemia, Reticulocytopenia) in infancy

lower extremity muscle atrophy, tongue fasciculations, dysphagia, difficulty walking, shortness of breath while supine. ventilatory function worsened when lying supine as shown by decreased forced vital capacity. atelectasis in lower lobes.

Diaphragmatic Paralysis On exam see paradoxical abdominal wall retraction during inspiration when the patient is lying supine, because diaphragm is not contracting. SNIFF TEST USING FLUOROSCOPY confirm diagnosis

Travelers Diarrhea

Diarrhea, Ab pain, Vomiting Ciprofloxacin for bacterial Metronidazole for protozoal forms: Giardia, Entamoeba. TMP-SMX for Enterotoxigenic E. coli, acute watery diarrhea

Hemosiderin laden macrophages are seen in

Diffuse alveolar hemorrhage syndromes (granulomatosis with polyangitis, anti-GBM disease)

sepsis, trauma, malignancy, obstetric complications. HIGH D-DIMER, Prolonged PT and aPTT, LOW Fibrinogen. Bleeding & Thrombosis

Disseminated Intravascular Coagulation Accelerated fibrinolysis = High D-Dimer Depletion of clotting factors = High PT, aPTT

Oozing from mucosal sites, abnormal coagulation studies (prolonged PT, aPTT, LOW fibrinogen, HIGH D-Dimer)

Disseminated Intravascular Coagulation (DIC)

Advanced AIDS with fever, night sweats, abdominal pain, diarrhea, weight loss

Disseminated Mycobacterium Avium complex

Billroth II (gastrojejunostomy)

Distal Gastrectomy procedures create a blind loop of small intestine that can experience bacterial overgrowth

Ureteral stone with proximal ureteral obstruction resulting in hydronephrosis, superimposed infection and hemodynamic instability

Drainage of obstructed portion of the urinary tract via percutaneous nephrostomy or retrograde ureteral stent placement Alpha blockers such as tamsulosin can facilitate stone passage in stable patients with small <10mm ureteral stones.

infectious mononucleosis

EBV Fever, Tonsillitis/Pharyngitis +/- Exudates, posterior or diffuse cervical LAD, fatigue, Hepatosplenomegaly RASH AFTER AMOXICILLIN -> RESOLVE SPONTANEOUSLY OVER TIME with observation and supportive care + Heterphile Antibody (monospot) test, atypical lymphocytes, Transient Hepatitis AVOID sports for >3 weeks due to risk of splenic rupture Symptoms will resolve spontaneously within weeks of onset, however persistent fatigue is common and may exist for months (>6 months)

Initiation of TCAs requires a baseline

ECG and monitoring due to arrhythmia

A patient is brought to the ED after a seizure leading to prolonged immobility on a sidewalk. He has dark urine and myalgias. What is the most urgent step in management?

EKG is the most urgent step in an acute case of rhabdomyolysis. Severe muscle necrosis leads to hyperkalemia, which leads to arrhythmia. peaked T-waves. treated with immediate IV calcium gluconate, insulin, and glucose.

red, painful, edematous and elevated. Sharp demarcation from uninvolved skin. Butterfly pattern invloving the cheeks and bridge of nose. Fever, chills, malaise.

ERYSIPELAS from GROUP A STREP

Glasgow Coma Scale (GCS) score

EYE OPEN: 4 -1-None -2-Pain Only -3-To speech -4-Spont VERBAL RESPONSE: 5 -1-None -2-Incomprehensible -3-Inappropriate -4-Confused -5-Oriented MOTOR RESPONSE: 6 -1-None -2-Extend to pain -3-Flex to pain -4-Withdraw to pain -5-Localize pain -6-Obey commands COMA = Doe not open eyes, Does not follow commands, Not understandable words Score of 3-8 (INTUBATE) HEAD INJURY: Mild 13-15, Moderate 9-12, Severe 8 or below (INTUBATE)

phenytoin toxicity

Earliest sign is Nystagmus on far lateral gaze Blurred vision, diplopia, ataxia, slurred speech, dizzy, drowsiness, lethargy, and decreased mentation progress to Coma. Therapeutic range of Phenytoin is 10-20 mcg/mL and most patients will have adverse effects at above 20. First step in management is to reduce the dose.

LYME DISEASE

Early Localized (days to months): Erythema Migrans, Fatigue, Headache, Myalgia, Arthralgia Early Disseminated (weeks to Months): Multiple erythema migrant, Unilateral/bilateral CN palsy, Meningitis, Carditis (AV Block), Migratory Arthralgia Late (months to years): Arthritis, Encephalitis, Peripheral neuropathy Synovial fluid WBC 20-60K Dx made by Enzyme-Linked Immunosorbent Assay and Western Blot Tx with 28 day course of PO DOXYCYCLINE or AMOXICILLIN Rest and avoid high impact activities until all symptoms resolve to reduce risk of additional joint damage. CUREd AFTER PO ABX

Organ Donation Pathway

Early Notification: Clinical/Hospital Representative notifies Organ Procurement Organization (OPO) of all impending deaths (ideally within 1 hr) Decoupling: Treating physicians discuss impending brain death with family, OPO discusses organ donation.

Nonimmune hydrops fetalis, Maculopapular or vesicular peripheral rash, Anemia, thrombocytopenia, and hepatosplenomegaly, Large and edematous placenta, Perinatal mortality

Early acquired (first trimester) congenital syphilis

Pregnancy cannot be visualized on US at b-hCG below the discriminatory zone (<3500)

Early pregnancy of undetermined location Ectopic or Intrauterine. If stable, repeat b-hCG every 48hrs to determine if increase is consistent with a normal pregnancy (>35% rise every 48hrs) US repeated until >3500 and intrauterine pregnancy visualized

Echinocandin's unique mechanism:

Echinocandins are a class of antifungal drugs that target the fungal cell wall. They are lipopeptide molecules that noncompetitively inhibit (1,3) beta-d-glucan synthase enzyme. This enzyme forms glucan, a major component of the fungal cell wall therefore by inhibiting its synthesis fungal cell walls are damaged. caspofungin, micafungin and anidulafungin.

All patients initially diagnosed with Turner syndrome require

Echo: Coarctation of aorta, bicuspid aortic valve, mitral valve prolapse, hypo plastic heart Visual and hearing assessment Renal Ultrasound: Horseshoe kidneys TSH level: Primary Hypothyroidism Estrogen given once reach 14yo to prevent premature fusion of epiphysis, GH can be given to improve final height

painful vesicular rash over the face in addition to fever and LAD in a patient with atopic dermatitis

Eczema Herpeticum (primary or reactivated HSV associated with atopic dermatitis) due to innate skin barrier dysfunction and immune dysregulation Painful vesicles on an erythematous base, most commonly involving face, neck, trunk. Evolve into punched out erosions that later become covered with hemorrhagic crusts. Immediate systemic antiviral (ACYCLOVIR) to prevent spread.

Dysphagia (trouble swallowing food), Heartburn & Epigastric pain, Regurgitation, Food impaction. Endoscopy & esophageal biopsy: Esophageal rings, Strictures, and Linear Furrows along the esophagus and EOSINOPHILS

Eosinophilic Esophagitis Th2-mediated inflammatory response triggered primarily by food antigen exposure Comorbid atopic disease (Asthma, Eczema, Food allergies, allergic rhinitis) Tx: Elimination Diet (limit exacerbating allergens), Proton Pump inhibitors, Topical Glucocorticoids (fluticasone sprayed and swallowed)-reduce local inflammation

Red blood cells in urine, Red cell casts in urine, Mild degrees of proteinuria (<2 g per 24 hours), Edema. Asthma, cough, and eosinophilia

Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome) The best initial tests are CBC for eosinophil count and MPO-ANCA. The most accurate test is biopsy. Treatment is glucocorticoids (e.g., prednisone). If no response, add cyclophosphamide.

meta-analaysis

Epidemiologic tool to increase power of a study. Ability to detect association if exist. By pooling the data from several studies. When a single study has a very small sample size and the outcome under study is rare its difficult for the study to find statistically significant associations even when real and valid asociastins exist. Meta analysis can help increase sample size, thereby increasing power . MAJOR DISADVANTAGE is pooling of the biases into one analysis.

tripod position, sniffing position, stridor, dysphagia, dysphonia, drooling, high fever

Epiglottitis (H. Influenza) Enlarged epiglottis (thumb sign) on CXR Management: Endotracheal intubation, Antibiotics Prevent: Immunization against Hib

Management of anaphylaxis

Epinephrine MOST IMPORTANT (IM may repeat x3 doses), IV crystalloid & Trendelenburg for Hypotension, Albuterol for Bronchospasm, Intubate if upper airway obstruction Adjunct = H1/H2 antihistamines, Glucocorticoids, GLUCAGON if on beta blockers

Steven Johnson Syndrome

Erosion of mucus membranes, small blisters on purpuric macules, atypical target lesions From Antibiotics (Sulfonamides, Aminopenicillins, Quinolones, Cephalosporins) and Anticonvulsants (Lamotrigene, Phenytoin, Carbamazepine)

infection of the skin. The skin is very bright red and hot because of dilation of the capillaries of the dermis due to locally released inflammatory mediators. The face is often the site of infection.

Erysipelas-group A (pyogenes) streptococcal infection

Common Skin Infections

Erysipelas: Strep Pyogenes -Superficial dermis and lymphatics -raised sharply demarcated borders -rapid onset & spread -Fever, chills TX: PENICILLIN Cellulitis: Strep Pyogenes, MSSA -deep dermis, sub q fat -ill defined, flat borders -indolent course -fever Abscess: MSSA, MRSA -dermis or sub q space -fluctuant, tender nodule -purulent drainage -fever

erythematous non pruritic, ring like rash that comes and goes

Erythema Marginatum manifestation of acute rheumatic fever, requires antibiotics to prevent rheumatic disease

best way to monitor a response to therapy in Osteomyelitis

Erythrocyte sedimentation rate (ESR). If the ESR is still markedly elevated after 4-6 weeks of therapy, further treatment and possible surgical debridement is necessary.

young patient. difficulty swallowing solid foods, prolonged and careful chewing, swallowing small portions. periodic chest pain behind the sternum.

Esophageal Stricture (Petic stricture) complication of GERD from healing process of ulcerative esophagitis Achalasia would require difficulty in swallowing solid & LIQUID

Multiple logistic regression models

Estimate the association between >2 independent variables and 1 Dichotomous dependent variable For example, evaluate association between ;presence or absence of type 2 DM (dichotomous dependent variable) and obesity while adjusting for age and smoking status (3 independent variables)

Maternal Hypothyroidism in Pregnancy

Estrogen stimulates synthesis of thyroxine-binding globulin, leading to an increased pool of bound thyroid hormone. Thyroid hormone production increased to maintain free hormone levels. hCG (shares common alpha subunit with TSH and very similar beta) directly stimulates TSH receptors. resulting in an increased thyroid hormone production with feedback suppression of pituitary TSH release. TSH: Low/Suppressed during first trimester due to Thyroid stimulating actions of b-hcg First Trimester: TSH 0.1-2.5 Second Trimester: TSH 0.2-3.0 Third Trimester: 0.3-3.0 Management: Increase Levothyroxine dose, Monitor TSH every 4 weeks If euthyroid then no additional workup necessary. PREFER MEASURE = TOTAL T4 in pregnancy For Overt Hyperthyroid use PROPYLTHIOURACIL in first trimester and METHIMAZOLE in the second and third trimester.

Methotrexate

Folic acid analog that inhibits dihydrofolate reductase → ↓dTMP → ↓ DNA and protein synthesis. (S phase). Use: leukemias, lymphomas, choriocarcinoma, sarcoma, abortion, ectopic preganncy, RA, psoriasis. Toxicity: BM suppression (reversible with folinic acid/leucovorin rescue), macrovesicular fatty change in liver, mucositis, teratogenic.

Pneumococcal vaccine

Everyone age >65 & Tobacco smokers single dose of 23 polyvalent vaccine. Healthy: 23 at age 65 Immunocompromised: 13 now, 23 in 8 weeks -First dose before 65: give a second dose of 23 polyvalent 5 years later -Chronic illness (e.g., COPD, HIV, diabetes, asthma): give 23 polyvalent with a booster 5 years later -Severe immunocompromise (e.g., steroid use, leukemia, lymphoma) or primary immunodeficiency (no spleen): give 13 polyvalent now and 23 polyvalent 8 weeks later

worsening cough with sputum production in a COPD patient , and hemoptysis

Exacerbation of COPD Airway in floatation in acute bronchitis can cause erosion of the superficial vessels leading to hemoptysis PLAIN CXR initials test of choice may identify site and cause of bleeding. Oral Antibiotics in COPD exacerbation if increased sputum purulence, increased sputum volume, increased dyspnea. As well as if need mechanical ventilation. ONLY Hospitalize if failed outpt therapy or have severe symptoms (rapidly worsening dyspnea, worsening hypoxia/hypoxemia, AMS, forced expiratory volume in <50%)

Primary Dysmenorrhea (Painful lower abdominal cramping associated with menses)

Excess Prostaglandin Production stimulates uterine contraction, resulting in lower abdominal pain and radiate to back and thigh. <30yo, BMI <20, Tobacco, Menarche <12, Heavy/Long menstrual periods, Sexual abuse Pain first 2-3 days of menses, N/V/D, Normal pelvic exam Management: 1st line=NSAID, 2nd line=OCP (unless sexually active then 1st line)

Most common adverse reaction within 1-6hrs after transfusion

Febrile Nonhemolytic Transfusion reaction When red cells and plasma are separated from whole blood, small amounts of residual plasma and or leukocyte debris may remain the red cell concentrate. During blood storage these leukocytes release cytokines which when transfused can cause transient fevers, chills and malaise without hemolysis. Stop transfusion administer antipyretics and use leukoreduced RBC products for future transfusions. This involves reducing the number of transfused leukocytes though filtering or other methods such as saline wash, freezin and deglycerolizing or buffyy coat removal. also reduces risk of human leukocyte antigen alloimmunization and transmission of cytomegalovirus (resides in leukocytes)

Endometriosis

Females 25-35yo Endometrial tissue outside of the uterus. Chronic pelvic pain, Dysmenorrhea, Deep Dyspareunia, Dyschezia pain on lateral movement of the cervix, a fixed immobile uterus, uterosacral nodularity and adnexal masses, more likely to have NORMAL exam First line tx: NSAID & OCP (decrease amount of endometrial implant shedding in the pelvis, reducing pain and inflammation) Other txs: Progestin-Only Therapy = Medroxyprogesterone Acetate, Gonadotropin releasing hormone analogues (leuprolide), Danazol (synthetic Androgen) Surgical tx = Excision of lesions and definitive tx with Hysterectomy and Bilateral Saplingo-oophorectomy

Febrile seizures in a child:

Fever and FH 6M-5YR Management: Abortive Therapy >5min, Antipyretics (fever reduction), Reassurance Prognosis: No long term sequelae, High risk of subsequent febrile seizures, Slight increase risk of epilepsy

centor criteria for strep pharyngitis

Fever, Exudative Pharyngitis, LACK of cough Treat With ORAL PENICILLIN

Treatment for Kawasaki disease

Fever, Rash, Conjunctivitis, LAD, strawberry tongue and swelling of hands and feet IV IMMUNOGLOBULIN

Prenatal Testing

First Trimester: 9-13weeks: Not diagnostic Cell Free Fetal DNA: >10weeks: Sensitive and specific for aneuploidy but not diagnostic Chorionic Villus Sampling: 10-13 weeks: Definitive karyotypic diagnosis: Invasive risk of spontaneous abortion Second Trimester Quad Screen: 15-22 weeks: neural tube defects and aneuploidy: not diagnostic Amniocentesis: 15-20 weeks: definitive karyotype diagnosis: Invasive, risk of membrane rupture, fetal injury and pregnancy loss Second Trimester US: 18-20 weeks: measures fetal growth, evaluates fetal anatomy, confirms placenta position

Varicose Veins Treatment

First conservative with leg elevation, weight reduction, compression stockings. If failed 3-6 months of conservative treatment then injection sclerotherapy (injection of scleorisng agent into the affected vein, causes endothelial damage and sclerosis of the involved vein, prevent further vein filling.

Colostrum

First few days after birth breast milk is Colostrum an antibody rich fluid that is low in volume. Up to 10% weight loss is expected in first week. By day 5 of life production of breast milk increases to meet the demands of hydration and nutrition and the newborns weight is expected to surpass birth weight by age 2 weeks. Close follow up to monitor weight should be within 2-3 days.

Macroadenoma -> Prolactinoma Large pituitary mass, erectile impotence, right upper temporal visual field defect, HIGH Prolactin levels. LOW LH&FSH

First line = Oral Dopaminergic Receptor Agonists (Bromocriptine & Cabergoline) Tumor size will decrease within days and improves vision NO NEED FOR SURGERY

Seizure Therapy

First-line: levetiracetam, valproic acid, carbamazepine, phenytoin (all equal in efficacy) Second-line: gabapentin, phenobarbital, lacosamide, zonisamide

After blood is ordered for transfusion, the following compatibility testing is usually performed

First: ABO & Rh Second: Screen for antibodies (pre transfusion antibody screening)-If negative can proceed with transfusion The major problem that leads to difficulties finding cross matched blood in patients is ALLOANTIBODIES (sickle cell anemia or myelodysplasia)Most commonly implicated RBC antigens are E, L, and K.

Study the association between two categorical variables when the number of observations is small (small sample size-20 subjects or less)

Fishers Exact Test

Tachypnea, Tachycardia, Shallow breathing, Anterior chest bruises after a motor vehicle accident as an unrestrained driver.

Flail Chest Double rib fracture in more than one site with paradoxical motion of the free segment of the chest wall during inspiration. Hypoxemia and increased work of breathing. non op supplemental oxygen, noninvasive positive pressure ventilation and medications for pain control.

Negative Symptoms of Psychosis

Flat affect, motivation, social withdrawal PSYCHOSOCIAL INTERVENTION (SOCIAL SKILLS TRAINING)

SSRIs (selective serotonin reuptake inhibitors)

Fluoxetine Sertraline (Zoloft) Paroxetine Fluvoxamine Citalopram Escitalopram

Age 1-4 weeks with painless blood streaked stools loose and may contain mucus, positive hem occult testing

Food Protein-Induced Allergic Proctocolitis (FPIAP) Non IgE-Mediated reaction caused by Cows Milk Protein found in standard formulas or breast milk (due to maternal dairy intake) - Eosinophilic Inflammation of rectosigmoid colon Triggered by cows milk and soy protein Tx: removal of offending food protein from infants diet. If mom stops eating/drinking dairy then can continue to breast feed. Alternatively infant can be switched to hydrolyzed formula containing predigested proteins. If symptoms resolve then can reintroduce dairy at age 1, if symptoms not resolved then alternate diagnosis order flexible sigmoidoscopy

postcholecystectomy Diarrhea

Form of bile salt induced Diarrhea Primary bile acids produced in the liver secreted into the intestinal lumen, converted to secondary bile acids by bacteria. These can cause colonic stimulation if present in excess. Gallbladder surgery alters hut dynamics and leads to increased bile acid flux to the colon resulting in increased proportion of secondary bile acids and cause diarrhea. Also seen in ill resection or short bowel syndrome TX: CHOLESTYRAMINE (bile salt-binding resin sequesters excess bile salts) effective against diarrhea.

50-60yo, loss of empathy, disinhibition, apathy, loss of empathy, hyperorality, executive dysfunction. emotionally cold, doesn't care about anything, flirting with others, urinating in front of people, memory difficulties

Frontotemporal Dementia TDP-43 Mutation-DNA binding protein Hyperphosphorylated Tau Protein Inclusions (Pick Bodies) CT, MRI: frontal/anterior temporal lobe atrophy Nonpharm: Behavior modification Pharm: SSRI, atypical antipsychotic

Dyspepsia (burning epigastric pain +/- Nausea, Vomiting, epigastric fullness and heart burn)

Functional (75%), Malignancy (gastric, Esophageal), PUD, NSAID, H. Pylori Infection, GERD >60yo: Upper Endoscopy <60: Test & treat for H. pylori, if high risk patient (GI bleed, weight loss) do upper endoscopy (Stool Antigen, Urea breath testing)

Thick Brittle Discolored nails due to ONYCHOMYCOSIS

Fungal Infection of toenails or fingernails Advanced Age, Tines Pedis, DM, Peripheral Vascular Dz Dx: KOH prep or periodic acid Schiff stain of nail scraping: Dermatophytic Hyphae and Arthrospores 1st line: Terbinafine, Itraconazole 2nd line: Griseofulvin, Fluconazole, Ciclopirox infection of fingernails requires 6 weeks of tx, toenails 12 weeks Tx can result in primary hepatotoxicity

jaundice and fatigue, Low Haptoglobin, Red blood cell fragments in a child with recent skin infection treated with abx

G6PD Deficiency, X-linked, Asian/African/Middle Eastern Jaundice and anemia day of life 2-3 or Secondary to oxidative stress (Java beans, sulfa drugs), jaundice, pallor, dark urine, ab/back pain Hemolytic anemia, Bite cells with Heinz Bodies on peripheral smear G6PD normally protects RBCs from Oxidative stress by producing NADPH, deficiency of G6PD leads to intra and extravascular hemolysis triggered by oxidative stress such as infection, sulfa drugs (TMP-SMX), lava beans Indirect hyperbili, Low haptoglobin, elevated lactate dehydrogenase. Bite cells and schistocytes on peripheral smear. Heinz bodies (denatured Hgb accumulations)

Chronic cough, hoarsenses, throat irritation episode of chest pain, worse with alcohol or big meal

GERD Decreased tone or excessive transient relaxation of LES, Anatomic disruption to gastroesophageal junction (hiatal hernia), high risk with obesity, pregnancy, smoking, alcohol intake Alcohol causes decrease in lower esophageal sphincter tone Complications: Esophageal-erosive esophagitis, barrett esophagus, strictures, Extraesophageal-Asthma, laryngitis Tx: Weight loss, dietary changes, H2R blocker or PPI 8 week course (Omeprazole)

initiation of chronic hemodialysis for CKD is delayed until

GFR 7.5-15 or complications of CKD (uremic symptoms, volume overload) become unmanageable with medications alone.

Age related decline in renal function

GFR slowly declines at age 30-40, and then rapidly age 40-50. Normal no additional studies needed. Oxidative stress and telomere shortening thought to play a role in age related loss of renal function by promoting nephrosclerosis (tubular atrophy, interstitial fibrosis, small artery arteriosclerosis and hyalinosis. Global and superficial glomerulosclerosis caused by reduced podocyte density, leading to glomerular tuft collapse. No significant rise in creatinine because derived from muscle tissue which decreases in mass with age (sarcopenia)

Asymmetric Peripheral Oligoarthritis, Enthesitis, Dactylitis, Uveitis, Conjunctivitis, Urethritis, Cervicitis, Prostatitis, Keratoderma blennorrhagicum, circinate balanitis (painless, shallow ulcers of the glans penis), oral ulcers.

GI: Salmonella, Shigella, Yersinia, Campylobacter, C. Diff GU: Chlamydia Trachomatis NAAT for chlamydia performed on urine samples Tx: Abx, NSAIDs, (if failed or contraindicated then intraarticular glucocorticoids, systemic glucocorticoids, disease-modifying anti rheumatic drugs.

causes of urinary incontinence in the Elderly

GU: DEC Detrusor contractility, Detrusor Overactivity, bladder or urethral obstruction (tumor, BPH), Urethral sphincter or pelvic floor weakness. Urogenital fistula Neuro: MS, Dementia (Parkinson, Alzheimer, NPH), Spinal cord injury, disc herniation. Potentially reversible: DIAPPERS Delirium, Infection (UTI), Atrophic Urethritis/Vaginitis, Pharm (Alpha blockers, , anticholinergics, opiates, calcium channel blockers, Diuretics), Psychological (depression), Excessive Urine output (DM, CHF), Restricted mobility (post surgery), Stool impaction

Normal Pressure Hydrocephalus (NPH)

Gait instability, Cognitive dysfunction, Urinary urgency/incontinence, depressed affect, upper motor neuron signs in lower extremities Enlarged ventricles out of proportion to underlying brain atrophy on MRI FIRST undergo LUMBAR DRAINAGE OF CSF (lumbar tap test Miller fisher test evaluates parameters such as gait, stride, verbal memory, and visual attention before and after removal of 30-50 ml of CSF. if improvement then definitive treatment with VP shunt. If no improvement no shunt necessary. TX: VENTRICULOPERITONEAL SHUNTING (VP SHUNT)

Hypoglycemia, and ill and dehydrates due to vomiting after ingestion of breast milk or cows milk based formula.

Galactosemia HIGH Galactose levels Autosomal Recessive Disorder inability to digest galactose due to deficiency of Galactose-1-Uridyl Transferase.

N,V, Abdominal Pain, Early satiety, bloating, weight loss, Sweating during meals, postural dizziness, postprandial fullness, early satiety, constipation

Gastroparesis Causes: Autonomic Neuropathy from DM, Opioids and Anticholinergic drugs, Vagus nerve injury from trauma or post surgery, MS or spinal cord injury, post viral Dx: Exclude obstruction by upper endoscopy +/- CT/MR enterography, Assess motility via nuclear gastric emptying study Tx: Frequent small meals (low fat, soluble fiber), Promotility drugs (metoclopramide, Erythromycin), Gastric electrical stimulation &/or jejunal feeding tube

Screening for HIV

HIV Antigen (p24) & HIV-1/HIV-2 Abs. Usually too low to detect first 1-4 weeks (window period). REPEAT after 4 weeks. Post exposure prophylaxis reduces the risk of HIV but should be striated <72hrs after exposure. Newly diagnosed HIV, and prior to initiating antiretroviral require testing for Hep B virus, TB, Hep C and sexually transmitted pathogens (treponema, Neisseria)

N, V, Epigastric abdominal pain, early satiety, bloating, weight loss, DM

Gastroparesis-Delayed gastric emptying Decreased gastric pacemaker activity (delayed gastric emptying in the absence of mechanical obstruction) Autonomic nervous system (parasympathetic, Symoathetixc) and intrinsic nervous system of the stomach (intestinal cells of Cajal-Gatric pacemaker cells) DM (Autonomic neuropathy), Medications (opioids, anticholinergics), Traumatic/Post surgery (vagal nerve injury), Neurologic (MS, Spinal cord injury), Idiopathic/postviral. Dx: Exclude obstruction by upper endoscopy +/- CT?MR enterography, Assess Motility: Nuclear gastric-emptying study. Tx: Frequent small meals (low fat, soluble fiber only), Promotility drugs (metoclopramide, erythromycin), Gastric electrical stimulation &/or jejunal feeding tube (refractory)

Diabetic kidney disease (DKD)

Glomerular Hyperfiltration (Dec serum Cr, Increased albuminuria) Due to afferent arteriole vasodilation by naturetic peptides and prostaglandins, and efferent arteriole vasoconstriction from Angiotensin II. This causes increase in glomerular hydrostatic pressure, which increases GFR (glomerular filtration rate) and sclerosis of glomerular capillaries. ACE-I (Lisinopril) or Angiotensin II Blockers (Losartan) blocks Angiotensin II efferent vasoconstriction to reduce glomerular hydrostatic pressure

Diabetic with a skin rash

Glucagonoma - Necrolytic Migratory Erythema Rare pancreatic tumor associated with mild diabetes and a classical skin rash. Secretion of VIP, calcitonin, and GLP1. Rash that has clearing from the center. Also lethargy, weight loss, Diarrhea, abdominal cramps, facial flushing. Confirm dx with glucagon levels Primary tx is surgical

Exposure to oxidative stress (sulfa drugs, lava beans) with hemolysis (jaundice, pallor, dark urine), abdominal and or back pain

Glucose-6-Phosphate Dehydrogenase Deficiency

Antithyroid Antibodies are useful in evaluation of

Goiter, Primary Hypothyroid (hashimotos/chronic autoimmune thyroiditis)

Gonococcal vs nongonococcal urethritis

Gonococcal: Neisseria Gonorrhoeae -Purulent Discharge -Intracellular Gram-Neg Diplococci on gram stain -Tx: Ceftriaxone NonGonococcal: Chlamydia, Ureaplasma Urealyticum, Mycoplasma Genitalium, Trichomonas Vaginalis -Watery discharge -Aseptic with leukocytes, no organisms on gram stain -Tx: AZITHROMYCIN or DOXYCYCLINE If continued symptoms then may be due to reinfection, medication non compliance or infection with an organism not sensitive to initial empiric therapy first diagnostic step is to repeat urethral fluid gram stain. if positive then need NAAT for chlamyida, gonnorhea

acute glomerulonephritis, alveolar hemorrhage, hemoptysis

Goodpasture Dz dx: antiglomerular basement membrane antibodies

Red blood cells in urine, Red cell casts in urine, Mild degrees of proteinuria (<2 g per 24 hours), Edema. Cough, hemoptysis, shortness of breath, and lung findings.

Goodpasture Syndrome Dx: Best initial test = ANTI-BASEMENT MEMBRANE ANTIBODIES (best initial test), Renal Biopsy showing linear deposits. Treatment is plasmapheresis and steroids.

beefy red genital lesion that ulcerates. Diagnosis & Treatment

Granuloma Inguinale Diagnostic testing is biopsy or "touch prep," Klebsiella granulomatis, Donovan bodies. Treatment is doxycycline, TMP/SMX, or azithromycin.

Red blood cells in urine, Red cell casts in urine, Mild degrees of proteinuria (<2 g per 24 hours), Edema. sinusitis and otitis. cough, hemoptysis, abnormal chest x-ray. Joint, skin, eye, brain and GI problems.

Granulomatosis with Polyangiitis (Wegner) Best initial test is C-ANCA (Antineutrophilic cytoplasmic Abs) or Antiproteinase 3-ANCA. Kidney biopsy. Tx: cyclophosphamide (or rituximab) and steroids.

Systemic Necrotizing Vasculitis marked by Glomerulonephritis, Chronic Pneumonitis, and recurrent sinusitis/otitis media. In older adults.

Granulomatosis with Polyangiitis (wegners)

c-ANCA elevated in

Granulomatosis with Polyangiitis and Microscopic Polyangiitis

+ Thyroid Stimulating Immunoglobulin Assay and Diffusely increased uptake on radio iodine scintigraphy

Graves Disease Symptomatic should be started on beta blocker (propranolol) to reduce symptoms, with additional measures to decrease thyroid hormone production and achieve euthyroid state such as Antithyroid drugs, radioactive iodine, thyroidectomy Methimazole preferred due to risk of hepatotoxicity with PTU however indicated for 1st trimester due to teratogenic effects of methimazole Mod to severe graves opthalmopathy (exopthlamos, periorbital edema , and visions changes) prior to definitive treatment with surgery or RAI should be treated with Prednisone.

Indications for Cystoscopy

Gross hematuria with no evidence of glomerular disease or infection Microscopic hematuria with no evidence of glomerular disease or infection but increased risk for malignancy recurrent UTI Obstructive symptoms with suspect stricture or stone Abnormal bladder imaging Or urine cytology

Growing Pains vs Pathologic Leg pain

Growing: -3-12yo, BILATERAL, nonarticular, paroxysmal (thigh, shin), non progressive, evening/night, no systemic symptoms, no activity limitations, normal exam Pathologic: -Any age, UNILATERAL (Osteoid Osteomalacia, Osteosarcoma), articular (joint involved in juvenile idiopathic arthritis), persistent, progressive, any time, systemic symptoms (Inflammatory such as osteomyelitis, leukemia, systemic arthritis), activity limitation, abnormal exam For pathologic get CBC, inflammatory marker and Xray

Erythropoietin (EPO)

Growth factor produced by the kidney that stimulates precursors of RBC to start producing erythrocytes within the bone marrow. CKD & End stage renal disease have LOW EPO due to kidney dysfunction

ascending paralysis with absent deep tendon reflexes following a GI or respiratory infection progresses over several days to weeks.

Guillain Barre Syndrome Electrodiagnostic studies and or lumbar puncture and cerebrospinal fluid analysis Tx: Therapeutic Plasma Exchange

GI Illness followed by severe symmetric muscle weakness and absent deep tendon reflexes

Guillain-Barre Syndrome Symmetric muscle weakness, paresthesias, Dysautonomia (Tachycardia, urinary retention), decreased or absent deep tendon reflexes at risk for rapid onset respiratory failure due to respiratory muscle weakness, frequent measures of vital capacity and negative inspiratory force required to monitor respiratory status end up requiring mechanical ventilation. TX: PLASMA EXCHANGE OR IVIG SPONT neurologic recovery without intervention, however treatment with plasma exchange or IVIG SHORTENS the time to recovery

fever, abdominal pain, profuse watery diarrhea (mucus/blood), mild leukocytosis

Guillain-Barré syndrome - Campylobacter Gastroenteritis Complication: Demyelination of axons

Isolated rise in anti-HBs

HBV Vaccinated

Exertional dyspnea, fatigue, angina, light headed, syncope, systolic ejection murmur accentuated by Dec LV blood volume (Standing) , Diastolic dysfunction with audible S4, increased risk of atrial fib and tachycardia

HCM Genetic mutation affecting cardiac sarcomere proteins AD inheritance ECG: Left axis deviation, Q waves (depolarization abnormalities), Inverted T waves (repolarization abnormalities) Echo: Septal LV Hypertrophy, Dynamic LVOT obstruction, LA dilation Management: Beta Blocker or Nonduhydropyridine CCB (Increase LV Blood volume), Avoid Dehydration & vasodilators (Dec LV blood volume), ICD for increased risk of SCD, septal ablation, cardiac transplant

Photosensitivity reaction in a patient started on an antihypertensive medication

HCTZ Thiazides are sulfonamides, cause photosensitivity or generalized dermatitis DC the med, use sunscreen and avoid sun exposure

Third trimester with hemolytic anemia, thrombocytopenia, elevated transaminases

HELLP Syndrome

hemolysis (H), elevated liver (EL) enzymes, and low platelets (LP)

HELLP Syndrome

Peripartum Cardiomyopathy (PPCM)

HF Maternal Age >30, Multiple Gestation, Preeclampsia, Eclampsia LVEF <45% 36 week gestation to 5 months postpartum Tx via standard Systolic HF regimen, Thromboembolism Prophylaxis Recurrence risk if LVEF <20% at diagnosis, and persistent LV systolic dysfunction EVALUATE WITH SERIAL ECHO for a few years, those with recurrent or persistent LV dysfunction are advised to avoid pregnancy

hCG and inhibin A are

HI in Down syndrome

High Output HF

HIGH Central Venous Pressure -> HIGH Pulmonary Capillary Wedge Pressure -> Decreased SVR -> HIGH CO Morbid obesity & Paget Disease: Increased quantity of peripheral vessels AV Fistula (Hemodialysis or Trauma) and Congenital AV Malformation: Bypass of systemic arteriolar resistance Hyperthyroid, Severe anemia, Thiamine Deficiency: Vasodilation due to unmet metabolic demand in tissues

All patients <75 with known atherosclerotic cardiovascular disease (MI) regardless of baseline LDL level

HIGH INTENSITY STATIN THERAPY (atorvastatin 20-40 daily, Rosuvastatin 20-40 daily) ALSO recommended for LDL>190, >40 yo with DM or 10 year risk of atherosclerotic cardiovascular disease >7.5-10%

Need to rule out diagnosis

HIGH SENSITIVITY, NEGATIVE RESULTS, RULE OUT Diagnosis SnNout Sensitivity is the ability of a test to correctly identify patients with the disease. HIGHLY sensitive tests are most likely to detect a disease and the least likely to give false negative results. MOST appropriate for SCREENING

Thyrotoxicosis due to surreptitious thyroid hormone use will result in

HIGH T4, T3 LOW TSH

HIV in Infancy

HIGH maternal Viral Load, breastfeeding by infected mother Failure to thrive, chronic diarrhea, lymphadenopathy, hepatosplenomegaly, Pneumocystis pneumonia, prolonged/refractory candidiasis Dx: HIV DNA or RNA PCR TX: ART

Acute Compartment Syndrome

HIGH pressure within enclosed fascial space LOW blood flow & tissue perfusion Causes: Crush injury, long bone fractures, Rhabdomyolysis, Reperfusion after prolonged ischemia, Massive fluid resuscitation EARLY: Severe pain, rapidly increasing and tense swelling, HIGH pain with passive stretching, paresthesia LATE: LOW sensation, Weakness within hours, paralysis, loss of pulses Compartment pressure measurements to confirm (Delta pressure (diastolic pressure - compartment pressure) <30 Emergency fasciotomy

A screening test must have

HIGH sensitivity (RULE OUT) disease: SnNOut: Increases negative predictive value (NPV). As few false negatives as possible. IF choose a highly specific test then get a lot of false negatives thus diseased people would be considered healthy.

HIV on antiretroviral develops loss of subcutaneous fat from face, arms, legs, abdomen and buffalo hump and visceral abdominal fat

HIV associated Lipodystrophy Lipoatrophy: Nucleoside Reverse Transcriptase Inhibitors (Stavudine, Zidovudine) Fat accumulation Abnormal lipid and glucose metabolism, leads to INSULIN RESISTANCE, dyslipidemia, and increased risk of CV dz.

<200 CD4 cells. Prophylaxis?

HIV patients at risk for pneumocystis, disseminated mycobacterial infections when CD4 cells below this number Pneumocystis jiroveci Pneumonia (PCP) TMP/SMX is the best prophylaxis for PCP by far. If TMP/SMX causes a rash, switch to atovaquone or dapsone. (Dapsone cannot be used if there is G6PD deficiency.)

genital warts (condylomata acuminata)

HPV 6 & 11 flesh colored hyperkeratotic papules, 1-2 cm in diameter, smooth surface and sessile Tx: Podophyllin resin, Trichloroacetic Acid, Imiquimod, Cryotherapy, Laser therapy, Excision Prevent with vaccination and barrier contraception Can be VERTICALLY transmitted. Children end up with lesions in oropharynx, larynx, trachea age 2-5. Most severe is juvenile-onset respiratory papillomatosis. C-SECTION DOES NOT prevent vertical transmission or decrease risk. Therefore expectant management with vaginal delivery is the best management. NO PODOPHYLLUM during pregnancy due to birth defects and intrauterine fetal demise

Plantar Warts (verrucae)

HPV in those with occupations in meat, poultry, fish handling) and more extensive disease in those with atopic dermatitis and decreased immunity HIV, Organ transplant Multiple or single hyperkeratotic papule on sole of the foot scraping can confirm dx by showing thrombnosed capillaries (seeds) Tx: Salicylic Acid preferred intimal treatment, soak the area in warm water for 10-20 min, then alicyclic acid applied to wart taped in place with duct tape and then kept dry for 48-72 hrs. then take it off file the area with sandpaper and then repeat application. liquid nitrogen is an alternative but causes scarring initials response to salicylic acid treatment takes 2-3 weeks and tx is continued for 1-2 weeks after clinical resolution to eradicate the virus and prevent recurrence,. Liquid nitrogen may also need regular intervals of 2-3 weeks.

Surgical Complications of Adrenalectomy for Pheochromocytoma

HTN Crisis: HIGH Catecholamines release due to endotracheal intubation & Adrenal gland manipulation. HIGH Serum Norepinephrine with larger tumors: TX with IV nitroprusside, Phentolamine or Nicardipine HYPOtension: Low catecholamine after tumor removal, Persistent Alpha blockade from preop long acting alpha blocker (phenoxybenzamine): Tx with NS bolus HYPOGLYCEMIA: High insulin secretion following tumor removal (catecholamines suppress insulin secretion): Tx with IV Dextrose Infusion Cardiac Tachyarrhythmias: High Catecholamine release from adrenal gland handling

CV effects of cocaine intoxication

HTN, Tachycardia, Coronary Vasoconstriction, High platelet activity & Thrombus formation. MI, Aortic Dissection, Neuro ischemia, Stroke. Tx: Benzo, Nitroglycerine, CCBs (Amlodipine) for chest pain, Phentolamine for persistent HTN. If persistent ST elevation despite medical therapy they should undergo coronary revascularization without delay (PCI), to prevent MI AVOID BETA BLOCKERS can lead to unopposed alpha-1 receptor-mediated vasoconstriction in patients with acute cocaine ingestion

Hyperactive Deep Tendon Reflexes, muscle cramps, convulsions immediately post op

HYPOCALCEMIA Due to volume expansion and Hypoalbuminemia Occurs Wirth massive blood transfusions related to large amounts of citrate used to anticoagulant blodd, the citrate chelates with calcium leading to hypocalcemia.

30 day mortality in PE (Chest pressure, syncope, pulmonary artery filling defect on CT angio)

HYPOTENSION (SBP<90) TACHYCARDIA (>110) TACHYPNEA (>30/min) HYPOTHERMIA (<86F) HYPOXEMIA (<90%) AMS Hx of Cancer >80yo RV dysfunction (MOST IMPORTANT PREDICTOR OF INCREASED SHORT TERM MORTALITY) HIGH Troponin & BNP

Laboratory abnormalities in vomiting

HYPOchloremic HYPOkalemic Metabolic ALKALOSIS LOW Na, K, Cl HIGH Bicarb, pH Loss of hydrochloric acid (Hypochloremic) leads to increased serum bicarbonate resulting in primary metabolic alkalosis with increased serum pH Loss of water and salt leads to intravascular volume depletion this leads to decreased renal perfusion and activation of the renin-angiotensin-aldosterone system. Aldosterone will stimulate Na reabsorption (passive Cl reabsorption) to increase blood volume. Greater loss of Cl compared to Na from stomach and kidneys leads to large Cl deficit and Hypochloremia. It stimulates potassium secretion leading to hypokalemia and stimulates hydrogen secretion exacerbating the metabolic alkalosis. Persistent hypovolemia also stimulates appropriate secretion of ADH in an attempt to restore itself to euvolemia. this leads to free water retention with hyponatremia.

hypothyroid features, Diffuse goiter

Hashimotos (Chronic Autoimmune Thyroiditis) + TPO Variable Radioiodine uptake

CAGE (alcohol use questions)

Have you felt you should CUT down on your drinking? have others ANNOYED you by criticizing your drinking? Have you ever felt bad or GUILTY about your drinking? Have you ever taken a drink first thing in the morning (EYE OPENER) to steady your nerves?

Awareness of being observed and possible impact on behavior, causes what type of bias?

Hawthorne effect Threat to internal validity Minimize by keep subjects unaware they are being studied

Participants modify their behavior due to their awareness of the fact that they are being studied

Hawthrone effect

Anemia in pregnancy

Hb <11 g/dL in the first and third trimesters and <10.5 g/dL in the second trimester. The most reliable indicator of true anemia is MCV. ↓ hemoglobin ↓ MCV: Give iron. Test for thalassemia if anemia does not improve. ↓ hemoglobin ↑ MCV ↑ RDW: give folate

Alpha Thalassemia

Hb Barts (4 Gamma Chains)

Sudden onset of weakness in the right arm and leg over the last hour. On exam he is unable to lift the bottom half of the right side of his face. Best initial step?

Head CT without contrast (rule out hemorrhagic stroke) Thrombolytics are indicated within at least the first 3-4.5 hours of the onset of the symptoms of a stroke. Avoid in Hemorrhagic stroke.

Microangiopathic Hemolytic Anemia (Schistocytes, High Bili), bruising, petechiae, oliguria, edema, fatigue, pallor, thrombocytopenia, acute renal failure in age <5 with bloody diarrhea

Hemolytic Uremic Syndrome Shiga Toxin produced by S. Dysenteriae or E. coli O157:H7 Tx: Fluid & Electrolyte, Blood transfusion, Dialysis No Abx because bacterial killing may lead to increased release of shiva toxin

pediatric patient with abdominal pain, skin rashes, joint inflammation

Henoch-Schonlein Purpura

adolescent or child with the following symptoms: -Raised, nontender, purpuric skin lesions, particularly on the buttocks -Abdominal pain -Possible bleeding -Joint pain -Renal involvement combined presentation of GI, joint, skin, and renal involvement.

Henoch-Schonlein Purpura Biopsy shows deposition of IgA

rash begins as erythematous macula's that coalesce into Palpable purpura/petechiae on lower ext, arthritis, arthralgia, abdominal pain, intussusception, renal disease, scorotal pain and swelling,

Henoch-Schonlein Purpura (HSP) Pediatric vasculitis from IgA deposition. Tx: Supportive care (hydration and NSAIDS), if severe hospital and systemic glucocorticoids

female with well demarcated lesion in the right lobe of the liver that shows peripheral enhancement with IV contrast administration.

Hepatic Adenoma Benign epithelial liver tumor, Young women on OCP Incidental finding, asymptomatic. <5cm - STOP OCP >5cm - SURGICAL resection May transform into malignancy, may rupture & hemorrhage

Most Common Cause of Ascites in the US

Hepatic Cirrhosis

Enlarged Liver with HIGH Alk Phos & Gamma-Glutamyl Transpeptidase (= Liver cause of all phos elevation NOT bone). Hilar adenopathy on CXR.

Hepatic Sarcoidosis Infiltration with noncaseating granulomas seen on CT and MRI, but NEED biopsy to rule out other granulomatous diseases like TB and metastatic malignancy Tx: Systemic Glucocorticoids (prednisone)

Increased hepatic echogenicity on US and HIGH Transaminases.

Hepatic Steatosis

Early sign of pityriasis rosea

Herald Patch pruritic 2-10cm pink/tan colored lesion usually appears on tieback

C1 esterase inhibitor deficiency

Hereditary Angioedema Angioedema of throat, tongue, lips without urticaria as well as abdominal pain due to angioedema of intestinal mucosa.

gross hematuria, progressive renal insufficiency. hematuria in childhood and develop hearing loss in adolescent.

Hereditary Nephritis (alport Syndrome)

IV acyclovir

Herpes Encephalitis Fever, Irritability, cutaneous lesions, seizures, vesicular rash

Screening tests for DM

Hgb A1c: Preferred test in non fasting state, >6.5% =DM, 5.7-6.4% =Increased risk, <5.7=Normal Fasting Blood Glucose: 8hr fast, >126 =DM, 100-125 = Increased risk, <100=Norm RandommGlucose Level: >200 with symptoms = DM, 140-199 = Increased risk, <140 = Norm Oral Glucose Tolerance Test: MOST SENSITIVE TEST, 75g glucose load with glucose testing for 2hrs, >200 = DM, 140-199 = increased risk, <140 = Norm Asymptomatic patients with an abnormal screening test for DM require a repeat measurement with the same test to confirm the diagnosis Symptomatic + HIGH HbA1c and +FH = Diagnose with DM

Primary hyperaldosteronism (Conn's syndrome)

High Aldosterone, LOW potassium, LOW H (Metabolic Alkalosis), HIGH Sodium (HTN, HIGH Blood Volume)-> LOW renin, LOW Angiotensin II Aldosterone Escape: HIGH Renal Blood Flow, HIGH Glomerular Filtration Rate, HIGH Atrial Natriuretic Peptide -> HIGH Sodium Excretion

HHSV 6 (Roseola Infantum)

High fever, erythematous maculopapular rash starts on trunk and spreads to extremities

Thyroid effects of amiodarone

High iodine content, direct effects on thyroid follicular cells 1. Decreased T4 to T3 conversion : HIGH T4, LOW T3, NORM TSH : Clinically Euthyroid : NO Tx 2. Inhibit Thyroid Hormone Synthesis -> PRIMARY HYPOTHYROID (Wolff-Chaikoff Effect) : Levothyroxine 3. THYROTOXICOSIS due to either increased thyroid hormone synthesis (AIT type 1) or Destructive Thyroiditis (AIT Type 2) : Antithyroid meds and Glucocorticoids

Non Occupational HIV Post Exposure Prophylaxis

High risk contact NEED prophylaxis (vagina, rectum, eye, mucus membranes, blood, semen, rectal or vaginal secretions, breast milk, any body fluid with visible blood Initiate within 72hrs continue for 28 days TRIPLE DRUG THERAPY for 4 weeks (TENOFOVIR-EMTRICITABINE + RALTEGRAVIR) preferred due to low side effects and fewer drug drug interactions. Two Nucleotide/Nucleoside Reverse Transcriptase inhibitors (TENOFOVIR, EMTRICITABINE, LAMIVUDINE, ZIDOVUDINE) + One Integrase Strand Transfer Inhibitor (RALTEGRAVIR), Protease Inhibitor (ATAZANAVIR, RITONAVIR) or Non Nucleoside reverse transcriptase inhibitor (RILPIVIRINE)

Febrile Neutropenia (Absolute Neutrophil count <1500)with no focus of infection given normal X-ray and urinalysis. On chemotherapy. Mucosal pallor and gingival erythema.

High risk for bacterial infection due to blunted neutrophil-mediated inflammatory response. Chemo may lead to disruption of the skin and mucosal Barries of the mouth and GI tract, resulting in mucositis. PSEUDOMONAS AERUGINOSA Empiric Abx therapy with mono therapy using antipseudomonal beta-lactam agent (Cefepime, Meropenem, Piperacillin-Tazobactam)

Failure to pass meconium leading to abdominal distension, poor feeding, bilious emesis. On Abdominal Xray multiple dilated bowel loops and absence of rectal air concerning for distal bowel obstruction

Hirschsprung Disease (Congenital Aganglionic Megacolon) Transition zone between a normal or narrow caliber rectosigmoid (ganglionic segment) and a normally innervated but markedly dilated descending colon. Dx: Rectal Mucosal Suction Biopsy (absence of ganglion cells) TX: Surgical resection of the aganglionic segment followed by anastomosis of normal bowel to anus. COMMON IN DOWN SYNDROME

Persons Needing Antimicrobial Prophylaxis following Neisseria Meningitidis exposure

Household, Roomates or intimate contacts, child care center workers, persons directly exposed to respiratory or oral secretions (endotracheal intubation), person seated next to affected person for >8hrs Neisseria Meningitidis - acute bacterial meningitis 2-18yo, Attaches to the nasopharyngeal epithelium where it can replicate asymptomatically or cause invasive disease. Mucosal invasion is followed by bacteremia leading to sepsis, meningitis or both. CHEMOPROPHYLAXIS can prevent spread - **RIFAMPIN (x4 doses PO), CEFTRIAXONE (IM x 1, can be used in pregnancy), CIPROFLOXACIN (PO x1, not used for children)

AUDIT- C ( The Alcohol Use Disorders Identification Test -Consumption)

How often do you drink alcohol? How many drinks do you have on a typical day when you are drinking? How often do you have 6 ( 4 women) or more drinks on 1 occasion?

Complications of Multiple Myeloma

Hypercalcemia: anorexia, nausea, polyuria, constipation, weakness, confusion. Tx with hydration and dexamethasone, bisphosphanates Renal Insufficiency: light chain cast nephropathy or deposition disease, normocytic anemia. Require plasmapheresis or dialysis Infections (pneumonia, Urinary Tract) Skeletal lesions: bone pain or pathologic fracture, prevent with bisphosphantes Hyperviscosity syndrome: Nasal or oral bleeding, blurry vision, neurologic symptoms, HF. DUE TO excess monoclonal IgM. IgM clogs the microcirculation in the brain leading to headaches, dizzy, vertigo, nystagmus, hearing loss, vision impairment. mucosal hemorrhage from impaired platelet function. Tx by plasmapheresis Thrombosis: High risk for arterial (stroke/transient ischemic attack, MI) and venous thrombosis

Drug induced pancreatitis

Hypersensitivity to sulfa, ischemia due to decreased intravascular blood volume, increased viscosity of pancreatic secretions Analgesics: Acetaminophen, NSAID, Mesalamine, Sulfasalazine, Opiates Antibiotics: Isoniazid, Tetracycline, Metronidazole, TMP-SMX Antiepileptics: Valproic Acid, Carbamazepine AntiHTN: Thiazide diuretics (HCTZ, Chlorthalidone), Furosemide (loop diuretic), Enalapril, Losartan Antivirals: Lamivudine, Didanosine Immunosuppresants: Azathioprine, Mercaptopurine, Corticosteroids Other: Asparaginase, Estrogens

Elderly with lethargy, apathy, decreased appetite, weight loss, muscle weakness

Hyperthyroidism Assess thyroid function with serum TSH Most older patients with hyper thyroid dont have a goiter. Cause of thyrotoxicosis include excess dosing of levothyroxine, nodular thyroid disease, and graves. Weight loss, temperature elevation, Widened pulse pressure (hyperthyroid induced increase in CO with decrease in systemic vascular resistance), new on set A fib

newborn with respiratory distress (Tachypnea, Nasal flaring, restrictions) and a heart murmur in a mother with gestational diabetes

Hypertrophic Cardiomyopathy Occurs in late second to early third trimester due to fetal hyperinsulinemia in response to maternal and fetal hyperglycemia Insulin triggers glycogen synthesis and excess glycogen and fat are deposited within the myocardium, inter ventricular septum. Increased oxidative stress of the inter ventricular septum contribute to this selective thickening. If left ventricular outflow is obstructed result in CHF. Pulmonary congestion and cardiomegaly on CXR, and echo confirms the diagnosis. If asymptomatic - No Tx If HF - Propranolol and Fluids Spont resolution expected within a few weeks after birth. Echo findings normalize within a year. Excess glycogen within the myocardium is depleted by normal metabolic process

nerve injury during carotid endarterectomy

Hypoglossal Nerve: Tongue deviation to the side of injury Recurrent laryngeal nerve: unilateral vocal cord paralysis (nerve lies distal to the area of the carotid dissection) Facial Nerve: marginal mandibular branch resulting in asymmetric smile (after exits from stylomastoid foramen and courses along the inferior portion of the ear) Vagus Nerve: posterolaterally in the carotid sheath Ansa HypoglossusL: innervates the strap muscle of the neck

Initial evaluation of dementia, rule out?

Hypothyroid, Vit B12 deficiency, Depression (most common cause of reversible dementia) MRI or Head CT to identify signs of chronic vascular disease, subdural hematoma, or normal pressure hydrocephalus.

Weak, fatigue, weight gain, bradycardia, delayed Deep tendon reflexes, constipation, cold intolerant. Coarse dry skin, horsenesss, non pitting edema, macroglossia. (Matrix glycosaminoglycan accumulation) Depression, myalgia, arthralgia, hypercholesterolemia

Hypothyroidism

Elevated TSH, New onset fatigue during tx with lithium

Hypothyroidism Lithium interferes with synthesis and release of thyroid hormone, causing range of thyroid abnormalities. Prior to starting lithium need thyroid function tests as well as q6-12m thereafter. DONT STOP lithium, continue it and ADD LEVOTHYROXINE

euvolemic hypo-osmolar hyponatremia. Fatigue, Weight gain, HIGH TSH, recent pregnancy

Hypothyroidism due to postpartum Thyroiditis (Autoimmune variant od hashimotos) If symptomatic and severe treat with Levothyroxine to correct Hyponatremia, if mild and asymptomatic then self resolves.

orthostatic hypotension in an athlete with dry mucus membranes, hemoconcentration, elevated blood urea nitrogen/creatinine ratio, hypokalemia

Hypovolemia common cause of orthostatic syncope can occur in athletes who use fluid restriction and diuretics to achieve rapid weight loss to complete in a light weight category. Dehydration & diuretic induced potassium elimination

alcoholic ketoacidosis tx

IVF (Dextrose + NS), Dextrose leads to an increase in insulin secretion, which leads to metabolism of ketone bodies to bicarbonate. ALSO add THIAMINE (as alcoholics are deficient) DO NOT DISCHARGE (mat develop alcoholic withdrawal, electrolyte imbalance, aspiration pneumonia, glucose can increase utilization of thiamine and cause more of a thiamine deficiency leading to Wernickes Encephalopathy.

Brain dead organ donors should be managed in the ICU to maintain hemodynamic support

IVF, Pressor, mechanical ventilation should be continued to prevent hypoxia and hypercapnia, Hormone replacement therapy (methylprednisolone, thyroid hormone, and vasopressin) to prevent diabetes insidious severe volume depletion and adrenal insufficiency contributing to hypotension.

Diffuse, scaly skin with mild pruritis, worse on extensor extremities, spares intertrigenous areas

Ichthyosis Vulgaris Loss of function in Filaggrin Gene (impaired epidermal barrier, reduced skin moisturization) The skin is rough and dry with white or gray fish-like scales First appears infancy or childhood and worsen during dry season (winter) Associated Conditions: Keratosis Pilaris, Palmar Hyperlinearity, Atopic Disease Therapy: Long baths to remove scales, Moisturization, Keartolytics (UREA, ALPHA-HYDROXY ACID, SALICYLIC ACID)

diffuse rough dry skin with fish like scales on the extensor extremities and trunk

Ichthyosis treat with Topical Lactic Acid

Vaginal Trichomoniasis can be ASYMPTOMATIC

Identified incidentally on routine cervical cytology with multiple motile flagellated organisms Regardless of symptoms BOTH patient and partners should be treated with ORAL METRONIDAZOLE

COHORT STUDY

Identify individuals as exposed or non exposed to a risk factor and THEN the rates of outcome (disease) are compared. PROSPECTIVE: study begins BEFORE the outcome RETROSPECTIVE: study begins AFTER the outcome has occurred

Obese woman headaches, nausea, vision changes, and papilledema (blurred optic discs). Elevated opening pressure on lumbar puncture.

Idiopathic Intracranial Hypertension Due to increased intracranial venous pressure due to impaired resorption of CSF by the arachnoid granulations and CSF lymphatic drainage sites. Tx: Prevent vision loss, reduce ICP, symptomatic relief of headaches. ACETAZOLAMIDE first line tx for symptomatic idiopathic intracranial hypertension, works by inhibiting choroid plexus carbonic anhydrase, thereby decreasing CSF production by the choroid plexus. + WEIGHT LOSS (sodium restriction)

Post Exposure Management for Hep B

If Source patient + and healthcare worker not immune then need to give Hep B Immunoglobulin and vaccinate If Source patient + and healthcare worker immune then No intervention needed Positive Hep B Surface antigen indicates active infection with Hep B Virus. Adequate response to vaccine shows hep B surface antibody titer of >10, and therefore not at risk for contracting the virus and do not require post exposure prophylaxis even if subsequent antibody titers fall below threshold for immunity.

Chronic HBV

If do not clear Hep B surface antigen after 6 months Risk of progression from acute to chronic decreases with age. -Progression rate for Perinatal acquired infection 90% due to increased immune tolerance. -1-5yo: 20-50% -Adults <5%

Fetal Rh Status after delivery

If infant is Rh-Positive and mom Rh -, Immunoglobulin can be administered to mom up to 72hrs postpartum

A 67-year-old man with diabetes and peripheral arterial disease comes in with pain in his leg for 2 weeks. There is an ulcer with a draining sinus tract. X-ray is normal. What is the next best step?

If the x-ray is normal, MRI is the next best test to diagnose osteomyelitis. Bone scan does not have the same specificity.

painless recurrent hematuria, particularly in an Asian patient after a very recent viral respiratory tract infection. Proteinuria and red cells and red cell casts

IgA Nephropathy (Berger Disease) Dx: Elevated IgA, Normal Complement levels, Renal Biopsy

Gross Hematuria, Elevated Creatinine, recent upper respiratory infection raise concerns for

IgA Nephropathy or Acute Post Strep Glomerulonephritis (APSGN) Urinalysis: + protein, RBCs, RBC casts, HIGH Creatinine IgA: Several days after URI, young adults, IgA based immune complex deposition in mesangium. NORMAL complement levels. APSGN: weeks after Group A strep (pharyngitis, impetigo), school aged children. Immune complex deposition along GBM (Subepithelial) and LOW complement levels. Dx confirmed with kidney biopsy

Anaphylaxis

IgE mediated immediate hypersensitivity reaction type I

nausea and vomiting, soft distended abdomen with decreased bowel sounds and gaseous distension of small and large bowel shown on xray

Ileus Gas in colon and rectum + air fluid levels = small bowel obstruction. with hx of surgery. Otherwise it is metabolic causes of ileus. HYPOKALEMIA can cause paralytic ileus. Loop diuretics can cause hypokalemia and hyponatremia as well as persistent vomiting can cause hypokalemia. Oral or parenteral potassium replacement needed.

phase IV or post marketing surveillance is conducted to detect fatal and serious side effects. Failure to detect such events in earlier phases of clinical testing is due to

Inadequate Power Power of study reflects ability to detect a difference between groups if such a difference exist, power depends on sample size.

squatting and passive leg raise: INC RV and LV preload

Inc valvular murmurs Dec MVP and HCM

Relative Risk

Incidence among exposed / incidence of unexposed RR<1=Decreased risk RR=1=No difference in risk RR>1 = Increased risk

Comedonal Acne Vulgaris

Increased sebum production, Follicular Hyperkeratinization, And bacterial colonization (Cutibacterium Acnes). Pharmacological tx for comedonal acne without inflammation = topical retinoids, organic acid preparations (salicylic acid, azelaic acid) If prefer to avoid pharmacology then can use pH-Neutral detergents cleaners, applied without vigorous scrubbing, also use Water based rather than oil based skin products

Valsalva Strain, Abrupt standing: DEC RV & LV preload

Increases MVP and HCMDecreases valvular murmurs (dec flow through valve)

Inspiration: INC RV preload, DEC LV preload

Increases murmurs on right side (Inc RV blood volume) Decrease murmurs on left side (Dec LV blood volume)

Asymptomatic groin mass, reducible, increases with abdominal pressure (Valsalva)

Inguinal Hernia: failed obliteration of the processes vaginalis Premature boys or GU abnormalities (cryptorchidism). Complications: Incarceration, Bowel Ischemia Management: Asymptomatic: Elective surgery in 1-2weeks. Immediate surgical repair for incarceration.

Linezolid MOA

Inhibit protein synthesis by binding to 50S subunit and preventing formation of the initiation complex.

Pharmacotherapy for HF with reduced EF

Initial Optimized Therapy: -Angiotensin receptor-Neprilysin Inhibitor- (Sacubitril-Valsartan)Slow Dz progression and improve mortality -Beta Blocker-Metropolol, Cardvedilol, Bisoprolol-Reduce Hospitalization and improve mortality -Diuretics-Loop Diuretic-Imporbve symptom and reduce hospitalization Step 2: -Aldosterone Antag (Spironolactone, Eplerenone)-Due to risk of Hyperkalmeia should be avoided in hyperkalemia or advanced renal disease and has side effects of gynecomastia, decreased libido. Step3: -SGLT-2 Inhibitor Supplemental: -Isosorbide Denigrate + Hydralazine -Digoxin

Routine Prenatal Lab Tests

Initial Prenatal Visit: -Rh(D) type, Antibody screen -Hgb/Hematocrit, MCV, ferritin -HIV, VDRL/RPR, HBsAg, Anti-HCV Ab -Rubella & Varicella Immunity -Urine Culture -Urine Dipstick for protein -Chlamydia PCR (if risk factor) -Pap Test 24-28 weeks: -Hgb/Hematocrit (CBC to check for anemia) -Antibody screen if Rh(D)-Negative (receive anti-D immune Globulin injection if needed) -1hr 50g GCT 36-38: -Group B Strep Rectovaginal Culture

chancre, adenopathy; can be asymptomatic in pregnancy. Diagnosis & Treatment.

Initial diagnostic test: Darkfield microscopy (most accurate), then VDRL or RPR (75% sensitive in primary syphilis). False positives are caused by SLE, increasing age, and many infections such as endocarditis. Treatment: Single IM shot of penicillin. Use doxycycline for the penicillin- allergic.

Secondary syphilis: rash, mucous patch, alopecia areata, condylomata lata

Initial diagnostic test: RPR and FTA Treatment: Single IM shot of penicillin. Use doxycycline for the penicillin- allergic.

Tertiary Syphilis Neurological involvement: tabes dorsalis, Argyll-Robertson pupil, general paresis, rarely a gumma or aortitis

Initial diagnostic tests: FTA (95% sensitive), lumbar puncture for neurosyphilis (test CSF with VDRL and FTA). FTA is 100% sensitive in CSF. Treatment: IV penicillin; if penicillin-allergic, desensitize

Hidradentits Suppurativa (acne inversa)

Initial solitary & inflamed Nodule in intertriginous area, abscess formation with purulent or serosanguineous drainage, multiple recurrent nodules with sinus tracts, comedones & scarring Tx: ALL PATIENTS: -weight loss -smoking cessation -daily skin cleansing HURLEY STAGE 1: Mild: -Topical clindamycin -intralesional steroids or oral antibiotics HURLEY SATGE 2: Mod with nodules, sinus tracts, scarring: -Oral tetracyclines (DOXYCYCLINE) -Oral Clinda + Rifampin HURLEY STAGE 3: Severe with diffuse involvement & extensive sinus tracts: -Biologic TNF-Alpha inhibitors (Infliximab) -Oral Retinoids (Acitretin) -Surgical Excision

ADHD treatment options

Initial treatment with nonpharm (behavior therapy) in children 3-5yo Parent-Child Behavior therapy improves problem behavior and parent child relationships. Children >6yo may receive pharmacotherapy as first line. (First line methylphenidate, second line clonidine (alpha2 agonist, non stimulant), or Atomoxetine (norepinephrine reuptake inhibitor, non stimulant). Prior to initiating stimulant therapy, comprehensive cardiac hx and exam, baseline weight, vital signs should be obtained. Hx of sudden cardiac death in family. Children with persistent symptoms despite adequate treatment with initial medication and or intolerable side effects can be treated with an alternate ADHD medication, no tapering or washout is needed. can switch immediately to another stimulant and most patients do well on a different one.

best initial test for fungal skin and nail infection

KOH preparation Fungi have chitin in their outer wall. Chitin is a polymer that will not break down with KOH. Chitin is what makes up crab and lobster shells. Epithelial cells melt and fungi remain behind in a KOH prep because the chitin in the fungus is tougher than epithelial cells.

Red or purple papules with no necrosis in men with HIV who are sexually active with other men

Kaposi Sarcoma

recently visited Guatemala, has intermittent Nausea, Abdominal Discomfort, Diarrhea. Mild cough for a few days prior to onset of GI symptoms

Intestinal Helminths-Ascaris Lumbricoides (roundworm), Trichuris Trichiuria (Whipworm), Ancylostoma Duodenale (hookworm). Early transient pulmonary symptoms (dry cough, dyspnea) followed by long term GI symptoms (N,V,D) Peripheral Eosinophilia, Positive fecal occult blood. Dx: Stool Ova and Parasite testing Tx: Oral Albendazole (Mebendazole better for whipworm)

Cycklic abdominal pain, secondary amenorrhea immediately following D&C and endometritis

Intrauterine adhesions (Asherman Syndrome)

Post-Extubation Stridor & respiratory failure

Intubation causes direct mechanical damage to the laryngeal mucosa, that leads to edema. Laryngeal edema requires reintubation. Risk goes up with females, small tracheal diameter, large endotracheal tube, prolonged duration of intubation. multiple-dose regimen of glucocorticoids prior to extubation can prevent laryngeal edema and extubation failure.

Microcytic Hypochromic Anemia in pregnancy

Iron deficiency anemia Iron defieicny impairs Hgb synthesis resulting in small, pale erythrocytes. Fetal hematopoiesis, placental development a d expansion of maternal RBC mass during pregnancy result in an increased iron requirement. Can be exacerbated by hyperemesis gravidarum during pregnancy resulting in inadequate iron intake risk for preterm delivery, C section, blood transfusion after delivery. Treat with oral ferrous sulfate.

Adolescent, absence seizures, morning myoclonus, generalized tonic-clonic seizure

JUVENILE MYOCLONIC EPILEPSY Dx: Electroencephalogram: Bilateral Polyspike & Slow wave activity Tx: Valproid Acid, AVOID triggers (Alcohol, sleep deprivation) Starts with absence seizures (staring spells) 5years before other signs. Classic presentation in adolescence is myoclonic jerks of the arms within first hour of waking aggravated by sleep deprivation and alcohol intake. Most patients also have dx of anxiety.

Oligoarthritis

Joint pain/swelling -> Aspirate -> 1. Bone Marrow Elements: Intraarticular fracture 2. Inflammatory (>2000 WBC, 75% PMNs) -> Crystals? Gout and Pseudogout, Positive culture? Infectious, Sterile? RA, Viral/Lyme, SLE, Sarcoidosis, Spondyloarthropathy 3. Bloody: Coagulopathy, Tumor, Trauma

Autoantibody induced inflammation of the joints which presents with chronic pain and swelling, multiple small joints (wrist, ankles)

Juvenile Idiopathic Arthritis

Bilateral Nonexudative Conjunctivitis, Mucositis (erythematous lips, tongue, oral. mucosa), Rash (inguinal folds, perineum, trunk), Cervical LN, Fever, Swelling/Erythema of palms/soles,

Kawasaki Disease Order C-reactive protein, Erythrocyte Sedimentation Rate, Prescribe Ibuprofen and Follow up next day. HIGH Platelets, CRP, ESR, AST, ALT, WBCs LOW Hgb Complications: Coronary Artery Aneurysm, Ventricular dysfunction -> ECHOCARDIOGRAM at baseline once diagnosed with Kawasaki Dz Tx: IV Immunoglobulin & Aspirin DEFER LIVE VACCINES for 11 months after IVIg Likelihood of relapse and recurrence is low, Self-limited, once responded to tx no longer need IVIg, If Echo was abnormal at baseline then future risk of future cardiac events and restricted from playing sports, but if normal then no risk.

>5 days of fever Plus Conjunctivits, mucosal changes, LAD, rash, Extremity changes (swelling and erythema)

Kawasaki Disease treat with IV IMMUNOGLOBULIN

High dose aspirin

Kawasaki Dz (fever, LAD, rash, conjunctivitis, mucous membrane change, edema of extremities) in a 1-4yo.

Chicken skin; small painless papules, roughened skin texture. pruritic in cold, dry weather

Keratosis Pilaris bx: keratin plugs, dilated hair follicles, sterile lymphocytic infiltrates Tx: Emollients, Topical keratolytics (Salicylic Acid, Urea) to help soften the papules.

Anterior nasal septal mucosa Bleed

Kiesselbach Plexus: Sphenopalatine, Greater Palatine, Anterior Ethmoid, Superior labial arteries Nostril pinching usually controls bleeding after 5-10min if not then topical vasoconstrictor (Oxymetazoline) applied with a squirt bottle or cotton pledget and direct pressure applied.

Tall, Gynecomastia and small or cryptorchid testes

Klinefelter syndrome 47 XXY diagnosed by karyotype analysis

children with unilateral hip pain

Kocher Criteria: differentiate septic arthritis from other etiologies, such as transient synovitis (inflammatory reaction of the joint occurring after viral infection) -Non weight bearing -Fever -ESR >40 or CRP>2 -Leukocytosis Greater than three of the above criteria = SEPTIC ARTHRITIS and immediate joint aspiration is performed. Once dx is conformed by synovial fluid analysis empiric parenteral Abx as well as surgical drainage and debridement of joint required.

Sensory loss of anteromedial thigh, medial shin, Weak hip flexion (iliopsoas), hip adduction, knee extension (quads), absent patellar reflex. WHICH NERVE ROOT?

L2-L4

lumbosacral radiculopathy (herniated lumbar disk)

L2-L4: Patellar Reflex: Anteromedial Thigh and Medial Shin Sensation: Weakness in hip flexion (Iliopsoas), adduction, and knee extension (quads). BACK PAIN THAT RADIATES TO THE LEG->L5: Lateral Shin and Dorsal of foot Sensation: Weakness in foot dorsiflexion & inversion (Tibialis Anterior), Foot eversion (peroneus), Toe Extension (extensor Hallucis & Digitorum) S1: Achilles reflex. Posterior calf , dole and lateral foot sensation, Weakness in Hip extension (Glut Max), Knee flexion (hamstrings), Floot plantarflexion (Gastrocnemius) S2-S4: Anocutaneous reflex. Perineum sensory loss. weakness in urinary or fecal incontinence, sexual dysfunction

Sensory loss of lateral shin, dorsal of the foot, weakness in foot dorsiflexion, inversion (tibias anterior), Foot eversion (peroneus), Toe extension (extensor hallucis, digitorum). WHICH NERVE ROOT?

L5

Bias seen with screening tests, when a test diagnoses a disease earlier than another test

LEAD TIME BIAS Therefore time from diagnosis until death appears prolonged even though there is no actual improvement in survival.

High-grade squamous intraepithelial lesion (HSIL) on Pap testing

LEEP (Loop Electrosurgical Excision Procedure) or Colposcopy If Cervical Intraepethelial Neoplasia (CIN) 2,3 ->Manage per guidelines NO CIN 2,3 -> 21-24 yo: repeat colposcopy & cytology at 6month intervals for 2 years >25yo: Manage per guidelines in stead of Colposcopy someone patients can proceed directly to LEEP, an excision of the cervical transformation zone and surrounding endocervix, women who are >25, NOT pregnant, and have completed childbearing.

recurrent skin/mucosal bacterial infections

LEUKOCYTE ADHESION DEFICIENCY Impaired neutrophil chemotaxis

Epidemiological parameter that compares the significance of a negative and positive result obtained in individual patients, irrespective of prevalence

LIKELIHOOD RATIO (LR) Probability of a given test result occurring in a patient with a disorder compared to the probability of the same result occurring in a patient without the disorder. LR calculated from sensitivity & Specificity Positive Test Result: +LR = Sensitivity/1-Specificity Negative Test Result: -LR = 1-Sensitivity/Specificity Sensitivity and specificity are independent of disease prevalence, LR do not change with prevalence of the disease. LR can be used to calculate post test odds Post Test Odds = Pre-test odds x LR LR can be used with tests that have >2 possible test results and they can be used to combine results of multiple diagnostic tests.

Contraindications to Varicella-Zoster Virus Vaccine

LIVE ATTENUATED VACCINE Administered in 2 doses (first at age 12-15months, Second at age 4-6 years) CONTRAINIDICATIONS: Anaphylaxis to Neomycin, or gelatin Pregnancy Immunodeficiency Pretransplant patients should receive 2 doses of VZV at least 4 weeks prior to transplant. Household contacts who receive VZV should be monitored closely for vaccine associated rash, contagious to immunocompromised people. If there isa rash then need to be isolated from transplant sibling until lesions have crusted over. Varizella Immunoglobulin should be administered to varicella-seronegative transplant receipts who have been exposed. DO NOT GIVE VACCINE TO IMMUNOCOMPROMISED PATIENT

Anabolic Steroid Abuse

LOW Testosterone, FSH, LH Testicular Atrophy Dec Spermatogenesis Normal Libido & erectile function LOW libido, impotence (during withdrawal) HIGH LDL, LOW LDH Cholesterol Erythrocytosis (increased erythropoietin production and suppression of the iron regulatory protein hepcidin) Acne Gynecomastia Affective symptoms Aggression Steroids decrease production of endogenous testosterone via suppression of gonadotropins (FSH, LH), some like Stanozolol can cause hepatotoxcitity. Levels recover in weeks to months after discontinuation but chronic abuse can be permanent

Evaluation of Anemia

LOW hgb: 1. LOW MCV (<80): Iron Def, Lead intoxication, Thalassemia, Sideroblastic Anemia 2. NORM MCV (80-100): 1. LOW RETIC COUNT: Leukemia, Aplastic Anemia, Infection, Medication Side effect 2. HIGH Retic Count: Hemorrhage, Hemolysis: paroxysmal nocturnal hemoglobinuria or auto immune 3. HIGH MCV (>100): Vit B12 deficiency, Folate Deficiency

Virallike symptoms (Fatigue, intermittent headache, myalgia, arthralgia) , visited Connecticut. 5cm circular, erythematous rash with central clearing. Patient is pregnant.

LYME DISEASE (Borrelia Burgdorferi) Erythema Migrans (erythematous rash with central clearing-Bulls eye appearance) No incfreased risk to fetus when mother receives treatment with 14-21 days of oral amoxicillin or oral cefuroxime. AVOID DOXYCYCLINE in pregnancy due to adverse effects on fetal long bone development and teeth coloration.

Fever, Breast pain, Focal inflammation. 3 months post party. poor latching during breast feeding.

Lactational mastitis Poor latching leads to prolonged engorgement, inadequate milk drainage, clogged milk ducts (tender, palpable, lump or cord). Bacteria from skin can go into to stagnant milk resulting in infection. STAPH AUREUS TX: PO DICLOXACILLIN (Antistaph penicillin) OR CEPHALEXIN (first gen cephalosporin) Breastfeeding using both the infected and uninfected breast is safe during tx, no need for formula if milk supply is adequate.

chronic watery diarrhea, flatulence, bloating after meals likely has

Lactose intolerance Common cause of adult onset diarrhea Lactose processed into glucose and galactose by intestinal lactase on the brush border of the small intestine. Reduced activity of the lactase enzyme with age most common cause of lactose intolerance. Symptoms occur as the osmotic load of undigested carbohydrates pass through intestines. drawing water into the lumen and decreasing transit time. Colonic bacteria ferment lactose creating short chain fatty acids and hydrogen gas leading to bloating and flatulence. Lactose breath hydrogen test tx: replace lactose rich foods (milk, ice cream) with low lactose content like yogurt snd aged cheese. supplement with lactase. VIT D and CALCIUM evaluated and supplemented if needed.

Localize the lesion. Ataxia. Parkinsonian signs. Sensory deficits. Hemiparesis (most notable in the face) Possible bulbar signs

Lacunar infarct

Hutchinson teeth, "Mulberry" molars, "Saddle" nose, "Saber" shins, Deafness (cranial nerve 8 palsy)

Late-acquired congenital syphilis (diagnosed after age 2)

+ IF-Gamma Release Assay, Asymptomatic, Normal CXR

Latent TB Infection Empiric tx without microbial isolation, need to use drug-susceptibility results. Normally isoniazid for 9months if resistant then rifampin for 4-6months

Test diagnosis a disease earlier and as a result the time from diagnosis until death appears prolonged even though there actually is no improvement in survival.

Lead Time Bias Different then length time which identifies more benign cases

Hyponatremia corrected with hypertonic saline due to seizures in setting of alcohol withdrawal. Several days later with quadriplegia (no extremity movements), preserved wakefulness (spont eye opening), awareness (blinking on command)

Locked-in Syndrome due to Central Pontine Myelinolysis Quadriplegia with intact consciousness Upper CNs spared: intact vertical EOM, blinking and pupil reflex Lower CN Paralyzed: loss of horizontal EOM, oral movements Due to overly rapid correction of Hyponatremia. A sudden increase in plasma sodium causes osmotic shock to oligodendrocytes that have adjusted to a hypotonic environment leading to rapid cell shrinkage, apoptosis, and demyelination of adjacent neurons. The central pontine gray matter is particularly susceptible due to highest density of oligodendrocytes. Irreversible supportive care only

Progestin Subnormal Implant

Long acting & Reversible Implant (>99% efficacy)-effective for 3 years-progesterone induced changes that result in cervical mucus thickening and decreased tubal motility which inhibit sperm migration also causes ovulation suppression via decreased FSH & LH secretion. MOST COMMON SIDE EFFECT = unscheduled bleeding, weight gain, headache. CONTRAINDICATED IN Progesterone receptor positive breast cancer. Ovulation and fertility return within a ,month after removal.

Control agitation, prevent harm, in a delirius patient

Low Dose Antipsychotics (Haloperidol)

male hypogonadism: sexual dysfunction/infertility, loss of body hair, gynecomastia, hot flashes, low bone density, testicular atrophy

Low serum testosterone confirmed on repeat testing HIGH LH/FSH: Primary hypogonadism: Karyotype analysis (Klinefelter syndrome 47XXY, gynecomastia, impaired secondary sex characteristics, firm testes, High FSH/LH. LOW LH/FSH: Hypothalamic or pituitary disorder. Secondary Hypogonadism: Testicular atrophy due to loss of gonadotropin effect: prolactin, iron studies, pituitary hormones, MRI of pituitary Prolactin may be elevated due to prolactin secreting pituitary adenoma (prolactinoma) or disruption of inhibitory dopaminergic hypothalamic neurons. Hyperprolactinemia is a common cause of secondary hypogonadism due to suppression of GnRH secretion.

Mechanism of Elevation of BUN in Prerenal Azotemia

Low volume status increases ADH. ADH increases urea absorption at the collecting duct. There is a urea transporter that brings urea in. ADH increases the activity of the urea transporter.

Anticoagulation during pregnancy

Low-Molecular-Weight Heparin: SubQ: Throughout pregnancy Unfractioned Heparin: SubQ or IV: BEFORE Delivery Warfarin: PO: Preconception & Postpartum: TERATOGENIC: CAN be used during breastfeeding

Duplex lower extremity US used to diagnose

Lower Extremity Venous Disease (DVT)

Major Drug Interactions of Levothyroxine

MOST COMMON = DECREASE Levothyroxine ABSORPTION: Bile Acid Binding Agents (Cholestyramine), Iron, Calcium, Aluminum Hydroxide, Proton Pump Inhibitors (pantoprazole, omeprazole), Sucralfate INC Thyroxine-binding globulin (NEED INCREASE IN LEVOTHYROXINE DOSAGE): Estrogen replacement for menopause or high estrogen state such as pregnancy, OCP, Tamoxifen DEC Thyroxine-binding globulin: Androgens, Glucocorticoids, Anabolic steroids INC Thyroid hormone metabolism: Rifampin, Phenytoin, Carbamazepine

Bicuspid aortic valve

MOST COMMON CONGENITAL HEART DISEASE IN ADULTS Males, Turner syndrome, AD Screening Echo for patients and first degree relatives Complications: Infective Endocarditis, Severe regurgitation or stenosis, Aortic Root or Ascending Aortic Dilation, Dissection, Thoracic Aortic Aneurysm Follow up Echo q1-2yrs, Balloon Valvuloplasty or surgery (valve & Ascending aorta replacement)

Risk Factors for Coronary Heart Disease

MOST SIGNIFICANT PREDICTOR of adverse CV outcomes: 1. Non coronary atherosclerotic disease (Carotid, peripheral artery, abdominal aortic aneurysm) 2. DM - strict glycemic control lowers microvascular complications (retinopathy, nephropathy, neuropathy but NOT microvascular complications (Coronary heart disease and stroke) 3. CKD ESTABLISHED RISK FACTORS: 1. Age (>50 in men & Menopause in women) 2. Male 3. FH in first degree <50 men <60 F 4. HTN (BP should be kept <140/90 in diabetics, and <130/80 in diabetics with nephropathy) 5. Dyslipidemia 6. Tobacco (>1 pack daily) 7. Obesity

Anion Gap Metabolic Acidosis

MUDPILES Methanol Uremia Diabetic Ketoacidosis Propylene Glycol/Paraldehyde Isoniazid/Iron Lactic Acidosis Ethylene Glycol (Antifreeze) Salicylate (aspirin)

digital ischemia, Livedo Reticularis, Retiform Purpura, hypercalcemia, renal insufficiency, Anemia, Lytic Bone lesions.

MULTIPLE MYELOMA -> produce cryoglobulin (abnormal immunoglobulin caused by 2 types of B-cell dysregulation) that precipitate intravascularly causing Microvascular occlusion Monoclonal protein in serum or urine END ORGAN DAMAGE = CRAB hyperCalcemia, Renal insufficiency, Anemia, lytic Bone lesions. Cryoglobulinemia (immuglobulin that precipitate <37) Type 1: Plasma Cell Dyscrasias (Waldenstrom, MM) B-Cell malignancy (monoclonal IgM). Vascular occlusion (lived reticular, retiform purport, digital ischemia), Blurred vision, vertigo, ataxia. HIGH ESR, MONO CLONAL SPIKE ON SPEP Type 2 or 3 (MIXED): Chronic Viremia (HCV, HIV), SLe, Sjogren. B cell hyper activation (IgM Rheumatoid factor bound to polyclonal IgG) Vasculitis (palpable purport, arthralgia, neuropathy, Heaptomegaly. + Viral or antinuclear Abs = SMALL VESSEL IMMUNE COMPLEX DEPOSITION

Prostaglandins

Maintain potency of the ductus arteriosus to allow blood flow to the systemic circulation. Indicated for patients with ductal-dependent lesions (Hypoplastic left heart, transposition of great arteries)

Bicuspid aortic valve

Males, Turner syndrome, Autosomal Dominant Ejection murmur and a sound or click best heard at lower left sternal border CXR: Av calcifications, aortic enlargement (due to aneurysm), or rib notching (due to coarctation) Dx: Screening Transthoracic Echo for patient & first degree relatives Complications: Infective Endocarditis, Severe regurgitation or stenosis, Aortic root or ascending aortic dilation, dissection Management: f/u echo q1-2yrs, balloon valvuloplasty or surgery (valve and ascending aorta replacement)

Severe malnutrition in a child

Marasmus: Wasting: sparse hair, disproportionate head size, emaciated, muscle wasting Kwashiorkor: Edematous Malnutrition: moon face, fatty liver, protuberant abdomen, dry peeling skin, pitting edema. Rewarm for hypothermia, Antibiotics for systemic infection, Oral rehydration solution, IVF if in shock, reseed cautiously Complications of HF and refeeding syndrome (hypophosphatemia, Hypokalemia)

Alkaline Phosphatase

Marker of bone turnover (bone fraction) & Biliary Tract Disease (Liver Function) In setting of Vit D deficiency's elevated serum all phos related to high bone turnover

Infant of mother with DM

Maternal Hyperglycemia: -First Trimester: Congenital Heart Dz, Neural Tube Defects, Small Left Colon Syndrome, Spontaneous Abortion -Second & Third Trimester: Fetal Hyperglycemia & Hyperinsulinemia -> Increase metabolic demand->Fetal hypoxemia -> Inc Erytheopoiesis -> Polycythemia Organomegaly Neonatal Hypoglycemia Macrosomia-> Shoulder Dystocia-> Brachial Plexopathy, Clavicle Fracture, Perineal Asphyxia Decrease surfactant->Dec lung maturity->Neonatal respiratory distress

Breast Abscess

Maternal age >30, First pregnancy, Tobacco use fever, focal inflammation, fluctuant, tender mass Dx: Breast US Management: Abx, Drainage (fine needle aspiration under LA) DO NOT DO I&D unless failed above. Can cause milk fistulas, slower recovery, and less desirable cosmetic outcome.

Seizure in Pregnancy complications

Maternal and fetal complications: Abruptio placentae/Hemorrhage, Spont abortion, Preeclampsia, preterm labor, Mortality, Injury. Antiepileptics can cause cleft plate, congenital defects, neural tube defects, skeletal abnormalities Valproate HIGHLY teratogenic. Changing to alternate should be done 6 months prior to conceiving. NO CHANGES should be made after conception, as about changes may trigger a seizure. Therefore HIGH dose folic acid supplement, Screen for congenital anomalies (NTD) with serum alpha-fetoprotein and anatomy US, if major abnormalities then pregnancy terminating may be considered. Antiepileptic meds are NOT contraindicated to breastfeeding as benefits of breastfeeding outweighs risk of medication exposure to infant. They DO pass into breast milk.

Preterm labor management

Maternal instability, Intrauterine infection, fetal distress/demise -> Immediate Delivery <32 weeks: Corticosteroids (IM Betamethasone; to decrease the risks of neonatal respiratory distress syndrome, Intraventricular hemorrhage, necrotizing enterocolitis, overall neonatal mortality), Penicillin if GBS + or unknown, Tocolysis (halt contractions and delay delivery to give time for corticosteroids to stimulate fetal lung maturity): Indomethacin (COX inhibitor contraindicated at >32 weeks due to risk of oligohydramnios and premature closure of the fetal ductus arteriosus), Mag Sulfate (fetal neuroprotection also for prevent seizures in preeclampsia and eclampsia) 32-34 weeks: Corticosteroids, Penicillin if GBS + or unknown, Tocolysis: Nifedipine 34-37 weeks: +/- corticosteroids, penicillin if GBS + or unknown

Preterm Labor

Maternal instability, intrauterine infection, fetal distress/demise -> Immediate Delivery <32 weeks: Corticosteroids, PENICILLIN if GBS + or Unknown, Tocolysis with indomethacin, Mag sulfate (Cerebral palsy risk reduction-can cause respiratory depression in mom) 32-34 weeks: Corticosteroids, PENICILLIN if GBS + or Unknown, Tocolysis with Nifedipine (Hypotension) 34-37: +/- Corticosteroids, PENICILLIN if GBS + or Unknown Most preterm labor is spont but at risk if hx of preterm delivery, multiple gestation, Group B strep

Breastfeeding contraindications

Maternal: 1. Active untreated TB 2. HIV 3. Herpetic breast lesions 4. Active Varicella 5. Chemo or radiation therapy 6. Active substance use Infant: Galactosemia

Sudden Infant Death Syndrome Risk Factors

Maternal: Substance use (Cigarettes, Alcohol, Recreational Drugs), Maternal age <20, Inconsistent prenatal care. Infant: premature (<37 weeks), low birth weight, prone/side sleep position, soft sleep surface/loose bedding, bed sharing, smoke exposure. Delayed brain maturation in a premature baby resulting in inadequate CNS arousal response after an inciting event (airway obstruction)

Cough, coryza (Rhinorrhea), conjunctivitis, koplik spots, fever, maculopapular exanthem (Morbilliform rash on face, trunk, ext)

Measles Virus (Rubeola) Prevent with live attenuated measles vaccine at 1yo Tx: Supportive, VITAMIN A for hospitalized patients Rash spares palms and soles Koplik spots are pinpoint white papules on buccal mucosa

Hypercalcemia

Measure PTH -HIGH -> PTH Dependent = Primary HyperPTH, Familial Hypocalciuric Hypercalcemia, Lithium -LOW -> PTH Independent -> Measure PTHrp, 25-Hydroxyvit D, 1,25-Dihydroxyvitamin D -> Malignancy, Vit D toxicity, Granulomatous disease, Drug induced, milk-alkali syndrome, Thyrotoxicosis, Vit A toxicity, Immobilization

Population Attributable Risk Percent (PARP)

Measure of excess risk in the population, not only in exposed subjects like that seen in attributable risk percent. PARP = (Risk in total population - Risk in Unexposed)/ Risk in total population

Pearson Correlation Analysis

Measure strength and direction of a linear relationship between 2 quantitative variables. Relationship between RFC (renal frame count) and BMI but doe not adjust for other variables.

A newborns first bowel movement

Meconium (thick, black, tarry stool that occurs within first 48hrs of life and sometimes during childbirth-meconium stained amniotic fluid) Normal frequency of stool passage in a breastfed newborn is 6-10x daily, or one soft, yellow green stool per episode of breast feeding. After the first month, stool frequency in some infants decrease to 1 episode every 1-2 days or less, with some only having 1 or 2 bowel movements per week. Formula-Fed Infants have 1-2 bowel movements per day.

impaction in the ileum and narrow underused "Microcolon"

Meconium Ileus in Cystic Fibrosis

Instability with lateral movement of knee, VALGUS LAXITY

Medial Collateral Ligament (MCL)

Positive stress testing (exercise or Dobutamine Echo)should be initiated on

Medical Therapy: Aspirin, High intensity statins (atorvastatin, Rosuvastatin) and beta blocker, as well as optimization of CV risk factors (smoking cessation, BP control, Glucose control) High risk stress testing features (ST depression at minimal exertion) likely have atherosclerotic disease that will benefit from revascularization and should undergo percutaneous coronary angio to assess for stent placement or coronary artery bypass grafting

Orthostatic Syncope

Medications: Vaodilators, Ionotropic/Chronotropic blockade, diuretics Autonomic dysfunction:L advanced age, neurodegenerative disease Hypovolemia: Fluid restriction, GI Loss, Fever With standing from seated/supine Light headed and visual blurring >20mm Dec in SBP or >10 Dec in DBP after standing from supine Tx: Rise slowly when standing, DC or decrease dose of meds causing it, Increase fluid and salt intake

Thyroid nodule in presence of multiple endocrine neoplasm with elevated calcitonin level

Medullary Thyroid Cancer

Calcitonin and Metanephrine assays used to screen for

Medullary thyroid cancer and pheochromocytoma components of MEN2

Ginko Biloba

Memory enhancement SE: Bleeding

screened for hyperlipidemia

Men age >35 and women age >45

Metabolic/Electrolyte Disturbances & Systemic Disorders causing Psychosis

Metabolic/Electrolyte: -Urea Cycle Disorders -Acute Intermittent Porphyria -Wilson Dz -Renal/Liver Failure -Hypoglycemia -Sodium/Calcium/Magnesium Disturbance Systemic: -SLE -Thyroiditis

Eval Barrett Esophagus

Metaplastic replacement in the lower esophagus of normal stratified squamous epithelium with columnar epithelium (normally lines intestines): Advancing squamocolumnar junction in response to chronic gastric acid exposure can lead to esophageal adenocarcinoma therefore if chronic GERD (>5yrs) for frequent heartburns should be considered for endoscopic screening Chronic GERD (>5yrs), >50yo, Male, White, Hiatal Hernia, Obesity, Current or former smoker, FH Screening endoscopy -> Columnar-lined esophagus Biopsy shows 1. No Dysplasia: PPI & Surveillance Endoscopy 3-5 yrs 2. Low Grade Dysplasia: PPI & Surveillance endoscopy 6-12months or endoscopic eradication 3. High Grade Dysplasia: Endoscopic eradication therapy

flatulence and diarrhea from DM medication

Metformin and Alpha-Glucosidase Inhibitor (ACARBOSE)

new onset hypoxia 85% by pulse oximetry during endoscopy with difference between oxygen saturation value estimated on blood gas analysis of 99%

Methemoglobinemia due to anesthetic use (altered state of hemoglobin) Topical anesthetics (benzocaine), dapsone, nitrates (in infants) can cause the iron component of hemoglobin to be oxidized thereby forming methemoglobin which cannot bind oxygen. the remaining normal hemoglobin also has an increased affinity for oxygen resulting in less oxygen delivery to tissues Pulse ox commonly is 85% regardless of true oxygen saturation due to methemoglobin absorbs light at distinct wavelengths. And blood gas analysis returns falsely elevated result for oxygen at 99% not an effective hemoglobin-oxygen binding estimate. Tx: DC the causative agent and administer methylene blue which reduces iron to its normal state.

used to reverse opioid induced constipation

Methylnaltrexone selectively blocks mu opioid receptors on gut mucosa without reversing analgesic effect of opioids.

Abx prescribed for the treatment of Rosacea

Metronidazole

best medication for abdominal anaerobes

Metronidazole

Alcohol Withdrawal Syndrome

Mild: 6-24hrs -Anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, Intact orientation Seizures: 12-48hrs Alcoholic Hallucinations: 12-48hrs Delirium Tremens: 48-96hrs -Confusion, agitation, fever, tachycardia, HTN, Diaphoresis, Hallucinations 2:1 ratio of aspartate aminotranferase: alanine aminotransferase TX: BENZODIAZEPINE (LORAZEPAM) Avoid Chlordiazepoxide a longer acting benzodiazepines in patients with liver disease Give IVF, monitor vital signs, thiamine, folate and nutritional support

Cough up blood, SOB, fatigue, Palpitations, cough while lying down, anxious, fatigues, Loud first heart sound with short apical low pitched diastolic rumbling murmur, bilateral crackles, broad notched P wave lead II as well as right axis deviation, CXR with pulmonary edema, prominent pulmonary arteries at the hilum, elevation of left mainstream bronchus, left atrial enlargement with flattening of left heart border

Mitral Stenosis from Rheumatic Heart Disease Can see A fib, systemic thromboembolism, Voice hoarseness from recurrent laryngeal nerve compression due to left atrial enlargement (Ortner Syndrome) Mitral facies (Pink-purple patches on cheeks), Loud S1, loud P2, opening snap, Mid-Diastolic rumble (at cardiac apex) CXR: Dilated pulmonary vessels, Left Atrial Enlargement, flat left heart border ECG: "P Mitrale" (broad and notched P waves), Atrial Tachyaarhythmias, RVH (tall R waves in V1, V2) TTE: MV thickening/calcifications/Dec Mobility, Coexisting MR

Systolic heart murmur can be a marker of

Mitral regurgitation, aortic stenosis, tricuspid regurgitation, are more related to heart failure

indicated in the treatment for seasonal allergic rhinitis and chronic management of asthma (exercise induced)

Montelukast (Leukotriene Receptor Antagonist)

sensitivity and specificity

More sensitive when able to correctly diagnose more patient who have the disease (MORE TRUE POSITIVES), fewer patient with the disease will have a negative result More specific when able to correctly identify patients who are healthy (MORE TRUE NEGATIVES), fewer patients without the disease will have a positive result Highly sensitive tests are more appropriate for screening as they are most likely to detect a disease and least likely to give false negative results. (High Sensitivity a Negative result will hep rule out a diagnosis; SnNout). After obatining a positive result from more sensitive test a more specific test is ordered. Highly specific test have a low rate of false positives. Confirmatory test to have high specificity so higher specificity a positive result would help rule IN a diagnosis (SpPin)

Elderly with fragility fracture despite osteoporosis treatment with Vit C, D and Alendronate. Has weight loss, Anemia, Hypercalcemia, Increased serum protein concentration (low-Normal Albumin concentration)

Multiple Myeloma Punched out skeletal lesions Rapidly progressive generalized bone loss (due to increased levels of osteoclast-activating factor secreted by neoplastic cells. Bone loss resembles osteoporosis but leads to fragility fractures. Dx: SERUM & URINE PROTEIN ELECTROPHORESIS

Sickle Cell Disease in Pregnancy

Multiple episodes of vasoocclusion (pain crises) cause irreversible renal damage resulting in nephropathy (proteinuria) and HTN. Sickle cell comorbidities (nephropathy, HTN) are all independent risk factors for preeclampsia. Which can also occur with DM and SLE. Prenatal: -baseline 24hr urine collection/testing for total protein -baseline chemistry panel -serial urine cultures -pneumococcal vaccine -folic acid supplement -aspirin (in high risk patients start in 2nd trimester decreases risk of preecmplasia) -serial fetal growth US exam Obstetric complications: -Spont abortion -preeclampsia, eclampsia -abruptio placentae -Antepartum Bleeding Fetal Complications: -Fetal growth restriction -Oligohydramnios -Preterm Birth

Risk Factors for Preeclampsia

Multiple gestation, hydatidiform mole, diabetes mellitus, age extremes, chronic hypertension, and chronic renal disease. Prevent preeclampsia in patients with risk factors by starting aspirin at 12 weeks' gestation.

Punched-out lesions on X-Ray are seen in

Myeloma

newborn with respiratory distress, decreased movement, intercostal retraction, absent developmental reflexes, profound hypotonia, bilateral red reflex absent (cataracts), upper lip with inverted V shape. clubfoot and bilateral Lower ext contractures. MOM with wasting of muscles of the face and lack of facial expression.

Myotonic Dystrophy Autosomal Dominant CTG trinucleotide repeat expansion, Adult: Myotonia, weakness in face, hands and ankles Childhood: Cognitive and behavioral difficulties Infant: hypotonia, respiratory failure V shaped upper Lip Cardiac: Arrhythmias, Cardiomyopathy GI: Dysphagia, constipation Resp: Pharyngeal weakness, hypoventilation Nonmuscular: Insulin resistance, hypogonadism, cataracts, frontal balding, excess daytime sleepiness Dx & Tx: Genetic testing and supportive menagaemt

negative skewed distribution Vs Positive

NEGATIVE: MEAN<MEDIAN<MODE POSITIVE: MEAN>MEDIAN>MODE A skewed data is a better reason for why use the median instead of mean -For continuous data normally distributed - Mean is better for central tendency -For ordinal data or continuous data - median is best choice for central tendency (Freshman, Sophomore, Junior, Senior) -For Nominal data (Male and Female) - Mode

Medication that lowers triglycerides but also poorly tolerated due to flushing, pruritis, and hepatotoxicity

NICOTINIC ACID

Efavirenz, Nevirapine, Etravirine, Rilpivirine, Doravirine

NNRTI

sensitivity and specificity

NOT AFFECTED BY DISEASE PREVALENCE Even though a negative result on a maximally sensitive test would effectively rule out the disease very few diagnostic tests are 100% sensitive. Sensitivity: Probability of an individual testing positive given presence of disease; TP/TP+FN Specificity: Probability of an individual testing negative given the absence of disease; TN/TN+FP

Antiviral therapy for hepatitis C during pregnancy

NOT approved

Cold compresses in sickle cell crisis

NOT recommended can trigger local intravascular sickling and worsen vast-occlusive pain episodes. HEAT packs help promote VASODILATION

Abacavir

NRTI SE: Rash (HLA-B*5701)

Stavudine

NRTI SE: pancreatitis and neuropathy

Didanosine

NRTI SE: pancreatitis and peripheral neuropathy

Tenofovir

NRTI SE: renal toxicity/RTA and bone demineralization

otherwise healthy young adult, fever, hypotension, swelling and erythema of leg, leg is painful to palpation, after injury to the leg.

Necrotizing fasciitis Strep Pyogenes (Group A strep), Staph Aureus, C. Perfringens, Poylymicrobial Surgical debridement and broad spec antibiotics (Piperacillin/Tazobactam or a Carbapenem (impinem, Meropenem) To cover Group A strep and anaerobes, VANCOMYCIN to cover Staph aureus, CLINDAMYCIN to inhibit toxin formation by streptococci/Staphylococci) TYPE 1: patients with diabetes or peripheral vascular disease due to staph aureus, bacteroides fragility, E. coli, Group A strep, Prevotella species. IF THERE IS CREPITUS THEN C. PERFRINGENS OR B FRAGILIS INVOLVED TYPE 2: most common, in patients with no medical illness, after laceration, blunt trauma or surgical procedure. Due to GROUP A STREP (Strep Pyogenes)

Hypopigmented spots in combo with FH of deafness

Neurofibromatosis Type 2 (NF-2) Autosomal Dominant Disorder HYPOPIGMENTED CAFE-AU-LAIT SPOTS (In NF-1 they are HYPERpigmented) Deafness is caused by bilateral acoustic neuromas

Status Epilepticus, Consult?

Neurology consult should be ordered for all seizure patients

Primary Nocturnal Enuresis

Nighttime Urinary Incontinence >5 Due to delayed maturation of bladder control HIGH Nocturnal urine Output (High evening fluids, LOW ADH), LOW Bladder capacity. FH Boys 5-8 EVAL: URINALYSIS to exclude other causes. Voiding Diary. Tx: Treat comorbid conditions (constipation), Behavioral modifications (restrict evening fluids), enuresis alarm, Desmopressin therapy.

Acute Management of Acute Coronary Syndrome (STEMI, NSTEMI, Unstable Angina) Acute onset chest pain, Nausea, weakness, lightheadedness, ischemic changes on ECG

Nitrates: Rapid chest pain relief, Caution with Hypotension (RV Infarct) Beta Blocker: Decreases myocardial Oxygen demand to limit infarct size. CONTRAINDICATED in cardiogenic shock and bradycardia. (Pulmonary edema, JVD, S3 = acute decompensated HF due to ischemic LV dysfunction-Beta Blockers are CONTRAINDICATED. Due to decrease contractility and HR and may worsen the pulmonary edema) Antiplatelet Therapy: Aspirin + P2Y12 Inhibitor (Prasugrel, Clopidogrel) Anticoagulation:Unfractioned Heparin, Bivalirudin, Enoxaparin. Limits Thrombus Expansion Statin Therapy: High potency (atorvastatin, Rosuvastatin). Stabilizes atherosclerotic plaque. Coronary Reperfusion: -STEMI (PCI <90 min from 1st medical contact), Fibrinolytics (Alteplase) if PCI unavailable -NSTEMI or Unstable Angina (coronary angio within 24hr)-P2Y12 inhibitor therapy os held until after coronary angio in case atherosclerotic coronary anatomy indicates need for CABG

Interferon-Gamma Release Assay (IGRA) vs TB Skin Test

No false positives in those with previous BCG vaccine, No need for return visit to measure induration size, No need for two step confirmation If previously received a BCG vaccine you should be screened with an IGRA, NOT a TST Patient with hx of latent TB are likely to be positive TST and IGRA for life therefore screen for TB with a CXR If screening test abnormal or symptomatic or radiographic finginds of cavitation and infiltrate require microbial confirmation with sputum acid fast bacillus samples and culture

Nonallergic vs Allergic Rhinitis

Non-Allergic: Nasal congestion, rhinorrhea, postnasal drainage, >20yo, no obvious allergic trigger, perennial symptoms (worsen with season changes), erythematous nasal mucosa. TX Mild with intranasal antihistamines (Azelastine) or glucocorticoids (Fluticasone), moderate to serve treated with combination therapy. Allergic Rhinitis: Watery rhinnorhea, sneezing, eye symptoms, earlier age of onset, identifiable allergen or seasonal pattern, pale/bluish nasal mucosa, associated with other allergic disorders like asthma and eczema. Tx with intranasal glucocorticoids and antihistamines

Propranolol

Non-Cardioselective beta blocker. Decreases conversion of T4 to T3 useful in Thyrotoxic Emergencies.

Lobular carcinoma in situ (LCIS) of the breast

Non-Malignant lesion arises in the terminal ducts and lobules of the breast. ocasionally incidental finding, no mlaigntn potential, signifies increased risk of developing invasive lobular or ductal carcinoma. tx: EXCISIONAL BIOPSY, then follow up surveillance (yearly mammogram), may include selective estrogen receptor modulators (SERMs) such as Tamoxifen, Raloxifene. May also prophylactically have a bilateral mastectomy.

Bupropion (Wellbutrin)

Non-Serotonergic Antidepressant, That inhibits the reuptake of Norepi and Dopamine

Bosentan

Non-selective endothelin receptor blocker. Blocks the endothelin mediated (ETa & ETb) pulmonary vasoconstriction Use for Pulmonary HTN CONTRA: PREGNANCY! This is a category X drug for pregnancy!

persistent, intrusive, unwanted thoughts of stabbing her children that causes her maked distress and anxiety.

Obsessive Compulsive Disorder Obsessions can include thoughts about contamination, images of violent or horrific scenes, or unwanted urges. Interfere with daily routine and cause severe distress. Also frequently have fears of causing dreaded events and may perform repetitive behaviors or mental acts to prevent them from happening Tx: SSRI, CBT (exposure & Response prevention)

hepatocellular injury in the absence of viral hepatitis, heavy alcohol use, abnormal iron levels in an obese diabetic patient

Nonalcoholic fatty liver disease Central obesity, DM, HLD, HTN Due to toxic lipid accumulation in the liver Insulin resistance which increases peripheral lipolysis (in adipocytes) and triglyceride synthesis leading to increased hepatic accumulation of fatty acids and triglycerides. Hepatocytes show macro vesicular fat deposition with peripherally displaced nuclei. Hepatic free fatty acid accumulation leads to increased free radical and pro inflammatory cytokine generation, which can lead to inflammation and hepatocyte injury it can also worsen insulin resistance by impairing insulin dependent glucose uptake and increasing hepatic gluconeogenesis insulin resistance is also associated with impaired free fatty acid oxidation (in the liver) and clearance (from the liver, due to decreased VLDL production)

Oligomenorrhea, Acne, Hirsutism, Clitoromegaly

Nonclassic Congenital Adrenal Hyperplasia

Management of C. Diff

Nonsevere (classic symptoms only-Profuse watery diarrhea, Ab pain), Severe (Symptoms + Leukocytosis and Serum Cr>1.5) = PO therapy: Fidaxomicin, Vancomycin Fulminant (Severe + Hypotension or Shock, Ileus or Megacolon) = Bowel rest, nasogastric tube placement, PO Vanc & IV Metronidazole -> If refractory consider fecal microbiota transplant, surgical intervention

Short, facial dysmorphism, congenital heart defects (pulmonic Stenosis, Atrial Septal Defects, Hypertrophic Cardiomyopathy)

Noonan Syndrome

Joint Fluid Characteristics

Normal = Clear, <200 WBC, <25% PMNs Non Inflammatory (OA) = Clear, WBC 200-2000, PMNS 25% Inflammatory (Crystals, RA) = Translucent or Opaque, WBC 2000-100,000, PMNS >50% Septic Joint = Opaque, WBC 50,000-150,000, PMNS >80-90%

osteoporosis/osteopenia

Normal = T Score of -1 or greater Low Bone Mass (Osteopenia) = T score of -1 to -2.5 Osteoporosis = T score -2.5 or less DXA to screen for osteoporosis recommended for women >65 and for postmenopausal women <65 who have additional risk factors (Low body weight, smoking, FH hip fractures, Use of glucocorticoids) Post menopausal women should be counseled on preventitive measures, regular weight bearing exercise and adequate intake of calcium and vitamin D Excess alcohol intake (>3 drinks/day) associated with increased risk of fracture Menopausal hormonal therapy (estrogen or combined estrogen/progrestoerone therapy) decrease risk of hip and vertebral fracture however higher risk of breast cancer, stroke, venous thromboembolism. Only advised for those women with intolerable menopausal symptoms. BISPHOSPHONATES INDICATED FOR: -Low bone mass with hx of fragility fractures -Osteoporosis defined by T score < -2.5 -Osteopenia (T score -1 to -2.5) with 10 year probability >20% for fracture or >3% for hip fracture by FRAX Risk Calculator Bisphosphonate alternative would be SELECTIVE ESTROGEN RECEPTOR MODULATOR (RALOXIFENE) for those at risk of breast cancer

Thyroid Disease During Pregnancy

Normal Changes: LOW TSH, HIGH Total T4, No change in free T4 HYPER (Hand tremor, nervous/restless, weight loss):LOW TSH, HIGH Free and total T4 HYPO: HIGH TSH, LOW T4, Variable Total T4 Serum TSH is the recommended initial screening test in pregnant patients with suspected HYPER. Then Free or Total T4, then Total T3

physiologic Anemia of Infancy

Normal and expected decline in Hgb in the first month of life After delivery, oxygen consumption in tissues increases compared to the concentration in utero, causing down regulation in circulating erythropoietin and a subsequent decline in RBC production in the bone marrow. Hgb naturally falls from level at birth (>14) to around 11. this happens around 2-3 months in term infants. Generally asymptomatic.

Contraception & adverse effects

OCP: Breakthrough bleeding, breast tender, nausea Depot medroxyprogesterone: initial irregular bleeding, amenorrhea, reversible bone loss, delayed return to fertility, +/- weight gain Progestin subdermal implant: Irregular bleeding IUD: Irregaulr bleeding, Amneorrhea Copper IUD: Heavy menses, Dysmenorrhea Progestins create a thin, atrophic endometrium that can shed erratically, especially when there is low dose estrogen as in OCP which normally act to thicken and stabilize the endometrium. therefore treat with OCP that has higher dose of estrogen.

Treatment of acute Deep Venous Thrombosis/ Pulmonary Embolism

ORAL FACTOR Xa INHIBITORS (RIVAROXABAN) Onset 2-4hrs, no overall needed, no lab monitoring WARFARIN Vitamin K antagonist, 5-7 days for onset, Overall with unfractioned heparin or low molecular weight heparin for 5 days, monitor PT and INR

St. Johns Wort

OTC herbal for ANTIDEPRESSANT, anti inflammatory, wound healing EFFECTIVE in tx of mild to moderate depression equivalent to TCA and SSRIs Induces P450 -> cause decrease in OCPs, Anti-retrovirals, immunosuppressive agents, narcotics, anticoagulants, antifungals SEROTONIN SYNDROME with serotonergic antidepressants

Hyponatremia due to inappropriate ADH release side effect of

OXCARBAZEPINE an anti epileptic drug

risk factors for pelvic organ prolapse

Obesity, Multiparty, Hysterectomy, Postemenopause Management: Weight loss, pelvic floor exercises, vaginal pessary, surgical repair.

Thrush (oral candidiasis) in a patient using inhaler for asthma

Observe the patient for proper use of inhaler as thrush is a sign of improper use with most of the medication depositing in his oropharynx as opposed to passing into his lungs. Can supplement with a spacer to make to easier. First line therapy for oral candidiasis is a topical antifungal (NYSTATIN SUSPENSION or CLOTRIMAZOLE TROCHES), also advise patients to rinse mouth after inhaler use. If resistant to treatment then second line is oral fluconazole

Localize the lesion. Amaurosis fugax.

Ophthalmic artery

treatment for erysipelas

Oral dicloxacillin or cephalexin. If the organism is confirmed as group A beta hemolytic streptococci, you may treat with penicillin VK.

erythematous, swollen eyelid, conjunctivitis, and fever.

Orbital cellulitis Most concerning signs are ophthalmoplegia (Painful eye movements) and proptosis due to orbital fat Predisposed to orbital cellulitis by sinusitis from viridian's group strep, strep pneumonia, Staph Aureus. Preseptal cellulitis is due to breaks in the skin and are from staph aureus and strep pyogenes. Confirm dx of orbital abscess by CT scan (Orbits and sinuses with contrast) Focal collection of pus consistent with orbital abscess a serious complication of orbital cellulitis that requires surgical drainage.

Upper eyelid laceration with fat protruding from the wound. Consistent with injury to the

Orbital septum Preseptal: Eyelid skin, orbiculares muscle postseptal: orbital fat, eyelid retractors (levator palpebral superior muscle and aponeurosis) and extra ocular muscles (superior rectus muscle) CT scan prioer to repair to asess extent of damage and rule out globe injury.

Adolescent with isolated proteinuria

Orthostatic Proteinuria (Higher protein excretion during the day when upright and normal at night when supine) Increased glomerular capillary pressure due to an exaggerated angiotensin II response with standing, Focal mesangial hypercellularity, basement membrane thickening, left renal vein entrapment. Dx: Compare urine protein to Cr ratio in urine samples collected in both supine and standing position, compare protein excretion in a split 24hr urine collection divided between daytime and nighttime. NO TX

Influenza can be treated with?

Oseltamivir

Multiple telangiectasias abd vascular lesions of the CNS

Osler-Rendu-Weber Syndrome

Compare the association between categorical variables (ex: Tx results of success or failure and male vs female gender)

Pearson Chi-Square test

Patient with poorly controlled DM and large non healing foot ulcer requires evaluation for

Osteomyelitis Initial screening bedside with probe to bone testing. Contact with bone is highly specific for osteomyelitis, and if negative need imaging. Plain radiographs are ordered first due to low cost and low radiation (cortical loss, bony destruction, periostea reaction) Diagnostic test of choice is MRI OF THE FOOT (If negative can rule out) if patient has a pacemaker and cant have MRI for any reason then CT scan is a good alternative Bone Biopsy with Culture is gold standard for identifying pathologic organisms and rerequired to determine appropriate antimicrobial therapy Tx: Diabetic foot infections with osteomyelitis need combination of glucose control, surgical debridement, weight off loading, revascularization, antibiotic therapy >6 weeks. Treatment response monitored with ESR.

left groin pain, while on prednisone for SLE. Walks with a limp, limited range of motion

Osteonecrosis of the femoral head (avascular necrosis or osteochondritis dissecans) occurs in the anterolateral femoral head can also affect the humeral head, femoral condyles, vertebrae, proximal tibia, and small bones of hand and foot. Related to SLE, Sickle cell, Antiphospholipid antibody syndrome, chronic renal insufficiency and hemodialysis, trauma, gaucheries disease, HIV, following renal transplant, caissons disease. Corticosteroid (chronic high dose 15-20mg/day)and excess alcohol is 90% of cases MRI Conservative therapy, core decompression (stage 1 or 2), osteotomy, joint replacement Total hip replacement is therapy of choice for stage 4 disease (flattening of femoral head and joint space narrowing)

7 days of Oral ciprofloxacin prescribed for

Outpatient treatment of acute pyelonephtirits

Community Acquired Pneumonia (CAP): fever, chills, SOB, cough productive of yellow-green sputum, consolidation in middle and lower lobes on CXR

Outpatient: Amox or Doxycycline if healthy vs Fluoroquinolones (levofloxacin, moxifloxacin) + Macrolides (Azithromycin) if have comorbidites Inpatient (NON-ICU): IV Fluoroquinolones (Levofloxacin) or Beta lactam (Ceftriaxone) + Macrolide (Azithromycin) Inpatient (ICU): Beta lactam + macrolide IV or Beta-lactam + Fluoroquinolone IV

Treatment of pyelonephritis in non pregnant

Outpatient: Fluroquinolones (Cipro, levo) Inpatient: IV Fluoroquinolones, Aminoglycosides +/- Ampicillin

CA-125

Ovarian Cancer Persistent abdominal bloating & adnexal mass

Type 1 DM can lead to secondary amenorrhea

Ovarian Insufficiency, associated with HYPOestrogen (vaginal dry, hot flashes)

Constant dribbling of urine, incomplete bladder emptying

Overflow Incontinence INTERMITTENT CATHERIZATION correct underlying etiology

Constant dribbling of urine, incomplete bladder emptying.

Overflow incontinence Incomplete bladder emptying due to decreased detrusor muscle contractility and or bladder outlet obstruction DECREASED PERINEAL SENSATION, LARGE POST VOID RESIDUAL (>150ml) Often associated with NEUROPATHY (poorly controlled DM, Spinal injury, MS) Tx: Intermittent catherization, correct underlying etiology

Constant urine dribbling from incomplete bladder emptying.

Overflow incontinence a complication of poorly controlled DM (diabetic Neropathy) and presents with constant urinary dribbling from incomplete bladder emptying. Eval with post void residual volume (>200mL diagnostic of overflow incontinence). Additionally evaluate with HgbA1C to assess blood glucose control. Intermittent cauterization or correct underlying etiology

Hyperthyroidism in pregnancy is treated with Antithyroid Drugs

Overtreatment of maternal hyperthyroid can cause fetal hypothyroid and goiter, treatment should be titrated to maintain a mild hyperthyroid state. PROPYLTHIOURACIL is preferred in the first trimester (teratogenic effects of Methimazole)..BUT METHIMAZOLE is preferred in the second and third trimester (due to hepatotoxicity of propylthiouracil) Beta blockers are used to control hyperadrenergic symptoms of hyperthyroid (tachycardia, palpitations). Short term <6weeks of Metoprolol or Propranolol is safe in pregnancy

Methemoglobinemia

Oxidation of iron molecules in hemoglobin, preventing oxygen binding. Most common cause is Medications (DAPSONE, BENZOCAINE) and toxins (Aniline dyes)

Endocrinopathy with Polyneuropathy can be seen with POEMS

P- Polyneuropathy O-Organomegaly E-Endocrinopathy M-M protein S-Skin changes SPEP looking for an M-Spike

Suspected foreign body ingestion

PA & Lateral Xrays High risk features (respiratory or obstructive symptoms, Button Battery (Ulceration, necrosis, perforation), Magnet, Sharp) -> Endoscopic removal Low Risk Features: Serial X-rays. If no transit endoscopic removal and if moving no intervention.

Majority of patients asymptomatic but others may have; Skull with deformity and enlargement, hearing loss, dizzy, Bone pain, Spinal stenosis, nerve compression, bowing deformity with high fracture risk, osteosarcoma, giant cell tumors

PAGETS DISEASE: Increased bone turnover Radiographic finding of thickened calvarium with inhomogeneous bone density or "cotton Wool" Appearance. HIGH Alkaline Phosphatase Normal Calcium & Phosphate XRAY: Osteolytic or mixed lytic/scleoric lesions Dx Radiograph and elevated Alk phosphatase, Bone scan to document extent and location Tx: Bisphosphonates or Calcitonin NO Tx for the resulting hearing loss

Photosensitive Dermatitis, Diarrhea, Dementia

PELLAGRA NIACIN (VIT B3)

gingival hyperplasia important side effect of

PHENYTOIN an anti epileptic drug

As disease prevalence increases

PPV increases and NPV decreases

PPV and NPV

PPV: Probability of having a disease given a positive test result: TP/TP+FP NPV: Probability of not having a disease given a negative test result: TN/TN+FN

Predictive Values (PPV vs NPV) depend on

PREVALENCE NPV: Probability that individual truly does NOT have the disease given a NEGATIVE test result. PPV: Probability that individual truly does have the disease given a POSITIVE test result. Prevalence affects NPV by changing TN and FN and affects PPV by changing TP and FP Populations with LOW disease prevalence have more TN and fewer TP therefore more positive tests would be associated with more FP with fewer FN. Therefore with decreasing prevalence NPV increases and PPV decreases Populations with HIGH disease prevalence have more TP and fewer TN therefore more negative tests would be associated with more FN with fewer FP. Therefore with Increasing prevalence NPV decreases and PPV increases

Multiple/recurrent episodes of bacterial pneumonia which responds to antibiotics in right middle lobe and leaves a persistent scar

Partial obstruction of the bronchus or a branch of the bronchus supplying right middle lobe Bronchogenic carcinoma in a smoker Endobrachial lesions cause a compression of the airway lumen and prevent adequate clearance of secretions causing stasis and recurrent pneumonia even after successful treatment of previous episodes. Bronchoaleveolar cell carcinoma, Lymphoma, Eosinophilic pneumonia, bronchiolitis obliterates organizing pneumonia (BOOP), systemic vasculitis, pulmonary alveolar proteinosis, drugs like Amiodarone Dx: Bronchoscopy to confirm Dx. can visualize and take biopsy same time.

Case-control study

Participants are identified initially as cases or controls with and without outcome then assess for past exposure to >1 risk factor of interest.

Aplastic crisis

Parvo B19 infection and spherocytosis or Sickle cell disease

abdominal pain and watery diarrhea, skin rash gets worse with sun exposure (pigmented scaly skin rash in the molar distribution of face neck and back of hands), depression.

Pellagra Due to NIACIN (Vit B3) Deficiency-Synthesized by tryptophan-heavy corn diet (unabsorbale form of niacin) or in heavy alcohols and chronic illness due to diet restriction, also carcinoid syndrome due to decreased tryptophan or Hartnupo disease (congenital disorder of tryptophan absorption) Prolonged isoniazid therapy without concomitant use of pyridoxine (via B6) needed for niacin synthesis can interfere with metabolism of tryptophan and lead to pellagra. DERMATITIS-rough hyper pigmented scaly skin lesions DIARRHEA-ab pain, nausea, loss of appetite DEMENTIA-neuronal degeneration in brain and spinal cord lead to memory loss

Evaluation of Primary Amenorrhea (15yo in breast developed girls, 13 if no breast)

Pelvic Exam or US Uterus present? HIGH FSH-Karyotype LOW FSH-Cranial MRI Uterus Absent? Karyotype, Serum Testosterone 46XX: Normal female testosterone levels - Abnormal Mullein Development 46XY: Normal male testosterone levels - Androgen Insensitivity syndrome

lower abdominal pain, tenderness, fever, and cervical motion tenderness. Dysuria and/or vaginal discharge are also possible.

Pelvic Inflammatory Disease

Pelvic pressure, Obstructed voiding, Urinary retention, Urinary incontinence, Constipation, Fecal urgency, sexual dysfunction Cystocele, Rectocele, Enterocele, Procidentia, Apical Prolapse

Pelvic Organ Prolapse Risk fx: Obesity, Multiparty, Hysterectomy, Postmenopausal Tx: Weight loss, Pelvic floor exercises, vaginal pessary, surgical repair

Antibiotics that are safe in pregnancy:

Penicillins, Cephalosporins, Aztreonam, Azithromycin, Metronidazole

per protocol analysis VS Intention to Treat Principle

Per Protocol Analysis: Compares treatment groups in a randomized trial by including in the analysis only those participants who STRICTLY adhered (compliant participants) and completed the protocol VS Intention to Treat Principle: Analysis that includes all participants as initially allocated after randomization, regardless of what happens during the study period.

Severe upper abdominal pain, radiates to the back, exacerbated by any movement. Hx of GERD takes antacids for years. Has "burning" symptoms in his stomach which drinks dairy products to relieve. Lies flat and motionless on the bed. Dry mucus membranes. Marked tenderness on superficial palpation.

Perforated Peptic Ulcer, most common etiology. Peritonitis evidence b y lie flat and motionless. Rupture of hollow organ allows air into the abdomen (pneumoperitoneum) Detect via UPRIGHT Chest and Abdominal Xray See free air under diaphragm if unclear then second choice would be abdominal CT. Emergency surgery (open or laparoscopic) is indicated in all patients. In preparation for surgery patients should receive fluid resuscitation and broad spec IV abx and IV PPI.

new onset dysarthria, right sided weakness, numbness post op

Periop Stroke most are ischemic rather than hemorrhagic and are caused by embolism, thrombosis or hypotensive episode (watershed infarction) EMERGENCY CT Head WITHOUT contrast to rule out hemorrhage. Once excluded reperfusion therapy (IV Thrombolysis, Mechanical Thrombectomy)

fever, sore throat, difficulty swallowing, trismus, muffled hot potato voice, uvula deviation, pooling of saliva

Peritonsillar abscess TRISMUS most specific finding that differentiates peritonsillar abscess from tonsillitis. Needle aspiration or incision and drainage of the abscess plus antibiotic therapy to cover group A hemolytic Strep and respiratory anaerobes

loss of proprioception, brisk reflexes, loss of ankle jerk, tingling and numbness in distal lower extremities. in a patient with primary hypothyroidism

Pernicious Anemia (Vit B 12 deficiency)-Atrophic Gastritis Dietary Vit B12 binds to intrinsic factor secreted by parietal cells in the gastric mucosa, intrinsic factor-B12 complex carried to the terminal ileum for receptor mediated absorption. Pernicious anemia results from autoimmune destruction of parietal cells. leading to achlorhydria and decreased production of intrinsic factor. Lack of intrinsic factor leads to Vit B12 deficiency. RBCs are microcytic due to ineffective erythropoiesis due to defective nucleic acid synthesis. Neuro involvement posterior and lateral columns in spinal cord (subacute combined degeneration) and leads to ataxia, loss of proprioception and vibratory sensation. Severe spasticity weakness and peripheral nerve Involvement. Tx with Vit B 12 can lead to HYPOKALEMIA results from uptake of potassium by newly forming RBCs. Serum potassium levels should be monitored during the first 48hrs, can transfuse packed RBC in patients with severe megaloblastic anemia before B12 supplementation to prevent hypokalemia.

Macrocytic anemia, normal serum folate level, depressed cobalamin level (B 12 Deficiency Anemia)

Pernicious Anemia (autoimmune destruction of parietal cells) - Anti-parietal and Anti-Intrinsic Factor (IF) Abs. Anti IF antibody testing is the recommended initial test for the detection of pernicious anemia. Associated with gastritis called Autoimmune Metaplastic Atrophic Gastritis (AMAG), caused by autoimmune aggression against gastric mucosa. Immune response mainly directed against oxyntic cells and intrinsic factor. GLANDULAR ATROPHY, INTESTINAL METAPLASIA and INFLAMMATION. Atrophy affects the gastric body and fundus. (ABSENT RUGAE IN THE FUNDUS)

Myringotomy & Placement of Tympanostomy Tube

Persistent treatment failure, persistent effusion >3 months, > 3 episodes of AOM in 6 months (>4 in. year)

Preseptal vs orbital cellulitis

Preseptal: -Eyelid Erythema & swelling -Chemosis -Oral Abx Orbital cellulitis: -Eyelid Erythema & swelling -Chemosis -Pain with EOM, Proptosis, ophthalmoplegia with diplopia -IV abx-Third gen cephalosporins (ceftriaxone) or ampicillin-Sulbactam, for patients with hx of MRSA or severe presentation Vancomycin should be added -Surgery if there is a drainable abscess

Episodic headaches, diaphoresis, tachycardia, Palpitations, Hypertension

Pheochromocytoma (familial syndromes MEN2, NF1, VHL) Adrenal incidentaloma on imaging, Pressor réponse during surgery/anethesia, Idiopathic dilated cardiomyopathy. MEASURE 24hr Fractionated Urinary METANEPHRINES & CATECHOLAMINE LEVELS IF HIGH Then CT or MRI of ABDOMEN +: Surgical eval, genetic testing, alpha & Beta blockade prior to surgery, MIBG (123I-Metaiodobenzylguanidine) scan (resembles norepinephrine, taken up by adrenergic tissues and can detect tumors not detected on CT or MRI if tumor >5cm and Suspicion of extra-adrenal disease. (Located in adrenal glands>4-4.5cm and have high tissue density on CT. Removal of tumor only after localization, need adequate preop control of BP for 10-14 days with alpha blocker and IVF volume repletion. Beta blocker given after alpha blockade otherwise paradoxical increase in BP.

First Line therapy for erectile dysfunction

Phosphodiesterase-5 (PDE-5) Inhibitor (Sildenafil, Vardenafil, Tadalafil)

examination of facial skin leathery appearance with many deep furrows, and wrinkles, skin is sallow and has variable pigmentation, surface texture is rough, scattered flesh colored scaly patches with slightly irregular margins and occasional clusters of dilated superficial capillaries and venues.

Photoaging Actinic keratoses, telangiectasias and brown liver spots

Smoking tobacco worsens what skin condition

Photoaging Alters production of collagen or elastin

Strategies to promote critical illness recovery (ICU Liberation)

Physical: Daily sedation holiday, Early PT mobility, Nutrition and swallow eval Cognitive:Minimize meds that cause delirium, Facilitate normal sleep wake cycle Iatrogenic: Removal of lines, drains, catheters, prevent harm from DVT or C. Diff Psychosocial: Family support and education, Spiritual care IMMEDIATE BENEFITS OF EARLY PT/MOBILITY -secretion mobilization, atelectasis recruitment, respiratory muscle strengthens, decreased DVT, restore normal sleep wake cycle, improve swallowing

Mild Normocytic, Normochromic Anemia. Late second to early third trimester.

Physiologic Anemia of pregnancy Due to a greater expansion of plasma volume relative to increase in RBC mass (Dilution Anemia)

lower extremity angulation of knees that is noticeable when children begin ambulating.

Physiologic Genu Varum. Self resolves by 2.

Neurodegenerative disorder of the frontal and temporal lobes that involves early onset (50s, 60s), personality changes, executive dysfunction progressing to dementia.

Pick Disease (Major Frontotemporal Neurocognitive Disorder

loss of pupillary reaction, vertical gaze paralysis, loss of optokinetic nystagmus, ataxia, headaches.

Pineal tumor causing PARINAUDS SYNDROME Germinomas and secrete HCG causing precious puberty in prepubertal males.

Self-limited condition with single primary plaque (herald Patch) with a fine collarette scale. Generalized eruption develops 1-2 weeks later, with dine scaling papule and plaques Christmas tree distribution.

Pityriasis Rosea

PAINLESS vaginal bleeding >20 weeks gestation

Placenta Previa Bleeding is from maternal origin, so normal fetal heart rate tracing. Risk factors: Prior C section, Multiparty, Multiple gestations, tobacco use. IF no previous anatomy US = TRANSVAGINAL US DIGITAL CERVICAL EXAM is CONTRAINDICATED MUST HAVE C-SECTION Cannot do vaginal delivery

Placenta Accreta VS Increta VS percreta

Placenta accreta: placental villi ATTACH to myometrium Placenta increta: placental villi INVADE the myometrium Placenta percreta: placental villi PENETRATE to or through the uterine serosa (possible to adhere to bladder or intestines)

Placenta previa VS Abruptio placenta

Placenta previa = painless vaginal bleeding Abruptio placenta = painful vaginal bleeding

Best initial and most accurate tests for Osteomyelitis

Plain x-ray & Bone biopsy and culture

Patient with CKD has easy bleeding and bruising with a normal platelet count and coagulation studies

Platelet dysfunction most common cause of bleeding tendencies in patient with CKD. Rising Urea -> Upregulate nitric oxide -> decrease platelet adhesion (Down-regulated von Willebrand Factor), activation and aggregation (blocked activation of glycoprotein IIb/IIIa receptors -> Bleeding despite normal platelet count and coagulation studies. Easy bruising, mucosal bleeding (epistaxis, GI hemorrhage) Tx: Desmopressin (Increase vWF secretion from endothelial cells and reduce bleeding time) only required if having bleeding symptoms or upcoming procedure

Purpose of "intention-to-treat" approach

Preserve Randomization Premise of intention to treat is that participants in trials should be analyzed in the groups to which they were randomized regardless of wether they received or adhered to the allocated intervention and regardless of wether they withdrew from treatment. Trying to avoid effects of crossover and dropout which may break randomization and affect the outcome.

HIV, fever, dry cough, SOB, SpO2 87% RA, Oropharyngeal thrush, scattered bilateral crackles and rhonchi, on CXR diffuse interstitial opacities b/l. CD4 85. weight loss.

Pneumocystis Jirovecii Pneumonia (PCP) When CD4<200 HIGH LDH levels Diffuse b/l reticulonodular infiltrates on pulmonary imaging. Dx: INDUCED SPUTUM or BRONCHOALVEOLAR LAVAGE definitive diagnosis requires isolation of organisms in respiratory samples. Can have respiratory decompensation during first 2-3 days of tx due to organism lysis which stimulates inflammatory response. Tx with corticosteroids when ABG shows alveolar-arterial oxygen gradient>35 and or arterial oxygen tension (PaO2)<70 Tx: TMP-SMX +/- Corticosteroids

Shortness of breath, dry cough, hypoxia, and markedly increased LDH. Diagnosis & Treatment?

Pneumocystis Pneumonia (PCP) best initial test is a chest x-ray, which will show increased interstitial markings bilaterally. The most accurate test is bronchoalveolar lavage. -IV TMP/SMX -If there is a rash, use IV pentamidine or the combination of clindamycin and primaquine -Dapsone for prophylaxis ONLY -Steroids if severe (pO2 <70 or A-a gradient >35)

Indolent fever, dyspnea, dry cough, bilateral interstitial infiltrates in HIV

Pneumocystis Pneumonia common in AIDS evaluate with induced sputum samples, bronchoalveolar lavage is the second line test

TMP-SMX used as a primary prophylaxis to prevent

Pneumocystis Pneumonia in HIV with CD4 <200 Toxoplasmosis in HIV with CD4 <100

Aspiration: Pneumonitis vs Pneumonia

Pneumonitis: inhalation of gastric acid leads to direct chemical injury of bronchial and alveolar epithelial cells. Abrupt onset of dyspnea, cough, hypoxemia, low grade fever, diffuse crackles/wheezes, INFILTRATE IN DEPENDENT PORTION OF LUNG. Supportive care, oropharyngeal suction Aspiration Pneumonia: Inhalation of large inoculate of oropharyngeal or gastric microbes. Fever, cough with putrid sputum, INFILTRATE IN DEPENDENT PORTION OF LUNG. Tx: CEFTRIAXONE+AZITHROMYCIN

Amenorrhea, Hirsutism (hair upper lip), Obese, Estrogen excess (breast tender), Bilaterally enlarged ovaries

Polycystic Ovary Syndrome

Multifollicular ovaries bilaterally

Polycystic Ovary Syndrome -Androgen excess: acne, male pattern baldness, hirsutism -Oligoovulation or an ovulation: menstrual irregularities -Obesity -Polycystic Ovaries on US HIGH testosterone and Estrogen, Imbalance of LH/FSH Chronic anovulation lead to unopposed estrogen resulting in uncontrolled endometrial proliferation and increased risk for endometrial hyperplasia and cancer Metabolic syndrome (DM, HTN), OSA, NonAlcoholic Steatohepatitis, Endometrial hyperplasia/cancer Tx: WEIGHT LOSS FIRST LINE, OCP (if cant take pills then PROGESTIN-CONTAINING IUD, provides endometrial protection by thinning the endometrium and reversing hyperplasia), LETROZOLE FOR OVULATION INDUCTION

Water-Induces (showers) Itching in the absence of a rash

Polycythemia Vera (Decreased Serum Erythropoietin Levels)

Erythrocytosis, Aquagenic pruritis, HTN, Arterial or venous thrombus.

Polycythemia Vera chronic myeloproliferative neoplasm associate with JAK2 mutation.

Fever, abdominal pain, cervical motion tenderness and mucopuruelnt cervical discharge: Pelvic Inflammatory Disease, treatment

Polymicrobial infection, antibiotic treatment should cover CHLAMYDIA Trachomatic, NEISSERIA GONORRHOEAE, and VAGINAL FLORA (E. coli) CEFOXITIN (Gram negative bacilli like E. coli) + DOXYCYCLINE (Gram positive Strep, Gram negative Gonorhhea, and atypical chlamydia)

>50 yo, subacute onset of diffuse muscle pain and stiffness, mild stiffness with active range of motion, normal passive range of motion

Polymyalgia Rheumatica

>50yo, pain and morning stiffness >1 month. Involve neck or torso, shoulders, thigh, hip, fever, malaise, weight loss, ESR >40, HIGH CRP

Polymyalgia Rheymatica Decreased active ROM in shoulders, neck, hips Tx: Low dose glucocorticoids (prednisone 10-20mg daily)

Pulmonary Barotrauma

Positive Pressure Ventilation allows for improved oxygenation with an alveolar-filling process (pulmonary edema, pneumonia) poses risk of pulmonary barotrauma leading to alveolar rupture and air leakage into undesired parts of body (sub tissue, mediastinum, pleural space) resulting in PNEUMOTHORAX-> Tachycardia, Tachypnea, Hypoxemia, decreased or absent breath sounds on affected side. Bedside US diagnostic test of choice but a CXR can show pleural line with an absence of distal lung markings. Management by placement of chest tube

Hyperthyroid (HIGH T4, Suppressed TSH). Non tender goiter. Recent pregnancy.

Post Partum Thyroiditis Radioactive Iodine Uptake test can distinguish Graves (INC THYROID HORMONE SYNTHESIS) from Post partum Thyroiditis & Silent Thyroiditits characterized by Thyroid inflammation and release of preformed hormone. Graves disease has a HIGH RAIU and Postpartum Thyroiditis and Silent Thyroiditis have a low RAIU. Thyroglobulin is co-secreted with thyroid hormone by thyroid follicles and is low in patient with exogenous thyrotoxicosis (due to suppression of follicular activity by exogenous thyroid hormone) but is elevated in postpartum thyroiditis due to destruction of thyroid follicles and Graves disease due to increased activity of follicles.

dark urine, described as "tea-" or "cola-colored." Periorbital edema and hypertension.

Post Strep Gomerulonephritis Antistreptolysin O, Anti-DNase, Antihyaluronidase LOW Complement Biopsy shows sub epithelial deposits of IgG & C3 Tx: Penicillin for infection and Diuretics for HTN and Fluid Overload.

headache, confusion, amnesia, difficult concentrating, vertigo, hypersensitivity to various stimuli, mood alteration, sleep disturbance, and anxiety. following traumatic brain injury.

Postconcussive Syndrome Typically resolve with symptomatic treatment within a few weeks to months. Most can have symptoms persisting >6 months

Pregnancy Induced Skin Changes Vs Intrahepatic Cholestasis of Pregnancy

Pregnancy Induced Skin Changes: -Focal Pruritis, No rash -Due to pregnancy hormone changes -No lab abnormalities, +/- Transaminitis -Tx: Oatmeal baths, UV light, Antihistamines Intrahepatic Cholestasis of Pregnancy: -Generalized pruritis -Due to intrahepatic cholestasis -High bile acids -Transaminitis -RISK: INTRAUTERINE FETAL DEMISE -DELIVER AT 37 WEEKS -Tx: DEFINITIVE TX = DELIVERY BUT Ursodeoxycholic Acid can alleviate pruritis by decreasing both cholesterol reabsorption from intestine and hepatic excretion of cholesterol, Antihistamines

Palpable bladder in an infant with prenatal US of bilateral hydronephrosis, dilated and thickened bladder and oligohydramnios

Posterior Urethral Valve (Urethra obstructed by congenital posterior urethral membrane)-Distended bladder with thick wall, dilated ureters, Hydronephrosis Congenital obstruction of urethra caused by residual embryologic tissue during GU development in Boys. Abnormal insertion of Wolffian ducts, not present in girls. Dilated bladder is highly specific. Oligohydramnios can result in Potter Sequence (pulmonary Hypoplasia, flattened facies) Dx: Confirm with VOIDING CYSTOURETHROGRAM, Visualization of a dilated proximal urethra when catheter is removed Once confirmed infants should have FOLEY CATHETER placed to temporarily relieve obstruction once infants condition stabilized CYSTOSCOPY allows direct visualization and ablation of the valve, which is curative.

Localize the lesion. Ipsilateral face. Contralateral body. Vertigo and Horner syndrome.

Posterior inferior cerebellar artery

ataxia and bulbar dysfunction indicate disruption in which artery?

Posterior inferior cerebellar artery aneurysms

fever >24hrs postpartum and uterine fundal tenderness, findings consistent with

Postpartum Endometritis (MOST COMMON CAUSE OF POSTPARTUM FEVER) Purulent vaginal discharge, boggy uterus, increased vaginal bleeding. Polymicrobial infection of the uterine decide caused by ascending vaginal flora during labor, delivery or immediate post party. Also common in patient with pre labor rupture of membranes or protracted labor. BROAD SPEC IV ABX (penicillin resistant anaerobes coverage required) **CLINDAMYCIN (aerobic gram + cocci & penicillin resistant anaerobes-bacteriodes fragilis)+ **GENTAMICIN (Gram - like E. coli, and some gram + like Staph) Continue tx until afebrile for 24hrs.

Obstruction of the kidney will lead to renal failure: -Stone in the bladder or ureters -Bilateral strictures -Cancer of the bladder, prostate, or cervix -Neurogenic bladder (atonic or noncontracting, such as from MS or diabetes) -Prostate hypertrophy/BPH

Postrenal Azotemia (Obstructive Uropathy) Dx: BUN to Cr Ratio >15:1, Distended bladder on exam, Large volume diuresis after passing a urinary catheter, Bilateral hydronephrosis on US.

long term tx of Parkinson's

Pramipexole (Dopamine agonist)

Treat nightmares

Prazosin

Hypoperfusion will lead to renal failure: -Hypotension -Hypovolemia from dehydration or blood loss -Low oncotic pressure (low albumin) -Congestive heart failure -Constrictive pericarditis -Renal artery stenosis (bilateral)

Pre-Renal Azotemia Dx: BUN to Cr Ratio >15:1, LOW Urinary Sodium <20, FeNa <1%, Urine Osmolality >500, Hyaline casts on Urinalysis

Acute Kidney Injury

Pre-Renal: -DEC Renal perfusion from volume depletion or DEC arterial blood volume. -BUN/Cr ratio >20 -FeNa <1% (renal sodium conservation) -Urine Osmolality >500 -Management = IVF Acute Tubular Necrosis: (LOW BUN/CR RATIO <20:1, and lack of response to IVF) -Tubular injury from ischemia, sepsis, nephrotoxins (ahminoglycosides) -FeNa >2% (sodium wasting) -Urine Osmolality 300 -Muddy Brown Casts -Tx: Supportive care, tx underlying cause, remove offending agent Post-Renal: -Urinary obstruction (BPH, Bilateral stones, malignancy) -management = relief of obstruction

BUN/CR >20. FeNa <1%. Urine osmolarity >500 mOsm/kg. Bland UA +/- hyaline casts.

PreRenal AKI DEC renal perfusion from VOLUME DEPLETION or HF Management via IV fluids

Phases of clinical trials

Preclinical: Lab & Animal Models (Explore if and how new tx will work) Phase 1: Small number (20-100) healthy subjects (Evaluate toxicity, max tolerated dose, adverse effects, pharmacokinetics, opharamcodynamics of new tx) - SAFETY Phase 2: Small number (a few hundred) affected subjects (explore efficacy, optimal dosing, adverse effects) - EXPANDED SAFETY Phase 3: Large number (300-3000) affected subjects randomly assigned to new treatment or control (Compare new treatment to current standard of care) - SAFETY & EFFICACY Phase 4: Post marketing surveillance (identify rare and long term adverse effects)

GOUT: Acute severe pain redness warmth swelling decreased ROM in the great toe (first metatarsopahalngeal joint) or knee

Predisposing factorors: -Meds: Diuretics, Low dose aspirin, immune suppressants -Surgery, trauma, recent hospitalization, CKD, Organ transplant, volume deplete -Obesity, high protein/high fat diet, excess alcohol Arthrocentesis with MONOSODIUM URATE CRYSTALS: NEGATIVE BIREFRINGENT< NEEDLE SHAPED CRYSTALS Patients with renal failure or those with renal transplant, NSAIDs (indomethacin) usually the firs line therapy for acute gout are CONTRAINDICATED, usually low -dose COLCHICINE is effective however increased toxicity if taking cyclosporine concurrently next option is systemic or intraarticular glucocorticoids (Triamcinolone) AFTER acute attack settled then can start on rate-Lowering Therapy with Xanthine Oxidase Inhibitor (Allopurinol, Febuxostat) or a Uricosuric Agent (Probenecid) if taking azathioprine after organ transplant then care when giving xanthine oxidase inhibitors because of impaired metabolism of azathioprine.

Systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg New onset cerebral or visual disturbance (includes headache) Hepatic abnormality (RUQ pain and/or transaminases more than doubled) Thrombocytopenia (<100,000) Renal abnormalities Pulmonary edema

Preeclampsia with severe features

During Pregnancy: BP elevation >140/90 mm Hg and proteinuria of at least 1+ (on dipstick), protein:creatinine ratio >3, or >300 mg (on a 24-hour urine) Sustained BP elevation >140/90 mm Hg and end-organ dysfunction with or without proteinuria

Preeclampsia without severe features

rapid increase in thyroid gland size result in difficult swallowing, Pembertons test have patient raise arm over head see facial plethora or engorgement of neck veins. HIGH TSH, LOW T4. + Antithyroid Peroxidase Abs

Preexisting Hashimoto's that has now led to THYROID LYMPHOMA

MOST COMMON CAUSE OF SECONDARY AMENORRHEA

Pregnancy Phenytoin for seizures + signs of increased estrogen (Breast tender) and amenorrhea = Pregnancy due to OCP failure. PHENYTOIN, CARBAMAZEPINE, ETHOSUXIMIDE, PHENOBARBITAL, TOPIRAMATE (Antiseizure meds) decrease efficacy of OCP by inducing CYP-450 system in the liver and lead to increased OCP metabolism thus decreasing the efficacy. NON OCP effecting anti seizure meds are Gabapentin and Valproate, and Long acting reversible methods of contraception like IUD and implant are less effected by P450 therefore better option for reproductive age women with seizures

Psychiatric illness itself has been associated with negative outcomes in pregnancy

Preterm Birth & Lower Apgar scores Guidelines for prescribing psychotropics: Avoid first trimester exposure if possible and use lowest doses as few agents as possible AVOID VALPROATE (NTF-spina bifida) SAFE Antidepressants (Citalopram), Antipsychotics (Quetiapine) Lithium is linked to Ebstein Anomaly, however if stable on it best to keep due to risk of recurrence leading to not caring for self or fetus and possible suicide Benzos are safe

<37 weeks gestation, no contractions, gush of clear fluids, a pool of nitrazine-positive vaginal fluid "ferns" on microscopy and Oligohydramnios (Amniotic fluid index 5cm)

Preterm Premature Rupture of Membranes (PPROM) Risk factors: Physical exertion, Anemia, First trimester bleeding, Hx of PPROM in a prior pregnancy At risk for umbilical cord prolapse - EMERGENCY - compression of the prolapsed cord can impede blood flow and cause fetal hypoxia (recurrent variable decelerations, Bradycardia), Chorioamnionitis, preterm delivery, abrupt placentae Dx: Confirmed by palpating a pulsatile umbilical cord in the vagina or cervix. Management includes elevation. of the presenting fetal part to prevent compression

low serum cortisol level, abnormal ACTH stimulation test, Hyperpigmentation, hypotension, orthostatic syncope, hyponatremia (salt craving), hyperkalemia

Primary Adrenal Insufficiency Due to Autoimmune Adrenalitis (Most common), TB infection, Metastatic infiltration Fatigue, weak, anorexia, weight loss, N, V, abdominal pain, salt craving, postural hypotension, hyoperpigementation, acute adrenal crisis: confusion, hypotension/shock Hyponatremia, hyperkalemia, eosinophilia, low morning cortisol, high ACTH (Increased melanocyte stimulating hormone, along with ACTH derived from proopiomelanocortin) Hyperpigemntation Loss of glucocorticoid and mineralocorticoid production from adrenal glands leads to hypotension, orthostatic syncope and hyponatremia and hyperkalemia Tx: HYDROCORTISONE or prednisone (glucocorticoids) but if treated alone can still have symptoms therefore need to add a (mineralcorticoid) such as FLUDROCORTISONE Unless central (hypothalamic or pituitary) adrenal insufficiency then treat with glucocorticoid alone because aldosterone secretion is related by renin-angiotensin system and therefore have adequate mineralocorticoid activity

common malignancy in patients with advanced HIV infections

Primary CNS Lymphoma related to EBV, associated with significant degree of immunosuppression, especially with CD4 <50 With increase in CD4 and decrease viral load by initiating HAART therapy = improved prognosis and prolong overall survival Diagnostic tool = Increase in level of soluble B-cell marker in CSF EBV DNA Levels in CSF to monitor therapy

Delayed puberty in Boys

Primary Hypogonadism: (HIGH FSH/LH -Klinefelter 47XXY Secondary: (LOW FSH/LH) -Constitutional, chronic illness, malnutrition -Hypothyroid, Hyperprolactinemia -Kallmann syndrome -Craniopharyngioma Absent testicular enlargement (>4ml) by 14yo Delayed growth spurt Hypogonadism due to inadequate testosterone. Primary or secondary (due to impaired GnRH) WORKUP: -FSH, LH, TESTOSTERONE, TSH, PROLACTIN -Bone Age Radiograph

Amenorrhea <40yo (no menses for >3months in patient with previous regular menses), Hypoestrogenic Symptoms (hot flashes), HIGH FSH, LOW ESTROGEN

Primary Ovarian Insufficiency Idiopathic, TURNER (45 XO), FRAGILE X (FMR1), Autoimmune oophoritis, Anticancer drugs, Pelvic radiation, Galactosemia on pelvic US = Thin endometrial stripe and small atrophic ovaries Adrenal antibodies, TSH, KARYOTYPE ANALYSIS Management: ESTROGEN THERAPY (With progestin if intact uterus) HIGH FSH = Loss of ovarian function (Hypoestrogenism) Hypergonadotropic Hypogonadism = HIGH FSH, LOW ESTROGEN

HIV and <50 CD4 cells with focal neurologic abnormalities. Diagnosis & Treatment.

Progressive Multifocal Leukoencephalopathy (PML) best initial test is a head CT or MRI. PCR of CSF for JC virus is most accurate. No specific therapy available for PML. Treat with ART. When the CD4 count rises, PML will resolve.

Metoclopramide (Reglan)

Prokinteic agent accelerates gastric emptying and indicated for gastroparesis partial paralysis of the stomach, is a disease in which your stomach cannot empty itself of food in a normal way. If you have this condition, damaged nerves and muscles don't function with their normal strength and coordination — slowing the movement of contents through your digestive tract injury to the vagus nerve due to surgery on your esophagus, stomach, or small intestine. hypothyroidism. certain autoimmune diseases, such as scleroderma link. certain nervous system link disorders, such as Parkinson's disease link and multiple sclerosis link. viral infections of your stomach.

Ocular problem seen in diabetics

Proliferative Retinopathy

Causes of Acquired Long QT Syndrome

Prolonged QT followed by a rapid ventricular rhythm = Polymorphic Ventricular Tachycardia = Torsades de Pointes Brief Arrhythmia that terminates spontaneously. Recurrent episodes in rapid succession with risk of degeneration into VFib and death. FIRST LINE TX: IV MAG SULFATE Meds: Diuretics (electrolyte imbalance), Ondansetron, Antipsychotics (Haloperidol, Quetiapine, Risperidone), TCAs, SSRI (citalopram), Antiarrhythmics (amiodarone, Stall, Flecainide), Antianginal drugs (Ranolazine), Anti-infective drugs (macrocodes, Fluoroquinolones, Antifungals) Metabolic Disorders: Electrolyte imbalances (LOW POTASSIUM, LOW MAG, LOW CALCIUM), Starvation, Hypothyroid Bradyarrhythmias: Sinus node dysfunction, AV block (2nd or 3rd degree) Hypothermia, MI, HIV

Hypokalemia, Hypomagnesemia, Dofetilide, haloperidol all can cause what change on ECG

Prolonged QT interval (480msec)

Study consisting of 5000 individuals without preexisting CVD who were categorized into study groups based on their LDL-P and LDL-C levels. Then monitored for 5 years to assess incidence of CV events. What type of study?

Prospective Cohort Study Group of subjects the cohort selected and their exposure status is determined (low LDL or High LDL) the cohort is then followed for a certain period and observed for development of outcome (CV events)

frequency, urgency, and dysuria and perineal or sacral pain. The prostate is tender and may be described as "boggy" on examination. Diagnosis & Treatment.

Prostatitis Sexually active men may get prostatitis from GC and chlamydia. The best initial diagnostic test is urinalysis. The most accurate test is urine WBCs after prostate massage. Treatment is ciprofloxacin or TMP/SMX for an extended period (2 weeks for acute and 6 weeks for chronic).

Bacterial Endocarditis Prophylaxis

Prosthetic Heart Valve Previous Infective Endocarditis Structural valve abnormalities in transplanted heart Unprepared cyanotic congenital heart disease repaired with residual defects Prophylaxis for: -Gingival manipulation or respiratory tract incision (Strep Viridans-AMOXICILLIN) -GU or GI tract procedure in setting of active infection (Enterococcus-AMPICILLIN) -Surgery on infection ted skin or muscle (Staph-VANCOMYCIN) -Surgical placement of prosthetic cardiac material (Staph-VANCOMYCIN)

Endocarditis Prophylaxis

Prosthetic valves, Unrepaired cyanotic heart disease, Previous endocarditis, Transplant recipients who develop valve disease Dental procedures that cause bleeding, Respiratory tract surgery, Surgery of infected skin For dental/oral procedures, amoxicillin; if rash with penicillin, then cephalexin; if anaphylaxis to penicillin, then azithromycin, clarithromycin, or clindamycin For skin procedures, cephalexin; if allergic to penicillin, then vancomycin

Ritonavir, Darunavir, Atazanavir: Class of drugs and Side Effects?

Protease Inhibitors SE: Hyperglycemia, Hyperlipidemia

Cystic Fibrosis, pulmonary exacerbations are due to? and treated with?

Pseudomonas or Staph Aureus MRSA coverage with VANCOMYCIN PLUS 2 drugs against Pseudomonas CEFEPIME, AMIKACIN

frequent headaches, rhythmic pulsating sound in ears as bend over, when straighten vision dims in both eyes, peripapillary =flame hemorrhages, venous engorgement, hard exudates, constriction of the visual field inferior nasal quadrant.

Pseudotumor Cerebri (idiopathic intracranial HTN) From chronically elevated intracranial pressure. Obese premenopausal women, or secondary to endocrine disorders (hypoparathyroid, Hypothyroid, adrenal insufficiency, Cushing disease), and the usage of some meds (Isotretinoin, All-trans-retinoic acid, minocycline, tetracycline, cimetidine, corticosteroids, danazol, tamoxifen, levothyroxine, lithium, nitrofurantoin)

Post-ICU Care Syndrome (PICS)

Psych: Depression, PTSD, occur within 5 years of the ICU stay, sleep disturbance in first few weeks Meurocognitive: Attention/memory deficits for several years Physical: Lose functional independence, require daily assistance for months to years. Need PT, able to eventually walk independently again

High dose prednisone (>40mg/day) may cause

Psychiatric symptoms in a dose dependent fashion, with Lori without hx of psych disorders more common in females mood symptoms, psychosis, anxiety, sleep disturbance, restlessness, memory loss. Dose reduction is first step in tx.

Major Depressive Disorder most effective treatment

Psychotherapy (Cognitive Behavioral Therapy, Interpersonal Psychotherapy) + Pharmacotherapy (SSRI) Combination is more effective than any one of them alone. Not all cause weight gain, BUPROPION Doesn't

Schizoaffective vs major depression vs bipolar

Psychotic symptoms occur exclusively during mood episodes however chronic psychotic symptoms (auditory hallucinations) when neither manic or depressed rules out bipolar disorder with psychotic features.

perioral tingling, incoordination, weakness, paralysis after ingesting fish

Pufferfish poisoning

Reduced DLCO, normalk lung volumes

Pulmonary Arterial HTN (due to intimal hyperplasia of the pulmonary arteries) Reduced DLCO due to combination of impaired blood delivery to the pulmonary capillaries and impaired diffusion of gas across the alveolar pulmonary capillary membrane.

weight loss in a patient with chronic lung disease

Pulmonary Cachexia Syndrome (PCS) loss of lean muscle mass associated with chronic lung disease, COPD. Seen in severe COPD. Increased work of breathing causes increased caloric use, significant energy imbalance in setting of decreased appetite and low dietary intake, systemic inflammation plus a role by decreased appetite and catalyzing skeletal muscle breakdown. Tx: Optimizing lung function, exercise, and nutritional supplementation.

Dyspnea, Chest tightness, Hypotension, Tachycardia

Pulmonary Embolism

CT pulmonary Angio is used to diagnose?

Pulmonary Embolism. Resp distress, Hypoxemia, Tachycardia, HIGH Pulmonary arterial pressure

Standardized Mortality Ratio (SMR)

SMR = Observed number of deaths/Expected Number of Deaths SMR of 1.75 indicates that observed number of deaths was 1.75 times (or 75%) higher than would be expected -Adjusted measure of the overall mortality -Used in occupational epidemiology -Mortality is often adjusted for age

Confirmatory test for Asthma

Pulmonary Function Testing (PFT) OBSTRUCTIVE PATTERN with reduced FEV1 and Reduced FEV1/FVC Ratio Total lung capacity and diffusing capacity of the lungs for carbon monoxide normal Bronchodilator (albuterol) can be administered and should result in significant improvement in FEV1. HOWEVER, if during testing NO SYMPTOMS then normal PFT findings. Adding Methacholine likely cause >20% reduction in FEV1 diagnostic for airway hyper responsiveness. Therefore A positive Methacholine test will diagnose asthma. IF negative can reliably rule out asthma.

LOW cardiac output (Exertional syncope/presyncope, fatigue, weakness. HIGH Pulmonary Artery Pressure (Chest tightness, Hemoptysis. RV demand ischemia: Exertional angina /tightness. Venous congestion (abdominal distension (bowel edema), early satiety. Holosytolic murmur of tricuspid regurgitation, JVD, Ascites, peripheral edema, hepatomegaly. Pulmonary artery enlargement on CXR.

Pulmonary HTN Pulmonary arterial HTN, or left heart disease, or chronic lung disease or hypoxemia (COPOD, OSA), or chronic thromboembolic disease, or sarcoidosis Initial eval: Transthoracic Echo. Estimates the PA systolic pressure and evaluates RV function. PH associated with HFrEF requires Renin-Angiotensin inhibitor and Cardioselective Beta Blocker PH due to lung disease and or chronic hypoxemia tx with inhaled muscarinic antagonist for COPD PH due to thromboembolic disease requires tx with thromboendarterectomy surgery and lifelong anticoagulation All forms of PH require pulmonary vasodilator therapy, dual therapy with phosphodiesterase type 5 inhibitor (Tadalafil) to increase Nitrous oxide in pulmonary circulation and an endothelin receptor antagonists (Bosentan) to block endothelin a potent pulmonary vasoconstrictor

progressive exertion dyspnea, elevated pulmonary artery systolic pressure, poorly functioning, hypertrophic right ventricle

Pulmonary Hypertension Group 1: CT disease (Scleroderma), Amphetamines, HIV, Schistosomiasis, Need Pulmonary vasodilator therapy and treat underlying cause Group 2: Left sided Heart Disease: Echo, Optimize LV function (HF therapy) Group 3: Lung disease &/or chronic hypoxemia: PFTs, chest imaging, polysomnography, treat underlying respiratory condition (OSA) Group 4: Chronic Thromboembolic Pulmonary HTN: V/Q scan, pulmonary angiography, Pulmonary Thromboendarterectomy surgery (curative), anticoagulant If refractory bilateral lung transplant

Endothelin Receptor Antag (Bosentan), Phosphodiesterase-5 inhibitor (Sildenafil) improve

Pulmonary hemodynamics and exercise capacity in patients with group 1 pulmonary HTN

Causes of hemoptysis

Pulmonary: Bronchitis, Lung Cancer, Bronchiectasis Cardiac: Mitral stenosis/Acute pulmonary edema Infectious: TB, Lung Abscess, Bacterial pneumonia, ASspergillosis Hematologic: Coagulopathy Vascular: PE, AV Malformation Systemic Dz: Granulomatosis with Polyangiitis, Goodpasture Syndrome Other: Trauma, Cocaine

hypothalamic-pituitary-adrenal (HPA) axis

Pulsatile secretion of GnRH to release FSH & LH which activates the ovaries to produce estrogen Breast development 8-12yo, Menarche 2-2.5 years later Normal for menses to occur by 15yo with normal secondary sexual characteristics

chest pain, dyspnea, hypotension, JVD, muffled heart sounds. Decline in blood pressure during inspiration.

Pulsus Paradoxus

Medial eyelid laceration can predispose to injury of

Punctum, canaliculi, nasolacrimal duct, sac

Uninsured individuals who do not qualify for federal health insurance porgrams (medicaid) and lack affordable access to private insurance plans (due to unemployment) can

Purchase insurance through the health insurance marketplace "exchange" established by the affordable care act and operated by the federal government Plans cant deny coverage or increase premiums due to patients preexisting health conditions Plans must cover essential health benefits, depending on the plan may still incur out of pocket copay or coinsurance PREVENTITIVE SERVICES (screening mammogram) must cover all costs sot hat patients have ZERO out of pocket spending

STOP-BANG questionnaire for OSA

SNORING TIRED during the day Observed paneas P-high blood PRESURRE BMI.35 AGE>50 NECK size Men>17, women >16 GENDER: Male 1 point for each 0-2: low 3-4: intermediate >5: high

Paroxetine Citalopram Sertraline Fluoxetine

SSRI

urinary frequency, urgency, burning, dysuria, and high fever, plus flank pain and tenderness

Pyelonephritis. urinalysis and urine culture to diagnose Sonogram or CT will help to identify the etiology. Treatment is a medication for gram-negative bacilli. For outpatient, ciprofloxacin or the third-generation oral medications cefpodoxime or cefdinir. For inpatient, use ceftriaxone, quinolones, or ampicillin + gentamicin. Ertapenem and other carbapenems are for multidrug-resistant (MDR) organisms such as ESBL.

Neutrophillic dermatosis associated with PAINFUL inflammatory bowel disease or an arthritides. Inflammatory nodules, pustules or versicles that turn into ulcers.

Pyoderma Gangrenosum

neutrophilic dermatitis associated with IBS and inflammatory arthritides.Tender papule that degrades into a bluish, violaceous ulcer

Pyoderma Gangrenosum

capillary proliferation after trauma presenting as a dome shaped papule with recurrent bleeding, more common in pregnant women

Pyogenic Granuloma (Granuloma Telangiectaticum)

Treat symptoms of myasthenia gravis

Pyridostigmine a cholinesterase inhibitor Ocular (ptosis, diplopia) or Bulbar (dysarthria, dysphagia) weakness

Tetanus vaccine

Q 10 years. Tdap (both the tetanus toxoid and vaccination for acellular pertussis). -Tdap is safe in pregnancy; revaccination with Tdap should be done with every pregnancy. -If a wound is strongly contaminated, the patient is considered protected for only 5 years after the last injection; revaccination, or booster, should be with Tdap as well. -Tetanus immune globulin is used only if the patient has never been vaccinated.

Six Sigma

Quality improvement approach that seeks to eliminate serious defects to a statistical standard. Appropriate to reduce catastrophic outcomes (like wrong site surgery)

Standardized Mortality Ratio (SMR)

Quantifies mortality in a specific group as compared to the general population. It is the ratio of observed to expected number of deaths in a specific group of the general population under the assumption that mortality rates for the group are the same as those for the general population. The expected number of deaths is calculated based on age specific mortality rates in standard reference population. Used in occupational studies to determine wether the observed number of deaths in a group (workers) exposed to a specific risk factor exceeds what would be expected in a similar population excluding the risk factor of interest. SMR<1 = number of observed deaths in the study group is lower than what is expected SMR = 1 indicated that the number of observed deaths in the study group is equal to what is expected SMR > 1 indicates that the number of observed deaths in the study group is greater than what is expected.

Diagnostic criteria for DM

Random Plasma Glucose >200 in patient with classic symptoms of hyperglycemia (polyuria, polydipsia, polyphagia), OR Hgb A1c>6.5%, Fasting plasma glucose >126, OR 2 hr plasma glucose >200 during oral glucose tolerance test

First line tx in premature ejaculation

SSRI Due to potential to cause delayed ejaculation

physical sign consistent with "Antifreeze" ingestion

Rapid and Deep Breathing Ethylene Glycol gets metabolized in the body by alcohol dehydrogenase into a toxic metabolite (Glycolic acid, Glyoxylic Acid, Oxalic Acid) Lead to severe anion gap metabolic acidosis, causing rapid and deep breathing known as kussmauls respiration. Also see N, V, slurred speech, ataxia, nystagmus, lethargy. TX: FOMEPIZOLE a competitive inhibitor of alcohol dehydrogenase. prevents formation of toxic metabolites causing a dramatic improvement in academia, and prevents renal failure. Used in methanol intoxication as well

Young Female with hx of cold intolerance. When weather is cold fingers get numb and turn blue.

Raynaud Phenomenon CALCIUM ANTAGONISTS = FIRST LINE TX = NIFEDIPINE, AMLODIPINE, DILTIAZEM If systemic disease symptoms like arthralgia and myalgia and resistant to treatment then need further evaluation -> ANA, RF, CBC, Blood Chem, Urinalysis, Measure complement level

Uveitis, Urethritis, Achilles Enthesitis, Dactylitis, Keratoderma Blennorrhagica, Circinate Balnaitis

Reactive Arthritis After GU (Chlamydia) or GI (Salmonella, Shigella, Yersinia, Campylobacter) infection. NO pathogens are isolated on synovial cultures

Teriparatide

Recombinant peptide identical to the N-terminal portion of PTH. Used as a second line agent in patients who's condition have not responded to bisphosphonate therapy. However a side effect is raising serum calcium concentration.

Vaccines during pregnancy

Recommended: Tdap (THIRD TRI (>28weeks), Influenza (Anytime), Rho(D) Immunoglobulin HIGH RISK ONLY: Hep B, Hep A, Pneumococcus, H. Influenza, Meningococcus, Varicella-Zoster CONTRAINDICATED: HPV, MMR, Live attenuated Influenza, Varicella

Develops red skin, particularly on the neck

Red Man Syndrome - red, flushed skin from histamine release. Vancomycin This happens from rapid infusion of vancomycin. Slow the rate of the infusion. There is no specific therapy, and the medication does not need to be switched. Simply slow the rate of infusion to prevent it. Telavancin does not cause red man syndrome.

Amphotericin side effects

Renal toxicity (increased creatinine); hypokalemia; metabolic acidosis from distal renal tubular acidosis; fever, shakes, chills Amphotericin is directly toxic to the tubules. Distal tubule toxicity results in renal tubular acidosis. Distal renal tubular acidosis gives excess potassium and magnesium loss and hydrogen ion retention. In cases where there is renal toxicity, switch to liposomal amphotericin.

Crush injury, Seizure or cocaine toxicity, Prolonged immobility in an intoxicated patient, Hypokalemia resulting in muscle necrosis, A patient recently started on a statin medication for hyperlipidemia

Rhabdomyolysis, large-volume muscular necrosis is associated with renal failure from the direct toxic effect of myoglobin on the kidney tubule. LOW SERUM PHOSPHATE Dx: Urinalysis best initial test, Elevated CPK, Urine Myoglobin most accurate test, On CCS (Potassium, Calcium, Chem panel) Tx: Bolus, Mannitol Diuresis to decrease contact time of myoglobin with the tubule, Alkalinization

Serum Antistreptolysin Titers Elevated

Rheumatic Fever Migratory Polyarthritis after pharyngitis Monthly Abx therapy with PENICILLIN G BENZATHINE

Effects of Combined Estrogen/Progesterone Menopausal Hormone Therapy

Risk of ischemic stroke increased in all age groups. and no benefit on skin wrinkling Benefits: -Menopause (Hot flashes, vaginal atrophy) -Bone mass/fracture -Colon cancer -Type 2 DM (Decreased insulin resistance) -All-Cause Mortality <60yo Detrimental: -Venous Thromboembolism -Breast Cancer -Coronary Heart Dz >60yo -Stroke -Gall Bladder Dz Neutral: -Cognition/Dementia -Endometrial Cancer (increased with unopposed Estrogen) -Ovarian Cancer -All Cause Mortality >60yo

H. Pylori Infection

Risk: Childhood in low-income country, Low socioeconomic status, International travel Clinically: PUD, Nonulcer Gastritis, Gastric Adenocarcinoma or Lymphoma, Immune Thrombocytopenia Dx: UREA BREATH TEST< STOOL ANTIGEN TESTING< UPPER ENDOSCOPY WITH BIOPSY Tx: Combo PPI & Abx Eradication should be confirmed if persistent symptoms. Done via urea breath testing and fecal antigen testing. Should occur >4 weeks after completion of therapy.

child after camping trip in North Carolina Fever, headache, myalgia, arthralgia, macular and petechial rash on wrist/ankles LOW platelets, Sodium HIGH AST & ALT

Rocky Mountain Spotted Fever Rickettsia Rickettsii Infection Transmitted by Tick Bite Peaks in Summer Dx: Rickettsia Serology, Skin Biopsy Tx: Doxycycline (start ASAP without waiting for confirmatory test results) - SAFE for children and pregnant patients

Chronic inflammatory disease causes erythema of the central face. First manifests as easy flushing and later results in persistent erythema and telangiectasia. Sensitive to chemical or physical insults and should limit exposure to sunlight.

Rosacea

Shoulder Pain

Rotator Cuff Impingement or Tendinopathy: -Pain with abduction, external rotation -subacromial tenderness -normal ROM with positive impingement tests (need, Hawkins) Rotator Cuff Tear: -Weak abduction and external rotation ->40yo Adhesive Capsulitis (Frozen Shoulder)-CONTRACTURE OF JOINT CAPSULE-Secondary to rotator cuff tendinopathy, subacromial bursitis, paralytic stroke, DM or humeral head fracture. Glenohumeral joint loses its normal distensibility due to chronic inflammation, fibrosis, and contracture of the joint capsule. -Decreased passive & active ROM -worse at night -Stiff +/- Pain -complete recovery 6-18 months, rest gentle range of motion exercises (pendulum swing hand held wights and walking fingers up wall . If no improvement in 2-3months then glucocorticoid injection into the joint. Biceps Tendinopathy or rupture: -Anterior shoulder pain -pain with lifting, carrying, overhead reaching -Weakness Glenohumeral Osteoarthritis: -Uncommon, usually caused by trauma -Gradual onset of anterior or deep shoulder pain -decrease active and passive abduction and external rotation

Painful arc test, onset of shoulder pain when arm is abducted between 60-120 degrees. Characteristic of

Rotator Cuff Impingement.

lateral shoulder or deltoid pain aggravated by reaching or lifting the arms up

Rotator cuff tendonitis or tear, Impingement syndrome, Frozen shoulder

physical findings are rarely seen but are useful in establishing the diagnosis of endocarditis if the blood cultures are negative:

Roth spots (retina) Janeway lesions (flat, painless in hands and feet) Osler nodes (raised, painful, and pea shaped) Splinter hemorrhages (under fingernails)

Lab workup for cognitive impairment: Dementia

Routine: CBC, Vit B 12, TSH, CMP Specific risk factors: Folate, Syphilis, Vit D level Atypical (<60yo,rapidly progressive) : CSF Routine Imaging: CT or MRI Atypical: EEG

Back pain that is worse with flexion, straight leg test positive (sciatic nerve root compression), in adolescent athletes

Rupture of annulus Fibrosis (leading to disc herniation)

+ Pregnancy test, Abdominal Pain, Unilateral complex adnexal mass on US

Ruptured Ectopic Pregnancy

Absent achilles reflex. Sensory loss of posterior calf, sole and lateral foot, weakness in hip extension (glut max), knee flexion (hamstrings), Foot plantar flexion (gastrocnemius). WHICH NERVE ROOT?

S1

topical permethrin is indicated for

SCABIES (scaly, erythematous linear papules involving hands, wrists and groin)

Mathematically what does RR mean, example RR of sudden cardiac death in the low dose group as compared to the high dose group is RR=0.4

SCD risk of the group in the numerator is 40% that of the group in the denominator Risk of of SCD in the low dose group is 40% of the risk in the high dose group

HIGH PTH, HIGH Phosphorous, LOW-NORMAL Calcium

SECONDARY HYPER PTH Complication of CKD - Failing kidneys unable to convert Vit D to active Vit D and decreased phosphate excretion. Lead to CKD-mineral bone disorder (renal osteodystrophy). Persistent PTH elevation causes increased bone turnover (HIGH Alk Phos) lead to osteitis fibrosa cystica. best treated initially with dietary phosphate restriction to reduce CKD-mineral bone disorder.

Raloxifene

SERM. Bone ER agonist. Prevents resorption of bone by inhibiting osteoclasts. Use: osteoporosis Antagonistic effects on other estrogen-responsive tissues and can worsen hypoestrogenic symptoms (hot flashes, vaginal dryness).

Canagliflozin

SGLT2 inhibitor (Sodium Glucose Cotransporter 2) decrease renal tubular glucose reabsorption. Leads to renal glucose wasting and lower blood glucose renoprotective effect by reducing hyper filtration by reducing intraglomerular pressures. Lower systemic blood pressure and facilitate weight loss.

SGLT2 inhibitors

SGLT2 promotes glucose reabsorption at the level of the proximal renal tubule. SGLT2 inhibitors can reduce hyperglycemia via glycosuria. Complication = VULVOVAGINAL CANDIDIASIS due to higher urinary glucose levels, Polyuria, and increased UTI

Antinuclear Ab Assay is helpful in screening for

SLE

Fluoxetine

SSRI used to treat unipolar major depressive disorder

Acute Otitis Externa = Swimmers Ear

STAPH AUREUS & PSEUDOMONAS AERUGINOSA MILD: mild discomfort & pruritis, Minimal canal edema. Tx: Topical Acetic Acid 7-10days MOD/SEVERE: Mod pain & pruritis, Partial or complete occlusion from edema. Tx: Clean ear canal with wire loop, TOPICAL ANTIBIOTICS (Polymyxin B/Neomycin, Colistin/Neomycin, Fluoroquinolones (ciprofloxacin), Place wick if canal is completely occluded INVASIVE (MALIGNANT): DM, Immunosuppressed, intense pain, complete canal occlusion from edema, pre auricular erythema, LAD and fever. Tx: Broad spec SYSTEMIC antibiotics (Ciprofloxacin) +/- Debridement TOPICAL GLUCOCORTICOIDS (Hydrocortisone, Dexamethasone) pain or itching present.

Risk of Peripheral neuropathy in Diabetics

STRICT GLYCEMIC CONTROL decreases the risk of progression

After taking a handful of pills. Tachypnea, Tachycardia, Hyperthermia, Dizzy, GI symptoms (N/V)

Salicylate Toxicity from aspirin ingestion Medullary respiratory center (Inc RR, causing respiratory alkalosis), chemoreceptor trigger zone (N/V), cochlear neurotoxicity (tinnitus), Cerebral tissue injury and neuroglycopenia lead to cerebral edema and mental status changes. Inhibition of cellular metabolism causes lactic acidosis and hyperthermia. Tx: Alkalinization of blood and urine with SODIUM BICARBONATE DRIP, Glucose and activated charcoal (if within 2 hrs)

treatment for cutaneous warts (multiple skin colored, hyperkeratotic papules)

Salicylic Acid

lupus pernio an erythematous papules and plaques affecting central face

Sarcoidosis

eye pain and redness, conjunctival injection, c ontricted and reacts sluggish to light, several small tender nodules on the shins, bilateral hilarity LAD on CXR.

Sarcoidosis ANTERIOR UVEITIS (inflamed Iris & Ciliary Body) Painful shin lesions = Erythema Nodosum

Young patient with unilateral facial nerve palsy, hepatomegaly, fatigue and LAD raise suspicion for

Sarcoidosis Pulmonary: B/l Hilar Adenopathy, Interstitial Infiltrates Cutaneous: Papular, Nodular, or plaque like lesions, Erythema Nodosum Opthalmologic: Anterior Uveitis (Iridocyclitis or Iritis), Posterior Uveitis, Keratoconjunctivitis Sicca Reticuloendothelial: LAD, Hepatomegaly, Splenomegaly MSK: Acute Polyarthritis, Chronic arthritis CV: AV Block, Dilated or restrictive cardiomyopathy CNS: Facial Nerve palsy, Central DI, Hypercalcemia Lofgren Syndrome: Erythema Nodosum, Hilaer Adenopathy, Migratory polyarthralgia, Fever Screen: CHEST XRAY (look for bilateral hilarity or mediastinal adenopathy HIGH CALCIUM, ESR, ALK PHOS, ANGIOTENSIN CONVERTING ENZYME CONFIRM with Biopsy of LYMPH NODES = NONCASEATING GRANULOMAS, if no lymph nodes then bronchoscopy with transbronchial biopsy

infant with a vaginal tumor "cluster of grapes" appearance

Sarcoma Botryoides

Oral Ivermectin treatment for

Scabies

Intense;y pruritic rash (worse at night) in the flexor surfaces of the wrist, lateral surfaces of the fingers, finger webs.

Scabies Delayed Type IV Hypersensitivity reaction Excoriations with small, crusted, red papules scattered around the region, often with linear burrows. Dx: Skin scrapings from lesions revealing mites, ova, and feces under light microscopy Tx: Topical 5% Permethrin cream over the whole body, common adverse effects = local burning pruritis. Oral Ivermectin useful in outbreaks in nursing homes. Oral histamine can decrease the dermaitis and itching. All family members and close contacts should be treated at the same time. Bedding and clothing cleaned or placed in a plastic bag for at least 3 days as the mote can only live away from human skin for 2-3 days.

Small papule, Circumoral Pallor, Fever

Scarlet Fever Sandpaper rash, Strawberry tongue Streptococcal pharyngitis PO AMOXICILLIN

weakness affecting most of the lower leg musculature, including hamstrings. sensory loss of lower leg. Ankle jerk absent.

Sciatic nerve injury Hip dislocation, fracture or replacement, wayward buttocks injections, prolonged bed rest, deep seated mass in the pelvis

acute onset of flushing, throbbing headache, palpitations and abdominal cramps. 30 minutes after eating fish. Tasted unusually spicy.

Scombroid Poisoning Due to ingestion of improperly stored seafood. If seafood is stored at greater than 15C, histidine can undergo decarboxylation and form histamine

Chlamydia in Pregnancy

Screening at first prenatal visit, repeat in 3rd try if high risk Risk factors are age <25, hx of sexually trasnmistted infection, recent new partner, hx of multiple partners. Result in preterm prelabor rupture of membranes, preterm labor, postpartum endometritis fetal complications: neonatal conjunctivitis, neonatal pneumonia TX: AZITHROMYCIN tx mom and sexual partner & advised to abstain from intercourse for 7 days following completion of treatment.

First Trimester Combined Test

Screening test for Aneuploidy Higher detection rate than second trimester quad screen US measurement of Nuchal translucency thickness at 9-13 weeks combined with B-hCG and pregnancy associated plasma protein A (PAPP-A) POSITIVE RESULT = LOW PAPP-A & HIGH B-hCG = Aneuploidy (Trisomy 21) Definitive diagnosis can be made only by karyotype requires a chorionic villus sample at 10-13 weeks or amniocentesis after 15 weeks.

serum protein electrophoresis (SPEP)

Screening test for suspected monoclonal gammopathy (Multiple Myeloma) Bone with scattered lytic lesions or occasional diffuse osteopenia

Chronic, superficial, inflammatory process that arises in areas of rich sebaceous glands. Worsesn during infancy and puberty. in adults erythema with fine scales on the scalp (dandruff), eyebrows, eyelids, and nasolabial creases, ears, sternal area and axillae, umbilicus, groin, and gluteal crease

Seborrheic Dermatitis

erythematous scaly plaques affecting scalp, face, chest, and Intertriginous areas associated with dementia (Parkinson Disease)

Seborrheic Dermatitis

Erythematous pruritic plaques with greasy scales on scalp, central face, ears, chest

Seborrheic Dermatitis Malassezia species Risk: CNS Disease (Parkinsons), HIV Tx: Topical Antifungals: Selenium Sulfide, Ketoconazole), Topical Glucocorticoids, Topical Calcineurin Inhibitors (pimecrolimus) Chronic, relapsing condition. Initial treatment can provide significant improvement in symptoms but inadequate to provide long term remission. Patients need intermittent re treatment, with topical ketoconazole or Ciclopirox every 1-2 weeks.

Selenium Sulfide is used for

Seborrheic Dermatitis presents with mild erythema with greasy scales seen at the scalp, ears and facial skin folds. Also for tines versicolor presents with discolored macules on trunk

Young patients age <50 with no past medical history, signs/symptom's of stroke or TIA. ORDER?

Sedimentation rate VDRL or RPR ANA double-stranded DNA protein C, protein S factor V Leiden mutation antiphospholipid syndromes

Serum-Ascites Albumin Gradient (SAAG)

Serum Albumin - Ascitic fluid albumin HIGH = >1.1 = CHF, Cirrhosis, Alcoholic Hepatitis, Budd-Chiari Syndrome LOW = <1.1 = Peritoneal Carcinomatosis, Peritoneal TB, Nephrotic Syndrome, Pancreatitis, Serositis

Evaluation of Hyponatremia

Serum Osm >290 -> Hyperglycemia, advanced renal failure Urine Osm <100 -> Primary polydipsia, Malnutrition Urine Sodium <25 ->Yes-> Volume deplete, CHF, Cirrhosis ->NO-> SIADH, Adrenal insufficiency, Hypothyroid

fever, abdominal pain, bloody diarrhea

Shiga Toxin-Producing E. coli (STEC)

High fever, abdominal pain, diarrhea, mucoid or bloody diarrhea, tenesmus

Shigella complication: Seizures in children <15 yo

Diagnostic Tests for TB

Skin Test: High specificity in NON BCG Vaccinated patients, Diagnose LATENT but NOT active TB, return visit in 48hrs for final results Interferon-Gamma Release Assay: Blood draw, results in 16-24hrs, no interference with BCG vaccine, Cant differentiate between latent and active Smear Microscopy: Estimates quantitative number of bacilli, can determine active infection and monitor treatment progress, cant distinguish from non TB mycobacteria Sputum Culture: GOLD STANDARD, takes 3-8 weeks, allows for drug sensitivity testing Nucleic Acid Amplification: 1-2 days, differentiate non TB mycobacterium, Can be positive after TB treatment When Active TB Suspected go with sputum sampling (False negatives are common) and sent for acid-fast bacillus smear, mycobacterial culture (2-6 weeks but considered gold standard), and nucleic acid amplification (confirmatory testing, rapid results, can distinguish between TB and non TB). TB Skin Test and Interferon Gamma later because they cant distinguish between active and latent disease.

Skin infection (erysipelas) vs Throat infection (pharyngitis)

Skin infection (erysipelas) goes only to kidneys (glomerulonephritis). Throat infection (pharyngitis) goes to both kidneys (glomerulonephritis) and heart (rheumatic fever).

Nausea & Vomiting in Pregnancy

Small frequent meals - 1st line: Vit B6 & H1 Antihistamine - 2nd line: Oral Dopamine (Metoclopramide) & Serotonin Antag (Ondansetron) - IVF & IV antiemetics - Corticosteroids - TPN or tube feed

sudden infant death syndrome (SIDS)

Smoke exposure (pre and post natal), premature, Prone sleep position Prevent: Avoid Smoke exposure, Supine position, firm flat surface with no loose bedding, room sharing (NO BED SHARING), Pacifier Use

Treating Salicylate Toxicity

Sodium Bicarb can alkalinize urine which enhances salicylate excretion by the kidney

oral agents for chronic hepatitis C

Sofosbuvir-ledipasvir, elbasvir-grazoprevir, and pibrentasvir-glecaprevir

To sleep for 8-12hrs without requiring overnight feeds to meet their metabolic demands, infants need:

Stomach large nigh to hold more food per feed, therefore requiring less frequent feedings Increased hepatic glycogen stores to maintain glucose homeostasis in the fasting state. These are met by age 4-6months, when most term infants no longer require feeding every 2-4hrs as newborns do.

Used to control confounding factors and distinguish between confounding and effect modification

Stratified Analysis

used to control confounding at the analysis stage of a study

Stratified Analysis

Preventing neonatal group B Streptococcus infection

Strep Agalactiae (GROUP B STREP) Rectovaginal Culture 36-38 weeks gestation Intrapartum prophylaxis indication: 1. GBS Bacteriuria or GBS UTI in current pregnancy, regardless of treatment. 2. GBS+ rectovaginal culture 3. Unknown GBS Status (<37 weeks, Intrapartum fever, Rupture of membranes >18hrs) 4. Prior infant with early onset neonatal GBS infection IV PENACILLIN pregnant + Asymptomatic GBS = Immediate Abx tx with amoxicillin or Cephalexin Repeat urine culture a week after completion of antibiotic therapy

lobar pulmonary infiltrate

Strep Pneumoniae most common bacterial cause of pneumonia prophylaxis with Levofloxacin

fever, pharyngitis and sandpaper like rash

Strep Progenes

Hyperglycemia and ketoacidosis in setting of sepsis with fever, hypotension, dehydration, tachycardia

Stress Hyperglycemia Transiently elevated blood glucose levels in the context of severe illness in patients without known diabetes. This can be a result of high levels of cortisol, catecholamines, pro-inflmmatory cytokines Risk factors: Severe illness, Fever >102, sepsis, meningitis, admission to ICU for adults glucose containing IVF are minimized and insulin administered to achieve a blood glucose target 14-180. But for children optimal target is unknown. No risk of long term DM.

Leak with cough, sneeze or laughing

Stress IUrinary Incontinence tx with lifestyle modification, pelvic floor exercises, pessary, urethral sling surgery

syndrome of inappropriate ADH (SIADH)

Stroke, hemorrhage, trauma Carbamazepine, Valproic acid, SSRI, NSAID Pneumonia Small cell lung cancer (Ectopic ADH secretion) Pain & or Nausea Mild-Mod Hyponatremia: Nausea, forgetful Severe Hyponatremia: seizure, coma Euvolemia Labs: HYPOnatremia, Serum Osm <275, Urine Osm >100, Urine Sodium >40 Management: Fluid restrict +/- Salt tablets Hypertonic saline for severe Hyponatremia

Cyanide poisoning

Structure fires, Occupational exposure, Cyanide containing meds like Sodium NITROPRUSSIDE INHIBIT MITOCHONDRIAL OXIDATIVE PHOSPHORYLATION-Blocking production of ATP and forced anaerobic metabolism HTN, Tachycardia, Tachypnea, headache, c confusion, axnityu, seizures, coma, CHERRY RED SKIN Elevated anion gap metabolic acidosis with INC lactic acid Decontaminate, supportive Care with 100% O2, IVF, Vasopressors, Empiric tx with HYDROXOCOBALAMIN +/- SODIUM THIOSULFATE

Type II error (beta error)

Study fails to reject the null hypothesis that is false this is related to the power (to detect a difference when a difference actually exist) Larger the sample size the greater the power. Power = 1- b or 1-power = b As power increases b decreases So when a study has a small sample size the power decreases so less likely to detect a difference between the groups therefore increasing chance of a type II error

Exercise Induced Hypothalamic Amenorrhea (FUNCTIONAL HYPOTHALAMIC AMENORRHEA)

Styrene's exercise, Calorie Deficiency, Stress fracture, Amenorrhea, Infertility DEC GnRH, LH, FSH, Estrogen (Breast atrophy) DEC Bone mineral density (DXA scan required) INC Total Cholesterol & Triglycerides Tx: Inc Calories, Estrogen, Calcium & Vit D IF USING STEROIDS THERE WOULD BE NO MENSTRUAL IRREGULARITIES

dementia, dorsal spinal column dysfunction (impaired vibration sensation), lateral corticospinal tract (spastic paresis and hyperreflexia) bilateral Lower extremities, + Romberg unable to balance when closed eyes.

Subacute Combined Degeneration due to VITAMIN B12 Deficiency

Post Viral infection, Fever, Hyperthyroid Symptoms, Painful/tender Goiter

Subacute Thyroiditis (De Quervain Thyroiditis) HIGH ESR, CRP, LOW radio iodine uptake HIGH T4 Supressed TSH Leukocytosis, anemia, elevated liver enzymes Thyrotoxicosis caused by release of stored thyroid hormone due to follicular injury Tx: NSAID & B-Blockers (propranolol, Atenolol)-to help with hyperadrenergic sxs like sweating and palpitations

Sulfonylurea overdose

Sulfonylurea Glyburide for DMII. Causes an increased insulin secretion, can lead to hypoglycemia if overdose. Dextrose administration can cause transient hyperglycemia that may elicit even higher level of insulin secretion and rebound hypoglycemia. OCTREOTIDE a somatostatin analogue decreases insulin secretion and considered in patient with large sulfonylurea overdose.

Loss of foot eversion is commonly caused by injury to

Superficial fibular nerve (fibulas breves and longus) or deep fibular nerve (Fibularis Tertius)

Elderly with chronic low back pain, progressive right shoulder pain, smoker, CXR with superior lobe mass.

Superior Pulmonary Sulcus Tumor (pancoast Tumor)-Non-Small Cell Lung Cancer Shoulder pain most common initial finding. Asymmetric lower extremity deep tendon reflexes and back pain suggest spread to the spinal cord. Shoulder pain, Horner Syndrome (Invasion of paravertebral sympathetic chain/stellate ganglion)-Ipsilateral ptosis, Miosis, Enopthalmos, Anhidrosis. Neuro symptoms in the Arm (invasion of C8-T2). weakness/atrophy of intrinsic hand muscles. pain/paresthesia of 4th/5th digits and medial arm/forearm. Supraclavicular LAD. Weight loss. Tx: Corticosteroids, surgery, radiation

addition to symptoms of fever, and otalgia due to aute otitis media have severe vertigo with nystagmus, nausea and vomiting and significant hearing loss

Suppurative Labyrinthitis

fever, crankiness, followed by purulent drainage from ear. Tympanic membrane obscured by otorrhea and no tenderness to manipulation of pinna

Suppurative Otitis Media (Acute or Bacterial Otitis Media) with Tympanic Membrane Perforation GROUP A STREP

Evaluation of Renal Colic During Pregnancy

Suspect stones? do a Renal & Pelvic US -> if Negative -> Transvag US -> If Negative -> Treat empirically for a stone & observe closely or Magnetic Resonance Urogram or Low dose CT Urogram (2nd & 3rd trimester ONLY) Paroxysmal, severe flank pain that radiates to the labia due to Nephrolithiasis (more common in 2nd and 3rd tri due ti increase in urinary calcium excretion, urinary stasis and decreased bladder capacity predispose pregnant patients

Management of Hypertrophic Cardiomyopathy

Symptomatic (Dyspnea, Angina) 1. Beta blocker or Nondihydropyridine CCB 2. Prior syncope or sustained VT -ICD placement 3. A fib-Rate and rhythm control, anticoagulation 4. Significant LVOT obstruction-Septal ablation or surgical myectomy 5. Nonobstructive-Cardiac Transplant

35 yo F, stiff fingers, runs white when takes food from freezer, heartburn and periodic sticking sensation in chest during meals. digits of both hands appear puffy with loss of skin folds

Systemic Sclerosis-Scleroderma Progressive tissue fibrosis, vascular dysfunction. Fatigue, weak, telangiectasia, sclerodactyly (Thickened puffy digits), digital ulcers, calcinosis cutis, arthralgia, contracture, myalgia, esophageal dysmotility, dysphagia, dyspepsia, Raynaud phenomenon (Finger stiff, changes due to claudication when exposed to cold). CREST SYNDROME: Calcinosis, Raynaud, Esophageal dysmotility, Sclerodactyly, Telangiectasia ANTINUCLEAR Ab, ANTI-TOPOISOMERASE I (Anti-Scl-70) Ab, ANTICENTROMERE Ab (SCREEN WITH PULMONARY FUNCTION TEST) Interstitial lung disease (Decline in both total lung capacity and diffusing capacity for carbon monoxide), Pulmonary arterial HTN (Drop in diffusing capacity for carbon monoxide but preserved total lung capacity) HTN, Scleroderma renal crisis (oliguria, Thrombocytopenia, MAHA), Myocardial fibrosis, pericarditis, pericardial effusion

2-3 weeks of headache, low grade fever followed by meningeal irritation (nuchal rigidity, vomit, confusion)CN palsies, coma, seizures. Chorid Tubercles (yellow white nodules near the optic disc) Basilar meningeal enhancement and CSF with HIGH protein, LOW glucose, Lymphocyte pleocytosis, elevated adenosine deaminase

TB Meningitis Definitive dx: serial lumbar punctures with CSF exam for acid fast bacilli Prolonged tx is required with 2 months of 4 drug therapy (isoniazid, rifampin, pyrazinamide, and either fluoroquinolone or injectable aminoglycosides) followed by 9-12 months of continuation of therapy (isoniazid + rifampin) As Anti TB meds can result in transient worsening of CNS inflammation, patients with TB meningitis are given 8 weeks of adjuvant glucocorticoid therapy (dexamethasone or prednisone) to reduce morbidity and mortality TB Meningitis is associated with high risk of long term Neuro squealea prompt treatment reduces risk but many patients have permanent neurologic damage.

Clomipramine

TCAs Adverse effects: Orthostatic Hypotension, Anticholinergic effects, cardiac conduction delay.

TCA's and Seizures

TCAs inhibit central GABA receptors and can cause seizures GABA agonists (benzodiazepines) are preferred to treat seizures

Ventricular Tachyarrhythmias seen with overdose of

TCAs, second gen antihistamines (astemizole, Terfenadine)

Ataxia, weakness, absent of deep tendon reflexes after a camping trip to Washington state

TICK PARALYSIS Develops over hours Neurotoxin in tick saliva transmitted over 4-7 days of attachment. Start with paresthesia and fatigue, then gait ataxia and ascending paralysis then absent deep tendon reflexes. NEED METICULOUS SKIN EXAM to identify the tick. Tick REmOVAL eliminates the precipitating neurotoxin and results in clinical improvement within hours. REVORE completely.

Stroke is distinguished from TIA based on

TIME. Stroke, symptoms last ≥24 hours. There will be permanent residual neurologic deficits. Stroke, caused by ischemia (80% of cases) or hemorrhage (20%). TIA, symptoms last <24 hours and resolve completely. TIA, always caused by emboli or thrombosis and never caused by hemorrhage.

Opportunistic infection in HIV (Pneumocystis Jiroveci) treated with

TMP-SMX

Acute uncomplicated cystitis (UTI) treatment

TMP-SMX for 3 days OR Nitrofurantoin for 5 days

A 25-year-old, generally healthy woman comes to the office with burning on urination. There are 50 white cells on the urinalysis. What is the next best step in management?

TMP/SMX for 3 days When there are clear symptoms of cystitis and white cells in the urine, it is not necessary to obtain a urine culture or to wait for results of the culture or a sonogram. For uncomplicated cystitis, go straight to treatment for 3 days. Ultrasound is important in males, as it is unusual for a male patient to have a UTI in the absence of an anatomic abnormality.

Specificity

TN / (TN + FP) Probability of a non diseased person testing negative

Increased serum thyroxine (T4), suppressed TSH, increased radio iodine uptake in a large thyroid nodule with suppressed uptake in the reminder of the gland.

TOXIC THYROID NODULE (Toxic Adenoma) Beta blockers (metoprolol, Atenolol) peroxide symptomatic relief in patients with toxic adenoma. Definitive therapy with radioactive iodine ablation or surgery (hemithryoidectomy) Prior to definitive therapy patients need to be pretreated with antithyroid drugs (Methimazole) to achieve chemical euthyroidism. THE BEST IS Surgery. METHIMAZOLE > Propylthiouracil (PTU) for most patients due to risk of severe hepatotoxicity with PTU. ONLY PTU if hyperthyroid is diagnosed in FIRST TRIMESTER of pregnancy as Methimazole was teratogenic.

Positive predictive value

TP / (TP + FP) probability that a person who has a positive test result actually has the disease

Sensitivity

TP/ (TP+FN) Probability of a diseased person testing positive

FDA approved med for reducing fine wrinkles, mottled hyperpigmentation, and roughness of facial skin. and reduce actinic keratosis and improve brown spots.

TRETINOIN (All-Trans-Retinoic Acid)

Newborn with webbed neck, congenital lymphedema (swollen hands and feet), Broad chest, wide spaced nipples, nigh arched palate, low post hairline

TURNER SYNDROME 45 XO Complete or partial loss of an X chromosome Random errors in cell division (NON DISJUNCTION) sex chromosomes fail to spectate during egg or sperm formation one gamete will lack an X chromosome and fertilization will result in 45 X Zygote (monosomy X) SPORADIC EVENT so likelihood of recurrence in subsequent pregnancies is similar to that of general population Karyotype analysis needed. Once diagnosed need 4 extremity BP measurements and Echo to look for aortic coarctation. US to screen for horseshoe kidney (predispose to UTI). Screen every few years for hypothyroidism and celiac disease. NORMAL INTELLIGENCE

Selective Estrogen Receptor Modulators (SERMs)

Tamoxifen, Raloxifene MOA: Competitive Inhibitor of Estrogen binding Indications: Prevent breast cancer in high risk patients (Atypical hyperplasia, >35, hx of lobular carcinoma in situ) TAMOXIFEN: Breast cancer tx adjunct RALOXIFENE: Post Menopausal Osteoporosis SE: HOT FLASHES, DVT, Endometrial Hyperplasia & Carcinoma (TAMOXIFEN ONLY), Uterine Sarcomas (TAMOXIFEN ONLY) Tamoxifen can cause endometrial polyps in premenopausal women. IF ON TAMOXIFEN EVALUATE ONLY IF SYMPTOMS DEVELOP

A patient develops recurrent episodes of gonorrhea. What should he be tested for?

Terminal complement deficiency. recurrent episodes of Neisseria infection. This includes any form, including genital and CNS infection.

Treatment of impetigo

Topical mupirocin or retapamulin -mupirocin has greater activity against MRSA. Severe disease: oral dicloxacillin or cephalexin Community-acquired MRSA (CA-MRSA): TMP/SMX or doxycycline; linezolid and delafloxacin are definitely effective

Management of Unstable Angina/NON ST Elevation MI

Thrombolysis in MI Risk Score: (1 point for each) ->65yo ->3 risk factors for CAD ->50% stenosis -Aspirin use ->2 anginal episodes past 24hrs -Elevated troponin -ST deviation 0-2 = LOW = Stress Test 3-4 = Intermediate = 5-7 = High = Early coronary angio within 24hrs HD unstable, HF, MR, Recurrent chest pain, Ventricular arrhythmia = Immediate Coronary Angio

Ischemic Stroke BP target

Thrombolytic Administration: -Prior: Lower BP to <185/110 -After: Maintain BP <180/105 for 24hrs Thrombolytics NOT indicated, to allow permissive HTN, Lower extreme HTN (SBP >220 or DBP >120 by 15% in first 24hrs Thrombolytics are indicated within 4.5 hrs eligibility window. BUT contraindicated if >180/110 As cuncontrolled HTN may increase risk of hemorrhagic conversion Therefore Strat with rapid acting titratable IV antihypertensive (NICARDIPINE) to lower BP prior to repercussion therapy with Alteplase

Schistocytes on peripheral smear, HIGH Lactate Dehydrogenase, Acute renal failure, Fever, Neurologic abnormalities

Thrombotic Thrombocytopenic Purpura Thrombocytopenia + Microangiopathic Hemolytic Anemia Tx: Plasma Exchange

child with midline neck mass that moves superiorly with swallowing

Thyroglossal Duct Cyst Detected when becomes secondarily infected after an URI Thyroid gland is formed as an out pouching from pharyngeal epithelium at base of tongue. Then descends to the base of the anterior neck via thyroglossal duct. (foramen cecum (base of tongue) to base of anterior neck) If duct fails to atrophy normally a thyroglossal duct cyst can develop from epithelial remnant within the duct. because the tract connects to the base of the tongue protrusion of tongue or swallowing causes it to move superiorly. Ectopic thyroid tissue is commonly associated with it and may be the only site of functioning thyroid tissue. Therefore imaging of the thyroid (US or CT) for definitive treatment. Tx: Surgical resection of cyst, associated tract & central portion of hyoid bone. MUST BE SURGICALLY removed due to risk of recurrent infections. Remove entirety of the cyst and fibrous tract remnants. Sometimes may contain the only functioning thyroid tissue therefore imaging to avoid iatrogenic hypothyroidism from inadvertent removal of the only functioning thyroid tissue

Plantar sensory loss indicate injury to

Tibial nerve and medial calcanea nerve)

Quality Adjusted Life Years & Disability Adjusted Life years

Time trade off is commonly used for Quality Years of life lost and years lived with disability are used for Disability

Blindness can occur as a complication of proliferative diabetic retinopathy leading to vitreous bleeding, followed by retinal detachment. Blindness can be prevented by?

Timely detection, and treatment using photocoagulation. Prevented by improving glycemic control.

Griseofulvin is used to treat

Tinea Capitis (dermatophyte infection seen in children) & Tinea Corporis causes annular plaques with peripheral scaling and central clearing.

Scaly, erythematous patch with hair loss on scalp

Tinea Capitis most common in African Americans Transmission from direct contact or from fomites (shared combs) Can diagnose with KOH exam of hair shaft TX: ORAL GRISEOFULVIN or TERBINAFINE MUST BE PO to penetrate hair follicles

Erythematous scaly annular patch or plaque that spreads

Tinea Facialis treated by Topical Clotrimazole

Annular erythema with a trailing scale on the dorsal or ventral hand. Mild itching. One hand involved.

Tinea Manuum

erythema, cracking, scaling, and pruritus of the hands

Tinea Manuum Superficial fungal infection of the hands in patients with pre-existing tines pedis

Slowly progressive pruritis of the feet, erythema, scaling between toes, extension to soles and sides of feet with sharp border between involved and uninvolved skin

Tinea Pedis Mild: Topical Antifungals (Terbinafine, Miconazole, Clotrimazole) 1-4 weeks Extensive Dz: PO Terbinafine, Itraconazole, Fluconazole WITH ONYCHOMYCOSIS - NEED PO ANTIFUNGALS 12 weeks

Aspirin toxicity symptoms

Tinnitus and vestibular symptoms But NO hearing loss

Low grade fever, limp, hip pain with restricted ROM, bilateral effusions on US, Age 3-8 yo.

Transient Synovitis - Transient Inflammation of the Synovium Unilateral hip pain and a limp ability to bear weight on affected extremity. Pain with internal rotation and limited range of motion. Preceding a viral illness Management: NSAID, full recovery within 1-2 weeks, recurrence uncommon

Guillain Barre Vs Transverse Myelitis

Transverse Myelitis: -Early flaccid, late spastic paralysis -clearly identifiable sensory level Bowel & Bladder Dysfunction -NO CN -Nerve conduction Normal -MRI with focal enhanced T2 -CSF: Pleocytosis +/- Increased IgG index Guillain Barre Syndrome: -Ascending paralysis -Weakness in LE / UE -Mild sensory loss -No spinal cord level -CV instability -Oculomotr, glossopharyngeal or facial paralysis -Peripheral motor and or sensory NCV reduced -Normal MRI, enhancement of anterior nerve roots or caudal equina -CSF NO pleocytosis, elevated protein

Ephedra

Treat Cold & Flu, Weight loss and improve athletic performance SE: HTN, MI, Stroke, Seizure

St. John's Wort

Treat Depression SE: GI Distress, Dizzy, Fatigue, Photosensitivity, and dry mouth, anorgasmia, urinary frequency, swelling

Garlic preparations

Treat Hypercholesterolemia

Kava Kava

Treat anxiety & Insomnia SE: Liver Toxicity

Black Cohosh

Treat menopausal symptoms (hot flashes, Vaginal dryness) SE: Hepatic Injury

Licorice

Treat stomach ulcers, Bronchitis/Viral infections SE: HTN, Hypokalemia

A 30-year-old woman comes to the ED with lower abdominal pain and tenderness, fever, leukocytosis, and cervical motion tenderness. What is the treatment?

Treatment for PID -Ceftriaxone (IM) and doxycycline (oral) for outpatient -Cefoxitin (IV) and doxycycline and maybe metronidazole for inpatient -Clindamycin and gentamicin for penicillin allergy, then doxycycline to treat chlamydia

treatment-resistant depression

Treatment resistant = No response to adequate trials of 2 different antidepressants Non responder-Consider Swtiching -Monotherapy with a different sntidepressant -Psychotherapy -Electroconvulsive therapy -repetitive transcranial magnetic stimulation Partial Responder-Consider Augmentation -Second gen antipsychotics -sntidepressant with different MOA -Lithium -Thyroid Hormone -Psychotherapy Augment with BUPROPION an activating antidepressant that does NOT cause weight gain or sexual side effects and used to treat SSRI induced sexual side effects

sTI with malodorous vaginal discharge and pruritis. Pear shaped motile organisms on wet mount. Vaginal pH>4.5.

Trichomonas Vaginalis.

Thin, yellow-green malodorous, frothy discharge, vaginal inflammation, pH>4.5, punctate hemorrhages

Trichomoniasis Tx: SINGLE DOSE PO METRONIDAZOLE 2g (treat sexual partner) - Can pass through breast milk and cause loose stools and candidiasis in infant, therefore breast milk produced immediately after tx should be discarded for 24hrs after dose administration Vaginal metronidazole is INADEQUATE

Thin, yellow-green, frothy discharge; Inflammation present pH > 4.5; motile organism on wet mount

Trichomoniasis (trichomonad Vaginalis) Tx: Metronidazole; treat sexual partner

Red annular patches, central clearing, scales, pruritic

Trichophyton Rubrum cause tines corporals (Ring Worm)

unilateral, intermittent sharp pain of the right cheek and lips triggered by brushing teeth or drinking cold water likely has

Trigeminal Neuralgia Due to compression of the trigeminal nerve root as it enters the pons leading to demyelination and atrophy of the nerve. compression most commonly occurs due to a vascular loop, neoplastic growth or multiple sclerosis plaque.

Vasovagal & Situational Syncope

Triggered by pain, anxiety, emotional stress, heat, prolonged standing, cough, micturition, defecatrion, eating, hair combing Prodrome (Warmth, pallor, nausea, diaphoresis), rapid recovery in 1-2 min. Dx With upright tilt table testing in uncertain cases Tx: Reassurance & avoidance of triggers, assume a supine position with raised legs at onset of prodromal symptoms. Counterpressure techniques for recurrent episodes (leg crossing with tensing of muscles, tensing of arm muscles with clenched fists)

Epilepsy is common in syndromes

Trisomies 13,18 & RETT Syndrome

early-onset Alzheimer's disease is associated with

Trisomy 21 Upslanting palpebral fissures, Epicanthal Folds, Transverse Palmar Crease

urethral discharge with or without dysuria

Urethritis Test: Nucleic acid amplification tests (NAATs) Treatment: COINFECTION GONORRHEA & CHLAMYDIA One drug active against gonorrhea (IM-Ceftriaxone) and one drug active against chlamydia (Doxycycline x1wk, or Azithromycin x1dose safe in pregnancy) If + for trichomonas, treat with metronidazole. The symptoms of urethritis can persist for several days after treatment. Do not choose "repeat NAAT 2-3 days after treatment"

A 19-year-old primigravida presents at 32 weeks' gestation for routine follow-up. She denies headache, epigastric pain, or visual disturbances. She has gained 2 pounds since her last visit 2 weeks ago. On examination blood pressure is 155/95, which is persistent on repeat BP check 10 minutes later. She has only trace pedal edema. Which of the following is the next step in management?

Urinalysis Always rule out preeclampsia in a hypertensive pregnant patient. Even if she is asymptomatic, proteinuria indicates preeclampsia and a worse prognosis.

suicide by antifreeze ingestion (ethylene glycol); patient will be intoxicated with metabolic acidosis with elevated anion gap.

Urinalysis shows envelope-shaped oxalate crystals (best initial test) Treatment is ethanol or fomepizole with immediate dialysis.

ALL RENAL cases on CCS should have orders for

Urinalysis, Urine Sodium, Potassium, Chemistries, Renal Ultrasound

Emigrated from Ghana has urinary symptoms, terminal hematuria, peripheral eosinophilia

Urinary Schistosomiasis = SCHISTOSOMA HAEMATOBIUM parasitic blood fluke infection from sub-Saharan Africa Dysuria, urinary frequency, terminal hematuria , peripheral eosinophilia, anemia. Urine sediment microscopy to identify eggs Tx: PRAZIQUANTEL is curative Chronic can lead to bladder cancer (cystoscopy with biopsy)

To evaluate mixed or complicated urinary incontinence

Urodynamic studies

second line option for patients with symptomatic cholelithiasis (biliary colic) who do not desire surgery

Ursodeoxycholic Acid

First generation antihistamines (diphenhydramine) used to treat

Urticarial reactions (hives)

cfDNA testing

Usage of maternal plasma cell-free DNA to accurately detect fetal autosomal aneuplody in high-risk pregnancies determine the karyotype of fetus As early as 9 weeks NO RISK

Patient with chronic HCV require

Vaccination against HAV and HBV unless have immunity (HAV antibody +, HBV surface antibody +) Screening for complications and comorbidities = Liver fibrosis, renal disease, extra hepatic manifestations (cryoglobulinemia) ALL PATIENTS SHOULD ABSTINENCE FROM SUBSTANCE USE AND ALCOHOL NO LONGER treated with Interferon and Ribavirin therefore drug associated depression no longer a problem now that treated with DIRECT ACTING ANTIVIRAL Agents

prevent preterm birth in patients with prior history

Vaginal Progesterone also indicated for patient with short cervix (<2.5 cm on second trimester US). It cant inhibit active preterm labor.

prevent preterm delivery in patients diagnosed with a short cervix (<25mm)

Vaginal Progesterone Supplementation Dx via US at 18-24 weeks

Treatment for CMV

Valganciclovir

best long term therapy for CMV retinitis

Valganciclovir

Antiviral agents for cytomegalovirus [CMV], herpes simplex, varicella

Valganciclovir, ganciclovir, and foscarnet

Treat breast abscesses and Group B strep prophylaxis in penicillin allergic patients

Vancomycin

Pharmacotherapy for smoking cessation

Varenicline: partial nicotine receptor agonist, reduces nicotine cravings and withdrawal symptoms. Most effective->SE: Disordered sleep and abnormal dreams Long-acting NRT (nicotine patch): Dec craving and daytime withdrawal symptoms, Long acting can be combined with short acting->NO SE Short-acting NRT (Nasal spray, gum, lozenge, inhaler) Bupropion: Decrease post cessation weight gain, good choice for patient with unipolar depression->SE: Contraindicated in patients with seizures or eating disorders INCREASED EFFECTIVENESS of combo Vareniciline + NRT only mid adverse effects (nausea, insomnia, mild skin reactions)

Neonatal infection presents with "zigzag" skin lesions, limb hypoplasia, microcephaly, microphthalmia, chorioretinitis, and cataracts.

Varicella rash appears in the mother between 5 days antepartum and 2 days postpartum Prevention includes vaccination (live-attenuated varicella virus to nonpregnant women) and postexposure prophylaxis: VariZIG (purified human immunoglobulin with high levels of antivaricella antibodies) within 10 days of exposure. Tx: Maternal varicella (uncomplicated): oral acyclovir to mother plus VariZIG to mother and neonate Congenital varicella: VariZIG and IV acyclovir to neonate

testicular enlargement that does not transilluminate feels like a bag of worms

Varicocele treat with venous embolization

leg pain that is worsened by exertion and relieved by rest. pulses are commonly decreased or absent to palpation and skin changes caused by poor circulation (dry, shiny, hairless skin)

Vascular claudication due to peripheral artery disease

Sickle Cell disease with acute severe pain, may or may not have fever

Vaso-Occlusive Pain Triggered by dehydration, infection, stress, weather, menstruation Tx: NSAID, OPIATES (IV MORPHINE), Hydration, +/- Transfusion

HD stable pt who needs emergency surgery with new onset Afib

Ventricular rate control with IV beta blocker (esmolol infusion, Metoprolol IV push) or Nondihydropyridine Calcium channel blockers (diltiazem infusion) If UNSTABLE: Some tachycardia is appropriate, goal rate of 100-110 NOT necessary to start anticoagulant as risk of thromboembolic event from Afib during surgery is low. If new onset and non emergency surgery then postpone until complete workup and optimize with pharmacologic measures.

Localize the lesion. Vertigo. Nausea and vomiting more likely than with other strokes "Drop attack" (loss of consciousness). Vertical nystagmus. Dysarthria. Sensory changes in face and scalp. Ataxia Bilateral findings.

Vertebrobasilar artery

cut hand cleaning a saltwater fish tank and developed rapidly progressive cellulitis with hemorrhagic bullae, and septic shock raising suspicion for

Vibrio Vulnificus Infection Free living, Gram - Bacteria that grows in marine environments Infection via raw oyster consumption or wound contamination If underlying liver disease (cirrhosis, Viral Hepatitis) or chronic medical conditions such as DM, Rheumatoid Arthritis) at higher risk. DX: Blood & Wound Culture Tx: IV DOXYCYCLINE + CEFTRIAXONE

fever, headache, vomiting, AMS, Nuchal rigidity (+ Brudzinski) with preceding upper respiratory symptoms in a child and close contact with a sibling who had fever, mouth sores and rash (Hand, Foot Mouth Dz)

Viral Meningoencephalitis Enterovirus: Coxsackie HSV Arbovirus: West Nile Lumbar puncture for definitive diagnosis. Empiric tx with Acyclovir and Antibiotics (Vancomycin and third gen cephalosporins) once HSV and bacterial infection excluded treatment for viral meningoencephalitis is supportive

Antiretroviral Therapy and Viral Load decrease

Virology failure is Viral load <200 within 6 months following ART measure viral load q3-6months Should decrease by <5000 by 4 weeks <500 by 8-16 weeks <50 by 16-24 weeks

Fatigue, myalgia, bone pain, weight gain, abnormal gait, increased risk of fracture

Vitamin D Deficiency - Osteomalacia Dx: Serum 25-hydroxyvitamin D (1,25-dihydroxyvitamin D reflects PTH levels and renal function)

Bowing of the radius/ulna and tibia, delayed closure of fontanelles and frontal bossing.

Vitamin D-dependent rickets Decreased Vit D and Calcium levels Delayed gross motor milestones

covers all Candida; best agent against Aspergillus

Voriconazole (side effects include visual disturbance)

Ascertainment Bias

When results from an atypical population are extrapolated into the entire population

A 34-year-old man comes to the clinic with multiple vesicles on his penis. There is enlarged adenopathy in the inguinal area. What is the next step in management?

When there are clear vesicular lesions present, there is no need to do a diagnostic test for herpes—go straight to treatment: acyclovir, valacyclovir, or famciclovir for 7-10 days. For recurrent genital herpes, give chronic suppressive therapy. If the roofs come off the vesicles and the lesion becomes an ulcer of unclear etiology, then the most accurate test for herpes is PCR.

Treatment of stroke and TIA depends on time elapsed since the onset of symptoms.

Within the past 3 hours: tPA. 3-4.5 hours ago, <80, Does not have diabetes with history of stroke Does not use anticoagulation. More than 4.5 hours ago or tPA cannot be given, Remove clot with a catheter. For all nonhemorrhagic strokes, add a statin. After thrombolytic use: start antiplatelet therapy after 24 hours. Small Stroke: Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. Stop clopidogrel after several weeks and continue aspirin indefinitely. Large Stroke: Aspirin ONLY. If already on aspirin: either add dipyridamole or switch to clopidogrel

Healthy Worker Effect

Working populations are generally healthier than the general population and exhibit lower mortality rates. Type of selection bias that may result when severely ill or disabled individuals are excluded from or not entering workforce. Mortality rates from general population may bot be appropriate as reference. Generally standardized mortality ratios that consider general population as reference will be biased and underestimate the effects of the exposure to a risk factor in a working population Therefore demographically similar working population without exposure to risk factor of interest may serve as a better basis for comparison then general population.

Recurrent Sinopulmonary infections. Encapsulated Bacteria (strep pneumoniae)

X-Linked Agammaglobulinemia Lack of opsonizing IgG (Defective opsonization and decreased immunoglobulin production) & Complement dysfunction (C3 Deficiency)

Hemophilia A

X-Linked Recessive occurs almost exclusively in Males Females are Asymptomatic carriers of the disease. If dad has it then all female children will be carriers, but if mom is a carrier then daughter has 50% chance of being a carrier and sons 50% chance of being affected

Colon cancer screening

colonoscopy at age 45 and is performed every 10 years. No screening after age 85. If a close family member has had the disease, begin screening at age 40 or 10 years earlier than the family member was diagnosed, whichever is earlier. If family has hereditary nonpolyposis colon cancer syndrome (HNPCC) (formerly known as Lynch syndrome), begin screening at age 25 and perform every 1-2 years. Sigmoidoscopy: every 5 years Fecal occult blood testing (FOBT): yearly Fecal immunochemical test (FIT) with DNA: every 3 years

Case-control study

compares a group of people with a disease to a group of people without a disease looks to see if odds of prior exposure or risk factor differ by disease state Asks what happened? Measures Odds Ratio Going back in time Investigate an acute infectious disease outbreak (association between exposure and disease) infected individuals should be questioned about their exposure and unaffected individuals should be chosen as controls to reflect the exposure experience of the general population.

unilateral, dermatomal vesicular rash

herpes zoster (shingles), due to reactivation of VZV from the dorsal root ganglia 7day PO Valacyclovir Zoster Vaccine for >60 to reduce risk of herpes zoster lesions that are not completely crusted over may still transmit VZV to other individuals via direct contact. Patients should cover the rash to prevent direct contact and to avoid patients who are susceptible to illness like pregnant (who never had varicella or vaccinated), low birth weight infants and immunocompromised infectious while on treatment until the rash is dry Continued pain and allodynia area of rash several months after lesion resolution = Postherpetic Neuralgia (PHN) - TCA (AMITRIPTYLINE) first line therapy but caution in elderly therefore next most effective us GABAPENTIN

Bell Palsy

inflammation and edema of the facial nerve CN VII No pain, but just unilateral facial paralysis

serotonin syndrome due to

ingestion of SSRI Autonomic dysfunction; Tachycardia, Hyperthermia, N/V Clonus, Hyperreflexia, slow horizontal eye movements, tremor, rigidity

Aconite

ingredient in Chinese herbal meds used to treat pain or HF case fatal arrhythmias (ventricular tachycardia, torsades)

For pseudomonal lung infection in cystic fibrosis

inhaled tobramycin or aztreonam. If those drugs are not available, try colistin.

MECHANISM OF ANTIFUNGAL MEDICATIONS Azole antifungals

inhibit conversion of lanosterol to ergosterol. Ergosterol is the major component of the cell wall of fungi. Disrupting ergosterol damages the cell membrane and increases its permeability, resulting in cell lysis and death

Cephalosporins MOA

inhibits cell wall growth by binding the penicillin-binding protein

Brain Death

irreversible absence of cerebral and brain stem function -clinical and brain imaging evidence of absence of confounding factors (endocrine disturbance, electrolyte disturbance or drug intoxication), HD Stability (Core body temp >36, Systolic BP>100) -Neuro imaging irreversible absence of cerebral and brainstem reflexes including pupillary, oculocephalic, oculovestiobular, corneal, gag, suck, swallowing, extensor posturing -positive apnea test, absent of respiratory response off the ventilator for 8-10 min -absence of intracranial blood flow ->24hrs of observation for diagnosis Normal to have spont movements originating from peripheral nerves or spinal cord: Finger flex, truncal movements, triple flexion response (flex at hip, knee, ankle with foot stimulation), plantar reflex (babinski), limb movement to painful stimuli, alternate flexion, extension of toes

correlational study

measure association between multiple variables and are conducted by natural observation, surveying or archival research. help develop hypothesis, not test. risk of finding an association that may not actually be true.

Valganciclovir & Ganciclovir side effects

neutropenia and bone marrow suppression

The earliest finding of osteomyelitis on an x-ray?

periosteum elevation

pseudocyesis

persistent non delusional belief of being pregnant in a non pregnant patient Neuroendocrine (prolactin, estrogen, FSH) and Psychosocial (trauma, infant loss, pregnant family member and internal or external pressure to conceive) thought to play a role

Risk factors for Uterine rupture

prior uterine surgery (C-section, myomectomy), trauma, Macrosomia, abnormal placentation. Palpable fetal parts

attributable risk percent (ARP)

proportion of the disease among exposed subjects attributed to exposure status ARP = (Risk in exposed-Risk in unexposed)/Risk in exposed OR ARP = (RR-1)/RR

Ritonavir

protease inhibitor inhibits hepatic p450 systems—the route through which protease inhibitors are metabolized. A small amount of ritonavir blocks metabolism of the other protease inhibitors, allowing higher blood levels with less frequent dosing.

Eval of suspected Myelopathy

rapidly developing myelopathy with flaccid paralysis and paresthesia along with clearly demarcated sensory level at the umbilicus. Flaccid paralysis and Hyporefelxia with a hx of URI suggest Guillain Barre Syndrome MRI necessary to diagnose cause of acute myelopathy in absent of trauma or hx of malignancy. Sensory Lebel and bowel/bladder dysfunction after a URI make Transverse Myelitis more likely treat with high dose corticosteroids 3-5 days

Wide confidence interval may be due to